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IMPROVING HEALTH THROUGH INTER-SECTORIAL ACTIONS: LESSONS FROM HEALTH FINANCING IN RWANDA

CONTENTSIntroduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21. General background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

1.1 Purpose and objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31.2 The proposed methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41.3 The rationale for selecting this case study . . . . . . . . . . . . . . . . . . 41.4 The study design and data collection tools . . . . . . . . . . . . . . . . . 4

2. Initiationofthepolicyonhealthfinancing . . . . . . . . . . . . . . . . . . . . . . 52.1 Internationalcallforinnovativehealthfinancingreforms . . . . . 52.2 Nationalhealthfinancingpolicyreformsinrwanda . . . . . . . . . . 52.3 Introducingtheperformance-basedfinancing(pbf)policy . . . . 6

3. Description of policy process for intersection action . . . . . . . . . . . . . 73.1 The role of top leadership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

He the president of the republic . . . . . . . . . . . . . . . . . . . . . . . . . . 7The members of parliament . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

3.2 Othersectors(keyrelevantministries) . . . . . . . . . . . . . . . . . . . . . 8The ministry of local government (minaloc) . . . . . . . . . . . . . . . . . 8The role of decentralized levels (districts) . . . . . . . . . . . . . . . . . . 8Ministry of finance and economic planning (minecofin) . . . . . . 9Ministry of women, gender and family promotion (migeprof) 10Other ngo working in health sector . . . . . . . . . . . . . . . . . . . . . . . 10

4. Experience/ lessons learned . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104.1 The lessons/experience learned . . . . . . . . . . . . . . . . . . . . . . . . . 104.2 The challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

5. Conclusions and recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . 126. Limitations to this study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Acknowledgement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Table of abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Rwandaintersectoral case study

WHO/AFRO Library Cataloguing – in – Publication

Improving health through intersectorial actions: lessons from health financing in Rwanda

1. Healthcare financing 2. Financing, Organized3. Quality Indicators, Health Care4. National Health Programs5. Social determinants of health6. Cooperative behavior7. International cooperation

I. World Health Organization. Regional Office for Africa

ISBN: 978-929023270-4(NLM Classification: WA 540)

© WHO Regional Office for Africa, 2013

Publications of the World Health Organization enjoy copyright protection in accordance with the provisions of Protocol 2 of the Universal Copyright Convention. All rights reserved. Copies of this publication may be obtained from the Library, WHO Regional Office for Africa, P.O. Box 6, Brazzaville, Republic of Congo (Tel: +47 241 39100; Fax: +47 241 39507; E-mail: afrobooks@afro.who.int). Requests for permission to reproduce or translate this publication, whether for sale or for non-commercial distribution, should be sent to the same address.

The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.

The mention of specif ic companies or of cer tain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters.

All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization or its Regional Office for Africa be liable for damages arising from its use.

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IntroductionInRwanda,thehealthindicatorsespeciallythoserelatedtoMDGshavesubstantiallyimprovedduringthelastdecade.Throughimprovedintersectoralactions,governmentcommitmenttonationalandinternationaltargets,boostedbydonorsupport;theMoHwasabletoattainmostkeyhealthtargetsthatweresetoverthelast10years(Rwiyereka,2013).Theinfantmortalityratiodecreasedfrom86per1000livebirthsin2004to50per1000livebirthsin2010andtheunderfivemortalityratiodeclinedfrom152to76per1000livebirthsoverthesameperiod(RDHS;2010).Iftherateofthisdeclinecontinues,RwandawillmostlikelymeetthematernalandchildmortalityMDGstargetsby2015.Despiteincreaseindonorsupportinlastdecade,thegovernmentspendingonhealthhasbeenincreasingsince2005:2005(8.2%)9.1%(2007);and11.5%(2010)(MoH,2011a,2011b).ThroughtheMinistryofFinance,thelevelofgovernmentspendingonhealthin2010waswithinthereachofAbujadeclaration(15%by2015)targetsfornationalbudgetallocationtowardsthehealthsector(MINECOFIN,2010).

Theintersectoralcollaborationhascontributedgreatlyinachievingtheaboveresults.TheMINECOFINhas been increasing its share of speeding to health over years and is still committed to increasing evenfurther.TheMinistryofLocalGovernmenthasstrengthenedgovernancestructuresatalllevelto

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ensure that strong administrative structures are in place to support implementation processes for most governmentprograms,includingthoseofhealth.Withstructuresinplace,theimplementationofvarioushealthinnovationswaspossible.Community-BasedHealthInterventionsimprovedaccesstohealthservicesgreatlyduetotheremoveofmostfinancialobstacles,butalsocreationmorefeederroadnetworkstoreducephysicalbarriers.TheintroductionofCommunity-BasedHealthInsurance(CBHI),facilityandCommunityPBFtostimulatedemandandsupplyofhealthservicesareallimplementedatvariouslevelsandsupportedbyvariousadministrativestructures(DHS,2010).CBHIcoversprimaryhealth care services that are mainly delivered at health center and community levels.

Rwandahasregisteredsignificantprogressinothersocialsectors,suchas:poverty,combatinghanger,andilliteracy,whichhavehaddirecteffectsonimprovinghealth((NISR),2011).Thiscasestudyisintendedtoexaminehowintersectoralactions(ISA)havecontributedinimprovinghealthinsurancefinancingandUHP.Thecasestudyspansfrom2005to2012,whenkeyhealthfinancingpolicyinnovationswereadoptedandothersscaledupfrompilotstocoverthewholecountrythroughthedecentralizationpolicy.Insubsequentchapters,weexplainthemethodologyappliedtorespondtothepurposeofthiscasestudy,thebriefbackgroundofthepolicy,policyinitiation,policydescription,theISA(descriptionofmechanismandtoolsappliedforintersectoralcollaboration,lessonslearned,conclusionandrecommendations,andlimitations.

1. General BackgroundAccordingtotheUNDP’sHumanDevelopmentIndex(HDI),Rwandaranks167outof187countries(UNDP(HDI),2013)andisinthecategoryofcountrieswithalowHDI.WithaHDIof0.429,thecountryisbelowtheregionalaverageof0.463.Thevastmajorityofthepopulationdependsonagriculturefortheirlivelihoods.RecentIntegratedHouseholdLivingStandardsSurvey(IHLSS)(2012)indicatedthatthepercentageofpeoplelivingunderpovertyhasdroppedbyalmost12%from56.7%in2006to44.9%in2012((NISR),2011).In2011,theNationalInstituteofStatisticsofRwanda(NISR)(2011)showedthatthepopulationdensitywasestimatedtobe4,161peopleperKM2withthetotalpopulationnowapproximately11million((NISR),2011).ThepopulationofRwandaisyoungwith43%<15yearsold.Moreover,womenaccountforabout52.6%ofthepopulation.

