TERMS OF REFERENCE - Job in Rwanda
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Situation Analysis in Gender Equity and Inclusion using The Fred Hollows Foundation’s
GAPSED+ Equity Framework
TERMS OF REFERENCE
1. Relevant Background Information
The Fred Hollows Foundation (The Foundation) is a secular non-profit public health organization based
in Australia, founded in 1992 by eminent eye surgeon Professor Fred Hollows. The Foundation focuses
on strengthening eye health systems and the treatment and prevention of avoidable blindness caused
by Cataract, Trachoma, Diabetic Retinopathy, and Refractive Error. The Foundation operates in more
than 20 countries across Australia, The Pacific, South and South East Asia, and Africa.
The Fred Hollows Foundation (FHF) began working in Rwanda in 2007 in Rubavu district in Western
Province. This followed results of a Rapid Assessment of Avoidable Blindness (RAAB) conducted in
Western province of the country in 2006 which found that 83.9 per cent of people living with blindness
had avoidable causes, primarily cataract. The Fred Hollows Foundation Rwanda (FHFR) works
with the Government of Rwanda in strong partnership through Ministry of Health (MOH), who leads
implementation in 44 district public hospitals, together with the Rwanda International Institute of
Ophthalmology (RIIO), other professional bodies such as Rwanda Ophthalmology Society (ROS),
Rwanda ophthalmic clinician Officers and Cataract Surgeon Society (ROCOCS) and other eye health
stakeholders including CBM, One Sight and Del Vecchio.
FHFR, together with the Government and its partners, have been working closely to implement
national policies and strategies to restore sight and eliminate avoidable blindness in Rwanda by
increasing access to comprehensive eye health services, with a focus on cataract treatment, through
a health system strengthening (HSS) approach for sustainability.
From 2007 to 2013 FHF projects were focused on eye health service delivery in one rural district in the
Western Province. During 2014 – 2016, FHF and other international organizations active in the Eye
Health sector supported the Ministry of Health to expand service delivery to several rural districts of
the country. In 2017, FHF launched the “Rwanda Integrated Eye Health Sector Development (July
2017- December 2021) with the aim being to support government in ensuring good quality eye care
is available to all people as an integral part of the wider health system in Rwanda. With challenges
experienced of inadequate number of ophthalmologists in rural areas, the modality for cataract
services delivery shifted to an outreach approach, delivered in partnership with the Rwanda
Ophthalmology Society (ROS). This saw a significant increase in cataract surgeries.
From 2019 the Foundation approach evolved to working in partnership with the Ministry of Health by
integrating cataract and eye care service indicators into the Performance Based Financing (PBF)
scheme (through the Integrating Eye Health into Rwanda Performance Based Financing (PBF) Project
(July 2019 to June 2023). The Foundation was the pioneer NGO to support this innovative model. The
PBF project is complemented by a health system strengthening (HSS) component to enhance human
resources for eye health, strengthen equity, demand and uptake for eye care services; strengthen
national level supply chain management; build strategic partnerships with key stakeholders for
comprehensive eye health care and undertake critical research to inform eye health programming.
12. Rationale for conducting the Gender Equity and Inclusion Analysis:
The Foundation is committed to ensuring that our programs consider the needs of the poorest and
most marginalised in the places where we work, including the complexities relating to issues of
inequity in access to eye health care and appropriate responses. To fulfil this commitment, we have
adopted the GAPSED+ equity organising framework. GAPSED+ stands for gender, age, place of
residence, socio-economic status, ethnicity/indigeneity/race, disability, or any other factor. The
GAPSED+ organising framework is used to understand who is most marginalised and excluded in terms
of access to eye care and ensure that our work targets the needs and respects the human dignity of
these specific groups and communities. The Foundation is committed to actively engage with those
groups and communities, and their representatives, in decisions about their eye health to support
their empowerment.
This analysis will inform the development of the Health System Strengthening (HSS) project, and it is
also hoped that the findings could inform the PBF project and the Country Strategy, more broadly.
