Introduction

The Fred Hollows Foundation (The Foundation) is a secular non-profit public health organisation based in Australia, which was 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. It operates in more than 20 countries across Australia, The Pacific, South and South-East Asia, and Africa. The Foundation was named The Australian Charity of the Year 2013 at the inaugural Australian Charity Awards.

Since 2006, The Fred Hollows Foundation (FHF) has partnered with Rwanda’s Ministry of Health to deliver eye care services. Initially focused on rural districts in Western Province (Zones 5 and 6), FHF expanded its reach between 2013–2016 to cover 22 public hospitals nationwide. This expansion included integration with primary eye care, specialist upgrades, surgical outreach, optometry development, and ophthalmology scholarships.

In 2017, FHF launched the Rwanda Integrated Eye Health Sector Development (RIEHSD) project (2017–2021) to support improved cataract surgical output and integration into the national health system. From July 2019, the service delivery component transitioned into Rwanda’s Performance-Based Financing (PBF) model.

There was recognition that though PBF would lead to a few health systems reforms, it would not of itself robustly address all the systemic bottlenecks affecting eye health service delivery in Rwanda. To address these systemic gaps, FHF initiated the complementary Strengthening Systems for Eye Health in Rwanda project (2023–2027), combining supply and demand side interventions. 

Project background

The project is designed to address systemic gaps in Rwanda’s eye health sector identified in FHF’s strategy. It complements the Performance-Based Financing (PBF) initiative by using a Health Systems Strengthening (HSS) approach to improve efficiency and sustainability. Key goals include increasing the number of skilled eye health professionals (especially ophthalmologists), raising the cataract surgical rate, and enhancing surgical quality.

The project strengthens leadership, coordination, and supply chain systems, while addressing shortages in equipment, consumables, and maintenance expertise. It also tackles gaps in evidence and research for eye health programming. Strategic partnerships with RIIO, ROS, CBM, OneSight, National NGOs/CBOs and others are central to achieving inclusive and equitable outcomes, especially for women, men, persons with disability and other vulnerable groups.

Operating across all 30 districts and the national Ministry of Health, the project has aimed to build a sustainable foundation for long-term eye health improvements through policy support and coordinated action.

This project is supported by funding from The Fred Hollows Foundation and the Australian Government’s Department of Foreign Affairs and Trade (DFAT). The Fred Hollows Foundation gratefully acknowledges the support from the Australian Government through the Australian NGO Cooperation Program (ANCP).

Expected Outcomes and Outputs

This project intends to achieve the following outcomes and outputs.

Outcome 1: Strengthened eye health leadership and coordination at the district and national levels to drive effective eye health planning and budgeting.

• Output 1.1 Strengthened coordination between govt, NGO and private stakeholders towards realisation of the outcomes and targets in National Strategic Plan for Eye Health 
• Output 1.2 Evidence from Cataract Surgical Business Case informs amount of CBHI reimbursement for cataract surgeries
• Output 1.3 Robust systems established to ensure eye health still functioning through PBF model following conclusion of the PBF project.

Outcome 2:Human resources for eye health are trained, well equipped for productivity and quality, and appropriately deployed for effectiveness in service delivery.

• Output 2.1: Capacity of cataract surgical teams is strengthened and functioning optimally at hospital level.
• Output 2.2: Resident in ophthalmology students is trained and posted to target hospitals to effectively provide ophthalmic services including cataract management.
• Output 2.3: Systems and processes for cataract surgical quality assurance are established and institutionalized (including advocacy for productivity and quality in training)
• Output 2.4: Human resources for eye health planning for effective deployment and retention of skilled eye health workers is in place.

Outcome 3:A strengthened, reliable and sustainable supply chain for eye health commodities and equipment is functioning optimally and independently procuring eye care equipment and consumables.

• Output 3.1: Output 3.1 Rwanda Medical Supply (RMS) independently coordinates, procures and ensures availability of eye care equipment and consumables to all public hospitals
• Output 3.2 Public hospitals are procuring eye health commodities from RMS.
• Output 3.3 Cataract surgical equipment and consumables are provided to select public hospitals 
• Output 3.4: Eye care equipment maintenance and repair capacities is increased

Outcome 4. Planning and monitoring systems for eye health resourcing are routinised and used in decision making.

• Output 4.1: Accurate and reliable eye health data is available from the national HMIS and PBF systems and utilized by eye health decision-makers at national and local levels.
• Output 4.2: Evidence of eye health monitoring are generated at the national and district level
• Output 4.3: Robust monitoring, evaluation and research systems is in place and findings inform improved eye health programming. 

Outcome 5:Increased equitable demand for engagement with and accountability in eye health services is generated.

