By Godfrey Ntagungira

The government has made huge effort in rebuilding society. The commitment of the government in attaining economic and social development and poverty reduction has resulted in developing and setting in place the institutions, legal frameworks and policy guides for the implementation of their strategies.

In an interview with Healthy Minister Dr Richard Sezbera said that the ministry of healthy came up with the health sector strategic plan (HSSP-II) 2009-2012 which elaborates the strategic directions, activities, and key indicators to achieve sector policy objectives. The plan identifies key outcomes to be achieved in the next three years as a reduction in the maternal, child and infant mortality ratios; a decrease in the fertility rate and the incidence of HIV.

The Report asserts that the overall total of 14 policy actions which were to be implemented in the period of July-December 2009. Among the 12 (86%) were fully achieved while 2 (14%) were partially achieved.

Among the health sector national health policies include: reproductive health, child health support system (Mutuelle de sante), malaria control, health communication for behavioral changes, environmental sanitation, health information system, and strategic framework for HIV/AIDs. The national policies have laid the groundwork for development and implementation of community based health financing schemes.
Local medical insurance
The community based pre-paid insurance scheme known as Muteulles is one of the best government initiatives to provide equitable, and quality health care services for the poor and the population at large. Using the lowest decentralized administrative levels (sectors, cells), people elected communities representatives in charge of gender, health and social affairs. These representatives organized communities to develop solidarity mechanisms, such as mutual aid societies and health insurance schemes.

The EDPRS policy action related to health insurance for 2009/2010 is to submit a Law on Health Insurance to Parliament. The policy for Health Insurance and community health insurance has been finalized along with the revised law on community health insurance.
Once the Health Insurance policy is approved by Cabinet, then the elaboration of the Law on Health Insurance will be commenced. This activity therefore, is not fully achieved.
Through Mituelle de Sante, a universal public medical insurance scheme introduced in 2001, the government has enabled millions of people, including those living with HIV/AIDS, widows and orphans to access health services easily.
The scheme is a global success story. The key thrust is to ensure that efforts are instituted at ensuring health care for all. This scheme is thus the biggest in terms of its membership.
It is organised on a household basis, whereby membership entails making an annual payment of Rwf 1000 (less than US$2) per family. Members are entitled to a basic health center package that covers all services and drugs provided by their preferred health center, as well as ambulance referral to the district hospital and a limited package at the hospital.
This may sound unbelievable to the western world, but it has been proved to be more efficient and very realistic.
The 2009/2010 EDPRS policy action for financial access to health services is "to pilot reducing "ticket moderateur” and introducing conditional cash transfers for children under five years old and pregnant women”. For children under five years old, a pilot initiative removing "ticket moderateur” has been implemented in two selected health centers: Muremure in Muhanga District and Gahanga in Kicukiro District. Pregnant women are exempted from paying the "ticket moderateur.
The policy action related to providing incentives to women who deliver in Health facilities is: "to pilot in-kind incentives for birth delivery in health facilitieas3. In-kind incentives for birth delivery have been piloted in 55 health centers. All 30 VUP sectors are currently covered by this incentive program.
Assisted birth delivery
In the quest to achieve the EDPRS target currently more than 60% of women delivering in health facilities, in the same framework the government targets to increase the price of PBF for assisted deliveries by 50 percent and to implement in kind conditional cash transfers for assisted deliveries.

This policy action has not yet been achieved; however, PBF for assisted delivery will be increased in health facilities by March 2010. In addition to targets for health centers, the Ministry of Health has elected to increase PBF for assisted delivery by 25% for community Health Worker cooperatives from January 2010.

Community based health care: this approach entails transferring block grants to administrative districts for the delivery of basic health care-mosquito nets or environmental sanitation, clean water and hygiene to households and communities.
Various approaches implemented by government thus far have proven to be successful in catering for health needs of the population to include the poor and vulnerable.

Rwanda has put huge efforts in the promotion of greater community participation that contributes to the democratization process and strengthens governance by providing a system of incentives and by the administrative districts being accountable to communities who could monitor health care services. Broaden the participation base to utilized community animators in the delivery of basic health care services such as mosquito nets, or, advocating for environmental sanitation, social mobilization and sensitization would result in greater efficiency of the system.

