Maternal Health in Rural Rwanda
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This document summarizes a presentation on a case study of maternal health in rural Rwanda. The presentation discusses: - Research conducted in two rural districts over 5 months using ethnographic techniques and interviews. - Key assumptions about components of safe motherhood that were examined. - Results showing that Rwanda has low maternal mortality, no recorded deaths since 2008, widespread family planning use, and most births occurring in health centers. - Quantitative data demonstrating improvements in maternal and reproductive health indicators from 1992 to 2010. - Factors contributing to Rwanda's success, including coherent policies, effective monitoring and incentives, and collaborative problem-solving between local actors and the state.
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Maternal Health in Rural Rwanda
- 1. Safe motherhood: A case study of rural Rwanda Vikki Chambers Overseas Development Institute Presentation for New Approaches to Maternal Health conference, Cambridge University, 3 July 2012 v.chambers@odi.org.uk www.institutions-africa.org
- 2. APPP local governance research Research question: What sorts of governance arrangements enable a ‘better’ provision of public goods (enabling key bottlenecks to be tackled) in sub-Saharan Africa? Public goods: Water and sanitation, facilitation of markets, public security and maternal health In-depth country studies − Multiple case studies: Malawi, Niger, Rwanda, and Uganda − Single case studies: Ghana, Sierra Leone, Senegal, and Tanzania www.institutions-africa.org
- 3. Methods and approach Scope of fieldwork: Two rural districts (Nyamagabe and Musanze), five months fieldwork in each, team of four researchers (incl. 3 Rwandans) Research methods: ethnographic techniques (participant and non- participant observation, casual conversations, informal interviews), semi-structured interviews, review of official documents. Assumptions about key components of safe motherhood: physical and financial access to maternal healthcare facilities, ante- and post-natal care, family planning use, assisted childbirth, efficient transfer between first and second level health care facilities. Bottlenecks taken as entry point. www.institutions-africa.org
- 4. What works and why? www.institutions-africa.org
- 5. Rwanda maternal health: observed results 1 Health infrastructure exist, are reasonably well equipped and staffed with professionals and offer full range of maternal health services. Community health workers in every village. Low MMR - Villagers struggle to recall women who have died in childbirth, no recorded maternal deaths in health centers since 2008 Households are increasingly limiting and spacing family size - condom distribution to young people, vasectomy uptake, contraceptive range equivalent to London (female condoms!), women demand ‘better’ Family planning methods available to women at Bisate health centre, Musanze district methods with no side effects and change methods. www.institutions-africa.org
- 6. Rwanda maternal health: observed results 2 Women give birth at health centres. Many use waiting facilities to avoid accidental home births. No evidence of ‘TBAs’ practicing. Women using the maternity waiting facilities at Jenda health centre, Nyamagabe district Women and men attend the 1st ANC. Both are tested for HIV. HIV+ women are integrated into PMTCT programmes. Local authority staff – no evidence of Men and women attending the maternity wing of absenteeism, contactable Kinigi health centre, Musanze district www.institutions-africa.org
- 7. Quantitative data Rwanda 1992 2000 2005 2008 2010 MDG MM per 100,000 1,071 750 540 476 268 Births at a health facility (%) 25 26 28 45 69 100 Total fertility rate (TFR) 6.2 5.8 6.0 5.5 4.6 Modern contraception 13 7 10 24 45 prevalence (%) % of women receiving: at least one ANC 94 92 94 96 99.8 four ANCs 13.3 24 35 * Source Demographic Health Surveys www.institutions-africa.org
- 8. How have bottlenecks been overcome? The coherence of the policy environment at all levels. Consistent national/local development objectives Coherent policy reforms accompanied by the strategies necessary for implementation, with clear lines of responsibility. Effective coordination and management of development partners avoids overlaps ensuring that interventions plug real resources gaps. Political commitment in pushing reforms through has been key www.institutions-africa.org
- 9. How have bottlenecks been overcome? Performance disciplines exist and function to ensure professional standards are respected and that policy is implemented Regular and effective supervision and monitoring of all actors (health providers are evaluated, imihigo objectives and reporting for local officials, CHW monthly reports). Upward accountability The incentive structures (rewards/sanctions) faced by different actors, at all levels, are consistent. (PBF, CHW cooperatives, imihigo rankings, user enforcement measures i.e. fines/public education). There are real consequences for poor performance www.institutions-africa.org
