This document summarizes a presentation on a case study of maternal health in rural Rwanda. The presentation discusses:
- Research conducted in two rural districts over 5 months using ethnographic techniques and interviews.
- Key assumptions about components of safe motherhood that were examined.
- Results showing that Rwanda has low maternal mortality, no recorded deaths since 2008, widespread family planning use, and most births occurring in health centers.
- Quantitative data demonstrating improvements in maternal and reproductive health indicators from 1992 to 2010.
- Factors contributing to Rwanda's success, including coherent policies, effective monitoring and incentives, and collaborative problem-solving between local actors and the state.
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Vikki Chambers: New Approaches to Maternal Mortality In Africa
1. Safe motherhood:
A case study of rural Rwanda
Vikki Chambers
Overseas Development Institute
Presentation for New Approaches to Maternal
Health conference, Cambridge University,
3 July 2012
v.chambers@odi.org.uk
www.institutions-africa.org
2. APPP local governance research
Research question: What sorts of governance arrangements enable
a ‘better’ provision of public goods (enabling key bottlenecks to be
tackled) in sub-Saharan Africa?
Public goods: Water and sanitation, facilitation of markets, public
security and maternal health
In-depth country studies
− Multiple case studies: Malawi, Niger, Rwanda, and Uganda
− Single case studies: Ghana, Sierra Leone, Senegal, and Tanzania
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3. Methods and approach
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.
Assumptions about key components of safe motherhood:
physical and financial access to maternal healthcare facilities, ante-
and post-natal care, family planning use, assisted childbirth, efficient
transfer between first and second level health care facilities.
Bottlenecks taken as entry point.
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5. Rwanda maternal health: observed results 1
Health infrastructure exist, are reasonably well equipped and staffed
with professionals and offer full range of maternal health services.
Community health workers in every village.
Low MMR - Villagers struggle to recall women who have died in
childbirth, no recorded maternal deaths in health centers since 2008
Households are increasingly limiting
and spacing family size - condom
distribution to young people,
vasectomy uptake, contraceptive
range equivalent to London (female
condoms!), women demand ‘better’
Family planning methods available to women at Bisate health
centre, Musanze district
methods with no side effects and
change methods.
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6. Rwanda maternal health: observed results 2
Women give birth at health centres.
Many use waiting facilities to avoid
accidental home births. No
evidence of ‘TBAs’ practicing.
Women using the maternity waiting facilities at Jenda
health centre, Nyamagabe district
Women and men attend the 1st ANC. Both
are tested for HIV. HIV+ women are
integrated into PMTCT programmes.
Local authority staff – no evidence of Men and women attending the maternity wing of
absenteeism, contactable Kinigi health centre, Musanze district
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7. Quantitative data
Rwanda 1992 2000 2005 2008 2010 MDG
MM per 100,000 1,071 750 540 476 268
Births at a health facility (%) 25 26 28 45 69 100
Total fertility rate (TFR) 6.2 5.8 6.0 5.5 4.6
Modern contraception 13 7 10 24 45
prevalence (%)
% of women receiving:
at least one ANC 94 92 94 96 99.8
four ANCs 13.3 24 35
* Source Demographic Health Surveys
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8. How have bottlenecks been overcome?
The coherence of the policy environment at all levels.
Consistent national/local development objectives
Coherent policy reforms accompanied by the strategies necessary for
implementation, with clear lines of responsibility.
Effective coordination and management of development partners
avoids overlaps ensuring that interventions plug real resources gaps.
Political commitment in pushing reforms through has been key
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9. How have bottlenecks been overcome?
Performance disciplines exist and function to ensure professional
standards are respected and that policy is implemented
Regular and effective supervision and monitoring of all actors (health
providers are evaluated, imihigo objectives and reporting for local
officials, CHW monthly reports). Upward accountability
The incentive structures
(rewards/sanctions) faced by different
actors, at all levels, are consistent.
(PBF, CHW cooperatives, imihigo
rankings, user enforcement measures
i.e. fines/public education).
There are real consequences for poor performance
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10. How have bottlenecks been overcome?
Collaborative space for local actors exists and is
facilitated/encouraged by the state
Advisory and oversight committees exist (i.e.
health committees, collaborative public
education campaigns).
Local population are involved in collective
action activities (CHW, traditional ambulances,
mutuelle committees, poverty reduction
strategies, CHW).
State has facilitated local problem-solving
initiatives (particularly those which address
specific bottlenecks). Feedback
mechanisms exist so that lesson-learning
feeds back into policy.
