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Presentation on theme: " Is the bride too beautiful? Safe motherhood in rural Rwanda Vikki Chambers Presentation to the Politics and Governance Programme,"— Presentation transcript:

1 Is the bride too beautiful? Safe motherhood in rural Rwanda Vikki Chambers Presentation to the Politics and Governance Programme, Overseas Development Institute, London, 6 Oct 2011

2 Background to Rwanda research Research question: what institutional arrangements permit the provision of safe motherhood at the local level in rural Rwanda? Key components necessary for safe motherhood: physical and financial access to maternal healthcare facilities, ante- and post-natal care, family planning use, medicalised childbirth, efficient transfer between first and second level health care facilities Scope of fieldwork: Two rural districts (Nyamagabe and Musanze), five months fieldwork in each, team of four researchers (incl. 3 Rwandans) Research methods: ethnographic techniques (participant and non- participant observation, casual conversations, informal interviews), semi-structured interviews, review of official documents

3 Key results observed Health infrastructure exists, is well equipped; staffed with professionals; offering full range of maternal health services; Low MMR - Villagers struggle to recall women who have died in childbirth, no maternal deaths in health centers since 2008 Households increasingly limiting and spacing family size – condom distribution to young people, vasectomy uptake, contraceptive range equivalent to London (female condoms!), women demand better methods with no side effects and change methods Women and men attend the 1 st ANC (and are both tested for HIV) Real evidence of behaviour change – increase in women giving birth at health centres, TBA no longer practice, shifts in attitude Local authority staff – no evidence of absenteeism, available

4 Why?

5 1. Horizontal coordination - Coherent policy environment Consistent National/local development objectives - Vision 2020, and MDGs embodied in EDPRS and reflected in DDPs Coherent policy reforms and strategies, with clear lines of responsibility. There is no passing the buck. Good coordination and management of development partners: overlaps are avoided (JADF) DP interventions plug key resource gaps (i.e. payment of health insurance for indigenes) Strong political commitment to achieving development objectives and single-mindedness in pushing through necessary policy reforms is key.

6 2. Vertical coordination – supervisory mechanisms (1) Effective monitoring system ensure professional standards are respected and national policy is implemented. Health service providers: regular supervision of health facilities/CHWs, quarterly evaluations, staff meetings, regular training Local authority entities: monthly reporting on imihigo objectives Users: CHW produce monthly village maternal health reports (2) Consistent incentive structures: Public sector health workers: performance based financing Community health workers: incoming-generating co-operatives, financial and non-financial benefits, training opportunities, elite status Local authority staff: Annual National dialogue, competition for imihigo ranking positions (pride) Users: enforcement measures (i.e. fines), rewards (i.e. gifts, exoneration of charges), public education to promote behaviour change

7 3. Collaborative space – bringing actors together Advisory and oversight committees: which bring together local authorities and health service providers exist and function i.e. Health committees: monitor maternal health indicators, identify problematic areas and find collaborative ways of addressing them Collaborative public education Arena for popular participation Collective action exists (CHWs, traditional ambulances, mutuelle committees, collective poverty reduction strategies) but impetus for collection action is not bottom-up Result of top-down state policies in which the state facilitates/motivates collective action within a defined arena (often to address a specific bottleneck) Genuine attempt to include participatory processes (ubudehe, political democratisation) and with sensitivity to local context (imiryango)

8 So, is the bride too beautiful? (too good to be true)

9 Is the bride too beautiful? Survey data says no Rwanda19922000200520082010MDG MM per 100,0001,071750540383*268 Births at a health facility (%) 2526284569100 Total fertility rate (TFR) Modern contraception prevalence (%) 134102745 % of women receiving: at least one ANC four ANCs 949294 13.3 96 24 99.8 35 * Source HMIS; otherwise DHS

10 Is the bride too beautiful? Ethnographic data says no Is the ethnographic data robust? Yes! Why? Some reflection on ethnographic techniques: Facilitates triangulation Immersion in field provides insights Injects realism into research

11 The Africa Power and Politics Programme is a consortium research programme funded by the UK Department for International Development (DFID) and Irish Aid for the benefit of developing countries.

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