Development Progress

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1 'S A D N A W R : Y R STO in t l n o, s p s i r s g r d Pro L : d n nd Rw c n m r o prf insurnc lt Rom o in R s z Po drígu nd Smu Fion ls Dvlopmnt Progrss Dvlopmnt Progrss

2 Progrss on lt in Rwnd: Ldrsip, prformnc nd lt insurnc Ky mssgs 1. Rwnd, vry low-incom country, s md significnt progrss in incrsing t qulity nd quntity of lt srvics nd in improving lt sttus, troug n ffctiv ntionl but dcntrlisd public lt progrmm. 2. Community lt insurnc, improvd srvic qulity troug prformnc-bsd finncing (PBF), dcntrlistion nd t xtnsion of community-bsd srvics v ll bn criticl to improving Rwnd s lt sttus. Govrnmnt s bility to dvlop nd scl up bsd on prticiptory consulttion nd grssroots vidnc s lso fcilittd improvmnts. 3. Strong ldrsip, vision nd ccountbility mcnisms t ll lvls r vitl to succssful lt sctor rforms. Additionlly, ffctiv coordintion of donor funding nd tru govrnmnt donor prtnrsip v brougt ids nd good prctics into t country nd nsurd tt id is usd ffctivly nd lignd wit ntionl prioritis. Dvlopmnt Progrss storis

3 Rwnd s md rmrkbl improvmnts in t lt sttus of its popultion. Summry Four yrs of civil wr nd gnocid in Rwnd took t livs of lmost 1 million popl, lving t country in stt of lmost totl collps in Wil 60% of t popultion still livs blow t povrty lin, in only 16 yrs t country s md rmrkbl improvmnts on ky lt indictors, including: infnt nd cild mortlity; immunistion covrg; us of fmily plnning; mlri mortlity nd morbidity; nd HIV prvlnc. Progrss cn b ttributd to mbitious rforms in t lt sctor, including introduction of community lt insurnc nd boosting of srvics troug stff incntivs nd PBF scms. Strong ldrsip, vision nd commitmnt v lso bn ky. Prticiptory dcntrlistion, including xtnsiv us nd formlistion of community lt workrs (CHWs), s brougt srvics closr to communitis nd mpowrd tm to prticipt in tir own dvlopmnt. Mnwil, ffctivly coordintd donor ssistnc s bn instrumntl in civing suc rmrkbl outcoms in t Rwndn lt sctor. Wt s bn civd? Rwnd s md rmrkbl improvmnts in t lt sttus of its popultion. 1 Altoug tr r still lt inqulitis btwn urbn nd rurl rs, mong incom quintils nd by gndr, most improvmnts v bnfitd t poor nd nncd quity. Howvr, it is importnt to rcognis tt ts outcoms strtd t vry low bs post-civil wr nd gnocid. Improvd lif xpctncy nd rducd cild mortlity Lif xpctncy t birt wnt down to 25 yrs in 1994 but rcovrd to 50 in Mnwil, in infnt nd undr-fiv mortlity, t formr wnt from 129 to 62 dts pr 1,000 liv birts nd t lttr from 219 to 103 btwn 1994 nd A ky fctor in tis is t incrs in immunistion covrg: t proportion of on-yr old cildrn immunisd rcovrd rpidly ftr 1994, to surpss pr-gnocid lvls. Dispritis of covrg r lso xtrordinrily low. Wil t ric-poor gp rmind round 3% in , rurl-urbn nd gndr dispritis lmost dispprd, bot going from round 3% to 0.6% in t sm priod. Tbl 1: Ky indictors of progrss 2 Pr-gnocid Post-gnocid Most rcnt Sourc Lif xpctncy 33 (1990) 29 (1995) 50 (2008) World DtBnk Undr-fiv mortlity rt pr 1,000 liv birts 151 (1992) 219 (1994) 103 (2007) IDHS Immunistion covrg (msls) 82% (1992) 25% (1994) 90.4% (2008) IDHS Cildrn undrwigt undr fiv 24% (1992) 20% (2000) 15.8% (2008) DHS 1992, 2000, CFSVA & NS 2009 Mtrnl mortlity rtio (MMR) pr 100,000 liv birts N/A 1,071 (2000) 750 (2005) DHS 2000, 2005 Totl frtility rt 8.3 (1983) 6.1 (2000) 5.5 (2007) IntrHlt 2009 Contrcptiv prvlnc 13% (1992) 4% (2000) 54.7% (2010) DHS 2000, KIIs Antntl cr (ANC) (t lst four visits) N/A 13% (2005) 25.9% (2007) DHS 2005, IDHS Birts ttndd by skilld lt prsonnl 26% (1992) 31% (2000) 52% (2007) Bsing t l. 2008, IDHS Mlri morbidity N/A 73.5% (2001) 15% (2007) World Bnk 2009, bsd on MoH 2009 HIV prvlnc (Kigli city) N/A 16% (1998) 11.5% (2007) World Bnk 2009, bsd on MAP ICR 2009 Hlt infrstructur Not: * Most fcilitis d to b rbuilt btwn 1990 nd ospitls 302 lt cntrs (1990) 29 ospitls 348 lt cntrs (2000)* 38 ospitls 411 lt cntrs (2007) MoH Annul Rport 2000, 2007