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11. Quantitative outcomes compared - 1
Maternal mortality ratios (MMR)
Malawi: Reduction in the MMR only
just recover losses in 1990s
Niger: Almost no progress in MMR
since 1992
Uganda: Modest decrease in MMR
Rwanda: Consistently falling MMR
Health centre deliveries
Malawi: significant increase since 2000
Niger: slight reduction since 1998
Uganda: only a very small increase
since 1995
Rwanda: spectacular improvement
since 2005
Source: Computed from Demographic and Health Survey data, various years. www.institutions-africa.org
12. Quantitative outcomes compared - 2
Contraceptive use
Malawi: Consistent increases since the early
90s with a slow-down in the early 2000s
Niger: Consistent but small increase over time
Uganda: Sharp increase between 1995 and
2000, followed by a reduction
Rwanda: Decrease post-1992, followed by
consistent and drastic increase post-2005
Ante-natal visits (4)
Malawi: almost consistent decrease
since high levels in the 1990s
Niger: small but consistent increase
Uganda: stagnating use with a small
dip in 2000
Rwanda: important increase since
2005
Source: Computed from Demographic and Health Survey data, various years. www.institutions-africa.org
13. Similarities
Similarities:
− General resource scarcity
− Cost recovery in the 1990s with recent shift towards some form of
user fee exemption.
− Health service delivery decentralised to local level
So what explains the difference?
Levels of health expenditure appear to indicate a relationship
between health expenditure per capita and maternal health outcomes
but this is not sufficient.
− Uganda has seen the greatest increase with little improvement in
outcomes.
APPP research indicates that the extent to which countries have
overcome particular bottlenecks can explain many of these
differences. www.institutions-africa.org
14. Common obstacles (bottlenecks) to safe
motherhood
Local choices about health-care (=delays in seeking medical
assistance)
Lack of accessible health infrastructure and failings in emergency
evacuation procedures (=delays in transferring women to adequate
health care facilities)
Shortage of trained staff, stock-outs of blood/medicine, low staff
morale and keeping of professional standards (=shortcomings in
quality of care
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15. Observed differences (in addressing bottlenecks)
Use of modern services :
− Uganda: uptake of maternal health services appears nominal.
− Banning of TBAs in Malawi, Niger and Uganda has not been
effective.
− Rwanda: evidence of real behavioural change due to effective
public education campaigns supported by enforcement.
Timely transfers:
− Niger: Ambulances exist but fuel expenses are prohibitive
− Rwanda: community health insurance has increased financial
accessibility; ‘waiting rooms’ help prevent accidental home births.
Better quality care:
− Uganda: Staff absenteeism; health centres don’t respect hours
− Malawi: Severe overcrowding; low staff morale affects service
− Niger: poorly trained staff, demeaning treatment of www.institutions-africa.org
patients
16. Lessons from Rwanda
Focusing on material resources alone can ignore the potential of
institutional factors to overcome service-delivery blockages in
resource-constrained environments.
Addressing key service-delivery bottlenecks is not just about ‘supply’
and ‘demand’ but the interaction between the two. Top-down policy
drive and grass-roots engagement have both been crucial.
Collaborative spaces in which actors come together can provide key
arenas in which service delivery bottlenecks can be overcome.
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17. Africa
power and
politics
The Africa Power and Politics Programme is
a consortium research programme funded
by the UK Department for International
Development (DFID) and Irish Aid for the
benefit of developing countries.
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Editor's Notes
This research was part of the APPP research
This research was part of the APPP research
Background to research. APPP, LL research stream. 11 months ethonographic fieldwork in Nyamagabe (south-west) and Musanze (north-west).
In Rwanda health infrastructure exists, is well equipped; staffed with professionals; offering full range of maternal health services. Preliminary Demographic Health Survey data for 2010 supports our finding: FP use gone from 10.3 to 45.1. 98% of women have at least one ANC. (44% in SSA as a whole). HC births have gone from 28.2 to 68.9%. These improvements have been equally in rural areas. Reported MMR (RHMIS) is 383 in 2010 down from 750 in 2005. vision 2020 goal is 200 and MDG is 268.
In Rwanda health infrastructure exists, is well equipped; staffed with professionals; offering full range of maternal health services. Preliminary Demographic Health Survey data for 2010 supports our finding: FP use gone from 10.3 to 45.1. 98% of women have at least one ANC. (44% in SSA as a whole). HC births have gone from 28.2 to 68.9%. These improvements have been equally in rural areas. Reported MMR (RHMIS) is 383 in 2010 down from 750 in 2005. vision 2020 goal is 200 and MDG is 268.