• Output 5.1 Gender and disability analysis, on access to eye care services conducted, and findings inform programming.
• Output 5.2: Improved knowledge of service providers in gender equity for sustainable eye health services
• Output 5.3: Gender and disability are mainstreamed to increase access to eye health for persons with disability
• Output 5.4 Community members are aware of eye health and the benefits of CBHI and actively seek services.

Outcome 6: A public private partnership model is established for increased access to quality eye health services to the last mile.

• Output 6.1: Scoping for eye care delivery model, through adoption of government hospital by RIIO is carried out.
• Output 6.2: Support for newly posted ophthalmologists is continued through ROS to enhance skills for quality surgeries.
• Output 6.3: Partnership established with private sector for reduced cataract backlog.

Project partners

Purpose of the evaluation

The overall objective of this mid-term review (MTR) is to identify the key successes and challenges in project implementation to date, identify factors which have contributed to the project successes, and areas of weakness that have impeded progress. The findings of the review will be provided to the Foundation’s Rwanda Team, Program Division and Ministry of Health in Rwanda, with recommendations to all stakeholders on addressing identified challenges and inform ongoing project plans and practices. This may include recommendations on variations to project design in order to improve delivery for the remainder of the project, to be discussed with the donor and implementing partners

The primary intended users of the mid-term evaluation will be; 

• FHF Rwanda Team
• Rwanda MoH
• Rwanda Ophthalmology Society (ROS)
• Rwanda International Institute for Ophthalmology
• Relevant eye health NGOs

These teams are involved in program implementation either directly or indirectly by providing support and guidance. Equally, the evaluation will also be of relevance to the following secondary users

• International eye health sector NGOs 
• The Australian Department of Foreign Affairs and Trade (DFAT/ANCP).

Evaluation scope and key questions

HSS is a national health systems initiative designed to deliver outcomes across all 30 districts. As part of the program, an 'Accelerate a Clinic' pilot is being implemented to strengthen the capacity of four district hospitals to increase cataract surgeries, aligned with the cataract business case. This evaluation will assess progress across the six defined program outcomes. The following indicative evaluation questions will guide the assessment. However, the consultant is encouraged to expand or adapt the questions as needed to ensure a comprehensive and contextually relevant evaluation.

Relevance

• To what extent are the six program outcomes and associated strategies aligned with the key barriers to eye health service delivery in Rwanda?
• Are there additional outcomes or strategic priorities that have emerged and should be considered during the remaining period of the project to enhance its relevance and impact?

Effectiveness

• What progress has been made toward achieving each of the six program outcomes and outputs?
• To what extent has the program achieved its key performance targets for both quantitative and qualitative indicators?
• What challenges have impeded progress for each of the six program outcomes? 
• How effectively have the project interventions improved the capacity, quality, and accessibility of eye health services?
• How well have the project’s systems and processes contributed to sustained improvements in planning, monitoring, and decision-making for eye health?

Efficiency

• Did the project leverage existing systems, structures, and partnerships to maximize value and minimize duplication? 
• How efficiently are project resources and systems being mobilized and coordinated across national, district, and facility levels to deliver planned eye health outcomes?

Equity

• To what extent have gender and disability analyses and partnerships informed the design and delivery of more equitable eye health services? 
• How aware are community members, particularly women, persons with disabilities, and marginalized groups of eye health services, and to what extent are they actively seeking and accessing these services? 
• How effective and sustainable is the public–private partnership model in increasing last-mile access to quality eye health services, including reducing cataract backlog?
• How well have district hospitals and the Ministry of Health integrated strategies to ensure equity and inclusion in service delivery?

Sustainability

• To what extent have the key project partners demonstrated ownership of each of the project outcomes and a commitment to sustaining project outcomes beyond the life of the project?
• How effectively is eye health integrated into the existing health system to support long-term sustainability?
• To what extent have financial and institutional mechanisms been strengthened to ensure sustained investment in eye health services (e.g. Community-Based Health Insurance [CBHI], Performance-Based Financing [PBF] etc

New insights

• What barriers (hospital and patient) havehinderedpatients diagnosed with cataracts from undergoing timely surgical intervention? Which of these barriers rank high?

Approach

FHF Rwanda will recruit a research consultant/institution to conduct the mid-term evaluation. The selected evaluation consultant will be required to prepare detailed evaluation methodology in collaboration with FHF Rwanda and head office team. The consultant will be required to propose the right methodology for the evaluation but at the minimum the chosen methodology should be broad enough to accommodate both quantitative and qualitative methods. 