Althoughrelativelypoor,Rwandahasbeenwidelyacknowledgedforattaininguniversalhealthprotection(WHO,2010).SomecountriesanddonorsaretryingtolearnwithinteresthowRwandawasabletoachievesuchimprovementinarelativelyshorttime.TheUHChassignificantlycontributedtoimprovingkeymaternalandchildhealthindicators(Lu,2013;MoH,2011a;WHO,2010).AccordingtoUNICEFreport(2012),RwandahasachievedMillenniumDevelopmentGoal#4(MDG4)—thereporthighlightthatchildmortalityratesinRwandahasbeenreducedfrom156deathsper1000childrenin1990to54deathsper1000childrenbornannuallyin2011,whichreflectsatwo-thirdsreduction.ThedecreasesignifiesthatthecountryisontracktoreachMDG4–reducingchildmortalitybytwothirdsby2015(UNICEF,2012).

1.1 purpose and objectives

Manystudieshaveindicatedthatuniversalhealthcoveragehassignificantlyimprovedaccesstohealthservices,especiallythoseofMaternalandChildHealth(MCH);andthishascontributedtowardsreachingtheMDGnumber4(DHS,2010;Lu,2013;MoH,2011b).Varioussectors,includingtheMoHmanaged to effectively coordinate efforts and resources to improve health insurance coverage to attain UHCtobreakfinancialbarriers.Thepurposeofthiscasestudyistoexaminehowintersectionactivitieshaveimprovedkeyhealthtargets(nationalandinternational)throughimplementationofinnovativehealthfinancingpolicies.Torespondtothispurpose,weproposedtolookatthekeyrelevantsectorsorpoliciesinvolvedintheISAandhowthepolicyimplementationwascoordinated.Weinaddition,

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examinekeydriversshapingthehealthfinancingpolicyimplementation,theavailableopportunitiesaswellaschallengesinimplementingISAandlimitationmetwhiledocumentingthiscasestudy.

1.2 The proposed methodology

Thissectiondescribestherationaleandtheprocessesforselectingthecasestudy,thestudydesign,datacollectionprocesses,anddatasources.Italsohighlightsthetoolsusedtocollectthedata,andconcludeswithmethodologicallimitations.

1.3 The rationale for selecting this case study

WHOrecommendsLMICtostriveforUHCasbestwaytobreakfinancialbarrierandavoidtocatastrophicexpendituresforthepooranddisadvantagedsegmentsofthepopulation(WHO,2010).SomeintheinternationalcommunityconsiderRwandaasamodeltocountriesinlow-andmid-incomeintermsofattainingUHCandimprovingservicedelivery.TheselectionofthiscasestudywasbasedonthehypotheticalquestionthatwhileRwandaisarelativelypoorcountry;ithasdonemuchbetterintermsattainingUHCthancountriesinthesameorhigherincomelevels(anexampleRwandaisoncleartracktoachievingMDG#4).

1.4 The study design and data collection tools

ThedesignofthiscasestudyheavilyreliedonRobertK.Yin’s(2008)modelforcasestudydesigns(Yin,2003).AHarvardprofessor,Yiniswidelyknownfromhisworkasasocialscienceresearcher.Inhisbook,“CaseStudyResearch:Designandmethods”,Yindemonstratesthatthetypeofthecasestudydesignwillmainlydependsontheresearchquestion(s)ortheproblemsthecasestudyintendstoanswer.Inourcontext,thecasestudyintendstoexaminehowintersectoralactorshavecoordinatedeffortstoimprovehealthfinancing.Yin,emphasizesthatthe“how”and“why”questionsoften“favourtheuseofcasestudies”andthatcasestudyfindingsshouldbe“generalizedtotheories”(Yin,2003).Ourresearchquestionmainlyfallsunder“how”categoryand“focusesoncontemporaryevents”(eventsoccurringatthesametimeorfromtimetotime).

Therearevariouswaysofgettinginformationneededforthecasestudy.PalenaNeale,etal.(2006),concurwithYin(2003)thatthetypeofdatacollectioninstructiondependonthetypeofquestionsforcasestudy(Neale,2006;Yin,2003).Ideally,ourcasestudydesignsuggestsusingdeskreviewsandstakeholderinterviewsasmainsourceofdata.Thereforedatasourcesforourcasestudywerederivedfromdocumentreviewandstakeholderinterviews.

Document review:Thedocumentsreviewedmainlyinvolvedpolicydocuments,strategicplans,sectoralevaluationreports,DemographicHealthandSurveys(DHS),IntegratedHouseholdLivingStandardsSurvey(IHLCS),EconomicDevelopmentPovertyReductionStrategyII1(EDPRSII),thecountry’sVision20202,peerreviewedpapers,etc.

Adeskreviewtemplatewasdevelopedtoguidethereviewprocesses.Duringdeskreview,weattemptedtoanswerthekeyissuestorespondtothepurposeofthecasestudy.Ourtemplateinvolved:nameandtypeofdocument(Policy,strategicplan,etc.);whathealthfinancingissueswereidentifiedtobeaddressedthroughpolicyandISA;lessonsinaddressingequityissuestoaddresshealthissuesthroughhealthfinancing;whatpolicyissueshindersISAforhealthfinancing;weretherepolicysolution;whichsectorsweremoreactivelyinvolvedinpushingpolicyagenda;andwhatwasthelevelofcivil society involvement.

1 EDPRSIIismedium-termstrategythatguidestheGovernmentofRwandatoattainthelong-termVision2020objectives,thataimstotransformRwandaintomiddleincomecountryby2020

2Vision2020isadocumentthathasbeenguidingGovernmentofRwandasince2000,forplanning.ThemainobjectiveVision2020istotransform the country into a mid-income country in the year 2010.

