Local politics and health: Performance-based contracts between mayors and the president in Rwanda

In mid-2005, Rwanda launched an ambitious phase of decentralization reform, culminating in district mayoral elections in March 2006. The reform included merging health districts, which had previously been managed by the Ministry of Health, into 30 new district-level government authorities. In April 2006, the 30 district mayors signed annual performance-based contracts with the President of the Republic, an unprecedented strategy to hold local government authorities accountable for meeting objectives related to health and other social services. The contracts' health indicators include contraceptive prevalence rate (CPR), births in health facilities, membership in community-based health insurance schemes, use of insecticide-treated nets (ITNs) and construction of latrines. IntraHealth International's Twubakane Decentralization and Health Program has provided technical assistance to districts to develop and implement budgeted action plans to meet their targets. Challenges have included insufficient data to establish and measure targets and the tendencies of mayors and their teams to be unrealistically ambitious and lack an understanding of the root causes of poor quality and inadequate use of health care services. Still, signing the contracts and assuming responsibility for the health of the local population has galvanized district-level efforts: mayors and other district authorities are not only becoming advocates for public health, but also are increasing their local health budgets and demanding additional resources from national health programs that had previously been centralized. Preliminary data from 2006 suggest that the performance-based contracts have had a positive impact on CPR, deliveries in health facilities, use of ITNs and other key indicators.