Malaria

In Rwanda malaria is the leading cause of morbidity and mortality in Rwanda, However, the country has made impressive progress in the prevention and treatment of malaria over the past years resulting in a decrease in malaria morbidity and mortality. To meet the target, the health sector aims to reduce malaria incidence in at-risk-groups by providing free ITNs to children under five.

The percentage of children under five sleeping under ITN was 60% according to the IDHS 2007/8. The EPDRS target for 2009/2010 is 65%, however, no recent figures are available from survey data for this indicator.

To promote and monitor malaria control services throughout the country, the policy action for 2009/2010 is scheduled to publish a pricing and distribution policy for long lasting ITNs and Artemisinin-based combination therapy (ACT) to eliminate malaria.

 This policy action has been achieved as the policy and its strategic plan is available. The documents will be published in April 2010.
Integration of grassroots health workers
The formal integration of 60,000 health community workers into the formal health system is considered to be landmark achievement in bringing services closer to the population. Malaria and other childhood killers and ailments are being checked in addition to related outputs by this new form of intervention which has entrenched community distribution of contraceptive commodities.
Community health workers
The general objective of Community Health Workers is to provide clear guidance for the provision of holistic and sustainable health care services to communities with their full participation.
For successful implementation of the strategy, it is essential to advocate and mobilize resources to support implementation of the community health programs, to build partnerships for community health and to develop a monitoring system that will also capture community activities at the community level.

The EDPRS policy action for 2009/2010 relating to CHWs is to "Pilot performance based financing signed with association of community promoters which must include key child health indicators into IMIHIGO”. This policy action has been achieved as 82 cooperatives of community promoters cooperatives have had their statutes signed by districts. Key child health indicators were also included in their IMIHIGO. Performance contracts at the district level have been signed with all steering committees.

Expanded program of immunization
The Expanded Program of immunization (EPI) has three major components: routine vaccination, supplemental immunization activities, and surveillance for target diseases. The program is one of the best in Sub-Saharan Africa as it is completely integrated into routine activities of health facilities and CHWs.
The percentage of children fully immunized according to the IDHS 2007/8 was 80.4 %; the EDPRS target for 2009/2010 is 90%. Routine HMIS data show that by the end of December 2009, coverage had reached 93%. The EDPRS policy action for 2009/2010 gives priority to do outreach services for immunization at 25% of all health facilities”. This activity has been realized at 100%.
Family planning

The objective of the family planning strategy is to reduce the proportion of unmet needs, thus decreasing the total fertility rate. The EDPRS indicator for family planning is to increase the use of modern contraceptives from 10% in 2005 to 70% by 2012.

Current data from the HMIS show that the modern contraceptive utilization rate was 45.1% at the end of 2009.
The EDPRS policy action for 2009/2010 is to fully fund family planning programs at US$0.3 per capita per year from government budget. According to the Health Sector Budget 2009/2010, the per capita allocation to family planning for individuals of reproductive age (males aged 15+ and females aged 15-49) is 0.41 for the recurrent budget. This policy action has been met.

Nutrition
In order to reduce malnutrition, the current EDPRS policy action will also put efforts to scale up provision of vitamin A and immunization services through CHW in 10 districts.
Training in IMCI, which is a complete package of care for childhood illnesses, was conducted in 18 districts, namely: Kirehe, Ngoma, Ruhango, Nyanza, Gisagara, Nyaruguru, Nyamagabe, Nyamasheke, Ngororero, Musanze, Nyabihu, Rubavu, Burera, Bugesera, Gasabo, Rutsiro, Kicukiro and Nyarugenge. This activity is now achieved at 60%

However communication and inter-personal relationship between all stakeholders in health was found to be very good and functioning. there is a management meeting every Monday of all the actors involved in decision making in healthy- Minister, Permanent Secretary, All Directors, Coordinators of major projects within the Ministry discuss healthy matters to date, iron out challenges, seek solutions to problems, and assigned tasks according to needs.

Role of decentralization in healthy sector

The decentralization process has enabled the smooth transfer of financial management at the sub-governments at a health districts and community levels. It has encouraged good governance at the local level and broader participation of civil society groups and community members to play a more active role in the delivery and management of their health services.

Decentralization has empowered civil society by providing people, especially the poor with voice, decision making and resources to be part of the implementation and management of health activities.

The governments have set up various contracts with the health administrative province/districts to effectively implement and manage quality health care that will serve the population to include the very poor and vulnerable groups.

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