THIS IS the last of my two opinion pieces intended to highlight some of the reforms that have taken place in the Rwandan health sector over the last few years. The first article looked at how the introduction of modern health services in rural areas has significantly improved maternal healthcare while at the same time registering low maternal mortality rates and improved life expectancy. The two reforms that I describe today have also had a tremendous impact on how healthcare services are delivered. These are; Community Based Health Insurance (CBHI); and accountability measures through Imihigo (performance contracts). It is without doubt that high levels of poverty have a high tendency to lead to poor health given that the inability to afford healthcare exposes an individual to risk being unchecked for any potential health problems. Severe poverty being the tune of the day on our continent, Rwanda looked for ways to improve access to health care for all. In doing so, in 2003, the government initiated a policy – Community Based Health Insurance (CBHI) – with a goal to provide Rwandans with universal and equitable access to quality health services. The philosophy behind CBHI is that it provides much needed financial protection by reducing considerably the amount ordinary citizens have to spend as out-of-pocket medical expenditure. Although there is little known evidence that this scheme has a direct impact on quality of healthcare, there is no doubt that CBHI has significantly improved numbers of people able to access services that would have been costly and out of reach. Notably, that access has been aided by the reasonable costs attached to CBHI from the beneficiary’s point of view, where a realistic Rwf2,000 annual premium (an equivalent of £2) is levied. Such low rates are in place to ensure practicability and guarantee that the poorest in society are not excluded from basic human rights such as – a right to decent healthcare. According to researchers from the Overseas Development Institute (ODI) in London, CBHI has benefited the poor the most especially with regards to subsidising ambulance costs, which can be preventative costs in many other regional countries. In fact, a report indicates that in Rwanda, healthcare obstacles have reduced significantly thanks to widespread adherence to CBHI, which covers 90 per cent of the cost of ambulance transfers. By comparison, the majority of the population from similarly situated countries such as Uganda, DR Congo and Burundi remain unable to afford healthcare services due to lack of similar schemes. Without subsidies, patients are required to pay full ambulance costs to health facilities, which can be preventative to the largely rural poor population. Indeed, Chambers and Booth (2012) from ODI confirm that ambulance costs have a direct negative impact on the lives of poor people in Niger and Uganda. Experts believe that to successfully deliver healthcare in a cost-effective, transparent and timely fashion, there must be firm rules and regulations to facilitate the process of accounting for scarce resources designed to deliver those services. With that in mind, the Rwandan government sought to improve levels of accountability among civil servants with the belief that improved accountability would have a direct impact on the way healthcare is delivered. To institutionalise this new approach policy, the government embarked on an effort to revitalise some of the traditional methods of accountability such as Imihigo that have been around for many centuries. Imihigo is a concept that dates back many centuries in Rwandan culture and relates closely to performance contracts. Under this concept, senior civil servants are required to commit publicly to specific goals and to ensure that such goals are achieved within an agreed timeframe. Consequently, Imihigo healthcare targets have been set in many parts of the country in a bid to improve healthcare delivery. For example, on many occasions, district mayors have publicly committed to reducing maternal mortality by increasing campaigns aimed at educating would-be mothers of the importance of attending health clinics. Several other healthcare targets such as child mortality reduction, improved health workers’ skills, have all been set and achieved in many cases. These sorts of public commitments are assessed periodically to determine their success. Indeed, research by the ODI shows that both central and local government regularly check that basic rules of service delivery are adhered to including, health centre opening hours; levels of hygiene; and that staff members are generally respectful towards patients. On the contrary, most African countries continue to suffer from poor levels of accountability. Evidence indicates that in some countries, health centres suffer from high levels of absenteeism because public health sector workers operate private facilities, often while moonlighting from their public positions. In Rwanda, there are restrictions for public health workers to operate in private facilities. Given these points, it is reasonable to conclude that the reforms that have taken place in the Rwandan health sector represent a commitment by all Rwandans to try and improve the most basic of human rights – access to healthcare. That said, however, it is worth noting with caution that to guarantee these achievements, we must continue to work at the double so that we can gradually reduce our dependence on aid. We must be able to guarantee the sustainability of these reforms. The writer is a UK Parliamentary Intern and holds a Master of Science in Public Service Policy. Twitter: @Jsabex
