RWANDA PERFORMANCE BASED SYSTEM: PUBLIC REFORMS

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RWANDA PERFORMANCE BASED SYSTEM PUBLIC REFORMS

• Claude SEKABARAGA, MD, MPH
• Director policy, planning and capacity building
• Ministry of Health

October 2008
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Outline

• Background and vision
• Health sector reforms Results based
  interventions, autonomization, decentralization,
  human resources management
• Rwanda is back on track for the health MDGs

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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

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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.

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Background

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

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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.

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• RWANDA HEALTH SECTOR PERFORMANCE STATUS

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CHILD MORTALITY CAUSES
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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
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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
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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.

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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

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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.

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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.

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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.

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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).

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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.

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THE MAIN BUILDING BLOCKS OF SWAp
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MDGs 5 REDUCTION OF MATERNAL MORTALITY

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MDGs 4 REDUCTION OF CHILD
MORTALITY
1/3 in two years
1/3 in two years
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63 of increase in two years
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25 of increase in two years
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COMMUNITY HEALTH INSURANCE IN RWANDA
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DISTRIBUTION OF HEALTH SECTOR BUDGET
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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.