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Stakeholder Interviews:stakeholdersfromrelevantsectorsandorganizationswhoseISAhavecomponentsdirectlyorindirectlylinkedtohealthfinancingwereconsideredforinterviews.Meetingswerearrangedwithseniorleadersoftheselectedinstitutionsandorganizationfortheinterviews.Aninterviewguideandquestionnaireswasdevelopedtoguidetheinterviewprocesses.Emailsandphonecallswereusedtocontactselectedsectorsandorganizationsforschedulingtheinterviews.Stakeholderswhowerenotavailableforinterviewsandwhopreferredtorespondtothequestionnairesthroughemailsorphonecall,weregiventhatopportunitytodoso.Noincentiveswhetherfinancialorotherwisewereprovidedtoparticipantstobeinterviewed.

Data Analysis:Relevantinformationfromthedocumentreviewwassortedoutaccordingtothereviewframeworksuggestedaboveandthenanalysed;whiletheinformationfromstakeholderinterviewswererecordedinanotebookaccordingtothethemescorrespondingtothepurposeofthecasestudy.Informationanalysiswasguidedbytheframeworkfor:coordinationofpolicyprocessestoimplementISAinhealthfinancing,keydriversshapingimplementationoftheISA,opportunitiesandchallengesinimplementingISAinhealthfinancing,andfinallythelimitation.Resultsfromthedeskreviewandstakeholderanalysiswaspresentedinnarrativeformwithquoteswherenecessary.

2. Initiation of the policy on health financing2.1 International Call for Innovative Health Financing Reforms

In2001,theAfricanHeadsofStatecommittedthemselvestoallocateatleast15%oftheirnationalannualbudgetstoimprovingthehealthsector(TheAbujaDeclaration).InMay2005,the58thWorldHealthAssemblyadoptedaresolutionthaturgesMemberStatestoensurethathealthfinancingsystemsincludeamethodforprepaymentoffinancialcontributionsforhealthcare,withaimtopromotesharingrisk(WHO,2005).Theworldhealthreports2008and2010andresolutionWHA62.12andWHA64.9,highlighteduniversalcoverageasoneofthe4keyspillarsofprimaryhealthcareandservicesthroughpatient-centeredcare(WHO,2010).UnderresolutionWHA62.14“Reducinghealthinequitiesthroughactiononthesocialdeterminantsofhealth”(RiodeJaneiro,Brazil,21October2011).StillinWHOreport(2010),RwandaishighlyacknowledgedforachievingUniversalcoverageandthereport further calls for intersectoral action to strive for sustainable universal health protection through intersectoral and development partners actions.

2.2 National Health Financing Policy Reforms in Rwanda

RwandahasacknowledgedtheimportanceUniversalhealthcoveragethrougheffectivehealthfinancing—asevidencedfromEDPRSplanning2012-2018(MINECOFIN,2012).Additionally,manyauthorshaveconsistentlyidentifiedfinancialaccessibilityasthemajorobstacletoaccessinghealthservicesinLMIC((NISR),2011;Basinga,2011a;Murray,2010;Savigngy,2009;WB,2004).Particularly,Rwandahashadmajorobstaclerelatedtofinancialandgeographicalaccessibility,inadditiontolackofknowledgefortheuseofhealthservices.Particularly,maternalandchildhealthservicesfaceduniquechallengesrelatedtodelaystoseekhealthcareservices.Delaysinclude:takingtimelydecisiontoseekcare,traveltoseekcare,waitingforhoursathealthfacility,anddelayinmakingdecisiontotreatortransfertothenextlevelofcare.Throughbroaderconsultativeprocesseswithpartnersandrelevantsectors,suchMinistryofFinanceandthatofLocalGovernment;andPrimeMinisters’office,theMinistryofhealthdevelopedacomprehensivehealthfinancingpolicyframeworkbasedonnationalandglobalhealthcarefinancingbestpracticestorespondtothefinancialaccessibilityproblems.Thehealthfinancingpolicyisbuiltonthecoreprincipalthatthecountryneedstoprotectallindividualsandfamiliesin both formal and informal sectors of the economy from out-of-pocket health care expenditures.

InanassessmenttodocumentISAinRwanda;PolicyissuesintheEconomicDevelopmentPovertyReductionStrategy(EDPRS)suchasimprovingthequalityofhealthcare,demandandaccessibilityof

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healthcarewereidentifiedascriticalpolicyissuestobeaddressed(UnpublishedWorkforWHOReport-Rwanda,2013).Policyoptionsincludedexpansionofgeographicalandfinancialaccessibilitythroughconstructionoffeederroadstoimprovingaccesstohealthservicesaswellasavoidingout-of-pocketspending.Supportingthevulnerableandextremepoorbyuseofsocialprotectionmechanisms,ensureincreasedavailabilityofdrugs,vaccinesandconsumableswasalsothoughabout.Inaddition,thegovernmentthroughfinancialincentivesencouragesprivatesectortoplayamajorroleinhealthcareservicesdelivery(MINECOFIN,2012). Theefforttoexpandedhealthprotectioncoveragepolicytookplaceonwasgradualbasis,andthisrequired political and broader consultative mechanisms to ensure that formal and informal sectors of the economyarecovered.Fortheformalsectorcoverage,amedicalinsuranceplan(policy)wasestablishedin2001[Rwandaised’AssuranceMaladie(RAMA)]tocoverpublicservantsandtheirdependents;plusprivatesectors(butnotindividuals).ThroughMinistryofDefence(MoD)andMoH,theMilitaryMedicalInsurance(MMI)wasestablishedtocoverthemilitaryandtheirciviliandependents.Thereareseveralotherprivatehealthinsurancescoveringaminorsegmentofthepopulation,mostlythoseworkinginthebankingsector.Fortheinformalsectorcoverage,theCommunity-BasedHealthInsurance(CBHI)wasformallyfirstintroducedin1998inthe3districtsoutof30(MoH,2005,2011b).Between2005and2005,astandardevaluationdemonstratedthatthe3pilotdistrictshadimprovedfinancialaccess(reducedout-of-pocket)andimprovedutilizationofhealthservices(Lu,2013;MoH,2011b)

Underhighlevelpoliticalleadership(presidents’office,MinistryofLocalGovernment,andMinistryofFinanceandEconomicPlanning)andwithsupportfromdevelopmentpartners,thecountryengagedinnationalscaleupofCBHIandby2004,enrolmentratehadreachedabout85%,andbyendof2011,theenrolmentratehitrecord92%.TheorganizationssuchastheUSAIDprovidedtechnicalsupportduringthepolicydesignandfinanciallyandtechnicallysupportedevaluationstudiestoinformthepolicymakers.Particularly,ManagementScienceforHealth(MSH)hasgreatlysupportedandpromotedCBHIfrompilotstocountrywidescaleup.

