2. Outline
Background and vision;
Rwanda is back on track for the
health MDG’s;
Health sector reforms: Results
based interventions,
autonomisation, decentralization,
human resources management
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);
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.
8. INFANT MORTALITY (PER 1000)
120
107
100
86
85
80
28% in two
years 62
60
40
28
20
0
1990 2000 2005 2008 2012
9. UNDER FIVE CHILDREN MORTALITY (PER 1000)
250
200 196
152
150 151
33% in
two
103
years
100
50 50
0
1990 2000 2005 2008 2012
10. Modern contraception prevalence (% 15 -49 year-old women)
80
70
70
60
50
40
63% of increase in
30 two years
27
20
13
10
10
4
0
1990 2000 2005 2008 2015
11. Births attended by skilled health personnel (% of births)
100
95
90
80
70 25% of increase in
two years
60
52
50
40 39
31
30
26
20
10
0
1990 2000 2005 2008 2015
12. COMMUNITY HEALTH
INSURANCE IN RWANDA
%
90%
83%
80%
75%
73%
70%
60%
50%
%
44%
40%
30% 27%
20%
10% 7%
0%
2003 2004 2005 2006 2007 2008
13. C O V E R A G E O F P R E V E N T IV E ME S U R E S (MOS QU IT O-
N E T S A N D P R E G N A N T WOME N T R E A T ME N T
2007
80% 73,8%
70%
70% 65%
59,9%
60%
60% 54%
50%
2005
40%
30% 24,5%
17%
20% 15% 13%
10%
0%
0%
N
N
N
TN
2
2
N
N
s
N
N
N
PT
PT
IT
IT
IT
IT
IT
IT
IT
IT
rI
r
er
er
)I
)I
1
t1
ith
ith
de
de
t2
st
nd
nd
yr
yr
)w
w
as
un
un
a
as
)u
)u
49
49
5
le
le
yr
le
U
5
5
yr
yr
5-
5-
H
H
U
U
C
49
H
H
H
(1
(1
C
C
49
49
H
5-
PW
PW
5-
5-
(1
(1
(1
PW
PW
PW
14. P roportionnal Malaria morbidity in Health
C entres vs Health Utilization R ate
80
75
73,5
71,1
70,3
70
67,4
60
50,4
50
44,4
40
37,8 37,9
30 29,9 28,4
27,4
25
20
15
10
0
2001 2002 2003 2004 2005 2006 2007
Malaria morbidity Health utilis ation rate
15. PREGNANT WOMEN TESTED HIV
814910
900000
800000
700000 602409
600000
500000
Women tested
364057
400000
300000
183724
200000
88278
46422
100000 11478
0
Période 1999-2001 2002 2003 2004 2005 2006 2007
18. Public Reforms
•Imihigo: Territorial performance contracts;
•Performance based financing;
•Autonomisation of health facilities;
•Development of health insurances;
•Decentralisation of management of health
personnel including salaries at facility level;
•Sector wide approach for sector coordination.
19. 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 2007: ITNs, Mutuelles, FP, safe deliveries,
hygiene..)
Quartely review with Prime Minister, President
attending twice a year
20. 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.
21. 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.
22. 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.
23. 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).
24. Human resources management
Decentralization of wages;
Facilities have the authority to hire and fire;
Facilities receive block grant from governmental;
“People follow the money”;
Retention of health personnel in rural areas with increased
incentives;
Spectacular results: rural health centers and hospitals are
recruiting large numbers of personnel.
25. THE MAIN BUILDING BLOCKS OF SWAp
H rm iz d
a on e
Im le e t t
p m naion
Se t Ex n it reF m w
c or pe d u ra e ork
Com re e siveSe t Polic / ra gie
p hn c or ySt te s
Sh re Vision&Pr ie
ad iorit s
Pa n rsh s b w e G . &D ve m n Pa n rs
rt e ip et e n ovt e lop e t rt e
G rn e tOw e ip &St w rd ip
ove m n n rsh e a sh
26. Conclusion
BUILDING CULTURE OF RESULTS MORE THAN
PROCEDURES ONLY
For ACCOUNTABILITY financing of providers and
services given to communities must 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.
