Rwanda - UNICEF
1 UNICEF/2019RwandaHealth Budget BriefInvesting in children’s health in Rwanda2019/2020
2Health Budget Brief: Investing in children’s health in Rwanda2019/2020 United Nations Children’s Fund (UNICEF) RwandaDecember 2019
3This health budget brief explores the extent to which thethe budget briefs is to synthesize complex budget informationGovernment of Rwanda addresses the health needs ofand offer recommendations to strengthen budgeting forchildren under 18 years of age and mothers in Rwanda. Thechildren. Financial data used in this analysis are drawn frombrief analyses the size and composition of budget allocationsthe 2019/20 approved budget and revised budget estimates forto the health sector for the 2019/20 financial year. The aim ofthe previous years.Key messages Over the past few years, budgets allocated to thehealth sector trended upwards, but in the currentfiscal year the allocation declined by approximatelyone per cent from FRW 232.4 billion in 2018/19 to230.8 billion. The health sector share of the totalnational budget also declined from 9.51 percent in2018/19 to 8.0 per cent in 2019/20. There is a needfor the Government to increase domestic allocationto strengthen the sector capacity and scale up theprovision of quality health services to all people inRwanda. The execution rate of the total health budget at thenational level has decreased from 84.3 per cent in2017/18 to 70.9 per cent in 2018/19. The decline inbudget execution should be investigated to betterunderstand its underlying reasons, and efforts needto be made to improve execution. The Government is making strides to increasedomestic financing of the health sector, althoughexternal resources are still significant. In 2019/20, justunder half of the health budget (48.2 per cent) willbe externally sourced. Increasing the domestic shareof the health budget is therefore a step in the rightdirection to ensure financial sustainability. Budget allocation for infectious diseases hasdeclined over the years. For infectious diseases thebudget allocation has declined from FRW 17.8 billionin 2017/18 to FRW 11 billion in 2019/20. Given thatinfectious diseases and maternal and childhoodillnesses are still the leading causes of mortality andmorbidity in Rwanda, and in order to maintain thegains made until now, efforts need to be made tocontinue to increase allocations for infection diseasesprevention. UNICEF/UN0319764/KanobanaPreface
41. Introduction and sector overview The Rwandan health sector is coordinated by the MinistryCommunity health: Basic treatments are providedof Health (MINISANTE), whose mission is to provide andin health posts (HPs) and health centres (HCs), andcontinuously improve affordable promotive, preventive,Community Health Workers provide basic assistancecurative and rehabilitative health care services to the Rwandanat the household level.4population.1 MINISANTE is supported by the Rwanda Biomedical Centre (RBC)2, an implementing agency responsibleDistrict: Upon referral from HCs, district hospitals(DHs) undertake advanced diagnosis and treatment.for executing key programmes, improving research activities in the field of disease prevention, and providing treatment toProvince or national: Upon referral from DHs, referralpeople at all levels of the health system. Additionally, the Foodhospitals (RHs) address specialized medical diagnosisand Drug Authority (FDA) was established in 2018 and, amongand treatment.other activities, is responsible for regulating pharmaceuticalproducts, vaccines, human and veterinary processed foodsThe health sector priorities5 are defined in the: i) Rwanda Visionand other biological products.2020: A long-term, 20-year development vision; ii) NationalStrategy for Transformation (NST1) 2017-24; iii) Health SectorHealth services in Rwanda are provided at various levels ofStrategic Plan (HSSP) 4: 2018/19 – 2023/24; iv) Health Financingthe health system by public, faith-based, private for-profit andSustainability Policy 2015.non-government organizations3. Three key levels for serviceprovision can be identified:Health sector performance against selected indicatorsRwanda has made significant progress over the past decade toThe under-five mortality rate fell from 152 to 50 per 1,000 liveimprove health