Rwanda Non-Communicable Diseases Programme: call for proposals

Strategic Context

The Review recognised Health as one of the thematic areas prioritised by all three of the SG’s African PCs. Health therefore remains a key area for co-operation within the IDF. The review also recognised the need to move from small grants funding with a focus on multiple different areas and types of interventions to a more strategic approach to funding.

A SG commissioned evidence review identified NCDs (including, but not limited to, mental health, cancer, road traffic accidents, and haemoglobinopathies) as a specific area of health in need of increased global attention. Despite being the leading cause of death and disability globally, investment in the prevention and management of NCDs is extremely low at under 2% of Development Assistance of Health. ^[7]This level of investment has been static for at least the last decade. In 2019 cost sub-Saharan Africa (SSA) over 225 million disability adjusted life years.^[8] This has increased from 90.6 million in 1990. WHO estimates that NCDs will be the leading cause of deaths in SSA by 2030 and will be responsible for 3.8 million premature deaths^[9]. In the SG’s partner countries, it is estimated that 30-50% of all deaths are due to NCDs.

In 2015 the United Nations Sustainable Development Goals recognised the importance of tackling NCDs, including a specific target to reduce the probability of premature death from the four main NCDs in adults aged 30-70 years by 30% by 2030. A Global Action Plan to tackle NCDs was adapted and extended to 2030, setting out a roadmap to guide Member States in how best to achieve targets. A list of cost effective interventions or ‘WHO Best Buys’ sets out ways of tackling the major risk factors associated with the four most common causes of death from NCDs (cardiovascular disease, diabetes, cancer and chronic respiratory conditions). In 2020 WHO MS launched a Global NCD compact 2020-2030 to encourage adoption of best practice policies on prevention and control to galvanise momentum towards the SDGs. A range of technical packages have been published to provide MS with support towards this. PEN (Package of NCD interventions) and PEN Plus provide the regional strategy for AFRO (adopted in 2022) for expanding access to NCD care. PEN is aimed at expanding access at community level and PEN Plus supports expanding access at district hospital level.

Given Scotland’s longstanding expertise in delivering NCD programmes domestically, NCDs were identified as an area where Scotland would be well placed to share learning beyond its borders^{[10] [11]}.

Rwanda, community palliative care programme investment case

The case for investing in NCDs is compelling given the increasing burden that will be seen over the coming years and the paucity of investment in NCDs both domestically and internationally. Given this divergence between need and prioritisation, Scotland has an opportunity to work with partners at a political level to shift the global dialogue on NCDs.

Globally NCDs are the leading cause of death and disability, killing around 41 million people each year. This number is predicted to rise with the World Health Organisation (WHO) predicting that NCDs will be the main cause of death and disability in SSA by 2030^{[12] [13]}. Many countries are facing a ‘double burden’ with increasing rates of NCDs coupled with ongoing high mortality from communicable disease. NCDs are inextricably linked to poverty, and amongst the poorest billion^[14].

NCDs are inextricably linked to poverty with the poorest disproportionately affected by NCDs throughout their life course. Hunger, exposure to toxic environments, infectious disease hazards and lack of access to health care compound this risk. Across the poorest billion more deaths under 40 years of age are a consequence of NCDs compared with HIV, TB and maternal deaths combined. The vast majority of those living with or at risk of NCDs are undiagnosed or unaware of their risk and are often diagnosed at a late stage of the disease making management more complex.

Given that between 30 and 55% of the populations of the SG’s partner countries live in poverty, the undiagnosed health burden faced by these populations from NCDs is likely to be high.

Palliative care is an essential component of NCD care. In 2014, the World Health Assembly adopted a resolution to integrate palliative care into national health policies. Despite this, only half of all countries have integrated palliative care into their NCD policy. Palliative care was consistently recognised as an area of need in each of the SGs partner countries with services in each of the three countries centralised making it hard for those in need to access care. Essential medicines are often unavailable. This is particularly the case for controlled drugs such as morphine containing pain relief. It is documented that only 13% of LICs report general availability of oral morphine^[15]. The Government of Rwanda were particularly keen for the SG to support them in improving access to palliative care at the community level.

In 2011, Rwanda became one of the first countries in Africa to launch a national policy for palliative care. This policy set-out an ambition for high-quality, affordable care at the end-of-life, encompassing physical, psychological, social, and spiritual needs. Subsequent national training programs aimed to address this, and the creation of home-based care practitioners in 2017 marked a significant step towards bringing palliative care closer to communities. However challenges remain, and a shortage of trained staff and increasing burdens on healthcare workers continue to hinder universal access. Recognising this, the Ministry of Health have outlined an ambition to train a new cadre specifically skilled in both non-communicable disease care and home-based palliative care highlights the growing emphasis on community-based approaches.

The Rwandan Ministry of Health have specifically requested support for palliative care - particularly exploring home-based care options. Previously, PEPFAR supported community-based palliative care programs for HIV in Rwanda. With improved HIV treatment and reduced need for palliative care, funding has been discontinued. Ministry of Health officials specifically requested support to re-establish similar community models.

Rwanda has made considerable progress in rolling out PEN and PEN Plus. PEN has is present across much of the country and the Government is prioritising scale up of PEN Plus with their partners. Given the presence of this platform, the Government and partners proposed exploring whether it is able to support provision of community palliative care to those in need.

Alignment with SG strategic commitments and ID principles

The proposed investment of up to £400,000 per annum for up to 3 years with an option of a further year extension, which supports:

• our ongoing commitment to SG’s Vision (2016 Strategy) for its international development investment, that “through embedding the UN Global Goals, Scotland will contribute to sustainable development and the fight against poverty, injustice and inequality internationally”;
• our commitment to equality in our ID Principles, that “We recognise the enduring and intersectional inequalities that exist, and we ensure reducing inequalities is central to how we work. We oppose racism in all its forms and aspire to be anti-racist in our work.”.
• our commitment to inclusion and diversity in our ID Principles, that “We question whose expertise we value, who we listen to and who holds the levers of power. We support new and innovative ways to break down barriers, to harness a diverse range of new voices and new ideas to drive change”;
• our overarching commitment to power equalisation in our programme through alignment with our ID Principles, to equalise power with the Global South, by ensuring that the programme design included participants from the Global South.

In line with SG Ministerial commitments to build a fairer and more sustainable environment, the NCD Health Programme in Rwanda should be designed in a way that minimises emissions, ensures sustainable use of resources (energy, materials, water) wherever possible and aligns with a circular economy approach and supporting our Carbon Management Plan. The Climate Change (Emissions Reduction Targets) (Scotland) Act 2019, which amends the Climate Change (Scotland) Act 2009, enshrined Climate Justice, committing SG’s future Climate Change Plans to have regard for the principles of climate justice. This includes the sharing of expertise and technology, action across low, middle and high-income countries to reduce emissions of greenhouse gases and adapting to the effects of climate change.

The grant holder must seek to align the NCD Health Programme in Rwanda with the Fair Work First criteria.