Specifically, Information to answer the evaluation questions will be gathered through the following processes: 

1. Review of recent research reports including HSS baseline evaluation, Cataract Business Case, Gender Equity and Inclusion Analysis, PBF Mid-term Evaluation. 
2. Focus group discussion with project beneficiaries. 
3. Key informant interviews with implementing partners, MOH, eye health service providers and stakeholders.
4. Review of Health Information Management System.

Deliverables 

The following deliverables are expected from the consultant in completing the assignment:

• • Evaluation/Inception Plan and methodology, including timelines.
  • Evaluation ethics review and approval
  • Completed data collection tools in line with evaluation questions.
  • Presentation and validation of preliminary findings
  • Draft and final evaluation reports using the recommended report template
  • Summarized slide decks for dissemination of findings among project partners.

• The Foundation shall require all raw data collected/generated during the evaluation provided in an agreed format. A backup of raw data shall be provided on a format accessible to The Foundation.

The Foundation will provide the following:

• Focal person to support in undertaking the assignment.
• Provide required template and documents required for desk review.
• Give feedback on the evaluation plan and methodology.
• Provide feedback on draft data collection tools, reports, and other deliverables.
• Support coordination between the consultant and partners during the entire evaluation activities.

Schedule

The mid-term evaluation is expected to start in November 2025 for an estimated duration of 90 working days. This will include desk reviews, fieldwork, interviews, and report writing and final presentation to FHF. The evaluation is scheduled to take place between October 2025 to February 2026 as the indicative schedule.

Evaluation team & qualifications

This evaluation will be contracted to an independent evaluator or team who will work closely with The Foundation staff in the design and implementation of the evaluation. The Foundation seeks to engage the services of an independent individual or registered organization, that have the following experiences and expertise in project/program evaluation.

• At least a master’s degree in medicine, Public Health, Ophthalmology, or related health sciences.
• Demonstrable experience in evaluation of public health programs including health systems assessments.
• Experience in development and use of quantitative and qualitative data collection tools and evaluation methods
• Strong knowledge and experience working with the Rwandan health care systems and overall understanding of Rwandan health sector policies.
• Strong analytical skills
• Excellent spoken and written communication skills in English.

Management and logistics

This evaluation is being commissioned by The Fred Hollows Foundation Rwanda. The Rwanda program team will work closely with selected consultant (s).

Individual or institutions interested should submit a cover letter, resume, technical and financial proposals to The Foundation office in Rwanda by 13th November 2025. Please reference “Consultancy to Conduct Mid Term Evaluation for Rwanda Health Systems Strengthening Project” and send to the following address: rwanda@hollows.org.  Only submissions with complete documents as stated in the TOR and those meeting minimum requirements will be considered. Qualified consultants may be subjected to a background check on child protection as a condition for engagement.

Confidentiality

The consultant (s) agree to not divulge confidential information to any person for any reason during or after completion of this contract with The Foundation. Upon completion or termination of this contract, the consultant (s) undertake to return to The Foundation any materials, files or property in their possession that relate to the work of The Foundation. The consultant will be responsible for safety, security and administration of primary and secondary data collected from FHF or otherwise. 

Intellectual Property

All intellectual property and/or copyright material produced by the evaluator/s whilst under contract to The Foundation remain the property of The Foundation and will not be shared with third parties without the express permission of The Foundation. The evaluator/s are required to surrender any copyright material created during the term of the contract to The Foundation upon completion or termination of the contract. 

Safeguarding People 

The Fred Hollows Foundation is committed to ensuring that its activities are implemented in a safe and productive environment which prevents harm and avoids negative impacts on the health and safety of all people, particularly children, vulnerable people, and disadvantaged groups. The Foundation has a zero-tolerance approach to sexual exploitation, abuse, and harassment of any kind. All personnel including contractors/consultants are expected to uphold and promote high standards of professional conduct in line with The Foundation’s Safeguarding People Policy including Code of Conduct. Contractors/consultants will be expected to sign and adhere to The Foundation’s Safeguarding Code of Conduct and provide any background checks as required.

INSURANCE

Any consultants involved in this evaluation will be required to have in place insurance arrangements appropriate to provision of the requirements in this Terms of Reference including travel insurance. 

Ethical and other Considerations 

The evaluator and evaluation team are expected to maintain high professional and ethical standards and comply with The Foundation’s Research and Evaluation Policy. The Foundation is committed to ensuring a safe environment and culture for all people, including children, with whom we come in contact during our work. This evaluation will be subject to an appropriate ethics review and approval process, in accordance with the level of risk identified in the research and evaluation policy. All members of the evaluation team will be required to comply with The Foundation’s Safeguarding People Policy and sign the Safeguarding Code of Conduct.