- 10. How have bottlenecks been overcome? Collaborative space for local actors exists and is facilitated/encouraged by the state Advisory and oversight committees exist (i.e. health committees, collaborative public education campaigns). Local population are involved in collective action activities (CHW, traditional ambulances, mutuelle committees, poverty reduction strategies, CHW). State has facilitated local problem-solving initiatives (particularly those which address specific bottlenecks). Feedback mechanisms exist so that lesson-learning feeds back into policy. www.institutions-africa.org
- 11. Quantitative outcomes compared - 1 Maternal mortality ratios (MMR) Malawi: Reduction in the MMR only just recover losses in 1990s Niger: Almost no progress in MMR since 1992 Uganda: Modest decrease in MMR Rwanda: Consistently falling MMR Health centre deliveries Malawi: significant increase since 2000 Niger: slight reduction since 1998 Uganda: only a very small increase since 1995 Rwanda: spectacular improvement since 2005 Source: Computed from Demographic and Health Survey data, various years. www.institutions-africa.org
- 12. Quantitative outcomes compared - 2 Contraceptive use Malawi: Consistent increases since the early 90s with a slow-down in the early 2000s Niger: Consistent but small increase over time Uganda: Sharp increase between 1995 and 2000, followed by a reduction Rwanda: Decrease post-1992, followed by consistent and drastic increase post-2005 Ante-natal visits (4) Malawi: almost consistent decrease since high levels in the 1990s Niger: small but consistent increase Uganda: stagnating use with a small dip in 2000 Rwanda: important increase since 2005 Source: Computed from Demographic and Health Survey data, various years. www.institutions-africa.org
- 13. Similarities Similarities: − General resource scarcity − Cost recovery in the 1990s with recent shift towards some form of user fee exemption. − Health service delivery decentralised to local level So what explains the difference? Levels of health expenditure appear to indicate a relationship between health expenditure per capita and maternal health outcomes but this is not sufficient. − Uganda has seen the greatest increase with little improvement in outcomes. APPP research indicates that the extent to which countries have overcome particular bottlenecks can explain many of these differences. www.institutions-africa.org
- 14. Common obstacles (bottlenecks) to safe motherhood Local choices about health-care (=delays in seeking medical assistance) Lack of accessible health infrastructure and failings in emergency evacuation procedures (=delays in transferring women to adequate health care facilities) Shortage of trained staff, stock-outs of blood/medicine, low staff morale and keeping of professional standards (=shortcomings in quality of care www.institutions-africa.org
- 15. Observed differences (in addressing bottlenecks) Use of modern services : − Uganda: uptake of maternal health services appears nominal. − Banning of TBAs in Malawi, Niger and Uganda has not been effective. − Rwanda: evidence of real behavioural change due to effective public education campaigns supported by enforcement. Timely transfers: − Niger: Ambulances exist but fuel expenses are prohibitive − Rwanda: community health insurance has increased financial accessibility; ‘waiting rooms’ help prevent accidental home births. Better quality care: − Uganda: Staff absenteeism; health centres don’t respect hours − Malawi: Severe overcrowding; low staff morale affects service − Niger: poorly trained staff, demeaning treatment of www.institutions-africa.org patients
- 16. Lessons from Rwanda Focusing on material resources alone can ignore the potential of institutional factors to overcome service-delivery blockages in resource-constrained environments. Addressing key service-delivery bottlenecks is not just about ‘supply’ and ‘demand’ but the interaction between the two. Top-down policy drive and grass-roots engagement have both been crucial. Collaborative spaces in which actors come together can provide key arenas in which service delivery bottlenecks can be overcome. www.institutions-africa.org
- 17. Africa power and politics The Africa Power and Politics Programme is a consortium research programme funded by the UK Department for International Development (DFID) and Irish Aid for the benefit of developing countries. www.institutions-africa.org
Notas do Editor
- This research was part of the APPP research
- This research was part of the APPP research
- Background to research. APPP, LL research stream. 11 months ethonographic fieldwork in Nyamagabe (south-west) and Musanze (north-west).
- In Rwanda health infrastructure exists, is well equipped; staffed with professionals; offering full range of maternal health services. Preliminary Demographic Health Survey data for 2010 supports our finding: FP use gone from 10.3 to 45.1. 98% of women have at least one ANC. (44% in SSA as a whole). HC births have gone from 28.2 to 68.9%. These improvements have been equally in rural areas. Reported MMR (RHMIS) is 383 in 2010 down from 750 in 2005. vision 2020 goal is 200 and MDG is 268.