Multilateralinstitutions,suchastheWorldBankandUNsystemsvehementlypromotethecoverageoftheinformalsectorthroughCBHI(UN,2012;WB,2004).BecausethemembersoftheCBHIarepoorandcomposebiggersegmentofthepopulation,thegovernment,throughhealthfinancingpolicy,introducedasystemofco-financingtheCBHIwherebyotherinsurancescoveringformalsectormakeanannualsharecontribution(about1%oftheirannualcollection)totheCBHItocoverthedeficits.Inaddition,theGovernmentcontributestotheCBHIfundtofurtherboostpoolinginanefforttocoverupthedeficit.Forthepoorest,whoprove(thereisacriteriaforwealthyrankingatthecommunitylevel)theycannotaffordthepremiums,thegovernment,somepartners;includingchurch(faith-basedorganization)coverstheirpremium.

2.3 Introducing the Performance-Based Financing (PBF) Policy

In2000,theGovernmentofRwandawithsupportofpartnersinitiatedPBFandstartedimplementingthis provider payment mechanism policy in 3 out of 30 districts. The policy aimed at addressing or improvingqualityandquantityofthehealthservicesofferedbyhealthworkersaswellastostrengthencapacityofinstitutionsintermsaccountabilityandgovernance(MoH,2005).The3pilotdistrictswerepurposivelyselected.ThePBFmodelremuneratedhealthfacilitiesandhealthworkers(doctorsandnurses)forimprovementinqualityandquantityofmaternalandchildhealthindicators.About5yearslater,astandardimpactevaluation(treatment-controlcomparison)wasconductedwhichshowedthathealthfacilitiesthatreceivedtheprogramimprovedindicators(Basinga,2011b).In2006,withthesupportofpartners,thehealthfinancingpolicywasscaledupcountrywide.In2009,thePBFwasscaledup to the community level to address challenge of access that had been discovered during impact evaluation.InCommunityPBFmodel,CHWsareremuneratedbasedoncoverageofselectedprimary

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healthcareindicators,whilewomenareprovidedwithin-kindincentivesforup-takeofpre-conditionedservices—thoserelatedtoMCH(Humuza,2010).

InalltheseprocessestheMinistryofHealthwasnotactingalone.OthersectorssuchasMinistryofLocalofGovernmentaswellMinistryofFinanceplayedkeyrolesinensuringsuccessfulpolicydesignandimplementationprocess.TheMinistryofFinance,agreedinthenameofGovernmenttocoveritssharecontributiontoPBFbasketfunding.TheMinistryofLocalgovernmentsupportedthepolicyacceptance to implement the policy along its district administrative structures and its staff at district levels to get involved in implementation process. Development partners stood upfront to support andpromotetheinitiate.GlobalFund,WorldHealthorganization,WorldBank,USAIDimplementingagencies,etc.wereactivelyinvolvedtomakesurepolicieswerewelldevelopedandimplemented.

WithUniversalHealthCoverageandusingPBFapproachtoimprovehealthworksmotivationtodeliverqualityandquantityofhealthservices,RwandahasbeenacknowledgedbytheinternationalcommunityasanaprobableexampleforotherLMICtoimprovecoverageandprotectpopulationfromout-of-pocketexpenditure,whilealsoimprovingdeliveryofhealthservicesthroughsupply-side(WB,2004;WHO,2010).However,policymakersanddevelopmentpartnersareworriedofchallengesmainlythoserelatedtosustainabilityoftheprogram(seechallengesinthenextsectionsofthereport).

3. Description of policy process for intersection actionThehealthfinancingpolicytakesseriouslytheinclusionoftheInformalsector(populationininformaleconomywhosetaxesarenotcapturedingeneraltaxcollection)intothemainstreamhealthfinancingthatconstitutemajorityofthepopulation(about85%).TheFormalhealthinsurancecoverslessthan15%oftheapproximately11millionpopulations.Forthesupplyside,theGovernmentendorsedPBFpaymentmechanismimplementationpolicyandpaysitssharecontributiontobasketfundwherepartnersalsoaddtheirshare.Below,wedescribehowthedifferentGovernmentactorsanddevelopmentpartnershaveactedintersectorallytoimplementhealthfinancingpolicy(HealthInsuranceandPBFpolicies).ThetablebelowshowstargetsforthemainfinancingindicatorsasderivedfromtheHealthSectorStrategicPlanIII,underitshealthfinancingpolicysection.

Table 1: baseline and TargeTs in HealTH Financing oF HssP iii

3.1 The Role of Top Leadership

Inthiscasestudyreport,weconsidertopleadershiptobethehighlevelleaders,suchas:HEthePresidentsoftheRepublicandMembersoftheParliament.Below,wedescribetheroleplayedbythetopleadershipinimprovinghealththroughintersectoralactioninhealthfinancing.

HE The President of the Republic

HEthePresidentoftheRepublicofRwandasignsperformancecontractswithDistrictMayorstoenhanceservicedeliveryandimprovewellbeingandhealth of the population. One of the critical activities undertheperformancecontractsisUniversalHealth

Key Outputs / Outcomes Baseline 2011 Targets 2015 Targets 2018

% GoR budget allocated to Health 11.5 12 > 15

Per capita total annual expenditure on health $ 39.1 $ 42 $ 45

Per capita allocation to PBF (USD) 1.8 2.0 --

% Population covered by CBHI 91 95 --

Source: Health Sector Strategic Plan III, 2012-2018

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ProtectionthroughimprovedCBHIenrolmentrates.Ineffect,allDistrictMayorstakeseriousincreasingtheenrolmentratesincommunitiesbecauseeveryyear,thePresident’sOfficedoesexternalevaluationondistrictperformancecontracts,andbelowcertainperformancelevels,mayorsaresackedfromtheirposition.Additionally,inallpublicspeeches,thepresidenttalksaboutCBHIenrolmentsaspriorityissueandencourageseveryoneinthecommunitytobecoveredthroughCBHIifnotcoveredinotherinsurance forms.