4 Cild nutrition civmnts Wil mlnutrition is still ig, undrwigt nd svrly undrwigt prvlnc mong cildrn s dcrsd. Howvr, cronic mlnutrition (stunting) is on t ris, going from 48% in 2000 to 52% in Mlnutrition s bn idntifid s brrir to furtr improvmnts in lt: in 2009, prsidntil inititiv prioritisd t issu by ndorsing nw protocol for its mngmnt. Rducd mtrnl mortlity nd incrsd ANC nd birt ttndnc T MMR droppd by 30% btwn 2000 nd Altoug no mor rcnt dt r vilbl, improvmnts in us of ANC nd birt ttndnc by skilld stff suggst tt t MMR migt v flln furtr. Improvmnts in birt ttndnc wr lrgr in t poorst quintil, going from 17.6% in 2005 to 42.7% in 2007; in t wltir quintil, t ris ws from 61.3% to 70.6%, mning t poor-ric gp rducd by 36%. T rurl-urbn gp lso rducd, by 34%, nd ccss to ANC in rurl rs incrsd mor tn in urbn rs (84% nd 47%, rspctivly). Dcrsd mlri mortlity nd morbidity nd low HIV prvlnc Mlri morbidity in lt cntrs s rducd 5 nd igr us of clinics s lpd driv down incidnc. T mlri mortlity rt s lso flln, from 10.1% in 2001 to 2% in Mnwil, HIV prvlnc rducd from n stimtd 13% in 2000 to 3% in Tis drop s bn drivn by dcrss in urbn rs; in rurl rs, prvlnc sms stbl, t round 2%. 7 1 Wil improvmnts in lt v bn nlysd witin t post-gnocid priod, wn possibl dt on t sitution bfor 1994 r usd to put into prspctiv t progrss md. 2 T priods sown in t tbl diffr s rsult of dt vilbility constrints. 3 IDHS ( ): MoH, NISR nd ICF Mcro (2008) Rwnd Intrim Dmogrpic nd Hlt Survy Kigli nd Clvrton, MD: MoH, NISR nd ICF Mcro. 4 Undrwigt rprsnts low wigt for g. Wsting is low wigt for igt, wic is strong prdictor of mortlity mong cildrn undr fiv. It is usully t rsult of cut wigt loss or significnt food sortg nd/or diss. Stunting is low igt for g nd is cusd by long-trm insufficint nutrint intk nd frqunt infctions. It rprsnts cronic mlnutrition nd ffcts r lrgly irrvrsibl. 5 World Bnk (2009) Rwnd: A Country Sttus Rport on Hlt nd Povrty. Kigli: MoH nd World Bnk, bsd on MoH (2009) Hlt Sctor Strtgic Pln July 2009-Jun Kigli: MoH. 6 WHO (2009) WHO Country Cooprtion Strtgy, Rwnd. Brzzvill: WHO Rgionl Offic for Afric. 7 Abbott, P. nd Rwirir, J. (2010) Millnnium Dvlopmnt Gols Rwnd Country Rport Kigli: UNDP. 8 MoH (2009). 9 World Bnk (2009). Figur 1: Mlri morbidity in lt cntrs nd lt utilistion rt, % % 25% 70% 27% Mlri morbidity Hlt utilistion rt 67% 30% Improvd infrstructur nd prsonnl Improvmnt of infrstructur, spcilly in rurl rs, s xpndd ccss to lt srvics. Nowdys, 60% of t popultion livs witin 5km of lt cntr. 8 T sctor still suffrs from srious sortg of skilld prsonnl, ltoug stimts suggst t lt workforc incrsd in t rng of 36% to 62% btwn 2005 nd Wt s drivn cng? T dmnd sid: Mutulls Community lt insurnc (mutulls) s bn ky to rmoving finncil brrirs to lt srvics. Aimd t sprding t finncil risk of sking cr cross tir mmbrsip bs, mutulls v nbld popl to ccss srvics t n ffordbl cost nd bfor tir condition worsns, tus lso rducing trtmnt costs. Tis s ld to incrsd dmnd nd uptk of lt srvics. Tos wo cnnot py, ccording to communitis tmslvs, r supportd by t govrnmnt or dvlopmnt prtnrs. T succss of mutulls is in prt rsult of govrnmnt bility to nforc locl implmnttion. 50% 38% 44% 38% 28% 71% 75% 15% Dvlopmnt Progrss storis

