The important governance functions related to the health sector are the legal framework, decentralization, and coordination with the various stakeholders.
Table 39. Baseline and targets in Regulation and Decentralization
TOPIC EXPECTED OUTPUTS /
OUTCOMES BASELINE 2011 TARGETS 2015 TARGETS 2018 4.1. Regulatory framework, decentralization and Intersectoral activities
% District that hold at least two effective DHMT meetings with stakeholders (comprehensive district annual planning, budgeting, reporting timely)
0 90% 96%
% Districts having quarterly health commission meetings.
16% 84% 96%
% GOR funds disbursed to districts (grants: national health budget plus district transfers)
31.4% 45% 60%
7.1.1 Governance structures and stakeholders
The situation analysis distinguishes five different sets of actors. Together they are the stakeholders involved in the governance of the health sector:
1. State actors in the public sector (MOH, other ministries, and local governments); 2. Health providers (public sector, private sector, and NGOs, CSOs, FBOs)
3. Civil society and professional bodies; 4. Beneficiaries and clients;
5. Development partners (bilateral and multilateral) and international NGOs, such as MSH, the Clinton Health Access Initiative (CHAI), and others (mainly involved in supporting national programs).
Governance structures in the health sector distinguish between (1) central and local administrative structures with constituency representative functions and (2) implementing agencies, responsible for providing health services to the population. The various levels of the health care pyramid are thus governed by the formal structures shown in Table 40.
Table 40. Governance structures in the health sector
LEVELS ADMINISTRATIVE STRUCTURES IMPLEMENTING AGENCIES
National Parliament / Government Ministry of Health
Province Governors Provincial Hospital (not yet in
place) District District Councils / Executive Committee
/ District Health Unit
District Hospital / Hospital Board
Sector / Umurenge Elected councils / Executive secretary and staff
Health Center / Health Center Committee
Cell / Akagari Elected councils / Executive secretary and staff
Health Post / Community Health Worker
Village /
Umudugudu
Village council / Village coordinator and staff
CHW
Performance contracts.
In addition, staff at all levels sign performance contracts with their supervisor / responsible person (Imihigo system). These performance contracts are formulated in terms of outcomes and outputs and mention in detail what the person is expected to achieve. In this way, these contracts are a planning, M&E, and accountability tool. For example, the thirty district mayors not only sign an annual performance contract with the president, but the deliverables mentioned in that contract (including health-related outputs coming from the sectors) are checked and verified before a decision is made about signing another contract for the next year. The district mayors sign performance contracts with each of the sectors belonging to their districts, thereby establishing a chain to the lower levels.
Similarly, the minister of health signs a performance contract with the president of Rwanda once a year in which baselines and specific targets are included for the various priorities of the sector. The outcomes, outputs, and indicators included in that contract are derived from EDPRS and other GOR priorities.
Operational collaboration.
As shown in Annex 2, the establishment of the Rwanda Biomedical Center has brought together under one roof a variety of institutions, most importantly (1) the Department of HIV/AIDS, Disease Prevention and Control, (2) the Department of Medical Production and Procurement, (3) the Medical Maintenance Division, (4) King Faisal Hospital Department, (5) the Rwanda University of Medicine and Health School, (6) Rwanda Health Communication Center, and (7) the Division of Medical Research. Together, these institutions are governed by a director general supported by a Board of Directors. An important consequence of this restructuring is that the Rwanda Medical Faculty and other training institutions that provide pre-service training to medical staff (nurses, midwives, lab technicians, etc.) have been brought under the responsibility of the MOH. However, this might change in the not too distant future.
While the national and international NGOs, CSOs, and FBOs are internally organized and have regular technical dialogue with the MOH, the operational collaboration with the private-for-profit sector, the civil society, and the professional bodies remains to be improved. In order to bring all these actors actively into the sector, HSSP III will need to develop strategies, interventions (including indicators) of private sector, civil society, and professional bodies engagement.
7.1.2 Legal and regulatory framework, legislation
According to the Rwandan Constitution, ―Public administration shall be decentralized in accordance with the provisions of the Law. Decentralized entities shall fall under the Ministry in charge of local government‖.
The Ministry of Health holds responsibility for central functions such as policy and priority setting, procurement, financial management, budget execution, and audits. However, within the Rwandan system of decentralized governance, elements of devolution, delegation, and deconcentration are combined as a means of establishing and empowering decentralized administration.13
Improving accountability and transparency is an important goal, and it is to be achieved by making local leaders directly accountable to the communities they serve, as well as to the president, through the
Imihigo performance contracts. The system aims to increase the responsiveness of public administration
by transferring planning, financing, and control of services to the point closest to where they are delivered.