- In Rwanda health infrastructure exists, is well equipped; staffed with professionals; offering full range of maternal health services. Preliminary Demographic Health Survey data for 2010 supports our finding: FP use gone from 10.3 to 45.1. 98% of women have at least one ANC. (44% in SSA as a whole). HC births have gone from 28.2 to 68.9%. These improvements have been equally in rural areas. Reported MMR (RHMIS) is 383 in 2010 down from 750 in 2005. vision 2020 goal is 200 and MDG is 268.
- Coherent policy environment created clear lines of responsibility. 1) Consistent national/local objectives: Vision 2020 (2000) objectives and MDGs were subsequently embodied in EDPRS (2008-12) and since adoption of decentralisation policies DDPs have become mandatory and must reflect national as well as local priorities thus they include things lie reduction in MMR, fertility and HIV prevalence rates. 2) Complimentary policy reforms with clear lines of responsibility 1) Ex. decentralisation policy & territorial administrative reforms has aligned health facilities with administrative entitities and 2) ex. health strategy (community health insurance scheme, community health system, performance based financing, focus on behavioral change) Decentralisation policy (2004): decentralised service delivery + political democratisation Territorial administrative reforms (2005) Health sector strategy (2005) and strategic plans I (2005-2009) & II – supported decentralisation strategy and service delivery improvements 3) Good coordaintion and management of DPs: DP relationships are managed centrally and their local activity is coordinated by JADF at district level. DPs need national Aid policy (2006) – all development assistanace must be in line with national and sector objectives/policies. DPs relationships are centreally controlld and any local DP activity must be channeled through the district JADF whcih ensures that activity is in line with DDP. Since 2010 division of labour initiative limits DPs to 3 sectors.
- Popular participation has contributed significantly to outcomes in maternal health. And although the collective action forms don’t typically resemble the sorts of things that we imagine civil society to be involved with as a means of improving services. They do provide community members with ways in which they can contribute to improving delivery and have a say in the sorts of things that matter. People might not have an equal voice and the arenas for action might be defined by external actors but there is some scope for participatory process within this. This also challenges the assumption that citizen ‘demand’ for better services has to be just about ‘civil society’ trying to force the state and service providers to improve the services they provide. Its also about citizens examining what they can do for themselves and how they can become engaged to improve services. Being a citizen is not just about demanding right but also about responsibility and engagement as well. An din resource-constrained environments voluntary citizen involvement is a necessary fact (‘big society’). The case of CHWs is a good example of a way in which local community members can contribute to improving local service delivery. CHWs helps overcome human resource capacity constraints and geographical access to healthcare. However the system doesn’t absolve the state and service providers of their responsibilities, quite the contrary. The health sector facilities are responsible for CHWs and as they are answerable for anything they do wrong so they are motivated to ensure that the CHWs are well trained and that any barriers they meet to fulfilling their roles successfully are managed. Likewise LG officials have imihigo (performance) targets to meet on maternal health indicators and they oversee the health centre facilities via their participation in the HC health committee. Arenas exist within which different actors involved in the local level of health service provision can collaborate together. This space means is an important factor in ensuring that everyone is working towards the same objective. Health committee example: During a Musange health committee meeting asked why there was a persistently high number of women giving birth at home. Response was to 1) criticise CHWs for poor results and visit them in their homes to ensure that they were upholding the practises they were being asked to promote and 2) CHWs were informed of the support and sanctions that local authorities can provide if the population refuse to implement the policies. Collective poverty reduction strategies (girinka, ubudehe, revolving savings schemes, micro-credits) State facilitation: ex. Setting up of SACCO accounts to facilitate poverty reduction strategies such as revolving savings schemes and micro-credits Participatory: ex. Ubudehe – villages were given money to use to (1) help poorest – identified by village committee during village meetings (2) create income-generating activites to reduce poverty.
- Coherent policies and accompanying strategies and reform necessary to implement them.
- Consensus around main causes of maternal death and the interventions necessary to reduce maternal mortality (WHO guidelines) * Causes: severe bleeding, infections, high blood pressure, obstructed labour and unsafe abortions * Interventions: ante and post-natal care, attendance of skilled professional during childbirth, use of family planning.
- Coherent policies and accompanying strategies and reform necessary to implement them.
- 1: mention that spending on health in Rwanda has clearly been important. However despite this per capita spending on health in Rwanda remains below the SSA average. 2: its not just about fixing supply and/or demand but about the ways in which the two come together. 3: in particular the collaborative spaces which bring together all actors are especially important. Where people can work out who can do what to achieve a goal which has been defined (maybe by the state) but which everyone agrees is in the interests of the community to resolve. An important part of this is about getting community members to do what they can. Being a citizen is not just about what we can expect but also what role we can play in contributing to our society.