Transcript Review of progress against JSR2006 recommendations

RWANDA
PRIMARY HEALTH CARE
AND DECENTRALISATION
OF HEALTH SYSTEM
Claude SEKABARAGA, MD, MPH
Director of planning, policy and capacity building
PRIMARY HEALTH CARE
SERVICES
MOH: HRF, OAI
30 DISTRICTS: DH, DP, CDLS,
MUTUELLE
416 SECTORS : Health center
2080 CELLS: Health community post
14980 AGGLOMERATIONS: 2 Community health workers
PRIORITY INTERVENTIONS OF
PRIMARY HEALTH CARE SERVICES
• Increase the use of family planning methods, especially the long
term methods;
• Investment in strong prevention interventions of major
diseases;
• Universal access to curative care for all people living in Rwanda
through universal coverage of health insurance;
• Improvement of quality of care through quality of training, ehealth, investment in infrastructure, drugs management,
equipment and performance based financing of providers;
• Decentralization of health services at Umudugudu (Health post)
and households level (Community Health workers);
• Mobilization of financial resources.
INNOVATIVE INTERVENTIONS
• Public subsidies (Health facilities budget support)
through performance based financing;
• Community health insurances;
• High subsidy of drugs and products of higher
prevalence diseases (Immunization, malaria,
Hiv/aids and TB);
• Autonomy of management of health facilities
(hospitals and health centres), include now
personnel;
• Decentralisation, integration and task shifting in
delivery of health care services.
DECENTRALIZATION OF
HEALTH SERVICES
System /process
Achievements
1. Setting up of Board and Management
Structures in all facilities
100% of health centers and 75% of
hospitals have set up governance bodies
2. Planning for the Health Sector at the
Decentralized level
Each District has a Health Strategic Plan,
All Hospitals have a 2008 Action Plan
linked to the HSSP, 40% of Health Centers
have comprehensive 2008 plans
3. Physical Infrastructure
There are 402 Health Centers, 36 District
Hospitals, 30 District pharmacies and 4
National Hospitals
4. Decentralization of Budget
85% of funds have been decentralised
5. Improvement of Community Health Services
2 Community health workers for each
umudugudu have been elected and are
being trained
HEALTH SECTOR BUDGET
DECENTRALISATION
3%
12%
District 49,8 billions
National hospitals and other
Institutions 7,0 billions
Ministry of health 1,8 billions
85%
GOR HEALTH BUDGET TRANSFERS TO
DISTRICTS:
17,1 billions of RWF (32 millions USD)
Salaries 10,6 billions
Mutuelle poorest 268
millions
22%
Mutuelle pooling risk 268
billions
Community health 900
millions
3%
5%
5%
61%
Hospital running cost 905
millions
2%
2%
Maintenance of
infrastructures 360
millions
Conditionnal performance
based transfers to health
facilities 3,8 billions
HEALTH OFF BUDGET (NGO’S) TRANSFERS TO
DISTRICTS: 10,4 billions (18 millions USD)
MUTUELLE/INDIGENT/GF
DIF/INTRAHEALTH (USA)
1 678 721 820
1 510 000 000
973 800 000
1 835 350 160
1 066 285 920
339 700 480
2 494 644 320
TREATMENT AIDS/CUICAP (USA)
TREATMENT AIDS/CRS
(USA)
TREATMENT AIDS
INTRAHEALTH/CAPACITY
(USA)
TREATMENT
AIDS/EGPAF (USA)
464 240 000
TREATMENT AIDS/FHI
(USA)
TREATMENT AIDS TB
MALARIA/GF
FAMILY PLANNING
Evolution de l'utilisation de PF dans les FOSA
Publiques depuis 2005 jusque fin Novembre 2007
Taux d'utilisation
25,00
22,54
20,00
15,00
10,00
9,99
10,78
2005
2006
5,00
0,00
Période analysée
2007
FAMILY PLANNING IN PBF PRIMARY
HEALTH FACILITIES PILOT SITES
194% increase
60
50
55
50
45
2
40
R = 0.8635
Percentage
35
30
25
20
17
15
10
5
0
1
2
3
4
5
6
7
2006
8
9
10 11 12
1
2
3
4
5
2007
6
7
8
ANTE NATAL CARE
Evolution de la ituation de CPN au Rwanda de 2001 à fin Novembre 2007
Taux d'utilisation de
CPN
94,4
100,0
90,0
80,0
70,0
60,0
50,0
40,0
30,0
20,0
10,0
0,0
85,8
78,3
84,2
84,4
82,4
63,5
2001
2002
2003
2004
Période
2005
2006
2007
BIRTHS DELIVERIES
Evolution des accouchements assistés dans les FOSA de 2001 à 2007
Taux d'accouchements
assistés
60,0
49,6
55,1
50,0
36,5
40,0
29,4
25,0
30,0
20,0
22,6
10,0
18,7
0,0
2001
2002
2003
2004
Période considérée
2005
2006
2007
IMMUNIZATION
120%
100%
80%
2005
60%
2006
40%
2007
20%
2007
2006
2005
0%
DTC3 VPO3
VAR
VAT2+
)u
)I
er
PT
IT
2
N
N
TN
IT
rI
N
60%
yr
nd
ith
de
)w
-4
9
yr
(1
5
-4
9
yr
un
IT
70%
PW
(1
5
