Review of progress against JSR2006 recommendations

RWANDA PERFORMANCEBASED SYSTEM: PUBLICREFORMS

Claude SEKABARAGA, MD, MPH

Director policy, planning andcapacity building

Ministry of Health

October 2008October 2008

Outline

Background and vision;

Health sector reforms: Resultsbased interventions,autonomization, decentralization,human resources management

Rwanda is back on track for thehealth MDG’s;



Background

Free care during 40 years.

In 1992, Based on Bamako Initiative,Rwanda introduced communityparticipation for financing andmanagement of health care.

In 2001, utilization of primary health care cutdown to 23% (EICV 1*).

*Households conditions survey

Total supply by financing inputs failed(Deficit of necessary staff, drugs and otherconsumables/quality compromisedseriously). Need of 35-40$ per inhabitant peryear in cash;

Community financing by out of pocket failed(Decrease of utilization of services);

Community participation policy didn't clearlydefine the responsibilities in sharing of thecost of care.

Background

PUBLIC for public risks byprevention and subsidy poorestcategories through Governmentbudget

FAMILIES AND INDIVIDUALS for

individual health risks throughinsurances.

Background

VISION

Investment in strong preventioninterventions of major diseases by publicsubsidies;

Universal access to curative care for allpeople living in Rwanda through universalcoverage of health insurances;

Performance based financing of publichealth facilities to improve demand forprevention services and quality for bothpreventive and curative services.

RWANDA HEALTH SECTORPERFORMANCE STATUS

CHILD MORTALITY CAUSES

HEALTH SYSTEM AND HSSP

The Health System

Public Health Functions

Infrastructure, human-and material resources,and health carefinancing

Public Health Servicesand High Impact HealthInterventions

Goal of the HealthSystem

To Guarantee

the Wellbeing of the Population

To Guarantee

the Wellbeing of the Population

To Ensure and Promote the Health Status of the Population

IMCI

ReproductiveHealth

EPI

Nutrition

Malaria

HIV / AIDS/ STI

Tuberculosis

Epidemicsand Disasters

MentalHealth

Blindness &Phys. Hand.

Environmen-tal Health

IEC / BCC

Health Care Financing

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

Institutional 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 servicesfor territorial administration

Strong political commitment to results

Contract between the President of the Republicand the district mayors and different localadministration levels;

Key health indicators integrated in the contract(in 2008: ITNs, Mutuelles, FP, safe deliveries,hygiene..)

Quarterly review with Prime Minister, Presidentattending twice a year

Performance based financingfor health sector (PBF)

Based on major bottlenecks;

Priority to composite indicators and avoidselective performance;

Quantity preventive interventions and quality ofboth prevention and curative services;

Promotion of local creativity and spirit forperformance;

Improvement of remuneration of personnel andequipment 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, needsbased block grant (initially for wages)

Support to planning: Strategic and operationalplanning are the fundament of the approach.

Health insurances

Strengthening demand for health services bybreaking financial barriers;

Prevention of financial risk as sickness isconsidered as an accident;

Build solidarity by sharing cost of care between allsocial economic categories;

Framework to ensure poor are subsidized toaccess to quality of care and avoid STIGMA andDISCRIMINATION by using supply channel.

Decentralization

Task shifting and community (Village andhouseholds) services ;

Administrative, fiscal and financialdecentralization has provided huge sums ofmoney to local levels of government and giventhem much flexibility by providing them withblock grants;

Community participation in governance andpromotion of quality of services throughcommittees (Health committees, partnership forimproving quality of care).