Equity barriers to eye health: Rwanda is one of the few countries where males experience more of
the burden of vision impairment and blindness than females.11 According to the RAAB 2015, the main
barriers to accessing cataract surgeries included: inability to reach the hospital, lack of awareness
that treatment is possible, inability to afford operation (due to lack of Community Based Health
Insurance (CBHI), but also due to additional costs even where one had CBHI). The lack of awareness is
attributed to inadequate community engagement and weak primary eye care
services. Comprehensive eye care services are not adequately available and affordable especially for
people in remote areas of Rwanda. The direct and indirect costs of accessing services are often not
affordable by the poorest and marginalised. People living with disability are not fully integrated, so a
further strategy for inclusion is needed. Also noted were high leakages in the referral system between
the primary eye health system and the secondary and tertiary levels, and lack of a system to track the
referrals. Since July 2019, eye care data has been captured in the national health information system
(HMIS) – a significant step in having single source data. Key challenges remain around the lack of
disaggregated data, particularly by sex and age (which PBF project seeks to address); limited research
to inform eye health; and information flow not clearly defined between levels of service provision.
3. Gender Equity and Inclusion Analysis Objective:
The purpose of this analysis is to gather and analyse data about the barriers faced by disadvantaged
groups in accessing eye care services and propose recommendations to address those barriers and
challenges. The analysis will examine the intersectionality between gender, disability, age, and other
marginalised groups and how these intersections of inequities can create more barriers to accessing
and uptake of eye health services. The analysis will also explore opportunities to integrate eye health
within existing community-based organisation health promotion initiatives, for increased community
engagement and ownership. The findings and recommendations from this study will inform The
Foundation in Rwanda on what interventions and partnerships it would need to forge, to
comprehensively address the barriers and challenges faced by these disadvantaged groups in
accessing eye care services, when designing new eye health projects.
It is envisaged this study will help Rwanda team to:
1. understand the trends of women and men, the elderly and persons with disabilities accessing eye
health services from health facilities from 2016 to December 2021;
2. understand patients’ perceptions on available eyecare service provision and barriers and enabling
factors of accessing the service, their satisfaction with regard to quality and accessibility to the
services.
23. identify the eye health needs and priorities for women and men, the elderly, people with disabilities,
and other disadvantaged groups.
4. identify the areas of greatest need for women and men, the elderly, people with a disability and
other disadvantaged groups and prioritise interventions
5. understand how well these groups are able to utilise the community-based health insurance (CBHI)
to access eye health services
6. understand the proportion of women, men, the elderly, people with disability in the eye health
workforce; and
7. understand the experiences of men and women, the elderly and people with a disability within the
eye health workforce.
8. Define what partnerships to enhance gender equity and disability inclusion in eye health would look
like.
9. Define what success would look like for gender equity and disability inclusion in eye health
10. Determine the key community-based organisations engaged in health promotion activities at
community level; and opportunities to integrate eye health and enhance community engagement in
eye health.
4. Findings Audience and utilization:
The key audience for this gender equity and disability inclusion analysis is the FHF program team, who
will use the findings to further refine the project design of the Health Systems Strengthening project.
In addition, information may also be shared with key partner organisations and where possible be
used to form base line data against which to measure project progress. Key partners will include
Ministry of Health,
Ministry of Gender and Family Promotion, Organizations for people with a Disability and the elderly,
Gender Equity Organisations and other eye health NGOs including CBM, One Sight and Del Vecchio.
5. Information Needs:
To complete the gender and disability analysis information sources will include:
• Review of any past similar analysis to eye health and health more broadly
• 2020 eye health data disaggregated by sex from key eye health stakeholders (private and
government sectors)
• Qualitative information from patients on their experiences disaggregated by gender, disability
and age
• HMIS data from 2016-2021
• Stakeholders’ data or studies on people with a disability, and the elderly access to eye health
(CBM, NUDOR, HelpAge International)
• Information on policies and processes within the eye health workplace regarding gender and
disability
• Data disaggregated by gender and disability on eye health personal at different levels or
cadre’s
• Data disaggregated by gender and disability on who is attending training
• Qualitative information from eye health personal of their experiences within the eye health
workplace
The key questions to be addressed in this study are as follows:
1. What are the different challenges faced by women, men, elderly, people with disability
and other disadvantage groups in accessing eye care services?
32. What are eye health initiatives currently doing to address those challenges? What more
needs to be done?
3. What changes due to COVID-19 have women, men and elderly experienced in eye health
service access & uptake?
4. To what extent has community-based health insurance (CBHI) enabled access to eye
health services for women, men, elderly, people with disability and other disadvantage
groups. What is working well and what are the gaps? What more needs to be done?
5. What actions can eye health programmes implement to address gendered, aging and
disability barriers for patients?
6. What gender discrepancies exist in the eye health workforce and why?
7. Has COVID -19 exacerbated any gender discrepancies in the eye health workforce and
how?
8. How can gender discrepancies in the eye health workforce be mitigated?
9. Who are the gender, disability and aged organisations that we could potentially work with
at local level and other levels?