Available national (and multisectoral) policies and strategies are listed in Annex 6. All the sector policies will be updated and harmonized with HSSP III, which itself will be submitted to Parliament for approval. The District Council is the sole level of local government that has legal standing with full administrative, political, and financial authority; all other levels are territorial units of and accountable to the district, including the health implementing agencies.
7.1.3 Decentralization
As noted above, decentralization is enshrined in the Constitution of Rwanda. Article 167 provides for decentralized entities and reiterates that they are the foundations of community development. Decentralization has been a key policy of the Government of Rwanda since 2000, when the National Decentralization Policy was adopted with the overall objectives of (1) ensuring equitable political, economic, and social development throughout the country and (2) making the district the center of the development trajectory necessary to reduce poverty.
The National Decentralization Policy was approved in 2001. It defined three phases of implementation, as follows:
1. From 2001 to 2005, a first phase was implemented that aimed at establishing democratically elected and community development structures at the local government level. The focus was to put in place the necessary legal, institutional, and policy reforms to institutionalize decentralization in Rwanda.
2. In the second phase, from 2005 to 2010, the focus was on carrying out a territorial restructuring, which considerably reduced the number of administrative entities (from 11 to 4 provinces plus Kigali City, 106 to 30 districts, 1,545 to 416 sectors, and 9,165 to 2,148 cells) and aimed at consolidating progress on national priorities.
3. For the third phase, the Ministry of Local Government has developed a decentralization implementation plan for 2011–2015. The MOH, together with relevant DPs, translated this plan for the health sector and developed district health system reorganization guidelines (May 2011). In May 2011 the GOR approved a revised Financial and Fiscal Decentralization Policy. In the light of these developments, the MOH, together with MINECOFIN and under the leadership of MINALOC, will update its guidelines and include resource allocation, planning, budgeting, budget execution, financial reporting, and fiduciary issues
Decentralization and strengthening of local governance is also reflected in the EDPRS, the Vision 2020, and the Government of Rwanda program for 2010–2017.
In summary, decentralization in the Rwandan health sector means:
Local governments (DHUs) are the focal point for delivery of and accountability for health services, being responsible for all their operations.
Health personnel, infrastructure, equipment, and financial resources are decentralized to the district level. The MOH remains responsible for policy development, technical guidance (protocols, tools) and supervision, while district councils (DHUs) control the program implementation process in the 30 districts.
In the 2011–2012 fiscal year, considerably more funds were channeled directly to the districts due to reduction in interagency transfers.
Sector-specific solutions (silos) must be avoided.
In this changing context, HSSP III will initiate the following activities in support of decentralization:
1. Develop a health sector decentralization roadmap (Strategic Plan) as part of HSSP III that is aligned to the overall GOR decentralization policies and strategies in consultation of MINECOFIN, MINALOC, and the Ministry of Public Service, Skills Development and Labor (MIFOTRA).
2. Update decentralization guidelines for effective implementation of devolved service delivery; 3. Based on DHMT guidelines, clarify roles/responsibilities of the MOH and district administration /
DHU and between DHU and the service providing units (DH, HC, pharmacies, and CBHI). Inform all stakeholders to ensure that they understand the legal and regulatory framework.
4. Develop a relevant and strong capacity-building program for all district managers (DHU, DHMT, and DH) in planning and financial management. This should include team-building measures and on-the-job trainings. An institutional capacity program will be developed for the districts to address current weaknesses in the PFM and fiduciary systems.
5. Establish a health commission under the Joint Action Development Forum (JADF) according to the provisions of the ministerial order determining the responsibilities, organization, and functioning of Joint Action Forum at district and sector levels. This should not only promote the implementation of SWAp, but also advance the aid effectiveness (harmonization and alignment) and accountability agenda at district level.
7.1.4 Regional integration
The GOR has adopted an active policy of integrating its various socioeconomic activities in the integration of the countries in the East African Community. For the health sector, examples are the procurement of medicines and medical / laboratory equipment, where joining forces will allow economies of scale and hence better prices for the products the country needs.
Regional integration may also include the active sharing of information and training opportunities in laboratory techniques, sector management, and medical education. Relevant platforms for exchange such as conferences in the EAC region can be envisaged.
These activities will continue and expand under HSSP III where opportunities arise (e.g., collaboration with universities in Kenya and Uganda).