RWANDA PERFORMANCE
BASED SYSTEM: PUBLIC
REFOMS
Dr Claude SEKABARAGA
Ministry of health
June 2008

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

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

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.

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

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.

RWANDA HEALTH SECTOR
PERFORMANCE STATUS

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

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

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

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

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

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
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2
N
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s
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N
PT
PT
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IT
IT
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ith
ith
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49
49
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5
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5-
H
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U
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C
49
H
H
H
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49
49
H
5-
PW
PW
5-
5-
(1
(1
(1
PW
PW
PW

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

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

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

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.

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

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
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
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
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
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.

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

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.