5 Prtnrsip btwn govrnmnt nd donors s bn crucil to Rwnd s progrss. T supply sid: PBF nd umn rsourcs T govrnmnt institutd PBF to boost t qulity nd quntity of lt srvics. PBF incntiviss lt outputs/rsults by supplmnting lt fcilitis nd t slris of lt workrs on prformnc bsis. It stbliss dirct link btwn srvic dlivry, rsults nd pymnt troug st of quntittiv nd qulittiv indictors ginst wic prformnc is msurd. Srvic dlivry s lso bn strngtnd by improving stff quntity nd qulity, liminting slry dispritis for comprbl jobs witin t sctor nd trining nd ncourging stff to improv tir qulifictions. Politicl ldrsip, ccountbility mcnisms nd policymking Rwnd s cntrl ldrsip nd control structur is dvotd to dvlopmnt, nd tr is ntionl commitmnt to using (multidimnsionl) povrty rduction s mns of ling. Strong ldrsip nd vision v bn ky to t strtgis nd policis tt li bind lt sctor rforms. Ldrsip from t tip s lso bn criticl in dvloping ffctiv govrnnc nd ccountbility procdurs for implmnting policy: prformnc contrcts r mns of nforcing socil dutis nd obligtions, nd ll lvls v to comply wit systmtic vlutions nd stndrds. Additionlly, policis r vidnc-bsd nd informd by prticiptory consulttion wit ll sctors of socity. Onc pilot inititiv provs succssful, it is scld up to ntionl lvl. Dcntrlistion, community prticiption nd CHWs Dcntrlistion of lt srvics s givn district lt dprtmnts t rsponsibility for orgnising district lt srvics, mnging rsourcs nd drug supplis in ospitls nd suprvising CHWs. 10 Bing closr to t popl, t district is bttr positiond to idntify nd ddrss nds mor fficintly nd ffctivly. In ddition, intgrtion of CHWs into t locl govrnmnt lt structur mns ty v bcom t finl tir in t dcntrlistion of lt cr t villg lvl. Ty v ky rol Dvlopmnt Progrss storis in snsitising t popultion nd intrvning in nd prvnting lt problms bfor ty bcom srious. Coordintion of dvlopmnt prtnrs Prtnrsip btwn govrnmnt nd donors s bn crucil to Rwnd s progrss. T govrnmnt s plyd proctiv rol in coordinting nd lding donors, gtting tm to liv up to Pris Dclrtion principls of lignmnt nd rmonistion in support of govrnmnt ownrsip nd ldrsip. Mor donor finnc is now cnnlld troug sctor budgt support, nd globl fund progrmms r bttr intgrtd wit ntionl nds, trby rducing distortions in prioritis. Donors, mnwil, v plyd positiv rol in sprding ids nd good prctic. Lssons lrnt T Rwnd cs offrs importnt lssons. Not tt t commitmnt of vry powrful ntionl ldrsip to ffctiv implmnttion nd ccountbility t locl lvl s drivn succss in Rwnd: otr countris my v diffring cpcitis to tk dvntg of ts lssons. Strong govrnnc nd ccountbility mcnisms nd zro tolrnc of corruption r ssntil to t succssful implmnttion of strtgis nd policis. Good communiction btwn lvls, togtr wit rgulr vlutions, nsurs ruls r followd nd objctivs ccomplisd ccording to qulity stndrds. Politicl ldrsip s fostrd Rwnd s lt rforms nd ccountbility mcnisms nd bn dcisiv in ngging t popultion in t country s dvlopmnt. Mutulls v incrsd utilistion of lt srvics by undrsrvd popultions. Mjor cngs in ltsking bviour nd in ownrsip v com prtly from t finncing nd prtly from t prticiption tt coms wit mmbrsip. Prformnc-bsd incntivs nnc stff commitmnt to work to igr qulity stndrds. Strict controls nd qulity ccks r ssntil to monitoring nd vlution of prformnc. 10 Bsing P., Skbrg C. nd Souct A. (2008) Scling Up Innovtion in Srvics Dlivry of Primry Hlt Cr: Cs of Rwnd. Princ Midol Awrd Confrnc Bngkok, 30 Jnury-1 Fbrury.