10. What referrals exists for people who are irreversibly blind? Who are the community
rehabilitation disability services in the areas that the project works in; and which ones
could FHF potentially work with?
11. Which are the key community-based organisations engaged in health promotion activities
at community level? What are the opportunities to engage with community-based
organisations for eye health promotion?
12. How could the health system function more effectively to promote gender and disability
inclusion/ equity in Rwanda?
13. Where do the opportunities or entry points for change exist along the continuum of care
from a supply and demand side perspective?
6. Data Collection Methodologies:
Data sources:
• Primary data from FGDs and KIIs with participants
• Secondary data from HMIS data from partners disaggregated by sex and age; and other
literature as discussed below.
Methods:
QUANTITATIVE DATA – this methodology will provide a baseline understanding of the current climate
around GAPSED+ in Rwanda
Desk Review
Consolidating of existing peer-reviewed, national/regional prevalence and community surveys, grey
literature and other information on barriers to accessing eye care services, including review and
analysis of the 2016-2021 eye health data from HMIS disaggregated by sex and age; and data from
key partners (private and government sectors) and available disability and elderly data. Review of any
past similar analysis to eye health and health more broadly.
The desk review will also review information on policies and processes within the eye health
workplace in regard to gender and disability and review data on eye health personnel at different
4levels or cadre and data on who is attending the residency training started in 2018. Information from
desk review will inform any information gaps.
QUALITATIVE DATA – this research methodology is intended to meet the study objectives by
addressing any information gaps remaining after Desk Review
Focus Group Discussions (FGDs)
FGDs will be conducted with key stakeholders, partners and beneficiaries to gain a deeper
understanding of the equity issues they face. The discussion should be semi-structured and provide a
safe space for participants to provide their perspectives around topics discussed. A guide for FGDs is
provided in the Gender Equity Analysis Toolkit.
Key Informant Interviews (KIIs)
These interviews should be on to one with participants. KIIs will be able to provide more in-depth
qualitative data from people who are ‘experts’ in their field. KIIs for this study can include health care
staff, health offices etc. Generally, interviews are ‘semi-structured’ – that is, they are guided by a set
of questions but allow for probing and exploration where appropriate. A guide on semi-structured KIIs
is provided in the Gender Analysis Toolkit.
Case studies of patients: Potentially ‘walk along’ methodology where researcher meets patient(s) at
home and goes on the journey with them to the health facility and records what they see and what
the patient(s) says. This would be observational
NOTE: The Fred Hollows Foundation understands the research approach will be informed by above
mentioned steps, and particularly the Desk Review and so design may change during this project.
Changes are to be made in consultation with FHF.
Conduct Research: Research undertaken.
a. A.
- Data Collection Plan
Methodology Data Source Participants Other notes
Desk review Secondary Data – HMIS data server
statistical; available
relevant
literature/reports
(qualitative)
FGDs Primary Data • Women from community
• Men from community
• Elderly men and women from community
• Men and women with a disability
• People who have undergone eye
treatment/cataract surgery
KIIs Primary Data • Ophthalmologists from owned Private
owned hospitals,
• Ophthalmologists from Gov-owned
provincial, district hospitals,
• District Health Officers
Case studies of Primary data • Patients screened for cataract (access
patients through health facility records)
57. Data Analysis:
Please refer to the Gender Analysis Rough Guide developed by The Foundation and endorsed by the
International Agency for the Prevention of Blindness (IAPB). This Rough Guide provides detailed
guidance about how to carry out a gender analysis, with much of the guidance being equally applicable
to disability. The Guide includes tips for carrying out interviews, observational investigation, guiding
questions etc. It is recommended this document be referred to at the outset and used during the
duration of the study. Also refer to the Rough Guide to Disability Inclusive Eye Health Programming
developed by The Foundation. The consultant(s) will propose the data analysis plan and software used
to The Foundation to ensure sex disaggregated data of women, men, the elderly, and people with
disabilities is generated answering all research questions above and meet the objectives set.