outcomes, but challenges remain.births in 2014/15, and the 2024 target sets the ambition tofurther reduce the under-five mortality rate down to 35. InfantBetween 2005 and 2014, the maternal mortality ratiomortality6 also significantly dropped from 86 to 32 per 1,000decreased by more than two thirds (from 750 per 100,000 livelive births over 10 years, with the 2024 target at 22.5 (Figure 2).births in 2005 to 210 per 100,000 in 2014/15). Furthermore, theGovernment of Rwanda aims to reduce the ratio to a target of126 by 2024, indicating a reduction of 40 per cent (Figure 1)700160152140Figure 1: Maternal mortality ratio per 100,000 (2005–2015)800Figure 2: Infant and under-5 mortality 2005210200Infant Mortality Rate1261000200520102014/15Source: Demographic and Health Surveys (DHS) and NST1201020242014/1522.52024Under 5 Mortality RateSource: Demographic and Health Surveys (DHS) and NST1
5However, the data significantly differ by household incomelevels. While there is a very commendable effort in reducinginfant and under-five mortality, the analysis by wealthFigure 4: Trend of Children stunting rates (%)60quintiles shows significant inequities, with mortality rates50among the lowest income households double to those of40the highest income group (Figure 3).This indicates thatefforts need to have a stronger focus on equity to support thedisproportionately affected poor 7201910Figure 3: Infant and under-5 Mortality rates by wealth : Demographic and Health Survey, NISR9Further, the analysis of stunting rates by gender shows a30higher stunting rate among boys, with 43 per cent affected2020against 33 per cent among girls. Stunting among children1010living in the poorest households is more than double (49 per00cent) than among children in the high-income households (212530LowestSecondMiddleInfant mortalityFourthHighestUnder-5 mortalitySource: Demographic and Health Surveys (DHS) and NST1per cent).The Government of Rwanda has committed to reduce thelevel of stunting to less than 20 per cent by 2024. To ensurecontinues to be a public health concern, with stunting rates at38 per cent nationwide, 41 per cent in rural areas and 24 percent in urban7 areas (Figure 4).coordination and streamline stunting reduction interventionsacross the country, the Government of Rwanda hasstrengthened the institutional framework, with the focus onthe districts with high stunting rates. UNICEF/UN0306629/MuellenmeisterThe nutrition status among children under five years of age
62. Trends in government spending in the healthsector2.1.Size of government spendingFigure 5: Health budget in FRW billion and as a share of total budgetand GDPAn analysis of the health sector budget over the past fouryears shows that budget allocations for health have nominallyincreased from FRW 189.3 billion in 2016/17 to FRW 230.8billion in 2019/20. However, the health budget slightly declinedto FRW 230.8 billion** in 2019/20, down from FRW 238.4 billionin 2018/19. The health budget as a share of the total nationalbudget decreased quite significantly from 9.7 per cent to 8per cent. As a share of the Gross Domestic Output (GDP), itdecreased from 2.7 per cent to 2.5 per cent (Figure 5). As theGovernment of Rwanda is in the third year of 06.04.02.672.52.00.00.02018/192019/20of the NST1 and the fourth year of implementation of the SDGHealth budget (FRW Billion) (left axis)agenda, investments in the health sector need to be increasedHealth budget as % national budget (right axis)to meet the health sector development targets.Gov. Health sepending as % of GDP (right axis)Source: Calculated using state finance laws and Macro-framework data**This analysis, however, excludes the interventions under the National Early Childhood Development Programme(NECDP), a body created to coordinate stunting reduction and early childhood development interventions in Rwanda.According to the structure of the Finance law, NECDP interventions are planned under the social protection sector and itsbudget is recorded under Ministry of Gender and Family Promotion (MIGEPROF). If the budget allocated to NECDP is alsotaken into consideration, the total health budget for 2019/20 increases to FRW 243.7 billion reflecting an increase of 4.8 per UNICEF/UN0258676/Rusanganwacent to the 2018/19 revised budget.
