Performance contracts to improve service delivery in health

The health sector has faced enormous challenges since 1994 and has only been able to stabilise in the last five-years.

The health sector has faced enormous challenges since 1994 and has only been able to stabilise in the last five-years.

Key health indicators are now in line with pre-Genocide levels. By 2005 the infant (under five) mortality rate had fallen to 15.3 per cent. HIV/Aids rates stood at three per cent of the adult population, severe malnutrition had fallen to 24 per cent and the maternal mortality figure had declined to 750/100,000.

The government remains committed to achieving three main strategic objectives.1) The prevention of disease, particularly malaria and HIV/Aids. 2) Increased access to health care. And 3) Improved quality of health services.

Steps towards achieving these objectives have been made. The fight against malaria has been stepped up, while strong progress has been made with the prevention of HIV/Aids.

Health insurance schemes (‘mutuelles de sante’) have improved access to care, especially through subsidies for the most vulnerable. Local government administration, working under strict performance based contracts, has improved the supply of health services to the population. And the construction of new hospitals and health centres and the higher number of ambulances has increased access to health care.

Improvements in the quality of health services are being addressed through the monitoring of performance and improved training.

Progress has been monitored through the introduction and the implementation of the Health Sector Strategic Plan (HSSP). The HSSP recognised that the needs of the poor were well analysed and formulated, but ways to help them were less clear.

Steps taken

It was realised that more nurses were needed. The proportion of nurses in rural areas was thus increased from 20 per cent of the total number of nurses in Rwanda to 56 per cent. This was a result of a change in policy allowing health centres to recruit and also due to improved financing, through mechanisms such as the Global Fund. The quality of doctors also improved with new training initiatives.

Drug and vaccine availability has been improved. Essential drugs are now available throughout the country 95 per cent of the time. If a drug is unavailable time required to deliver the drugs reduced from almost two days in 2004 to less than half a day in 2005. Vaccines were in stock throughout Rwanda for all of 2005.

The share of the budget to be spent on the health sector increased from 8 per cent in 2004 to 10 per cent in 2005. The 2003 NHA shows a strong increase in health funding to $13.93 (Frw7,530) per capita from $9.27 (Frw5,000) in 2002.

Enrolment rates at insurance schemes have increased sharply to 44.1 per cent of the population by the end of 2005.


Malaria: Progress has been made in preventative treatment of women. Large numbers of bed nets have been distributed.

HIV/Aids: An increase in the number of counselling and testing sites has been recorded. The detection and treatment of HIV/Aids cases has increased. However, little progress has been made in the prevention of mother to child transmission (PMTCT) and the use of condoms.

Tuberculosis: Case detection rates are lagging behind regional standards, but successful DOTS completion rates have improved.

Vaccinations: More than 85 per cent of children under five have access to vaccinations.

Nutrition: Severe malnutrition rates have only fallen slightly over the last few years and require significant improvement if the Millenium Development Goals are to be achieved.

Population growth: Family planning has been a priority. However, population growth rates remain high and contraception use remains low.

What the future holds:

Financing: The introduction of performance based financing marks a major reform in the health sector. The sustainability of the insurance (mutuelles) schemes needs improvement.

Information: A comprehensive health review has been carried out, enabling the reform and improvement of the country’s Health Management and Improvement Systems (HMIS).

Human Resources: The number of qualified personnel in rural areas still remains low.

Drugs, Vaccines, Consumables: Money for drugs is still limited. Subsidies for the poor are being phased in.

Access to health care: Although more facilities are being built, about 40 per cent of health centres are still without electricity.

Going forward, EDPRS is to concentrate on securing funds for the health sector, increasing disease prevention methods and subsidising drugs for the most vulnerable.


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