The Members of Parliament

InRwanda,MembersofParliament(MPs)areconsideredasopinionleaders.Thereareseveralclustersintheparliament,includingthehealthandsocialwelfarecluster.Underthiscluster,theMPshave the responsibility to reach out the population in their respective constituencies to explain the country’spolicypriorities.AmongthepolicyprioritiesoftencitedareexplicitlyexplainingthebenefitsandencouraginglocalpopulationtoenrolintheCBHIscheme.Thecommunitymembersaregivenchance to ask any problems or challenges they face. And one of the critical challenges is the relatively lowqualityofhealthservicesinadditiontolowvolumeofservicepackageundertheCBHIbenefits.TheMinistryofLocalGovernmenthasestablishedclearcriteriathatrankthepopulationaccordingtheirwealthwherethe“poorest”areprotectedfromtheout-of-pockethealthexpenditures.

3.2 Other Sectors (Key Relevant Ministries)

The Ministry of Local Government (MINALOC)

MINALOCisinvolvedinallsectoralaffairsdueitsroleingovernance.UnderMINALOC,acrosscuttingprogramcalledHealth,SocialDevelopmentandChildProtectionwasbeenjointlydevelopedwithMoHandimplementedandthisledtojointactionforhealthinhealthinsuranceorCBHI,familyplanning,childimmunization,fightingmalaria,fightingHIV/AIDS,andGenderParity.All30districtsthatmakeupthecountrywereprovidedwithresourcestoimplementrelevantactivitieswhoseoveralleffectshavehaddirectorindirectimpactpopulations’health.Inonestudytoassesstheintersectoralactiononhealth,akeyinformantfromMINALOCstressedthecountry’sneedistostrengthencurrentsocialhealthprotectioneffortsthroughcommunity-basedhealthinsurance(seebox1).

MINALOCisinchargeofidentifyingvulnerablegroupssuchPeoplewithDisabilities(PWDs),FALGchildren(FundforGenocideSurvivesChildren),demobilizedsoldiersandsupportthemfinanciallyto access essential health services based on subsidized service costs. Institutions involved in thesupportoftheinitiativeinclude:MinistryofwomenGender&FamilyPromotion(MIJEPROF),Nationalcouncilofchildren,MinistryofEducation(MINEDUC),MoH,MinistryofYouth(MINIYOUTH),CivilSocietyOrganizations(Cos)andNGOs.MINALOCprovidesoverallguidance.ThepoorestpeopleascategorizedbyUbudehe(seedefinitionofubudehe)—aMINALOCwealthrankingsystem.TheypaymentaremadebylocalauthoritiesorthroughCBHIscheme.

The Role of Decentralized Levels (Districts)

Theroleofdistrictinsupportingtheimplementationofthehealthfinancingpolicycanbeseenfromfourmaindimensions:

First,thedistrictsundertheleadershipofmayorsareunitsofLocalGovernment—theyrepresentministryofLocalGovernment.Thedistrictleadersworkwithlowestadministrativeunits(sectors,cells

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andvillages,throughCommunityHealthWorkers)tomobilizethepopulationontheadvantagesofenrollingintheCBHI.Theindicatoronenrolmentrateisincludedinalmostallperformanceindicatorsfromthedistricttothelowestadministrationlevel(cellsandvillages).Therefore,thedistrictleadersandotherhealthleadersfromwithindistrictsworktogethertomobilizethepopulationandfacilitatethemtoenroltotheCBHIscheme.

Secondly,thedistrictsareinvolvedinimplementingseveralstrategiestoachievecertainpriorities,includingthoseofhealth.Healthfinancingpolicywasimbeddedintheimplementationofcore Imihigo3 program targets. ImihigowasthetermusedinRwandaforcenturiesbytheking,hissubordinatesandthepopulation/followers(Musahara,2007).Today,thesameconceptsareusedwherebythePresidentoftheRepublicsignscontractswithDistrictMayorsforattainingcertainperformancetargets.MobilizinglocalpopulationtoachievecertainCBHIenrolmentlevelsareamongprioritytargetssignedinthecontractbetweenmayorandHEthepresidentoftheRepublic.Theindicatoronenrolmentrateissignedunderthebroadercategoryon:Health,SocialDevelopmentandChildProtection.Imihigo hasbeenwidelyseenasmaindrivertowardsachievingthecurrenthighrecordCBHIenrolmentrateinRwanda(Rwiyereka,2013).

Thirdly,thedistrictofficialsworkwiththelocalbanksknownasBanque populaires to offer soft loans to thelocalpopulationwhowishtoborrowmoneyandpaytoCBHIschemeinordertobeenrolled.Thebankloanrepaymentsoftentakeperiodofoneyear.Thishasworkedinmostandismoreasstrategythatcansustainschemethroughownershipofthescheme(MoH,2011b).Atdistrictlevel,themayorshavethemandatetohireandsackhealthworkers(Doctors,nurses,labtechnicians,etc.)fromdistricthospitalsandhealthcenters.ThedistrictMayorcoordinatesimplementation of policies including those of health. The mayor through the staff in charge of health atdistrictareresponsibleforoverseeingthehealthfinancingpolicyimplementation—ensuringthatallinputsnecessaryforimplementationofthispolicyareinplaceandreportsonoutput(indicators)onroutinebasis(managedatabaseforCBHIandensureremunerationforthestaffforCBHIandPBFpayments).Thedevelopmentpartnersatthedistrictlevelarealsoresponsibleforsupportingtheeffortstoimplementvariouspoliciesincludinghealthfinancing.

Ministry of Finance and Economic Planning (MINECOFIN)

HighpopulationgrowthposesamajorchallengeinRwanda(MINECOFIN,2010).Thecountryhaschosen to integrate population issues in the broader national development agenda to tackle the problem.Thestrategicplanaimsatensuringabalancebetweensocio-economicdevelopmentsbuildonthefoundationofahealthypopulation(MINECOFIN,2010;MoH,2012).Strategiescurrentlyinclude:mainstreamingpopulationissuesintosectorandDistrictDevelopmentPlans(DPP),conductcountrywidemobilizationcampaignondangersofhighpopulation,theimportanceofenrollingintheCBHItoaccesshealthserviceswheneverthereisneed,disseminatethenationalpopulationpolicy,includinghealthfinancingandCBHIatalllevelsandmonitorthepopulationindicatorswithrespecttoEDPRS,MDGsandVision20204(MINECOFIN,2012;MoH,2012).Intrackingpriorityhealthindicators,theMoHworkjointlywithMINECOFIN

3 The Imihigowasa“positivemechanisminregulatingpeople’seffortsandenergiesintheirendeavourstoensuretheirsecurityandprosperity”.Itengenderedplanning,executionoftasksindividuallyoringroupsinacompetitivebutamicableatmosphere.Intheimplementation of tasks everybody strove to get the best results possible and this encouraged emulation in the society at large. Consequently,thesocietybenefitedfromsuchspiritofpositivecompetition

4Vision2020isGovernmentleadingplanningdocumentthatseektotransformRwandaintomiddle-incomecountryby2020.Allsectoralpolicies and strategies are aligned to this document.

