1. Working in Health: Financing and Managing the Public Sector Health Workforce Chapter 4 – Background Country Study for Rwanda Marko Vujicic, Kelechi Ohiri, Susan Sparkes with Aly Sy The World Bank, Washington, DC

2. Outline  Country macroeconomic and fiscal context  Impact of government wage bill policy on the health workforce Wage bill budgeting process Budget for overall wage bill Budget for health sector wage bill Impact on staffing  Human resource management policies and practices in the health sector Creating funded posts Recruiting health workers Tenure (types of contracts) Paying health workers Transfers Promotions and sanctions  Key Messages

3. Macroeconomic and Fiscal Context  Traditionally the health sector had little control over the wage bill budget and the recruitment process in the public sector.  At the time of the study, reforms were underway to introduction performance- based grants (PBG) to health facilities that are autonomous  Under the new system wages are paid out of block grants provided to facilities Districts have more flexibility in controlling wage bill budgets. Facilities have more control over how they allocate budgets across different line items Facilities manage their own recruitment process Health workers employed by facilities  The reform has been fully rolled out. But at the time of the study: Not all health workers had still not been fully delinked from the civil service PBGs were being used to pay salary top ups, but not salaries of health workers Source: Vujicic, Ohiri and Sparkes (2009), Working in Health: Financing and Managing the Public Sector Health Workforce, Washington, DC: World Bank.

4. Impact of Government Wage Bill Policy on the Health Workforce

5. Wage bill budgeting process 1. A joint review process involving analysis of previous year’s budget execution relative to set objectives for next year. 2. Strategic planning period during which Ministry of Health (MINISANTE) and other ministries prepare strategic issue papers, including provisional MTEFs and earmarked transfers. Ministry of Finance (MINECOFIN) prepares budget framework paper, which is finalized after consultations with ministries. 3. Budget are finalized for each ministry by MINECOFIN. Wage floor for spending in priority sectors, including health and education. MINECOFIN sets limit on government expenditure, and ministries negotiate within overall expenditure constraint. MINECOFIN can place limit on hiring by sector. Source: Vujicic, Ohiri and Sparkes (2009), Working in Health: Financing and Managing the Public Sector Health Workforce, Washington, DC: World Bank.

6. Budget for overall wage bill  2003 – 2005: Cuts in public workforce and decreases in wage bill as share of GDP.  2005 – 2006: Wage bill grew by 15% Public sector salary reform changed the index value from 100 to 250 An incentive package was introduced in 2006  2008: Wage and salaries decentralized from central level to district and facility levels.  2003 – 2009: Government wage bill declined from 20% to 16.1% of government expenditure.  Total recurrent government human resource expenditure includes ALL government salaries and wages. Source: Vujicic, Ohiri and Sparkes (2009), Working in Health: Financing and Managing the Public Sector Health Workforce, Washington, DC: World Bank.

7. Budget for health sector wage bill  2003 – 2007: Increasing prioritization of health within overall wage bill.  2007: IMF PRGF states that spending on health will increase by at least 1.5% of GDP. Increased decentralization of wage bill to provinces and districts.  Funding of HRH: 1. MINISANTE budget 2. MINECOFIN transfers to districts 3. Performance-based grants 4. Local revenue  PBGs used for top-ups do not show up in wage bill. Can comprise up to 86% of health worker salary PBGs reach RF 3,439,221,438 in 2007. At least 25% of PBG has to be committed to nonwage expenditure.  Impact of decentralization In 2006, MINISANTE wage bill was less than half of what it was in 2003. Salaries transfers to public institutions are declining. Performance based pay at provincial and district level is increasing. Source: Vujicic, Ohiri and Sparkes (2009), Working in Health: Financing and Managing the Public Sector Health Workforce, Washington, DC: World Bank.

8. Budget for health sector wage bill Health Spending  2003 – 2006: Health expenditure increasing share of government expenditure.  2006: Dip after sharp increase in 2005. Wages as % of Health Spending  2003 – 2006: Relatively constant except for dip in 2005. Source: Vujicic, Ohiri and Sparkes (2009), Working in Health: Financing and Managing the Public Sector Health Workforce, Washington, DC: World Bank.

