Case Study: Rwanda 1

Transcription

1 1 Author: Susy Ndaruhutse November Note: This case study was drafted over the period February to June 2011, so refers to data that was available over that period rather than more recent data such as the 2010 Demographic and Health Survey which came out in August 2011.

2 Acknowledgements This country case study benefitted from general and sector-specific inputs provided by Mansoor Ali, Frances Cleaver, Janice Dolan, Nigel Pearson and Tony Vaux. Additional comments and technical inputs were provided by Save the Children staff. Funding for this research was provided by UKaid from the Department for International Development (DFID). The team is grateful to DFID staff and particularly Anna Miles for comments and feedback on the initial draft. Any errors or omissions remain with the author. The views and opinions expressed in this case study do not necessarily represent the official views of DFID, CfBT Education Trust, Practical Action Consulting Ltd, or Save the Children. 2

3 Acronyms CBO Community-Based Organisation DRC Democratic Republic of the Congo EDPRS Economic Development and Poverty Reduction Strategy FBO Faith-Based Organisation Gacaca A system of community-based reconciliatory justice (community courts) GoNU Government of National Unity GoR Government of Rwanda Imihigo Performance Contracts (with targets identified by the local population) Iringaniza Literally translated means balance but is used in reference to the quota system used post-independence up to the 1994 genocide to limit Tutsi involvement in schools, universities and public positions MINALOC Ministry of Local Government, Community Development and Social Affairs (Ministère de l Administration Locale, de l Information et des Affaires Sociales) MINEDUC Ministry of Education MINELA Ministry of Environment and Lands MININFRA Ministry of Infrastructure MINISANTE Ministry of Health (Ministère de la Santé) MINITERRE Ministry of Land, Environment, Forestry, Water and Natural Resources MMI Military Medical Assurance Mutuelle Pre-Paid Health Insurance Scheme NER Net Enrolment Rate NURC National Unity and Reconciliation Commission P4P Pay for Performance RAMA Rwandaise d Assurance Maladie RoR Republic of Rwanda Ubudehe Community-Based Participatory Approach WHO World Health Organization 3

4 1. Introduction and Purpose Context of the Case Study This case study is part of a larger DFID-funded research programme implemented by a consortium of three partners: CfBT Education Trust, Practical Action Consulting Ltd and Save the Children, led by CfBT Education Trust. The research programme is exploring the links between service delivery in education, health, sanitation and water, and wider processes of state-building and peace-building in fragile and conflict-affected states. The first output of this research programme was a literature review. Building on this, DFID wanted the consortium to undertake a preliminary desk analysis to identify possible trends in secondary data on service delivery (funding, expenditure, modalities and coverage), democracy (public perceptions and accountability) and any available political economy analysis in six countries that reflect different typologies of fragility or conflict-affectedness. The following countries were selected (from a longer list given by DFID) to reflect a diversity of situations geographically and in terms of where they lie on a fragility-resilience continuum: Cambodia, the Democratic Republic of the Congo, Nepal, Rwanda, Sierra Leone and Southern Sudan. DFID would then like the consortium to draw on the findings of the literature review and these six desk-based country case studies undertaken as part of Phase 1 of the research programme, to undertake country-level fieldwork in three of these countries (planned for Nepal, Rwanda and Southern Sudan) to build a stronger evidence base for how service delivery is contributing to wider state-building and peace-building processes in these three countries. This is planned as Phase 2 of the research programme. The context for this research is provided by the DFID (2010) practice paper Building Peaceful States and Societies and this case study (along with the five other deskbased case studies) is seeking to test the framework set out in this practice paper by exploring if there is any evidence for the following statement: States provide public services and in doing so increase their legitimacy as well as national stability. The DFID practice paper as well as the research programme of which these case studies are part, contributes to a growing body of literature exploring how donors can best provide support and assistance to state-building and peace-building in fragile and conflict-affected states. Purpose of the Case Study The purpose of this desk-based case study is to examine secondary data on how responsive the state is being in Rwanda in meeting the expectations of its citizens in relation to service delivery, and infer how this impacts or might impact on citizens perception of state legitimacy and thus upon state-building and peace-building. This will be done by considering how the different ways of accessing and delivering education, health, water and sanitation services (looking at coverage and inclusivity of services, modes of provision and financing of services) and accountability 4