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to ensure that regular reports are submitted on time in order to avoid delays in implementing programs. Likeinmanycountries,theroleofMINECOFINistoworkwithothersectorstoensurethattheprioritiesareimplementedinintersectoralmannertooverallimprovewelfareofthepopulation.TheMINECOFINhassupportedtheMoHeffortsto:expandhealthinfrastructureincludingequippingpublichealthfacilities,communitymobilizationviaCHWforfullparticipationinhealthcare(enrolmenttotheCBHIanddemandforhealthcareservices).“Avoidfragmentedofhealthinsuranceschemesandimprovefinancialsubsidiestothepoorestandensurechargesmirrorabilitytopay”.Thereareseveralpartnersinvolvedintheseactivities:themainonesincludeMINALOC,MINIYOUTH(MINECOFIN,2012).TheroleofMINECOFINinthesupportingtheperformance-BasedFinancingpolicyhasbeenoutlinedinthesubsequentchapters.AninformantfromMINECOFINnarratesthatthereMinistryplanexpandfurtherfeed roads so that all health centers are interconnected so that ambulances can move freely from one level to the other.

Ministry of Women, Gender and Family Promotion (MIGEPROF)

MIEGEPROFisanothersectorthathasareasofintersectoralactionwithMoH.In2002,MIEGEPROFinpartnershipwithUNFPAconductedastudyon“beliefs,attitudesandsocio-culturalpracticesinRwanda”whereamongotherthings;thestudyillustratedhowseveralsocio-culturalpracticesespeciallyamongwomenhavehadnegativeaffectsonhealthoutcomes(RWAMREC,2012).AlsointhestudyconductedbyUNWOMENin2010(onMasculinityandGenderbasedviolenceinRwanda),thestudyshowedthatincreasingnumberofpeopleareabusingalcoholanddrugthisisthemajorsourceofviolence.Thestudyshowedthatexcessivealcoholusealsoleadstomostdomesticviolence,rape,andtheft,evendeath.TheMinistriesofYouthandthatofCultureareworkingMIGEPROFandMoHtoaddress these behaviours.

Abottomupstrategywassuggestedsuchascommunity-basedprogramsandpoliciesthatguidewomenandmenintochangingattitudestowardshealth,education,justice,andeconomicempowerment(development).Throughalsocommunity-basedapproach,MIGEPROFsupportsthewomenvictimsandsinglemotherswhoareaffectedbytheconsequencesofthesehabits.

Other NGO Working in Health Sector

EventhoughtheMOHhasoverallstewardshiponallhealthrelatedissues,15othergovernmentministries implement activities that either directly or indirectly impact on the health of the people (MoH,2012).Inadditiontothe15GovernmentMinistries,thehealthsectorissupportedbyseveralDevelopmentPartners(DPs),Faith-BasedOrganizations(FBOs),andNon-GovernmentalOrganizations(NGOs).Differentcadreswithvaryingqualificationsprovideservicesatdifferentlevelsofthehealthcaresystem.ManyNGO’splayanimportantroleinimprovinghealththroughtheintersectoralactiononhealthfinancing.Forthechurch(public,confessional,private-for-profitandNGO)aredirectlyinvolvedinthe supporting community to provide care and supporting to cover annual premiums subscriptions for poorest category of the population.

4. Experience / lessons learnedRwandahasmadesignificantprogressinimprovingtheavailability,distributionandmotivationofqualifiedhealthpersonnelthroughinnovativehealthfinancingpolicies.Currently,bothformalandinformalsectorsoftheeconomyhaveimprovedaccesstohealthservicesthanbefore.However,policychallenges still remain that can be routinely addressed through future policy reforms.

4.1 The Lessons/Experience learnedWiththesupportofothersectors(MINECOFIN&MINALOC)anddevelopmentpartners,Rwandahasrecordedhighrevenuemobilizationfromdomesticsources,mainlyorganizedinCBHIschemes

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andotherprivateinsurances;andincreasedpublicfunds(fromtax-basedfunding).Asresultofgoodgovernanceandusingthedonormoneymoreefficientlycoupledwithrelativelylowlevelsofcorruption,therehasbeensustainedincreasedexternalfundingchannelledthroughgeneralbudgetsupport,sectorbudget,andprojectsupport(wherethelargestshare(63%in2010)ofTotalHealthExpenditure(THE)camefromdonorfunding;comparedtoashareof53%ofTHEin2006.Duetoincreasedfunding,totalhealthexpenditurehasincreasedto$401million(in2010)whichtranslatesto$39.1percapita(havingincreasedfrom$34percapitain2006)andareductioninout-of-pocketspending(downfrom28%)(NHAunpublishedreport2009/10.

UndertheMoHleadership,severalsectorscontributedtotheimplementationoftheinnovativehealthfinancingpolicy(CBHIandPBF).ThecoverageofhealthinsuranceinRwandahasincreaseddramaticallyovertheyears,withover78%ofhouseholdsestimatedtohavebeencoveredattheendof2010,ofwhich97.7%ofhouseholdsreportedinsurancecoverageundertheCBHI(DHS,2010).TheCBHIdatabaseshowed85%CBHIcoveragein2011whiletheformalsectorschemesandprivateinsuranceaccountforabout7%ofthepopulation,bringingthetotalhealthinsurancecoverageto92%.CBHIschemesnowcovertheentire30districtsthatmakeupthecountry.AlatestCBHIPolicywasdevelopedin2010andimplementedstartingatstartofJuly2011toaddresstheemergingchallengesofCBHIimplementation,suchas:institutionalcapacitybuilding,financialsustainabilityandimprovedequitableaccess,poolingresourcesfromvaryingsources(Government,donors,civialsocietyorganizations,andmembersandmandatorycontribution),andfurtheraddressissuesthroughcross-subsidizationbetween“better-off”healthinsuranceschemeswithhighrevenuesandlowriskpoolsand“worse-off”schemessuchastheCBHIhave.

