Good Governance and Health: Assessing Progress in Rwanda Derick W. Brinkerhoff Catherine Fort Sara Stratton April 2009 TWUBAKANE Decentralization and Health Program Rwanda Acknowledgements All field studies are made possible by the efforts of numerous people. Without their support and commitment we could not have conducted this study. We would like to thank USAID/Rwanda’s Soukeynatou Traore and Tye Ferrell for their interest in documenting the health governance outcomes resulting from Twubakane’s interventions. We acknowledge the support of Laura Hoemeke, Twubakane’s chief of party, for her endorsement of the study as well. We owe Twubakane’s Dean Swerdlin and Antoinette Uwimana a large debt of gratitude for their enthusiasm and their essential support to making the study a success and for contributing their knowledge and experience. Antoinette was our indispensable partner, both in preparing for the fieldwork and in conducting it. We thank the various Twubakane staff that we interviewed for their patience and substantive responses to our questions and requests for information. We also thank all our Rwandan interviewees both in Kigali and in the districts we visited for their efforts to respond to our inquiries, their willingness to share their views, and their commitment to improving the health status and quality of life of Rwanda’s citizens. Rwanda’s story is one that deserves widespread dissemination, and we feel privileged to contribute in a small way to that endeavor. Finally, we would like to state the usual caveat that the views expressed in this report are ours alone and do not reflect those of USAID, IntraHealth or RTI International; any errors of fact or interpretation lie with us. Good Governance and Health: Assessing Progress in Rwanda Table of Contents INTRODUCTION ........................................................................................................................................ 1 STUDY OBJECTIVES ..................................................................................................................................... 1 METHODOLOGY .......................................................................................................................................... 2 IMPROVING RWANDA’S HEALTH GOVERNANCE: REFORMS AND CHALLENGES ............. 3 DECENTRALIZATION ................................................................................................................................... 3 SERVICE DELIVERY AND PERFORMANCE ..................................................................................................... 5 CITIZEN PARTICIPATION ............................................................................................................................. 6 HELPING THE HEALTH SECTOR MEET THE CHALLENGES: THE TWUBAKANE PROGRAM ................................................................................................................................................... 7 PROGRAM START -UP ................................................................................................................................... 7 TWUBAKANE COMPONENTS ........................................................................................................................ 8 TAKING STOCK OF PROGRESS TO DATE: HEALTH GOVERNANCE RESULTS ..................... 9 PARTICIPATORY PLANNING AT DISTRICT , SECTOR AND COMMUNITY LEVELS ............................................11 DISTRICT SWOT ANALYSIS .......................................................................................................................12 JOINT ACTION DEVELOPMENT FORUMS ....................................................................................................13 DISTRICT MANAGEMENT AND LEADERSHIP TRAINING THROUGH RALGA FORUMS ...................................15 DISTRICT INCENTIVE FUNDS ......................................................................................................................17 COMMUNITY PARTNERSHIPS FOR QUALITY IMPROVEMENT ......................................................................19 HEALTH POLICY AND PROTOCOL DEVELOPMENT .......................................................................................21 AUDITOR TRAINING ...................................................................................................................................23 OPEN HOUSE AND ACCOUNTABILITY DAYS ..............................................................................................24 IMPROVING COMMUNICATIONS USING MASS MEDIA ..................................................................................25 FISCAL AND FINANCIAL DECENTRALIZATION .............................................................................................26 FACILITIES PLANNING AND MANAGEMENT ................................................................................................27 QUESTIONNAIRE SURVEY RESULTS ............................................................................................................28 SUMMARY OF HEALTH GOVERNANCE OUTCOMES ...................................................................29 EFFICIENCY AND EFFECTIVENESS ..............................................................................................................30 ACCOUNTABILITY .....................................................................................................................................30 RESPONSIVENESS .......................................................................................................................................31 VOICE AND TRANSPARENCY ......................................................................................................................31 LESSONS FROM RWANDA AND TWUBAKANE ...............................................................................32 POLITICAL WILL AND INSTITUTIONAL CAPACITY .......................................................................................32 ACCOUNTABILITY AND CITIZEN PARTICIPATION ........................................................................................33 MANAGING FOR RESULTS AND BEST PRACTICES ........................................................................................33 DONOR DEPENDENCE .................................................................................................................................34 IMPLICATIONS FOR RWANDA ............................................................................................................35 IMPLICATIONS FOR DONORS .............................................................................................................36 REFERENCES ............................................................................................................................................37 ANNEX 1: PERSONS CONTACTED .......................................................................................................40 ANNEX 2. HEALTH GOVERNANCE QUESTIONNAIRE RESULTS ...............................................43 Good Governance and Health: Assessing Progress in Rwanda Acronyms CDF Common Development Fund DDP District Development Plan DFID Department for International Development (United Kingdom) DIF District Incentive Fund EDPRS Economic Development and Poverty Reduction Strategy FP Family Planning GBV Gender-Based Violence GTZ Deutsche Gesellschaft für Technische Zusammenarbeit (Germany) HIV Human Immunodeficiency Virus IMCI Integrated Management of Childhood Illness JADF Joint Action Development Forum M&E Monitoring and Evaluation MIFOTRA Ministry of Public Service and Labor MINALOC Ministry of Local Administration MINECOFIN Ministry of Economic Planning and Finance MINISANTE Ministry of Health MIS Management Information System MTEF Medium Term Expenditure Framework NGO Nongovernmental Organization PAQ Partenariat pour l’Amélioration de la Qualité/ Community Partnership for Quality Improvement PBF Performance-Based Financing RALGA Rwandese Association of Local Government Authorities SWAps Sector-wide Approaches SWOT Strengths, Weaknesses, Opportunities, Threats USAID United States Agency for International Development VNG Association of Netherlands Municipalities Good Governance and Health: Assessing Progress in Rwanda Introduction Experience around the world has demonstrated that attention to governance is important to the ability of health systems to fulfill essential public health functions. Health governance concerns the institutions and linkages that affect the interactions among citizens/service users, government officials and health service providers. There is general agreement that good health governance is characterized by responsiveness and accountability; an open and transparent policy process; participatory engagement of citizens; and operational capacity of government to plan, manage, and regulate policy and service delivery. However, explorations of health system strengthening through the governance lens are few. Thus health decision-makers and international assistance agencies have few examples of how to incorporate health governance into system strengthening. This report contributes to filling that gap; it provides a case study of Rwanda’s experience in addressing health governance in tandem with service delivery improvements. The U.S. Agency for International Development’s (USAID’s) Decentralization and Health Program, known as Twubakane, provides financial and technical assistance to a selection of Rwanda’s districts, health facilities and communities to