Pathway 1: How did Rwanda change its approach to health system administration?

A health system for a new era

Rwanda’s prewar health system

After independence in the early 1960s, the health system’s reach was limited. Hospitals and clinics were expensive and inaccessible to people who lived in rural areas.¹ Consequently, few Rwandans received primary or preventive health care.²

Leading up to the 1990s, Rwanda participated in continental efforts to expand access to primary health care (PHC). In 1987, health ministers from countries across Africa adopted the Bamako Initiative, a joint World Health Organization/UNICEF initiative that aimed to expand community access to PHC. The Bamako Initiative emphasized decentralized decision making, community participation, and “cost recovery”—typically by ensuring the availability of essential drugs for sale at local health posts—as a means of ensuring sustainable financing for PHC.^3,4,5

In 1990, Rwanda joined the Bamako Initiative while the country had 34 hospitals, 186 health centers, 17 private medical clinics, 261 doctors, and around 250 pharmacies and dispensaries to serve more than 7.3 million people.⁶ However, research showed 70% of the country’s population did not have regular access to essential drugs.⁷ Across sub-Saharan Africa, the early results of the Bamako Initiative were mixed.⁸ In Rwanda, they are especially difficult to assess, since the genocide quickly stalled its progress.²

Read more about the Bamako Initiative here.

The Rwandan civil war (1990–1994) and genocide (1994)  destroyed much of Rwanda’s physical and social infrastructure, including its health system, resulting in fewer than one in four children fully vaccinated against measles and polio in 1994 and the highest under-5 mortality rate in the world.⁹ In part, this is because many of the educated professionals and skilled workers who delivered key public services, especially in the health sector, were killed or exiled.² The genocide also destroyed the public’s trust in government and government workers—and often in health facilities and health workers, since many killings took place in hospitals and clinics.^9,10

In the wake of this crisis, Rwanda’s government adopted policies aimed at encouraging unity and reconciliation and restoring the public’s trust—in government as well as in their neighbors. Many of these policies encouraged decentralization. They aimed to build decision-making capacity in districts and communities and enable citizens to hold public authorities accountable for their actions.¹¹

Sharing authority and responsibility for decision making

In the health sector, decentralization typically aims to make service delivery more efficient, effective, and responsive by tailoring it to local needs. It also seeks to improve access to health services, particularly in poor or rural areas that health systems may not comprehensively or adequately serve, by enabling resource distribution and decision space closer to local settings.

The process of health system decentralization in Rwanda had two main components: administrative decentralization for service delivery and local oversight, and fiscal decentralization for budgeting and spending.

Administrative decentralization in Rwanda’s health sector: the district health system

In Rwanda, the MoH is responsible for regulating the health sector, implementing and monitoring health policy, distributing performance-based funding to districts, and coordinating the delivery of health services nationwide. In 2005, as part of the second phase of Rwanda’s administrative decentralization process, the MoH incorporated each of the country’s 30 districts into an administrative unit in charge of the delivery of health and other social services, personnel management, and policy implementation at the local level.^16,17

According to the MoH, this change aimed to bring “improved service delivery, greater coverage, improved quality, cost-effectiveness, as well as greater local control over health activities at all the levels of the district health system.”¹⁸

Rwanda’s health districts serve many purposes:

• District pharmacies distribute essential medicines and other key commodities to district-level hospitals and health facilities.¹⁹
• District hospitals monitor and evaluate the quality of care provided by health workers under their supervision.¹⁷
• District administrative offices plan and coordinate managerial and administrative decision making, maintain infrastructure, and budget and pay for health services.¹⁶

Since 2011, the Rwanda Biomedical Center (RBC) has been the country’s national health implementation agency. It merged 14 different health agencies to provide high-quality and affordable health care to Rwandans.²⁰ Districts implement RBC policy and strategy but maintain some levels of financial and legal independence. (RBC also builds district capacity via trainings in leadership, planning and forecasting, and implementation.)²¹

This autonomy allows districts to manage localized needs while aligning with RBC’s overarching national health goals. Through a study sample of four districts, district—and health facility-level data showed that administrative and decision-making autonomy was greatest for planning and financial management, followed by human resource management and procurement (see Figure 9). Some of these functions were reported as being less autonomous at the district level, suggesting that health facilities may be able to make decisions independently than the district-level health authority, who is more responsible for the oversight and coordination of health services in its jurisdiction.

Fiscal decentralization in Rwanda’s health sector

Rwanda’s districts and health facilities have had the authority to develop and implement their own budgets since 2007. After the nationwide scale-up of performance-based financing (PBF)  in Rwanda, the MoH began to transfer public tax revenues directly to local health facilities on the basis of their performance on 22 key indicators.²²

The designation of districts and health facilities as budgeting units reduced resource misuse and improved the availability and timeliness of funds allocated to district health systems.^23,24 As a result of fiscal decentralization, intra-governmental funds transfers increased from RWF 36 billion in 2006 to RWF 365 billion in 2017. This enabled greater capacity for local government entities, including PHC service delivery entities. These financial transfers corresponded with the increased delivery of public services, including health.²⁵ More fund availability and greater financial discretion at local levels enabled greater autonomy and granularity in planning practices, which enhanced the alignment of district health spending with local priorities.