Coherent policy environment created clear lines of responsibility. 1) Consistent national/local objectives: Vision 2020 (2000) objectives and MDGs were subsequently embodied in EDPRS (2008-12) and since adoption of decentralisation policies DDPs have become mandatory and must reflect national as well as local priorities thus they include things lie reduction in MMR, fertility and HIV prevalence rates. 2) Complimentary policy reforms with clear lines of responsibility 1) Ex. decentralisation policy & territorial administrative reforms has aligned health facilities with administrative entitities and 2) ex. health strategy (community health insurance scheme, community health system, performance based financing, focus on behavioral change) Decentralisation policy (2004): decentralised service delivery + political democratisation Territorial administrative reforms (2005) Health sector strategy (2005) and strategic plans I (2005-2009) & II – supported decentralisation strategy and service delivery improvements 3) Good coordaintion and management of DPs: DP relationships are managed centrally and their local activity is coordinated by JADF at district level. DPs need national Aid policy (2006) – all development assistanace must be in line with national and sector objectives/policies. DPs relationships are centreally controlld and any local DP activity must be channeled through the district JADF whcih ensures that activity is in line with DDP. Since 2010 division of labour initiative limits DPs to 3 sectors.
Popular participation has contributed significantly to outcomes in maternal health. And although the collective action forms don’t typically resemble the sorts of things that we imagine civil society to be involved with as a means of improving services. They do provide community members with ways in which they can contribute to improving delivery and have a say in the sorts of things that matter. People might not have an equal voice and the arenas for action might be defined by external actors but there is some scope for participatory process within this. This also challenges the assumption that citizen ‘demand’ for better services has to be just about ‘civil society’ trying to force the state and service providers to improve the services they provide. Its also about citizens examining what they can do for themselves and how they can become engaged to improve services. Being a citizen is not just about demanding right but also about responsibility and engagement as well. An din resource-constrained environments voluntary citizen involvement is a necessary fact (‘big society’). The case of CHWs is a good example of a way in which local community members can contribute to improving local service delivery. CHWs helps overcome human resource capacity constraints and geographical access to healthcare. However the system doesn’t absolve the state and service providers of their responsibilities, quite the contrary. The health sector facilities are responsible for CHWs and as they are answerable for anything they do wrong so they are motivated to ensure that the CHWs are well trained and that any barriers they meet to fulfilling their roles successfully are managed. Likewise LG officials have imihigo (performance) targets to meet on maternal health indicators and they oversee the health centre facilities via their participation in the HC health committee. Arenas exist within which different actors involved in the local level of health service provision can collaborate together. This space means is an important factor in ensuring that everyone is working towards the same objective. Health committee example: During a Musange health committee meeting asked why there was a persistently high number of women giving birth at home. Response was to 1) criticise CHWs for poor results and visit them in their homes to ensure that they were upholding the practises they were being asked to promote and 2) CHWs were informed of the support and sanctions that local authorities can provide if the population refuse to implement the policies. Collective poverty reduction strategies (girinka, ubudehe, revolving savings schemes, micro-credits) State facilitation: ex. Setting up of SACCO accounts to facilitate poverty reduction strategies such as revolving savings schemes and micro-credits Participatory: ex. Ubudehe – villages were given money to use to (1) help poorest – identified by village committee during village meetings (2) create income-generating activites to reduce poverty.
Coherent policies and accompanying strategies and reform necessary to implement them.
Consensus around main causes of maternal death and the interventions necessary to reduce maternal mortality (WHO guidelines) * Causes: severe bleeding, infections, high blood pressure, obstructed labour and unsafe abortions * Interventions: ante and post-natal care, attendance of skilled professional during childbirth, use of family planning.
Coherent policies and accompanying strategies and reform necessary to implement them.
1: mention that spending on health in Rwanda has clearly been important. However despite this per capita spending on health in Rwanda remains below the SSA average. 2: its not just about fixing supply and/or demand but about the ways in which the two come together. 3: in particular the collaborative spaces which bring together all actors are especially important. Where people can work out who can do what to achieve a goal which has been defined (maybe by the state) but which everyone agrees is in the interests of the community to resolve. An important part of this is about getting community members to do what they can. Being a citizen is not just about what we can expect but also what role we can play in contributing to our society.