IntersectoralactionshavebeenalsoinwherethroughtheMoH,MINECOFINandcentralbank,theGovernmentpurchasesservices,by(a)providingdirectfinancialsupporttohealthfacilities(b)throughperformance-basedfundingtohealthfacilities,and(c)directcontributionstoCBHIfundtocoverthepercentageofthepopulationidentifiedaspoor.DevelopmentPartners(DPs)supporttheeffortsofgovernmentthroughGeneralBudgetSupport(GBS),SectorBudgetSupport(SBS),andthroughcontributionstoPBFandsupporttoCBHI.Households(HH),ifnotcoveredbyanyinsurance,willpaydirectlyOOPforservicesthroughuserfeesatthepointofuse.ThepopulationcoveredbyCBHI,RAMAandMMIhaveareasonablycomprehensivebenefitpackagethathasgreatlyreducedcatastrophicexpenditures.

PBFintroducesanincentivetofacilitiestomaintainanoptimumstaffinglevelinordertomaximizefinancialincomeandincentivesforstaff(henceintroducesincentivestoimprovetheefficiencyoffacilities),basedonanimpactstudyconductedbySPH/WBin2011wherePBFwassingledouttohavehadsignificantimpactoninstitutionaldeliveries;preventivecarevisitsbyyoungchildren,improvedqualityofprenatalcareandencouragesindividualandmarriedcouplesVCT.

DuetosupportfromtheMINALOCandMINECOFIN,thePBFmodelwasscaledfrompilottocovertheentirecountry’shealthfacilitiesandgraduallytootherlowerlevelsofthehealthsystem,includingthecommunity-level.Despitesomechallengesattheinitialimplementationstages,PBFiscurrentlyconsideredakeyfinancingmechanismanditsimplementationisbeingstreamlinedandenhancedtoincludethelowestlevels.WithinthePerformance-basedfinancingframework,providersarereimbursedonafee-for-servicebasis,thuscreatingincentivesfor“over-servicing”.PBF,asamechanismforpurchasingservices,isthesecondlargestexpenditureitemandrepresents10%ofthetotalMedium-TermExpenditureFramework(MTEF)forhealth.ThePBFallocationwasmorethandoubletheplannedpublicexpenditureonhumanresourcesforhealth,includingsalariesandwagesin2012.

InRwanda,PBFapproachhasbeenwidelyseentosignificantlycontributetothehealthworkers’motivation,improvedfinancialaccesstohealthservicestoclients,andminimizedinternalmigrationof

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healthworkersfromhealthfacilitiestotheNGOwheretheygetmorepay(MoH,2011b).LikeinmanyLMICimplementingthePBFapproach,Rwanda’scriticalchallengeremainsitssustainabilityasbigshareoffundingcomesfromthedevelopmentpartners.However,Rwandaisstrivingtokeepthestrategyby:increasingmoreresourceallocationtoPBFfrominternallygeneratedrevenues,mobilizingmoreinternalresources,andusingpartoftheinsuringtofinancePBFprogram.TheGovernmentishopefulthat,withthesestrategies,thePBFapproachcannotderailbutratherkeepsurviving.IntheHSSPIII2013-2018,theGovernmentthroughMINECOFINplanstospendmore2.0%ofthecapitaallocationby2015,morethan1.5spentfrompreviousyears(MoH,2012).

4.2 The Challenges

Notwithstandingtheexcellentachievementsinhealthfinancing(healthinsuranceandPBFapproach),thefollowingkeychallengesremain,andifnotcarefullyaddressed;thethreatsmightderailthealreadyachieved results.

Therearestillpolicyobstaclesthataffectsmoothimplementationofhealthfinancingpolicy.Themainonesinclude:weakprivatesectorwhichmakelessthan10%oftotalfacilities,accesstohealthservicesinremoteareasstillanissue,whileimprovementtofinancialaccessibilityhasregisteredrecordhigh,this has also compromised the quality of care and sustainability over years to come remain a issue for both the Government and development partners.

ThereisstillneedtostrengthenthemanagementstructuresoftheCBHIandconsiderappropriateinterventionsforensuringthesustainabilityofCBHIfunds.Managementcapacitiesatthesector,districtandnationallevelsstilllowandneedstobestrengthenedinordertoimprovetheinstitutionalsustainabilityoftheCBHI.

ItisimportantthatMINECOFINsustaintheincreaseinfinancialallocationtotheMoHinordertosustaintheincreaseinpublicexpenditureonhealth.However,asthecountry’sincomegrow,thepoorpopulationwillaffordtobuyinsuranceandactuallyexpandontheservicepackage.MINALOChasbeencritical in supporting and strengthening the administrative structures and increasing accountability for all staffworkingforCBHI.Despitetheexistingcoordinationmechanismsbetweenthepartnersandsectorsonimplementingthehealthfinancingpolicy,alignmentandharmonizationframeworksinplace,theflowofexternalfundsandinformationaresometimesnotalignedaswouldbeexpected.Thereisneedtoimprovestrongsectoralandstakeholders’coordinationmechanismtostrivesforenhancedequityinallocation of resources.

5. Conclusions and recommendationsRwandahasimplementedinnovativehealthfinancingpolicies.Throughthesupportofothersectors,MoHmanagetodevelopthesepoliciesandeffectivelyimplemented.Theresultsfromtheimplementation have been applauded by the many in the international community calling for other LMICwithsimilarcontexttolearnmoreaboutRwandainreformingtheirhealthcaresystem.Rwanda’s92%ofits11millionpopulationiscurrentlyprotectedfromcatastrophichealthcareexpenditures.ThePBFpaymenthasabitstabilizedthehealthworkersbecauseofPBFpaymentsystem.Thehealthoutcomesespeciallytheprioritytargetshavebeenonthesteadyincrease,andRwandaisonclearpathtoachievetheMDG#4.Othersocioeconomicareashavealsobeengrowingwithpercapitaincomegrowth,povertyreduction,andimprovedfoodsecuritythroughagriculturalintensificationprogram.Thegender-basedviolenceisbeingaddressedintersectorallyamongtheNationalPolice,MIGEPROF,MoH,MINECOFIN,andMINALOC,andsomemembersoftheUNSystem.

Whereastheachievementshavebeenoutstanding,thesustainabilityremainsabigchallengeforboththegovernmentanddonors.Morethan50%ofthefundsthatfinancethehealthcomefromdonors.