-4
9
5
wi
th
70%
PW
(1
5
CU
5
N
Ns
IT
IT
1
2
N
30%
CU
2
st
st
le
a
PT
IT
10%
le
a
HH
)I
er
TN
13%
yr
nd
rI
N
60%
HH
)u
-4
9
yr
de
IT
15%
(1
5
-4
9
un
1
40%
PW
(1
5
5
st
80%
PW
PW
le
a
20%
CU
HH
P R E VE NT ION B Y MOS K IT O-NE T S
74%
2007
60%
54%
50%
2005
25%
28%
17%
0%
0%
HIV TESTING SERVICES
Evolution des FOSA-VCT
350
313
300
Nombre des sites
256
229
250
200
129
150
100
44
50
0
Période
15
1997-2001
23
2002
2003
2004
2005
2006
nov-07
PREVENTION OF TRANSMISSION OF HIV
FROM MOTHERS TO CHILDREN SERVICES
Evolution des FOSA-PMTCT de 1999-2007
285
300
234
Nombre de FOSA
250
209
200
120
150
100
50
53
33
1
2
11
1999
2000
2001
0
2002
2003
Année
2004
2005
2006
2007
PREGNANT WOMEN TESTED
HIV
Evolution du nombre de femmes enceintes testées au VIH
814910
Nombre cumulé des femmes
900000
800000
700000
602409
600000
500000
364057
400000
300000
183724
200000
100000
11478
46422
88278
0
Période
1999-2001
2002
2003
2004
2005
2006
2007
ART SERVICES AND PATIENTS
TB DETECTION
200
120%
181
180
170
160
99%
149
100%
98%
131
140
86%
120
70%
100
80
80%
60%
CDT
73
40%
60
39%
% of CDT
40
20%
20
0
0%
2003
2004
2005
2006
T1-3 2007
COMMUNITY HEALTH INSURANCE IN
RWANDA
73%
75%
44%
27%
7%
2003
2004
2005
2006
2007
UTILISATION OF CURATIVE CARE
SERVICES IN RWANDA
Pourcentages
Evolution des taux d'utilisation des services de santé par la
population: de 2001 à 2007
80,00%
60,00%
40,00%
20,00%
0,00%
1
2
3
4
5
6
7
Series1 24,70 28,40 30,70 39% 46,80 60,70 71,90
2001
2002
2003
2004
2005
2006
2007
IMPACT ON HEALH
OF POPULATION
1200
1071
1000
750
800
611
600
400
200
0
Maternal mortality
DHS 1992
DHS 2000
DHS 2005
DHS 1992
DHS 2000
DHS 2005
196
150
152
107
86
85
Infant mortality
Child mortality (Under Five)
MALARIA MORBIDITY
50
45
40
45,13
42,37
41,34
46,15
41,27
39,36
45,55
42,23
40,25
38,12
36,05
33,79
35
41,81
37,31
35,59
30
34,59
29,04
26,97
25
24,7
20
Moins 5ans
Plus 5ans
Total
15
15,01
11,57
10
5
0
2001
2002
2003
2004
2005
2006
2007
HIV PREVALENCE
Prévalence du VIH dans les FOSA-CDV (2004-Nov 2007)
12
10.8
9.3
Prévalence (%)
10
7.3
8
6
4.8
4
2
0
Période
2004
2005
2006
Nov-07
TUBERCULOSIS MORBIDITY
Graph 3: Evolution du nombre de suspects et de la positivité
80 000
16,0%
70 000
14,0%
60 000
12,0%
50 000
10,0%
40 000
8,0%
30 000
6,0%
20 000
4,0%
10 000
2,0%
-
2005
2006
2007
Nb suspects
28 637
45 075
67 350
Taux de positivité
13,7%
11,3%
6,6%
0,0%
Challenges of primary health
care
Solutions
Quality of Care
BCC for health providers, Performance Based
Payments, citizen voice systems
Brain Drain of Human Resources for health
Management of HRH labour market based
High level of poverty as vicious circle with
health status
Universal coverage of community health
insurance with mobilisation of resources to
temporarily subsidy poorest categories
Lack of resources for infrastructure and
equipment
Mobilise and decentralise infrastructure
maintenance, construction and equipment
Poor transport and communication system for
emergency
Development of a national medical emergency
transport system (SAMU)
Off budget with many implementers and
difficulties of alignment and harmonization
Sector Wide Approach (SWAP) with Joint Work
plan and sector budget support
LESSONS LEARNT
• Decentralisation and community participation:
Accessibility, early treatment, ownership,
implication of local leaders, community health
workers, youth and women organisations,
autonomy in management.
• Community health insurance: Financial barrier,
utilisation of primary health services.
• Performance based financing: Quality, Rural to
urban brain drain, local investment: Equipment,
maintenance
• Strong prevention: Universal distribution of
mosquito-nets, hygiene and environment.
• Partnership: Public, private, civil society and
international cooperation implication.
CONCLUSION
• Decentralisation and community participation
contributed to rapid and efficient results;
• Primary health care have been improved very
much in terms of prevention of major diseases like
malaria, HIV/AIDS, although many challenges due
to level of poverty and quantity and quality human
resources;
• Great efforts must be put in elimination of major
diseases like malaria, diseases due to lack of
hygiene and/or which vaccines exist, universal
access to mosquito-nets and health insurance.