72.2. Government spending trends in different sectorsTaking as reference the NST1 sectors, the health sector is the fifth largestin budget allocations with 8.2 per cent, after Public Financial Managementreforms with 28.9 per cent, Education with 10.8 per cent, Justice, Law andReconciliation with 9.4 per cent, and Transport with 9.3 per cent (Figure 6).Figure 6: National budget allocations by NST1 Sectors 2019/20 015.010.89.49.38.210.05.72019/20 allocations (FRW Billion) (left axis)5.55.44.93.92.35.00.0Share of sectors (%) (right axis)Source: Calculated using state finance laws2.3.Health sector spending compared with other countriesRwanda’s per capital health spending is above the average spending ofcountries in sub-Saharan Africa.A comparative analysis of per capita health expenditure for Rwanda againstthat of neighbouring Kenya, Uganda and Tanzania, as well as sub-SaharaAfrica as whole, reveals that Rwanda’s per capita health expenditure(domestic revenues) is above the sub-Saharan Africa average of US 11,despite a slight decline from US 12.5 in 2013 to US 12.1 in 2015. Amongthe selected countries, Kenya (the only middle-income country) ranks firstin per capita health expenditure with US 23.3 in 2015 (Figure 7).Figure 7: Domestic General National Health Expenditure (GGHE-D) per Capita inUS 30.030.022.925.018.320.015.012.510.05.023.23.912.0 11.510.8 10.78.84.720.08.3 8.512.19.44.211.05.9 6.211.215.010.05.00.00.0201320142015Burundi Kenya Rwanda South Sudan Uganda United Republic of Tanzania Sub-Saharan AfricaSource: WHO health expenditure database “http://apps.who.int/nha/database” UNICEF/UNI212777/Rudakubana25.024.0
83. Health sector budget changes3.1. Health budget revisionsThe difference between the nominal and real budget changesis very small and narrowed significantly between 2018/19 andThe aim of the budget revisions is to respond to emerging2019/20. This is due to lower inflation rates registered in thepriorities during the budget year, align expenditures withpast three years. For 2018/19, the real budget change was 16.1revenue flows and to capture new donor financing that maycome in halfway through the budget execution cycle.per cent against 17.8 per cent in nominal budget changes.Furthermore in 2019/20, the real health sector budget changewas -2.1 per cent against -0.7 per cent (Figure 9). To sustain theFrom 2016/17 to 2018/19, the health budget allocations wererevised slightly upward. In 2018/19, the budget revisionsignificantly impacted the health sector, bringing funding fromFRW 200.8 billion to FRW 232.4 billion, a 15.7 per cent increase(Figure 8). More specifically, the following programmes wererevised upward: (i) “Administrative and support services”,with a budget increase of 40 per cent; (ii) “Infectious diseasesprevention and control” with 13.1 per cent; (iii) “Health sectorplanning and information” with 13.7 per cent and (iv) “Healthservice delivery and quality improvement” with 28.7 per cent.The upward budget revision shows stronger capacity to dealwith emerging priorities throughout the budget executionphase. However, these revisions have not contributedsignificantly to addressing priority areas like maternal andchild health.health sector gains and expand health services, there is a needto increase the health budget to at least the same rate of thetotal national budget annual increase.Figure 9: Health budget changes: inflation adjusted and 016/170.02017/182018/192019/20Initial Health budget (FRW billion) (left axis)Revised Health Budget (FRW billion) (left axis)Health budget changes (Orginal vs revised) (right axis)Source: Calculated using the National Budget laws3.2. Changes in the health budget: Inflation adjusted changesInflation-adjusted (real) and nominal budget trends forthe health sector indicate that the effect of inflation wassignificantly lighter over the past two years.2016/172017/18Source: Calculated using state finance laws14.0232.4-9.52018/19Health budget infla on adjusted (%)18.0-0.7-7.2Health Budget nominal changes (%)16.0150.0-2.1-1.70.0 UNICEF/UN0299983/Kanobana200.04.35.0billion and as a percentage)230.816.110.0Figure 8: Health budget allocations, initial vs. revised budget (in FRW250.017.815.02019/20
94. Composition of Health sector spending4.1. Health sector priorities: Budget trends forselected programmesHealth service delivery, quality improvement, health sectorbillion up from FRW 45.6 billion, the latter comprisingplanning and information and health sector governancesalary allocations, other allowances to staff and other fixed(administrative services) are the main health programmes,expenditures to be incurred by the sector. Dealing mainlyabsorbing more than a half of the total health budget.with health planning activities, health data management,health sector planning and information was allocated FRWHealth service delivery and quality improvement was allocated43.4 billion, down from FRW 46.6 billion. The allocations forFRW 63.8 billion in 2019/20, down from FRW 66.9 billion thethe disease prevention and control programme declined fromprevious year. The health sector governance (administrativeFRW 14.2 billion to FRW 10 billion (Figure 10).and support services) programme was allocated FRW 51.2Figure 10: Budget allocation by health sector priorities in billion FRW10Food and Drugs registra on and Inspec 1.216.963.836.7Specialised Health ServicesHealth Human ResourcesMaternal And Child HealthDisease Preven on And ControlHealth Sector Planning And Informa onAdministra ve and support servicesHealth service delivery and Quality Improvement2019/20Source: Calculated using state finance 60.070.080.0
