This month Rwanda bagged the 2012 Resolve Award for innovation in reproductive and child health presented by Aspen and administered by USAID and Management Science of Health[i]. This comes as a little surprise not just for the progress it has made on the maternal and child health front but with a bouquet of innovations spanning across its health sector.
It seems to have been first mover on many policy developments. It was one of the first countries where performance-based financing was pioneered[ii]. Today it has been scaled at a national level with performance contracts enforced between the local units and the President, Paul Kagame[iii]. Its community-based health financing scheme, called as Mutuelle De Sante covers almost 90 percent of the population, and is only health financing scheme to have been scaled up to this extent. When it comes to technology-based initiatives too, Rwanda was among the early birds to get started with the eRwanda project to be the first eGovernment project that got supported by the World Bank in East African countries in early 2003[iv]. In 2009, when Rwanda launched the telemedicine project in partnership with the Ministry of Health, it allowed regional hospitals to be connected with advanced hospitals, thus enabling doctors to seek remote diagnosis, second opinion or send referrals to the advanced hospital. Today it looks like it is reaping the benefits of its early investment in technology with projects in mobile health being rolled out such as TRACNet, which makes it possible for health workers in distant locations to record real-time data regarding treatment of their AIDS patients.[v]Thanks to such early adoption of technology that a recent evaluation noted that about 80 percent of health workers now report data on patients and treatments using cell phones.[vi] This is not enough. To overcome the shortage of skilled workers it has a signed an agreement with United States, worth $34 million to bring more than 100 senior medical faculty from American universities to Rwanda over the next seven years in an effort to to train and work with the local physicians and build specialty capacity as well as create new residency programs, writes Ms Agnes Binagwaho, Rwanda’s Minister of Health on her blog website. Ms Agnes, who is a trained physician and a lecturer at Harvard Medical School, boasts of her ministry’s partnership with elite US medical school such as Harvard, Duke, University of Texas, Yale School of Medicine and about seven schools for nursing and midwifery.
This begs the question as to what makes this country a hub of innovative health policy and programs and what lays the context for this country to become a darling of donors? Its infant mortality rate which climbed to 149 in 1995 post genocide from 99 in 1990 has been brought down to 49 by 2010. Under 5 mortality rate too, which increased to 183 from 164 in 1990 stood at 64 in 2010. Maternal Mortality Rate is now at 340 from 910 in 1990s.
After the genocide that decimated about 30-40 percent of the population or had them flee the country, there was a shortage of health workers and financial resources. Local non profits and church organizations such as Cordiad, MSH, USAID initiated performance-based schemes in some of the provinces. Rwanda’s strong emphasis on a decentralization policy reflected in its key documents such as country cooperation strategy with multilateral organizations and created a firm grounding to enable such contracting mechanism with a focus on outputs to be enforced.
While the process began in 1996 with the support of W.H.O and through the formation of health districts, it was in 2006 that the process kick started with the government launching Imihigo (performance contracts) in order to achieve its targets and indicators. These intentions were articulated as a part of its Vision 20:20 and Poverty Reduction Strategy Paper. Echoing a similar spirit was the Economic Development and Poverty Reduction Strategy for 2008-2012, which envisaged that 80 percent of the district by 2012 would be using performance contracts, citizens score card and report delivery services, thereby increasing accountability. And its latest decentralization strategy document 2012 states that the central government would reduce its earmarked grants to local units in order to encourage the latter to improve their planning and budgeting capability and give them more autonomy.
As the evaluation kicks in this month for the districts, Rwanda’s current minister for local government, James Musoni said,”The annual performance of all districts, provinces and Kigali City will be evaluated by a national evaluation team composed of senior officials and experts from different institutions led by the President’s Office.” A statement on the local government website noted that the evaluation will assess the implementation progress in all priority sectors and targets indentified in the performance contracts signed between the mayors and the President. It further said that through Imihigo, the government will identify major challenges that impede effective implementation of targets and by showcasing the performance and ranking of each district, the government hopes to promote competitiveness amongst districts as well as identify areas that need strengthening.”
While this doesn’t make a case for any causal argument or even a correlation, intuitively it does seem to be right: you cannot have a strong performance-based system without a solid base for decentralization; you cannot have a community-based financing scheme at a national level without commitment of local units to organize groups; you cannot have workers in remote areas to report data on real time basis accurately through projects like telemedicine without reinforcing the culture of local autonomy and performance-based system. And you cannot have collaborative partnerships with American universities without having the political will and the culture to innovate and bring reforms. It is like fixing each spoke of a wheel when it comes to improving outcomes in social sector. You get one spoke right but if you can’t fix others it is hard to achieve desired results. Rwanda seems to have learnt this much early.
[ii] Rena Eicher, Ruth Levene, Performance-based financing for global health: potential and pitfall 2009
[iv] World Bank, Project Appraisal Document for Rwanda
[v] Ministry of Health website
[vi] Nsanzimana S, Hinda R, Lowrance DW, Cishahayo S, Nyemazi JP, Muhayimpundu R, Karema C, Raghunathan PL, Binagwaho A, Riedel DJ. “Cell phone- and internet-based monitoring and evaluation of the national antiretroviral treatment program during rapid scale-up in Rwanda: TRACnet, 2004-2010.” JAIDS 2011; 59(2): e17-e23
Rwanda Human Resources website: http://hrhconsortium.moh.gov.rw/about/participating-us-schools/
PBF Changing the health system in Rwanda, WHO Bulletin, 2006, Cordaid Website