Recognizing the close link between good governance and health system strengthening, Rwanda has launched several initiatives to strengthen health governance to date. Government- and nongovernmental organization (NGO)-led programs have been implemented to strengthen the interactions between citizens, health providers, and government agencies. These initiatives range from the Government of Rwanda's (GoR) ambitious and comprehensive decentralization reform to move decision making concerning policy implementation closer to the population, to the use of citizen score cards to make service deliverers more responsive to users. Benchmarking progress made through these reforms, as well as identifying and addressing existing challenges, is essential if Rwanda is to sustain this momentum and further improve health governance in the country. To this end, the Rwandan Ministry of Health (MINISANTE) identified the need for an independent review of the state of health governance in Rwanda. The U.S. Agency for International Development in Rwanda (USAID/Rwanda) convened a team of international and local consultants through the USAID-funded Health Systems 20/20 project to design and implement a health governance assessment. This report presents the team's findings. The goals of the assessment were to document successes, identify persisting challenges, and recommend ways by which health governance in Rwanda could be further strengthened. The report provides an indepth analysis of five themes broken down into two analytic areas:

(1) Governance Analysis of the Rwandan Health System; Processes for health policy and law formulation; Decentralization of policy implementation; Citizen participation in health policy decisions and service delivery.

Although it is possible to discuss separately issues of policy formulation, health system decentralization, and citizen participation in health on a conceptual level, it is difficult to separate these issues on a practical level. Thus, although we provide individual discussions of the three areas, it should be clear that the conceptual framework of co-governance that we have used in our analysis treats these governance issues as integral components of a holistic health system.

(2) Application of a Governance Optic to Ongoing Institutional Reforms; Creation of the Rwanda Biomedical Center (RBC); Reformation of the pharmaceutical supply and management system. As a subset of the broader governance assessment, the team was asked to review and recommend steps to improve the functioning of the newly created RBC and propose reforms related to the Rwandan pharmaceutical system with a special focus on the Centrale d'Achats des Medicaments Essentiels du Rwanda (CAMERWA), the central medical store of Rwanda. Since CAMERWA will become part of the new RBC, the subanalysis will specifically examine the governance arrangements between the two entities and, more generally, the application of good governance practices to the new institution and procurement process...