6 E vidnc-bsd policis nd piloting of strtgis prior to scl-up lso contribut to mor succssful outcoms. I nvolving ll stkoldrs in t plnning procss, including dvlopmnt prtnrs nd t community, is mor likly to rsult in succssful outcoms nd in nsuring ty mtc popl s nds. D cntrlistion llows locl govrnmnt to dl dirctly wit locl nds, nd involving communitis gurnts ownrsip. A clr dcntrlisd structur of rsponsibilitis lso rducs ovrlp btwn diffrnt dministrtiv lvls, nd t proximity of sctorl dprtmnts fvours multidisciplinry pprocs. Effctiv dcntrlistion dpnds on ntionl ldrsip nd ccountbility systms, toug, wic my not b prsnt in otr countris. Effctivly intgrting CHWs into t dcntrlisd lt systm s lso nncd t uptk of bsic lt cr srvics nd t snsitistion of community mmbrs on lt, ygin, nutrition nd snittion. I ntrntionl donors v plyd n importnt rol, troug bot budgt support nd gnrtion of vidnc on otr succssful scms. Constnt dilogu nd coordintion btwn donors nd govrnmnt s nsurd funding is lignd wit ntionl prioritis nd usd ffctivly nd fficintly. Tis brif is n bridgd vrsion of rsrc ppr nd is on of 24 dvlopmnt progrss storis bing rlsd t T dvlopmnt progrss storis projct communicts storis of country-lvl progrss from round t world, outlining wt s workd in dvlopmnt nd wy. T projct sowcss xmpls of outstnding progrss cross igt min rs of dvlopmnt. You cn find out mor bout t projct, mtodology nd dt sourcs usd t Tis publiction is bsd on rsrc fundd by t Bill & Mlind Gts Foundtion. T findings nd conclusions contind witin r tos of t utors nd do not ncssrily rflct positions or policis of t Bill & Mlind Gts Foundtion. Poto crdits from top to bottom Pnos/Gicomo Pirozzi. Rwnd Flickr/Rcl Strom. Rwnd ODI/Romin Rodríguz Pos. Rwnd Pnos/Trygv Bolstd. Rwnd ODI/Romin Rodríguz Pos. Rwnd I ntgrting vrticl funds in t lt sctor s strngtnd t lt systm, llowing for t support of undrfundd componnts. Ovrss Dvlopmnt Institut 111 Wstminstr Bridg Rod London SE1 7JD Unitd Kingdom Tl:+44 (0) Fx:+44 (0) Ovrss Dvlopmnt Institut ODI is t UK s lding indpndnt tink tnk on intrntionl dvlop mnt nd umnitrin issus. ODI olds t copyrigt for ll ODI publictions, wic r subjct to UK copyrigt lw. ODI wlcoms rqusts for prmission to rproduc nd dissmint its work, s long s ty r not bing sold commrcilly. As copyrigt oldr, ODI rqusts du cknowldgmnt nd copy of t publiction. T viws prsntd in tis ppr r tos of t utors nd do not ncssrily rprsnt t viws of ODI. Ovrss Dvlopmnt Institut 2011

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