RWANDA PERFORMANCE BASED SYSTEM: PUBLIC REFOMS Claude SEKABARAGA, MD, MPH Director policy, planning and capacity building Ministry of health October 2008

Outline Background and vision; Health sector reforms: Results based interventions, autonomization, decentralization, human resources management Rwanda is back on track for the health MDG’s;

Background Free care during 40 years. In 1992, Based on Bamako Initiative, Rwanda introduced community participation for financing and management of health care. In 2001, utilization of primary health care cut down to 23% (EICV 1*). *Households conditions survey

Background Total supply by financing inputs failed (Deficit of necessary staff, drugs and other consumables/quality compromised seriously). Need of 35-40$ per inhabitant per year in cash; Community financing by out of pocket failed (Decrease of utilization of services); Community participation policy didn't clearly define the responsibilities in sharing of the cost of care.

Background PUBLIC for public risks by prevention and subsidy poorest categories through Government budget FAMILIES AND INDIVIDUALS for individual health risks through insurances.

VISION Investment in strong prevention interventions of major diseases by public subsidies; Universal access to curative care for all people living in Rwanda through universal coverage of health insurances; Performance based financing of public health facilities to improve demand for prevention services and quality for both preventive and curative services.

RWANDA HEALTH SECTOR PERFORMANCE STATUS

CHILD MORTALITY CAUSES

the Wellbeing of the Population HEALTH SYSTEM AND HSSP To Guarantee the Wellbeing of the Population Goal of the Health System To Ensure and Promote the Health Status of the Population IMCI Reproductive Health EPI Nutrition Malaria HIV / AIDS / STI Tuberculosis Epidemics and Disasters Mental Health Blindness & Phys. Hand. Environmen-tal Health IEC / BCC Public Health Services and High Impact Health Interventions Quality of and Demand for Health Services and Efforts to Control Disease Human Resource Development Drugs, Vaccines and Consumables Infrastructure, Equipment & Laboratory Network National Referral Hospitals & Treatment and Research Centres The Health System Infrastructure, human- and material resources, and health care financing Health Care Financing Public Health Functions Institutional Capacity

FIVE LEVELS MOH: HRF, OAI 30 DISTRICTS: 39 HD, PD, CDLS, MUTUELLE 416 SECTORS : Health center 2148 CELLS: Health community post 15000 AGGLOMERATIONS: 2 Community health workers

Public Reforms Imihigo: Territorial administration performance contracts; Performance based financing; Autonomization of health facilities; Development of health insurances; Decentralization of management of health personnel including salaries at facility level; Sector wide approach for sector coordination.

IMIHIGO: Performance based services for territorial administration Strong political commitment to results Contract between the President of the Republic and the district mayors and different local administration levels; Key health indicators integrated in the contract (in 2008: ITNs, Mutuelles, FP, safe deliveries, hygiene..) Quarterly review with Prime Minister, President attending twice a year

Performance based financing for health sector (PBF) Based on major bottlenecks; Priority to composite indicators and avoid selective performance; Quantity preventive interventions and quality of both prevention and curative services; Promotion of local creativity and spirit for performance; Improvement of remuneration of personnel and equipment linked to services to community: ACCOUNTABILITY.

Autonomization Based on Bamako Initiative Delegation of management Health centers and hospitals fully autonomous Subsidized by the government: PBF, needs based block grant (initially for wages) Support to planning: Strategic and operational planning are the fundament of the approach.

Health insurances Strengthening demand for health services by breaking financial barriers; Prevention of financial risk as sickness is considered as an accident; Build solidarity by sharing cost of care between all social economic categories; Framework to ensure poor are subsidized to access to quality of care and avoid STIGMA and DISCRIMINATION by using supply channel.

Decentralization Task shifting and community (Village and households) services ; Administrative, fiscal and financial decentralization has provided huge sums of money to local levels of government and given them much flexibility by providing them with block grants; Community participation in governance and promotion of quality of services through committees (Health committees, partnership for improving quality of care).

Human resources management Decentralization of wages; Community through facility committee have the authority to hire and fire; Community through facilities receive block grant from government; “People follow the money”; Retention of health personnel in rural areas increased; Spectacular results rural health centers and hospitals recruited more personnel, including Doctors.

THE MAIN BUILDING BLOCKS OF SWAp These are the fundamental building blocks of a swap. Government ownership Partnership formalised through Memorandum of Understanding Shared visions and priorities- the participatory process of developing HSSP and EDPRS Comprehensive sector policies – EDPRS, HSP, HSSP Sector Expenditure Framework – Existing MTEF, need to build a joint action plan Harmonised implementation – we are not yet fully at this level

MDG’s 5: REDUCTION OF MATERNAL MORTALITY

MDG’s 4: REDUCTION OF CHILD MORTALITY 1/3 in two years 1/3 in two years

63% of increase in two years

25% of increase in two years

TUBECULOSIS PREVALENCE IN SUSPECT CASES - 10 000 20 000 30 000 40 000 50 000 60 000 70 000 80 000 0,0% 2,0% 4,0% 6,0% 8,0% 10,0% 12,0% 14,0% 16,0% Suspect number 28 637 45 075 67 350 Positive case rate 13,7% 11,3% 6,6% 2005 2006 2007

COMMUNITY HEALTH INSURANCE IN RWANDA

DISTRIBUTION OF HEALTH SECTOR BUDGET

Conclusion BUILDING CULTURE OF RESULTS MORE THAN PROCEDURES ONLY For ACCOUNTABILITY financing of providers and services given to communities must be very clear; Ensure complementarily of health financing: Input, output and demand based for TOTAL COVER OF HEALTH SERVICES COST. Ensure efficiency of health financing and quality of health services by developing health financing policy and monitoring and evaluation tools.