Enabling decision makers at the district level and in individual health facilities improved the functioning of PHC systems: it increased the availability of essential health commodities and improved management and oversight of health facilities and staff by increasing decision space closer to the point of care.

In 2006, to ensure accountability to deliver these initiatives among public local officials, Rwanda adapted the concept of performance contracts to a traditional goal-setting practice known as imihigo.²⁶ The use of performance contracts for district mayors under the general framework of decentralization contributed to the increased flow of resources and capacity, as well as the delivery of PHC services, at local levels.^27,28

Learn more about imihigo and performance contracts here.

Coordinating donor support

In the health sector, donors and development partners often support distinct and sometimes parallel programming for particular health needs or disease areas. This fragmented approach to health funding can create separate systems for decision making, supply procurement, and resource allocation and can channel key funds away from a government’s own priorities for its health system, such as PHC.

Since aid from development partners and other foreign support comprises a substantial proportion of Rwanda’s health spending—from year to year during the Exemplars study period, development assistance for health ranged from 37% of total health spending to 64%—donor coordination is especially important.²⁹

Immediately after the genocide ended in 1994, development partners stepped in to aid the reconstruction of Rwanda’s key infrastructures, including its health system. However, these efforts were often inefficient or duplicative, and they often channeled resources into vertical or disease-specific funding streams that did not meet the health system’s broader objectives.³⁰

Coordinating donor support at the national level: the sector-wide approach

One tool country health systems often use for donor coordination is the sector-wide approach (SWAp). SWAps bring together governments, donors, and related stakeholders to carry out joint planning, financing, monitoring, and/or oversight of countries’ health programs. SWAps may or may not include pooled funding instruments, but they maintain government ownership of health system priorities and key functions—including the development of budgets and plans, the facilitation of policy dialogue, and general oversight via monitoring and evaluation of health programs. SWAps aim to boost management capacity and enable overall improvements in system performance and efficiency.

Rwanda initially leveraged a SWAp mechanism, which has evolved into a coordinated donor mechanism within the MoH. In 1998, Rwanda’s Ministry of Finance and Economic Planning established the Central Public Investments and External Finance Bureau (CEPEX) to monitor donor-financed programming across all sectors.³⁰ However, this approach quickly proved cumbersome, and in 2006, officials phased out CEPEX and established sector-specific SWAps in its place. These, alongside a mechanism known as Multi-Donor Budget Support that streamlined funding from big donors such as the World Bank through established government systems, helped align donor contributions with national priorities across sectors and deliver investments to their intended beneficiaries at all levels of the health system.³¹

The SWAp that the MoH developed aligned donors and development partners to the priorities set out in Rwanda’s Health Sector Strategic Plans (HSSPs) and its overall Economic Development and Poverty Reduction Strategy.

Since 2005, officials have issued four HSSPs (2005–2009³², 2009–2012³³ , 2013–2018³⁴, and 2018–2024³⁵) that aim to guide donor support and channel resources from all sources toward the government’s medium- and long-term priorities and objectives for Rwanda’s health sector.³⁶ It also aims to steer resources to the promotion of PHC at all levels of the health system.³⁷

The objective of Rwanda’s health sector SWAp was “one plan, one budget, one report.”³¹ This framing was designed to ensure harmonization and alignment of the goals and implementation of the SWAp. To meet these goals, participants in the SWAp engaged in:

• Joint planning

  The MoH and development partners worked together to develop the Annual Work Plan for the health sector and the health Mid-Term Expenditure Framework.³¹

• Joint monitoring and evaluation

  The MoH and development partners approved a common framework and performance indicators for monitoring and evaluation.³¹

• Joint financing

  Development partners committed to using the government of Rwanda’s disbursement and financial reporting systems, and to align their support to the HSSP and the Mid-Term Expenditure Framework.³¹

Coordinating donor support at the district level: The Single Project Implementation Unit

The SWAp was a top-down, centralized operation focused on high-level MoH priorities that did not have much bearing on district-level decision making and planning.³⁰ As a result, in 2011—the same year in which the RBC was established—officials also adopted a more decentralized model for donor coordination: the Single Project Implementation Unit (SPIU), established by the MoH to implement and monitor funding for health programs and HSSP priorities at the district level.³⁰ The SPIU offers strategic support for the RBC’s priorities at the district level, and is responsible for donor budget execution, financial transactions and tendering processes, reporting, audit management, and procurement and logistics. The SPIU has enabled efficiency gains by reducing health sector transaction costs, reducing employee turnover, simplifying project coordination and monitoring, and supporting the development and maintenance of systems that enable data-driven decision making.³⁰

Rwanda’s MoH has established other mechanisms for coordinating donor support at the district level, including District Health Management Teams.

According to the MoH, District Health Management Teams are “responsible for overseeing implementation of all health programs in the district, setting district health indicators and monitoring their progress.”³⁸

As Figure 10 shows, the degree of coordination between donors and government reported across a four-district study sample varied across health system functions. Despite this variation, most of the sampled study districts had efficient PHC delivery—as measured by the district efficiency score.