9. Impact on staffing Hiring Trends  2003 – 2006: Data is limited but estimates show increasing trend in number of government health workers.  Provides evidence of increased health worker recruitment.  2007: 500 least-qualified health workers dismissed. Budget Execution  2003 – 2006: Unable to fully execute its ordinary budget.  2003 – 2005: Provinces and districts are able to fully execute budget.  2006: Budget execution rate falls dramatically at provincial and district level. May be due in part to decentralization. Source: Vujicic, Ohiri and Sparkes (2009), Working in Health: Financing and Managing the Public Sector Health Workforce, Washington, DC: World Bank.

10. Human Resource Management Policies and Practices in the Health Sector

11. Creating funded posts  Two types of vacancies: 1. Centrally funded positions = civil service and approved during MTEF process. MINECOFIN approves additional wage bill budget, vacancies are created and considered approved. 2. Funded from local resources = Usually short-term and contract-based. Have to be within the establishment. Often paid less than regular wage in hopes of becoming “rationalized” during the next budget cycle. Source: Vujicic, Ohiri and Sparkes (2009), Working in Health: Financing and Managing the Public Sector Health Workforce, Washington, DC: World Bank.

12. Recruiting health workers  Recruitment can only happen if a vacant post exists within organizational structure and has been budgeted for.  Follows civil service process of advertising positions, receiving applications, proceeding to a test, and selecting the best candidate.  For doctors and other high level staff, due to limited supply all available workers are automatically recruited and offered positions.  Entire recruitment process takes 70 days from when a position is advertised to when a health worker can begin work.  Local levels have authority to select, test candidates, and hire lower level staff.  Local authorities circumvent budget constraints by employing lower level health workers on a contractual basis.  6 month probation period. Source: Vujicic, Ohiri and Sparkes (2009), Working in Health: Financing and Managing the Public Sector Health Workforce, Washington, DC: World Bank.

13. Tenure  Managed by two sets of regulation – the Civil Service Commission Regulations (for regular workers) and the Code du Travail (for contractual workers).  Cabinet has authorized the formulation of specific statues to govern health professionals.  Three types of employees – statutory, non-statutory, and contractual (see table)  Introduction of decentralization and PBG - All health workers are considered staff of the government.  Facilities are expected to set performance targets for health workers. Source: Vujicic, Ohiri and Sparkes (2009), Working in Health: Financing and Managing the Public Sector Health Workforce, Washington, DC: World Bank.

14. Remuneration  Salaries attached to specific positions and not to the employee. Every position is evaluated and classified in terms of a set of criteria. Salaries are determined by: An index value Districts = 250 Reference hospitals = 600 Multiplier factor  Allowances Housing allowance and loans to target doctors Only allowances in place = housing and transport Intent to introduce allowances based on location, but not currently in place. Decreasing share of total remuneration. Source: Vujicic, Ohiri and Sparkes (2009), Working in Health: Financing and Managing the Public Sector Health Workforce, Washington, DC: World Bank.

15. Transfers  Transfers 83% of health workers are posted in urban areas. Differences in earning potential Access to opportunities and social services Incentive structures and system of transfers do not address geographic inequities. Incentive packages for doctors posted to rural areas has been introduced. Before 2008, government makes automatic transfer to health workers, regardless of where he or she works. January 2008 reforms stopped this practice. Transfers are now only allowed if a vacant and funded post exists. Salary follows the post.

16. Promotion and Sanctioning  Promotion Supposed to be based on performance evaluation. In practice not strictly adhered to. Follow civil service statutes. Contingent on an annual evaluation by supervisor. 2008: Decentralization of some management responsibilities.  Termination and Sanctioning Two types of disciplinary sanctions: First degree = Imposed by competent authority (eg. Management of the health facility) Second degree = Requires consultation with Civil Service Commission No performance evaluations are consistently performed Source: Vujicic, Ohiri and Sparkes (2009), Working in Health: Financing and Managing the Public Sector Health Workforce, Washington, DC: World Bank.

17. Key Messages  Despite the relative contraction of the public sector wage bill, Rwanda has not only protected the health sector, but also succeeded through decentralization and the introduction of performance-based financing in linking salaries to performance in the health sector.  Within a shrinking public sector wage bill, the health sector has been effectively protected.  The decentralization of budgets, along with the implementation of the PBGs scheme, has had positive effects.  Public sector management capacity could be strengthened.  The health wage bill budget execution rate has not been satisfactory.  Recently, salaries have been attached to specific positions instead of the employee.  The share of allowances as a proportion of the total remuneration has decreased over the years.  Donor funding in the health sector is significant and could be better coordinated. Source: Vujicic, Ohiri and Sparkes (2009), Working in Health: Financing and Managing the Public Sector Health Workforce, Washington, DC: World Bank.