The Network Survival Method for Estimating Adult Mortality: Evidence From a Survey Experiment in Rwanda.

Adult death rates are a critical indicator of population health and well-being. Wealthy countries have high-quality vital registration systems, but poor countries lack this infrastructure and must rely on estimates that are often problematic. In this article, we introduce the network survival method, a new approach for estimating adult death rates. We derive the precise conditions under which it produces consistent and unbiased estimates. Further, we develop an analytical framework for sensitivity analysis. To assess the performance of the network survival method in a realistic setting, we conducted a nationally representative survey experiment in Rwanda (n = 4,669). Network survival estimates were similar to estimates from other methods, even though the network survival estimates were made with substantially smaller samples and are based entirely on data from Rwanda, with no need for model life tables or pooling of data from other countries. Our analytic results demonstrate that the network survival method has attractive properties, and our empirical results show that this method can be used in countries where reliable estimates of adult death rates are sorely needed

Understanding the Role of Political Commitment and Coherence Across Sectors and Across National and Sub-National Levels in Enabling Improvements in Nutrition in Rwanda

Reducing undernutrition is on the political agendas of many low- and middle-income countries. There is general consensus that to improve nutritional outcomes involves actions across the different sectors that influence both the immediate and underlying determinants of optimal nutrition and an enabling environment to support the political and policy processes. Despite renewed attention over the last 15 years, addressing nutrition in a multisectoral way was previously promoted in the 1970’s but failed to have sustained political commitment due to its organizational complexities to plan and implement strategies across sectors. We conducted an in-depth retrospective case study to understand how Rwanda, a low-income country with high burdens of undernutrition, achieved progress reducing undernutrition and how the country addressed the challenges presented by multisectoral nutrition strategies. We conducted a document review of nutrition and nutrition-related policies and programs since 2000, in-depth interviews with nutrition stakeholders at national (n=32), district (n=38), and community (n=20) levels, and community focus group discussions (n=40) in 10 purposefully selected districts in Rwanda’s five provinces. In each province, we selected one district with decreased stunting (reduced districts) and one where no change or an increase occurred (non-reduced districts) between the two last Rwanda Demographic and Health Surveys (2010 and 2014/15). After 2008, reducing undernutrition became a national priority in rhetoric, policy, and institutionally. Nutrition goals were gradually integrated into different sectoral policies and in national economic development strategies. Political commitment to nutrition was generated across sectors at national level and translated to sub-national levels where, because of the country’s decentralized governance system, mid-level leaders had increasing responsibilities for coordinating and implementing nutrition strategies. Institutional bodies were established to facilitate collaboration across sectors and actors at both the national and sub-national levels. At the sub-national context, we find that capacity in nutrition, nutrition monitoring and evaluation, and the implementation of coherence were reported to be more optimally implemented in the districts that improved stunting compared to the non-reduced districts. The results from this study provide a narrative on how improvements occurred in Rwanda, a better understanding of implementing multisectoral nutrition strategies at the sub-national context, and the perspectives of the mid-level leaders and frontline workers coordinating and implementing multisectoral nutrition programs and services

Translation of Policy for Reducing Undernutrition from National to Sub-national Levels in Rwanda

Understanding how countries improve children’s nutrition can inform policies and contribute to further improvements. We examined the relationship between improvements in nutrition in Rwanda (1992–2017) and political commitment to- and policy coherence in- nutrition. We reviewed nutrition-relevant Rwandan policies and programs (2000–2018) and conducted 90 semi-structured interviews with national (n = 32), mid-level (n = 38), and community (n = 20) nutrition stakeholders and 40 community-level focus group discussions (FGDs). FGDs and sub-national interviews were conducted in ten purposefully selected districts, five each in which stunting decreased (reduced) and increased or stagnated (non-reduced) between the 2010 and 2014/15 Rwanda Demographic and Health Surveys. Analysis consisted of thematic analysis and the assessment of events, policy developments, and strategies that influenced nutrition in Rwanda, including operationalization of political commitment and policy coherence for nutrition. Political and institutional commitment to nutrition increased in Rwanda as evidenced by the adoption of a multisectoral nutrition policy that was reinforced with national and subnational horizontal coordination platforms. These platforms strengthened multisectoral strategies to address nutrition and supported operational and institutional commitment. The role of mid-level actors in nutrition governance increased as responsibilities for planning, implementing, and monitoring nutrition programs were increasingly delegated to sub-national administrative levels. Variations in policy implementation existed between reduced and non-reduced districts. Despite improvements, challenges remained in coordination, financial commitment, and capacity to address, monitor, and evaluate nutrition. Political commitment to- and policy coherence in- nutrition at the national level are important for improving nutrition, and when reinforced institutionally, can be translated to sub-national levels where implementation occurs