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

2. 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;

3. 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

4. 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.

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

6. 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.

7. RWANDA HEALTH SECTOR PERFORMANCE STATUS

9. CHILD MORTALITY CAUSES

10. 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

11. 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

12. 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.

13. 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

14. 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.

15. 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.

16. 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.

17. 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).

18. 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.

19. 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

20. MDG’s 5: REDUCTION OF MATERNAL MORTALITY

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

22. 63% of increase in two years

23. 25% of increase in two years

29. 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

30. COMMUNITY HEALTH INSURANCE IN RWANDA

31. DISTRIBUTION OF HEALTH SECTOR BUDGET

32. 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.