8. Participants:
Engagement with participants for this study will be conducted in a COVID safe manner which may
include remote data collection and/or virtual interviews, and will include but not limited to:
• Sample eye health facilities (including key eye health personnel)
• Gender and DPO agencies/CBOs/NGOs (gender organisations including Profemmes/Twese
Hamwe, Rwanda Men’s Resource Centre (RWAMREC))
• HelpAge International & in country partners
• Social Protection agencies
• Community members (male and female and elderly)
• Community members (male and female and elderly) who have accessed cataract surgeries
using CBHI
• Community health workers
• MOH (Directorate implementing PBF and National Eye Health strategic plan)
• RIIO, CBM, One Sight etc (need to have specific questions for each NGO/partner based on their
level of engagement around gender and disability inclusion e.g CBM doing a lot on disability
inclusion so questions should be tweaked to take this into consideration)
9. Timeframes, Activities and Deliverables:
Timeline Activities Deliverables
26 November 2021 Terms of Reference for Gender Analysis & Term of Reference & Scope of Work
Inclusion Research Development finalized
29 November -19 Publish EOI. Select consultant/research team Contract for consultants/Research
January, 2022 and preparing paperwork for consultants who institution
conduct the research
Researchers obtain Ethical Clearance Ethical Clearance to conduct research
21 January -2nd
obtained.
February 2022
Researchers undertake Desk review Consolidated report on existing
information/research findings
Research plan with methodology, data
collection tools, and data collection plan.
6Researchers develop and submit plan and Presentation of desktop review and draft
By 2nd February 2022 methodology for the collection of additional of research plan to FHF.
necessary data Completed primary & secondary data
sets
Data collection as per research plan Draft Report of Analysis
14 - 24 February 2022
Research Team prepares 1st Draft Report of
4 March 2022
Analysis detailing key findings implications &
recommendations (an initial presentation by
consultant may be requested by FHF)
14 March 2022 FHF provides feedback to Research Team on Feedback on Draft Report
Draft Report
23 March 2022 Research Team prepares and submits Final Final Report
Report
31 March 2022 Research Team presents findings to FHF and Presentation
FHF partners
10. Ethics approval
It is the responsibility of the research team to gain appropriate ethics approval with support of FHF
for this study.
11. Budget:
Detailed itemised budget to be provided by consultants as part of EOI. Any proposed changes to the
budget would need to be negotiated between Researcher Team and The Foundation.
12. Reporting and Dissemination of Findings:
The Research Team will provide a brief presentation of desk review focused on relevant findings and
identification of gaps. At this presentation, research team will provide a draft of research plan for
primary data collection (specifically research questions, approach, methods and analytical approach)
to FHF.
The Research Team will prepare and share a draft report of key findings of the analysis and
implications for future programming with The Fred Hollows Foundation. FHF may request consultant
to conduct an initial workshop for presentation of findings based on this draft report.
7After the report has been reviewed (and initial workshop held), the Research Team will incorporate
the feedback and prepare final report to be submitted to The Fred Hollows Foundation. Research team
will also submit all data collected to FHF foundation.
Lastly, the Research Team will present the findings to the Fred Hollows Foundation and its Partners in
a dissemination workshop
13.Management team (FHF and Consultant)
Name Responsibility
Moses Munyamahoro Overall project focal person, provide all project information
Country Manager FHF Rwanda and data to the selected consultant, help support organize
meetings and field data collection. Ensure implementation of
the assignment.
Finance and Operations Coordinator Contract management/ Financial and administrative related
functions
Lead Consultant Evaluation Plan development based on data, report and
secondary information shared by FHF Rwanda.
Development of Data collection tools
Data collection, Analysis, Synthesis,
Report writing, reviewing, and finalizing the report
Gender and disability technical Technical support, review evaluation plan, tools, and report.
advisors Guide the consultant about FHF GAPSED framework, ,
guidelines and sharing examples (samples) for effective
completion of GAPSED analysis.
Monitoring & Evaluation Review of data collection tools, study protocol, and final
Coordinator, CSN FHF Rwanda report.
PD Partner, CSN Africa & Middle East Technical Support, review TORs, evaluation plan, data
collection tools and report
14. Consultant Key Selection Criteria:
Essential
• Well experienced in mixed-methods research design, implementation and analysis
(Experience in equity studies, preferred)
• Demonstrated ability to lead consultative stakeholder processes and prepare quality reports
in English
• Strong ability to translate research evidence into programmatic and advocacy
recommendations.
• Understanding of Rwanda and the health system; and ability to work in Rwanda context,
including ability to speak French and English. The consultancy team must also include
Kinyarwanda speakers.
• Research Team are resident in Rwanda
• Able to conduct data collection remotely and/or virtually through local networks or if possible
to travel domestically for data collection. As there are current WHO recommendations and
FHF organisational restrictions limiting international and national travel, we are seeking
proposals that outline innovative and rigorous methodological approached to digital and/or
local data collection to ensure the research is conducted in a COVID-19 safe manner.
• Availability to deliver project from 14th January to March 2022.
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