Is the bride too beautiful?

1. Is the bride too beautiful? Safe motherhood in rural Rwanda Vikki Chambers Presentation to the Politics and Governance Programme, Overseas Development Institute, London, 6 Oct 2011 v.chambers@odi.org.uk

2. Background to Rwanda research • Research question: what institutional arrangements permit the provision of safe motherhood at the local level in rural Rwanda? • Key components necessary for safe motherhood:physical and financial access to maternal healthcare facilities, ante- and post-natal care, family planning use, medicalised childbirth, efficient transfer between first and second level health care facilities • Scope of fieldwork: Two rural districts (Nyamagabe and Musanze), five months fieldwork in each, team of four researchers (incl. 3 Rwandans) • Research methods: ethnographic techniques (participant and non-participant observation, casual conversations, informal interviews), semi-structured interviews, review of official documents

3. Key results observed • Health infrastructure exists, is well equipped; staffed with professionals; offering full range of maternal health services; • Low MMR - Villagers struggle to recall women who have died in childbirth, no maternal deaths in health centers since 2008 • Households increasingly limiting and spacing family size – condom distribution to young people, vasectomy uptake, contraceptive range equivalent to London (female condoms!), women demand ‘better’ methods with no side effects and change methods • Women and men attend the 1st ANC (and are both tested for HIV) • Real evidence of behaviour change – increase in women giving birth at health centres, TBA no longer practice, shifts in attitude • Local authority staff – no evidence of absenteeism, available

4. Why? “

5. 1. Horizontal coordination - Coherent policy environment • Consistent National/local development objectives - Vision 2020, and MDGs embodied in EDPRS and reflected in DDPs • Coherent policy reforms and strategies, with clear lines of responsibility. There is no passing the buck. • Good coordination and management of development partners: • overlaps are avoided (JADF) • DP interventions plug key resource gaps (i.e. payment of health insurance for indigenes) • Strong political commitment to achieving development objectives and single-mindedness in pushing through necessary policy reforms is key.

6. 2. Vertical coordination – supervisory mechanisms (1) Effective monitoring system ensure professional standards are respected and national policy is implemented. • Health service providers: regular supervision of health facilities/CHWs, quarterly evaluations, staff meetings, regular training • Local authority entities: monthly reporting on imihigo objectives • Users: CHW produce monthly village maternal health reports (2) Consistent incentive structures: • Public sector health workers: performance based financing • Community health workers: incoming-generating co-operatives, financial and non-financial benefits, training opportunities, elite status • Local authority staff: Annual National dialogue, competition for imihigo ranking positions (pride) • Users: enforcement measures (i.e. fines), rewards (i.e. gifts, exoneration of charges), public education to promote behaviour change

7. 3. Collaborative space – bringing actors together • Advisory and oversight committees: which bring together local authorities and health service providers exist and function • i.e. Health committees: monitor maternal health indicators, identify problematic areas and find collaborative ways of addressing them • Collaborative public education • Arena for popular participation • Collective action exists (CHWs, traditional ambulances, mutuelle committees, collective poverty reduction strategies) but impetus for collection action is not bottom-up • Result of top-down state policies in which the state facilitates/motivates collective action within a defined arena (often to address a specific bottleneck) • Genuine attempt to include participatory processes (ubudehe, political democratisation) and with sensitivity to local context (imiryango)

8. So, is the bride too beautiful? (too good to be true) “

9. Is the bride too beautiful? Survey data says no

10. Is the bride too beautiful? Ethnographic data says no • Is the ethnographic data robust? Yes! • Why? • Some reflection on ethnographic techniques: • Facilitates triangulation • Immersion in field provides insights • Injects realism into research