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Cross-country exchange Ethiopia and Rwanda

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Cordaid Ethiopia organised a seven-day study tour to Rwanda, for representatives from the Federal Ministry of Health (FMoH), Ethiopian Health Insurance Service, Regional Health Bureaus, Regional Bureaus of Finance, Zonal PBF-Focal persons, and Cordaid staff from Ethiopia and Global office, from September 3rd to 10th, 2023.

Figure 1: Group photo on the first day of visiting the Rwanda Genocide Memorial Museum, Kigali.

The primary objective of the tour was to enhance participants’ understanding of the Rwandan healthcare system and learn from the successful implementation of the Performance-Based Financing (PBF) approach. Participants engaged with the Ministry of Health and other ministries on topics such as healthcare financing, clinical service quality, policy and planning, and health insurance services. They learned about Rwanda’s integration of PBF into health policies, its expansion nationwide, and the success of co-financing arrangements. They also witnessed the positive impact of PBF and Clinical Quality Improvement (CQI) on healthcare financing and quality of care. The tour also highlighted the importance of community engagement in health management affairs, the integration of CQI with the District Health Information Software (DHIS2) system, and the linkage between PBF and Community-Based Health Insurance.

Highlights of Rwanda’s Healthcare System Transformation

The healthcare system transformation journey in Rwanda has been marked by several key efforts. One of the notable achievements is the establishment of a strong healthcare financing system, which has become a model across Africa. This system focuses on expanding access to quality healthcare services throughout the country. Through innovative approaches like community health insurance, Rwanda has ensured that its citizens have financial protection against high healthcare costs, leading to increased utilization of healthcare services and improved health outcomes.

Figure 2: The Delegates attending a briefing session by Rwanda MoH Representatives at the Rwanda Cooperation Meeting Hall.

Rwanda and Ethiopia have been implementing the PBF approach, a model that has played a key role in improving healthcare quality. Cordaid played a key role in piloting PBF in Rwanda in 2001, which was later expanded to cover the entire country. The government has shown a proactive commitment to financing the PBF approach, demonstrating its dedication to sustainable healthcare development. While the current implementation in Ethiopia aligns with Rwanda’s initial implementation, lessons can be learned. For example, the PBF approach in Rwanda incorporates complementary activities focused on CQI to enhance the effectiveness of the PBF approach.

I was stunned by Rwanda’s well-organized healthcare system, where individual performance is incentivized, and digitalization plays a crucial role. The innovative mechanisms in PBF financing and mandatory accreditation standards for quality of care truly left a lasting impression.” – Tarekegn Jabara | CQI Specialist for PBF project at Cordaid Ethiopia.

Figure 3: The delegates visited a health facility in the southern province of Rwanda

Dr Ruth | Chief of Staff and representative from the FMoH, emphasized “The most significant takeaway from my visit was witnessing Rwanda’s remarkable progress in achieving Universal Health Coverage (UHC). It became clear that this achievement is a result of strong government leadership, active community engagement, and innovative financing mechanisms.”

With Rwanda’s model, it is focusing on full performance incentives for staff, a mandatory hospital accreditation program and robust monitoring and evaluation systems. Ethiopia, on the other hand, is at an earlier stage, leveraging foundational elements from Rwanda’s initial approach like government co-financing, incentivizing the facility as a whole and health care workers individually. Both countries prioritize incentivizing healthcare staff based on performance metrics, but their implementations may differ in complexity. Rwanda’s more advanced stage provides valuable insights for Ethiopia. Both countries emphasize the need for continuous refinement and adaptation in PBF implementation for sustainable healthcare quality improvements.

Health care financing plays a crucial role in improving service quality. It involves adapting to existing systems, enhancing social protection and economic development. Reforms in provider payment mechanisms and homegrown plans can enhance capacity building, efficiency, and stakeholder involvement.” – Dr. Halima Abate | Claim Management Director, Ethiopian Health Insurance Service.

Figure 4: Group photo on the final date of the exchange visit to the Museum for the Campaign against Genocide

When we bring these learnings to our setup, paving a way to harmonize healthcare financing, prioritizing quality care, and implementing a comprehensive national healthcare quality and safety strategy is crucial.” – Tarekegn Jabara, CQI Specialist for PBF project.

The study tour to Rwanda provided participants with a valuable opportunity to witness the successful implementation of PBF and gain valuable insights that can positively contribute to the future direction of healthcare financing in Ethiopia. Furthermore, Dr Ruth suggested exploring the possibility of adapting Rwanda’s successful community health insurance model to the Ethiopian context as an additional avenue for improvement.