Changing Policy- Rwanda's change in guidelines African Regional meeting on interventions for Impact in essential obstetrics and new born care Addis Ababa Feb 2011 Stephen Rulisa, MD, MMed (Ob/Gyn) University Teaching Hospital of Kigali (CHUK) National University of Rwanda

Rwanda Population approx. 10m, 1m in Kigali 90% subsistence farmers Life expectancy gone up 50.1 yrs Adult HIV prevalence 3% Addis Ababa Feb KUTH

Rwanda Addis Feb Milles collines Mountain gorillas Lac Kivu

MAIN CAUSES OF DEATH (MoH 2010)

Policy Changes Maternal and child survival are on top of the list of Rwanda’s health priorities, having been identified as absolutely crucial for the long-term health of the country on its road to development. “Healthier mothers mean healthier children, and healthier children mean a healthier, more productive society in the future”.

Main support documents EDPRS: targets for maternal deaths in 2012 is 600/ LB Vision 2020 Health systems strategic plan (HSSP II) National Reproductive Health Policy National Strategic plan

Priorities in Maternal Health Priority n° 1 : To offer to all population quality, accessible and affordable package of Maternal and Neonatal health services Priority n° 2 : To improve Essential Obstetrical and Neonatal Care (EONC) as well as EMOC and FP services (RH Supplies security, infrastructures and equipment) Priority n° 3 : To empower women and families for decision making regarding their Sexual and reproductive Health concerns Priority n°4 : To ensure diagnosis and quality treatment for women with Obstetrical fistula and their re-insertion and re-integration in the community,

Priorities in Maternal Health(2) Priority n°5 : To integrate Gender in all MNH strategies and activities Priority n° 6 : To reinforce the implication and participation of the population in their RH expectations and needs : male involvement in RH as well as empowering the CHW (ASM) Priority n°7 : To strengthen the MOH Information System (HIS) which can enable quality surveillance, M&E of EONC/EMONC, FP and Human Resources for Health (HRH) management activities

Key strategic interventions Capacity building in RH Maternal Deaths review: clinical and community level FP made a priority: available in health posts and HC Coordination of activities through Safe motherhood technical working group Distribution of equipment and ambulances FANC: new protocol Community care: CHW, package, incentives, associations

Supportive approaches Rwandan parliamentarians Network to address development and population issues: active involvement Health insurance Coverage: from 3% in 2002 to 96% in 2010.Delivary at health facilities increased from 52% in 2007 to 62% (2010) Performance based financing (PBF)in all health facilities: aiming to motivate health providers (incomes), increase the quality and quantity of delivered services. Motivating women to utilize health services through incentives such as free delivery services if 3 ANC visits done, ITN,

Supportive approaches(2) Involvement of Local government in monitoring of MCH indicators (IMIHIGO) and sensitizing the population (Umuganda) Community interventions: CHW elected, re- orientation of former TBA Involvement of Faith based organizations: sermon guide;

Innovative changes in health policies Increased budget allocation for health over the years Fiscal decentralization increased community participation and allocated funds to district governments Performance contracts were established between the president and district mayors A PBF system to allocate money to health facilities based on performance/Results Community health insurance, over 96% health insurance

Policy changes.. Involvement of professional bodies and other stake holders Decentralized Emoc at health centres Introductions Oxytocin, mgso4, misoprostol, on essential drug list & decentralized to health centers Strengthened CHWs at community level, community PBF through cooperatives TBAs training to CHWs Formation of clusters from different ministries to address health issues

Policy Changes Use of Innovative technologies Rapid sms, phone for health,.. Phones to CHW Internet Access- health facilities a priority

Outcome of Policy Changes

From far…. & still going!!

Thank you AMESEGINALEHU