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Thereforesustainabilityisnotassuredshoulddonorspullout.Inaddition,theinternationaleconomiccrisis that has hit global economy might affect the results already observed. Therefore donors and RwandanGovernmenthaveinterestinavoidinganysetbackthatcanderailthealreadyachievedresults.RwandaandDonorsneedstoworkoutamechanismthatwouldsustaintheresultsattainedthusfar.Intersectoralactioncancontributeheavilytosustainingtheseresults.Theministrieswhoseactionshaveprofoundimpactonhealthoutcomesneedstobeaddressedbroadlywithallpertinentsectorsand funding sought to improve health issues in non-health sectors and there is a need for a strong collaboration on this.

6. Limitations to this studyTherearethreeessentiallimitationsofthiscasestudy:

1) Methodologicalissues:thestudyplannedtousedata/informationfromdocumentreviewandstakeholderinterviews.However,theresultsreliedmoreonthedocumentreview.Wedidfewstakeholderinterviews—wethinkbyconductingmanystakeholderinterviewscouldnothavechanged the outcome of the case study

2) Thesecondlimitationwasshortageofpublicationinthepeer-reviewedjournalfortheinformationwewerelookingfor.ThereislimitedliteratureparticularlyforRwanda.Wecanexpandonthispieceofworktodocumentdeepintersectoralactionsandeconomicsbehindstheseacts—actingtogether or not acting.

3) Wefailedtofindsimilarcasestudieswithintheregiontoattemptthecomparisonwithourcasestudy.Itwouldbehelpfultodevelopsimilarcasestudieswithintheregiontoexamineifintersectoralactioninhealthfinancingimprovedhealthservicedeliverytothebeneficiaries.

AcknowledgmentsThisdocumentwaspreparedwiththesupportoftheRockefellerFoundation(grantno.2012THS317)aspartoftheRockefellerTransformingHealthSystemsInitiative,Supporting the Development of Regional Positions on Health in All Policies and Identifying Lessons and Opportunities for Implementation (for the sake of brevity: Supporting Regional Positions on Health in All Policies).Thegrant,receivedbytheDepartmentofEthicsandSocialDeterminantsofHealthoftheWorldHealthOrganization(WHO),aimedtosupportevidence-informeddecisionsonhowgovernmentscanenhanceintersectoralapproachestoimprovehealthandhealthequitythroughimplementingaHealthinAllPoliciesapproachinthreeWHOregions:Africa(AFR),South-EastAsia(SEAR)andtheWesternPacific(WPR),withaparticularemphasisoncontributingtoevidenceanddialogueinrelationtotheWHO8thGlobalConferenceonHealthPromotionin2013.Theprojectteam,coordinatedbyMsNicoleValentine(principalinvestigator)oftheDepartmentofEthicsandSocialDeterminantsofHealth,included,forWHOheadquarters,MrTomasAllen(librarian),XeniadeGraaf(intern)andDrOrielleSolar;fortheregions:DrTigestKetsela(WHOAfrica),DrDavisonMunodawafa(WHOAfrica),andMrPeterPhori(WHOAfrica),DrSuvajeeGood(WHOSEAR),DrShilpaModiPandav,ProfessorKRNayar,MsAnjanaBhushan(WHOWPR),andMsBrittaBaer(WHOWPR),ProfessorSharonFriel,MrPatrickHarrisandMsSarahSimpson.ThecasestudywasdevelopedandwrittenbyJ,Humuza1;J,Shema2;JB,Gasherebuka3;L,Rugema4;JL,Mukunzi5

1DepartmentofHealthPolicy,Economics,andManagement,SchoolofPublicHealth,NationalUniversityofRwanda;2HealthFinancingUnit,MinistryofHealth;3WorldHealthOrganization,RwandaOffice;4DepartmentofCommunityHealth,SchoolofPublicHealth,NationalUniversityofRwanda;5HealthFinancingUnit,MinistryofHealth.

References1. (NISR),N.I.o.S.o.R.(2011).The Third Integrated Household Living Conditions Survey (EICV3).NISR.2. Basinga.(2011a).EffectonmaternalandchildhealthservicesinRwandaofpaymenttoprimaryhealth-careprovidersfor

performance:animpactevaluation.Lancet,377,1421–1428.3. Basinga.(2011b).Performance-basedfinancing:theneedformoreresearch.Bull World Health Organ,698-699.4. DHS.(2010).Demographic and Health Survey.MinistryofHealth:MoH.5. Humuza.(2010).Program Implementation Manual.MinistryofHealth:MoH.6. Lu,C.(2013).TowardsUniversalHealthCoverage:AnEvaluationofRwandaMutuellesinItsFirstEightYears.Journal.

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8. MINECOFIN.(2012).Economic Development and Poverty Reduction Strategy 2013 – 2018.MinistryofFinance:MinistryofFinance.

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Watertown,MA02472USA:PATHFINDERINTERNATIONAL.15. RWAMREC.(2012).MasculinityandGender-BasedViolence:TheexprienceofmenandWomeninRwanda.MIGEPROF:

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Table of abbreviationsBP BanuqePopulaire(popularBankmostlyfrequentedbylocalpopulation

CPBF Community-Performance-BasedFinancing

CBHI Community-BasedHealthInsurance

DP Development Partners

EDPRS EconomicDevelopmentPovertyReductionStrategy

HDI HealthDevelopmentIndex(UNDP)

IHLCS IntegratedHouseholdsLivingConditionsSurvey

ISA Intersectoral Action

LMIC LowMiddleIncomeCountries

MCH MaternalandChildHealth

MDGs MillenniumDevelopmentGoals

MIGEPROF MinistryofGender,WomenandFamilyPromotion

MINALOC MinistryofLocalGovernment

MINECOFIN MinistryofFinanceandEconomicPlanning

MINEDUC MinistryofEducation

MMI MilitaryMedicalInsurance

MoD MinistryofDefence

MoH MinistryofHealth

MTEF MediumTermExpenditureFramework

NISR NationalInstituteofStatisticsofRwanda

PBF Performance-BasedFinancing

RAMA RwandaMedicalInsuranceforcivilservants

UHC UniversalHealthCoverage

UNDP UnitedNationsDevelopmentProgram

UNCEF UnitedNationsChildrenEducationFund

WB WorldBank

WHO WorldHealthOrganization