198578 Health governance and decentralization in Rwanda

Monday, November 9, 2009: 8:45 AM

Derick W. Brinkerhoff, EdD , International Development Group, RTI International, Washington, DC
Catherine J. Fort, MA , International Development Group, RTI International, Research Triangle Park, NC
Sara Stratton, MPH , IntraHealth International, Chapel Hill, NC
Experience around the world has demonstrated that attention to governance is important to the ability of health systems to fulfill essential public health functions. Health governance concerns the institutions and linkages that affect the interactions among citizens/service users, government officials, and health service providers. Beginning in 2001, the Government of Rwanda began an ambitious program of decentralization to improve governance and service delivery. Local governments are assuming greater roles in service delivery, facilities management, infrastructure investment and maintenance, revenue collection, and budgeting. USAID has funded the Twubakane Program to provide financial and technical assistance to Rwanda's districts, health facilities, and communities to provide improved services for maternal and child health, family planning, nutrition, and prevention and treatment of malaria. This study investigated the progress Rwanda has made with decentralized health governance to assess the contribution of these reforms to improved capacity, responsiveness to citizens, and health services delivery. The study used in-depth field interviews, focus groups, document analysis, and questionnaire data. Several districts were visited to enable comparative assessments.The study found that governance and decentralization reforms have increased local accountability and created incentives for more responsive service delivery by government and local providers. Innovations such as community-provider quality teams, joint planning and budgeting exercises, and district incentive funds have expanded health system capacity and performance. Twubakane's efforts to support the decentralization of Rwanda's health system and build the capacity of local governments to plan, budget for, and deliver health services demonstrate the importance of focusing on health governance as a contributor to improved health outcomes. Rwanda's experience demonstrates that decentralization is an administrative reform that can be an enabler of good governance, but it also shows that decentralization is not a panacea for governance or performance problems. Capacity issues remain an important constraint, not just inside the health system but in local--and central--government as well.

Learning Objectives:
Participants will understand how decentralization and governance influence system strengthening and service delivery, and will be able to draw lessons from Rwanda applicable for other countries.

Keywords: Developing Countries, Service Delivery

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: Dr. Derick W. Brinkerhoff is Distinguished Fellow in International Public Management with RTI International (Research Triangle Institute) and is an associate faculty member at George Washington Universityís Trachtenberg School of Public Policy and Public Administration. He is a specialist in policy implementation, strategic management, democracy and governance, decentralization, civil society and NGOs, and organizational change. Among his current activities, he is advising Indonesian civil society organizations on advocacy strategies for democratic reforms, drafting a training manual for the Peacekeeping and Stability Operations Institute of the U.S. Army War College on governance in post-conflict states, conducting research on decentralization in the health sector in Rwanda, and leading the health governance component of USAIDís Health Systems 20/20 Project. He has worked with public agencies, NGOs, and the private sector, across a broad range of development sectors in 30 countries, with an emphasis on Africa. He served as Principal Social Scientist at Abt Associates for ten years, where he spearheaded the research program of USAIDís Implementing Policy Change Project, managed a USAID-World Bank support program for African agricultural and NRM research systems, and worked on health sector reform under USAIDís Partners for Health Reform Project. Prior to joining Abt in 1993, he spent ten years on the faculty of the University of Maryland at the International Development Management Center, including six years as the Center's associate director for research and four years as resident advisor to Haiti's planning ministry; two years in USAID's Science and Technology Bureau; and several years freelance consulting both overseas and in the U.S. He was also a Peace Corps volunteer in Chad for three years. Dr. Brinkerhoff has published extensively, including eight books and numerous articles and book chapters. His most recent book is an edited volume, Governance in Post-Conflict Societies: Rebuilding Fragile States (Routledge, 2007). A frequent guest speaker at universities, conferences, and policy forums, he was an adjunct lecturer at Johns Hopkins Universityís School of Advanced International Studies from 1996-2002. He has been teaching at GWU since 2003. He holds a doctorate in public policy and administration from Harvard University and a masters in public administration from the University of California, Riverside.
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.