RWANDA PERFORMANCE BASED SYSTEM: PUBLIC REFOMS

Claude SEKABARAGA, MD, MPH

Director policy, planning and capacity building

Ministry of healthOctober 2008October 2008

OutlineBackground 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

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.

Background

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

HEALTH SYSTEM AND HSSPT

he H

ealt

h S

yste

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Public Health Functions

Infrastructure, human- and material resources, and health care financing

Public Health Services and High Impact Health Interventions

Goal of the Health System

To Guarantee the Wellbeing of the Population

To Guarantee the Wellbeing of the Population

To Ensure and Promote the Health Status of the PopulationTo Ensure and Promote the Health Status of the Population

IMC

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Mala

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Mala

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HIV

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Quality of and Demand for Health Services and Efforts to Control DiseaseQuality of and Demand for Health Services and Efforts to Control Disease

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Infr

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Institutional CapacityInstitutional Capacity

MOH: HRF, OAI

30 DISTRICTS: 39 HD, PD, CDLS, MUTUELLE

416 SECTORS : Health center

15000 AGGLOMERATIONS: 2 Community health workers

FIVE LEVELS

2148 CELLS: Health community post

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

Partnerships between Govt. & Development Partners

Government Ownership & Stewardship

Sector Expenditure Framework

Comprehensive Sector Policy/Strategies

Shared Vision & Priorities

Harmonized

Implementation

MDG’s 5: REDUCTION OF MATERNAL MORTALITY

MDG’s 4: REDUCTION OF CHILD MORTALITY

1/3 in two years

1/3 in two years

Modern contraception prevalence (% 15 -49 year-old women)

13

410

27

70

0

10

20

30

40

50

60

70

80

1990 2000 2005 2008 2015

63% of increase in two years

Births attended by skilled health personnel (% of births)

2631

39

52

95

0

10

20

30

40

50

60

70

80

90

100

1990 2000 2005 2008 2015

25% of increase in two years

C OVE R AGE OF P R E VE NT IVE ME S UR E S (MOS QUIT O-NE T S AND P R E GNANT WOME N T R E AT ME NT

15% 13%17%

0%

54%

24,5%

70%

60%

73,8%

59,9%65%

0%

10%

20%

30%

40%

50%

60%

70%

80%

2005

2007

P roportionnal Malaria morbidity in Health C entres vs Health Utilization R ate

73,570,3

67,4

50,4

37,9

28,4

15

2527,4 29,9

37,8

44,4

71,175

0

10

20

30

40

50

60

70

80

2001 2002 2003 2004 2005 2006 2007

Malaria morbidity Health utilis ation rate

MAL AR IA C AS E F AT AL IT Y R AT E IN H E AL T H C E NT E R

0.3

2

4.6

6.25.7

7.7

10.1

0.6

2.9

5.25.75.8

8.1

9.3

0

5

10

15

2001 2002 2003 2004 2005 2006 2007

Yea rs

Perc

entag

e

Malaria cas e fata lity rate < 5 Malaria cas e fata lity rate

PREGNANT WOMEN TESTED HIV

1147846422

88278

183724

364057

602409

814910

0

100000

200000

300000

400000

500000

600000

700000

800000

900000

1999-2001 2002 2003 2004 2005 2006 2007Période

Wom

en te

sted

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.