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

Transcription

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

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.

7 RWANDA HEALTH SECTOR PERFORMANCE STATUS

8 INFANT MORTALITY (PER 1000) % in two years

9 UNDER FIVE CHILDREN MORTALITY (PER 1000) % in two years

10 Modern contraception prevalence (% year-old women) % of increase in two years

11 Births attended by skilled health personnel (% of births) % of increase in two years

12 COMMUNITY HEALTH INSURANCE IN RWANDA % 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 83% 73% 75% 44% 27% 7% %

13 80% 70% 60% 50% 40% 30% C OVE R AG E OF P R E VE NT IVE ME S U R E S (MOS QU IT O- NE T S AND P R E G NANT WOME N T R E AT ME NT % 24,5% 70% 60% 73,8% 59,9% % 20% 15% 13% 17% 10% 0% HH least 1 ITN C U5 under ITN 0% PW(15-49 yr) under IT N PW(15-49 yr) IPT2 HH least 1 ITN HH least 2 ITNs C U5 with ITN C U5 under ITN PW(15-49 yr) with ITN PW(15-49 yr) under IT N PW(15-49 yr) IPT2

14 P roportionnal Malaria morbidity in Health C entres vs Health Utilization R ate ,5 70,3 67,4 71, ,4 37,8 44,4 37, ,4 29,9 28, Malaria morbidity Health utilis ation rate

15 PREGNANT WOMEN TESTED HIV Période Women tested

16

17 TUBECULOSIS PREVALENCE IN SUSPECT CASES ,0% 14,0% 12,0% 10,0% 8,0% 6,0% 4,0% 2,0% 0,0% Suspect number Positive case rate 13,7% 11,3% 6,6%

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 Harmonized Implementation Sector Expenditure Framework Comprehensive Sector Policy/Strategies Shared Vision & Priorities Partnerships between Govt. & Development Partners Government Ownership & Stewardship

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.