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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. Outline. Background and vision;

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rwanda performance based system public reforms

RWANDA PERFORMANCE BASED SYSTEM: PUBLIC REFORMS

Claude SEKABARAGA, MD, MPH

Director policy, planning and capacity building

Ministry of Health

October 2008

outline
Outline
  • Background and vision;
  • Health sector reforms: Results based interventions, autonomization, decentralization, human resources management
  • Rwanda is back on track for the health MDG’s;
background
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

background1
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.
background2
Background
  • PUBLIC for public risks by prevention and subsidy poorest categories through Government budget
  • FAMILIES AND INDIVIDUALS for

individual health risks through insurances.

vision
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.
health system and hssp
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

five levels
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

public reforms

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
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
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
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
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
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
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.
mdg s 4 reduction of child mortality
MDG’s 4: REDUCTION OF CHILD MORTALITY

1/3 in two years

1/3 in two years

slide29

TUBECULOSIS PREVALENCE IN SUSPECT CASES

80 000

16,0%

70 000

14,0%

60 000

12,0%

50 000

10,0%

40 000

8,0%

30 000

6,0%

20 000

4,0%

10 000

2,0%

-

0,0%

2005

2006

2007

28 637

45 075

67 350

Suspect number

13,7%

11,3%

6,6%

Positive case rate

conclusion
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.