Beyond MDGs: Why we need to strengthen our institutions

We know how far we have come to be where we are today. As I reflect upon several achievements attained not only as the health sector but the entire nation, I am also reminded of the long journey ahead to meet the set goals in the interest of all Rwandans. A good example is the positive outcomes we have witnessed following the decentralization of our health system. Decentralization in Rwanda has translated into real and meaningful empowerment, placing critical responsibility in the hands of the local leaders. This empowerment has grown in parallel with the increasing capacity of the central government to monitor, evaluate, and strengthen its auditing role. This has helped improve accountability across all levels to ensure we are doing all we can to better the healthcare system. For instance, by applying the fiscal decentralization with the national budget, hospitals have been assigned their funds through the district budgeting process. Also, other health financing strategies for the country are based on decentralization. This includes the community-based health insurance known as Mutuelles de Sante, which serves as a useful example to demonstrate how the local and central governing structures work together. It also shows how we are continually learning and adapting to improve the program. Mutuelles was created about 15 years ago and it is now undergoing its third major reform. The first reform involved changing the amount that each household paid for their health insurance premiums. At first, each household paid for a single household, but the reform ensured that each household would contribute the amount appropriate to reflect the number of people in their domicile to improve fairness of the contributions across the country as well as financial access for all. The second reform involved the implementation of the stratification system, so that each person would pay in accordance with their income as opposed to a flat fee per person. The third reform is ongoing. The government is transitioning the management of Mutuelles to the financial professionals at the Rwandan Social Security Board which has the mission to provide quality management of health insurance. This will ensure the sustainability of the programme. All of these reforms have relied upon an effective decentralization of responsibility and authority to the local governments that also oversee Mutuelles starting at the district level; the direct management of the Mutuelle staff by the local administration puts the Mayor in charge of this programme in that district. In general, this decentralization structure has been working well. Having local leadership overseeing the local implementation of Mutuelles has been helpful. These local leaders have, on the whole, been loyal, trustworthy and hardworking, and are dedicated to their mission vis-a-vis their administrees. Unfortunately, however, there have been a handful of local leaders who have been dishonest – acting as though they were more powerful than Rwandan institutions. They did so by stealing the hard-earned money that people had placed to get their health insurance locally. And such dishonest acts were discovered through the complementary, central auditing system in place through the Ministry of Internal Affairs, the Ministry of Local Government, Ministry of Finance and Economic Planning, and the Ministry of Health. In Rwanda, we have a zero tolerance for corruption. Thus, at all levels, we create institutions, such as the auditing system noted above, that reinforces accountability and discourages dishonest actionsby making the cost of corruption high. In this case, those local leaders who unjustly took money from the health insurance pool for their own personal gain were appropriately identified by this system. These individuals will be held accountable for their criminal actions and will reimburse up to the last penny of what they have taken, even if this means that they have to sell their assets. Rwandans should rest assured that their investment into their health insurance will not be lost. We have learned from this experience that we can be even more vigilant in our fight against any form of corruption, nepotism, or any crime moving forward. Creating systems that reinforce honesty and accountability is very vital to protecting our integrity, our rights, and development as a country, especially as we strive to reach our Vision 2020 goals. Yet this experience has taught us that we need to foster the growth of honest local leaders coupled with improved central level institutions that bolster accountability and reassure the people that their interests are being protected. I am grateful to live and work in a country where systems are strong enough to identify and correct problem areas or loopholes. Our effort to learn from both our successes and mistakes allows us to continuously improve every day in our efforts to protect public goods, community assets and people’s rights. The writer is the Minister of Health

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Beyond MDGs: Why we need to strengthen our institutions