104.2. Budget allocated to nutrition-specificinterventions4.3. Budget allocation by the spending agenciesLooking at the health budget composition by institutions,The Government of Rwanda has increased investments tofive main agencies can be identified. As the main spendingtackle stunting over the past two years. Malnutrition andagency, the Rwanda Bio-medical centre (RBC) has benefitedstunting remain public health challenges. The Governmentfrom an increased budget share in the last five years andof Rwanda, through the Ministry of Health (MINISANTE),accounts for 52.8 per cent of the total health sector budgetRwanda Biomedical Centre (RBC), Ministry of Agriculturein 2019/20. The Ministry of Health follows with 25.7 per cent,(MINAGRI)/Rwanda Agriculture Board (RAB), Ministry ofthen subsequently districts which cater for salaries and otherLocal Government (MINALOC), Ministry of Gender andoperational costs of the district hospitals with 17.3 per cent.Family Promotion (MIGEPROF) and National Early ChildhoodReferral hospitals (which are budget agencies) were allocatedDevelopment Programme (NECDP), has established specific3.8 percent (Figure 12).budget lines to address nutrition challenges. /From 2016/17to 2019/20, the budget allocated to nutrition programmesFigure 12: Health budget by spending agencies (as a share of totalincreased substantially, from FRW 8.2 billion to FRW 26.3health budget)billion in 2018/19 followed by a slight decrease to FRW 23.360.0billion in 2019/20, or -9.7 per cent (Figure 11).50.0Figure 11: Budget allocation for nutrition specific 0RWANDA BIOMEDICAL CENTERMINISANTEDISTRICTREFERRAL HOSPITALS**Rwanda Food and Drug Authority8.2Source: Calculated using state finance laws2016/172017/182018/192019/20Nutrition budget (Frw Billion) (left axis)Source: Calculated using state finance lawsThe increase in public investments for nutrition and stuntingreduction indicates strengthened high-level commitment toeradicate malnutrition, particularly among children under fiveand pregnant mothers from the poorest households. Theseefforts have attracted new sources of external financing fornutrition promotion in Rwanda. However, given the magnitudeof the issue these funds many not be adequate enough tomeet the needs. UNICEF/UN0302510/Nkinzingabo-
114.4. Health budget by recurrent and development categoriesBoth the development budget and recurrent budget under theFigure 13: Health budget allocation by recurrent and developmenthealth sector have increased.budget categories160.0The budget allocated to development projects8 under the140.0health sector increased from FRW 115 billion in 2018/19 to120.0FRW 135.8 in 2019/20, while the recurrent budget increasedfrom FRW 85.7 billion to FRW 95 billion. Over the past three100.0sector increased from 55.6 per cent in 2017/18 to 58.9 per cent20.0to four years ago. This can have a significant impact on thebudget available for programmes addressing diseases thatare still a major burden in 0.010.00.00.02016/172017/182018/192019/20Recurrent (FRW Billion ) (left axis)Development budget ( FRW Billion) (left axis)% of development budget (right axis)Source: Calculated using state finance laws of development budget has declined substantially compared57.355.680.0years the share of the development budget of the health(Figure 13). As the recurrent budget increases, the proportion70.063.2
125. Budget execution in the Health sectorThere is a noticeable difference in the budget executionbetween central government and districts, with a downwardtrend observed at central level.Figure 14: Health Budget execution rates120.0100.0The health budget execution rate at the central level in 2018/19was lower (70.9 per cent) than in the previous year (84.3 percent). Execution seems to systematically perform better at99.677.180.09784.3 88.470.960.0district level. In 2018/19, 97 per cent of the budgeted resources40.0were spent, up from 88.4 per cent in 2017/18. The low budget20.0execution at national level can be explained by delays in-execution of development projects which constitutes a sector2015/16challenge (Figure 14). The budget execution rate is computed2016/172017/18Execution rate (National)by comparing the revised health budget and the executedbudget as reported by the Ministry of Finance and Economic94.786.02018/19District ratesSource: Calculated using MINECOFIN- Budget execution reportsPlanning.6. Financing of the Health sectorThe financing of the health sector still relies heavily onFigure 15: Source of Financing of the health sectorexternal finances. However, the Government of Rwanda hasdeveloped a Health Financing Strategic Plan which sets out themechanisms for more sustainable sector financing to bridgethe gap created by declining official development assistance(ODA) and increase efficiencies in public health spending.In 2019/20 domestic resources accounted for 51.8 per cent .5100.897.7
Government of Rwanda addresses the health needs of children under 18 years of age and mothers in Rwanda. The brief analyses the size and composition of budget allocations to the health sector for the 2019/20 financial year. The aim of the budget briefs is to synthesize complex budget informat
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