2009年-世界发展银行全球_Rwanda___Fiscal_Space_for_Health_and_the_MDGs_Revisited_47页_2mb

Summary of "Rwanda: Fiscal Space for Health and the MDGs Revisited"

Core Content

This document, authored by Chris Lane and published as a World Bank Health, Nutrition, and Population (HNP) Discussion Paper in November 2009, examines the fiscal space requirements for achieving health-related Millennium Development Goals (MDGs) in Rwanda. It provides an updated analysis of the country's health financing strategy, the role of development partners, and the alignment of public and private spending with health objectives through 2015.

Main Objectives

• To assess the progress made by Rwanda towards its health-related MDGs and strategic health objectives.
• To evaluate the fiscal space for health, including both domestic and external sources of financing.
• To explore the efficiency and equity challenges in the health financing system and propose solutions.
• To discuss the potential of a government-donor compact to improve health financing and support long-term health strategies.

Key Findings and Main Messages

• Fiscal and Policy Progress: Large increases in financing and supportive policy reforms have put Rwanda back on track to achieve most, if not all, of the health-related MDGs.
• Aid Dependency: Rwanda is expected to remain aid-dependent for the foreseeable future, or at least until 2020, due to limited domestic resources. This highlights the need for long-term commitments from development partners.
• Fiscal Space Trends: The expansion of aid-financed fiscal space for health is likely to slow between 2009 and 2015, as major donors show no or slow growth in health funding.
• Domestic Financing: Realizing the planned increase in the health share of domestic government spending will be critical to achieving health goals.
• Efficiency Gains: With financing gaps expected before 2015, efficiency gains will be essential to sustain the rate of health improvement.
• Mismatch in Funding: There is a considerable mismatch between the government's health priorities and the allocation of external financing, which requires a more flexible and reliable funding mechanism.

Strategic Health Objectives and Drivers of Change

The Rwanda Health Sector Strategic Plan (HSSP) for 2005–2009 outlines seven programmatic objectives, including improving human resources, quality drugs and vaccines, geographical and financial access to health services, disease control, strengthening referral hospitals, and building institutional capacity. These objectives were further refined in the Economic Development and Poverty Reduction Strategy (EDPRS) for 2008–2012, which sets targets for 2012 and 2015:

• Reduce fertility rate from 5.8 to 4.2 births per woman.
• Reduce under-5 child mortality from 196 to 50 deaths per 1,000 live births.
• Reduce maternal mortality from 1,061 to 268 deaths per 100,000 live births.
• Improve child nutrition by reducing chronic malnutrition from 42% to 25% of under-fives.

The EDPRS identifies several "drivers of change" to achieve these objectives, including:

• Increasing modern contraceptive use.
• Expanding access to health insurance.
• Improving the utilization of primary health care services.
• Increasing the proportion of births attended by skilled personnel.
• Reducing the incidence of HIV and increasing condom use.
• Reducing infant mortality and malaria incidence through the use of insecticide-treated bed nets.

Health Financing System

The health financing system in Rwanda is structured around two main channels:

Supply Side

• Needs-based transfers: Monthly block grants to health centers and hospitals, calculated based on population and poverty levels.
• Performance-based transfers (PBF): Quarterly block grants to health facilities and districts for community health.
• History-based transfers: Subsidies to maintain assets of health facilities.
• Investment grants: Used for construction and equipment, based on national plans.
• Donor transfers: Fragmented and often inefficient, with unclear allocation criteria and significant overheads.

Demand Side

• User payments: Account for about 20% of total health expenditures, mostly funding private providers.
• Formal insurance: Includes the civil service pension scheme RAMA.
• Community health insurance (mutuelles): Funded through capitation, with 70% from users, 8% from employers, 9% from donors, and 13% from the government. Three levels of risk pooling exist: Umurenge (subdistrict), Akarene (district), and National Risk Sharing Pools.

Challenges

• Equity and Efficiency Issues: The current system faces challenges in equitable and efficient distribution of both domestic and external financing.
• Governance Weaknesses: There is a lack of functional hospital boards and limited oversight of public subsidies.
• Mismatch in External Funding: External financing often does not align with government priorities, requiring a more coordinated mechanism like a health compact.

Proposed Solutions

• A government-donor health compact is suggested as a way to ensure flexible and reliable external financing.
• The compact should aim to align external aid with national health priorities and improve the efficiency of financial flows.
• Strengthening the governance of both health facilities and funding pools is critical to ensuring accountability and effective use of resources.

Conclusion

Rwanda has made significant strides in improving health outcomes, particularly in reducing child and maternal mortality, and has seen a substantial increase in health financing. However, continued progress will require both increased domestic financing and more efficient, aligned external support. A compact between the government and development partners is proposed as a key mechanism to support this, ensuring sustainability and alignment with long-term health strategies.