5 mechanisms that support the delivery of these services including dialogue and information flows, meet, and impact on, citizens expectations for services and perceptions of legitimacy. It is important to note that the time allocated for this case study was only 10 days and the work involved sourcing and reviewing accessible published and grey literature on service delivery in the four sectors as well as on key political and economic developments in the country. In the limited time, it was not possible to undertake a comprehensive literature search, so only key documents have been accessed. Thus any analysis provided is based on available information in the key literature rather than any fieldwork at country level and is likely to be incomplete. It is also important to stress that there is a strong reliance on government, donor and NGO reports as very little academic literature was available related to the specifics of service delivery. This means there is a risk of selection bias. Structure of the Case Study This case study has six main parts. Part 1 (above) provides an introduction to the purpose of the case study. Part 2 provides an overview of the country context in relation to fragility and conflict, and a brief political and economic situational overview of the country and recent history. Part 3 looks in detail at service delivery across the four sectors (education, health, sanitation and water) including sub-sections on coverage of services, modes of delivery of services and financing of services. Part 4 explores mechanisms for state responsiveness including sub-sections on accountability mechanisms, dialogue and information flows and the expectations of citizens in relation to service delivery. Part 5 seeks to draw out the main conclusions of the case study using the examples of service delivery in the four different sectors to provide insight on how this has impacted (or might have impacted) upon the political settlement, the responsiveness of the Government, and the way in which the different sectors have or have not contributed to state-building and peace-building, and what role external support has played in this. Part 6 outlines implications for Phase 2 methodology including commenting on data gaps and further areas to investigate in Rwanda during Phase Overview of Country Context History and Genocide The monopoly of power by one of the two dominant ethnic groups has been a longstanding grievance in Rwanda s history (McDoom, 2011: 12). Rwanda s population is made up of three ethnic groups the Hutu, Tutsi and Twa (around 1 per cent). The Hutu are the majority population (between 80 and 90 per cent) but up until the late 1950s, a Tutsi monarchy governed the country supported by the colonial powers. In 1959, the Hutu overthrew the Tutsi monarchy leading to significant numbers of Tutsis becoming refugees in neighbouring countries. At independence in 1962, Rwanda was led by a Hutu government with Grégoire Kayibanda as President with a desire to end Tutsi feudalism (Chrétien, 2003). 5

6 His desire was strongly played out in the education sector where the Tutsi had been largely favoured during the Belgian colonial era and as the Hutu took power in 1959 leaders wanted to overturn this situation. They introduced an ethnic quota known as iringaniza which limited the percentage of places for Tutsis in schools, the university and positions of power to around 9 per cent (their share in the overall population) largely controlling the influence Tutsis could have (UNESCO, 2011). In 1990, the Rwandan Patriotic Army (RPA), the armed wing of the Rwandan Patriotic Front (RPF), a rebel group of predominantly Tutsi exiles, invaded Rwanda from Uganda demanding the return of the exiles to Rwanda, which led to a civil war and further instability. Peace talks began between the RPF and the Government of Rwanda in 1992 and in 1993, both parties signed the Arusha Peace Agreement (Arusha Accords) in Tanzania. The United Nations Security Council then authorised the United Nations Assistance Mission for Rwanda to supervise the implementation of the Arusha Accords (Dallaire, 2004). On 6 April 1994, an aeroplane carrying Rwanda s President Juvenal Habyarimana and Burundi s President Cyprien Ntayamira, was shot down as it was coming in to land in Rwanda killing both men. This was the catalyst for military and Hutu militia groups such as the Interahamwe to target and kill Tutsis and moderate Hutus. The RPF then reinvaded and civil war recommenced, with the RPF defeating the Rwandan army and taking control of the country on 16 July The genocide resulted in an estimated 500,000 to 1 million people being killed (Rieff, 2003; Dallaire, 2004; McDoom, 2011). Tutsi children and their families were an easy target as schools and local authorities had a register of their ethnicity (Dallaire, 2004; UNESCO, 2011). During the 100 days of the genocide, Rwanda was plunged into chaos and the basic functions of the state completely ceased to operate. The Rwandan army, key leaders and many other Hutus fled, largely into the Democratic Republic of the Congo (DRC) (estimates of around 1.2 million people) but also into Tanzania and Burundi. The central bank was emptied of its reserves and the country both economically and politically had to rebuild itself from the devastation of civil war and genocide. Post-Genocide Post-genocide, Rwanda was a fragile and conflict-affected state with a new, unelected political leadership formed without a negotiated political settlement. There were frequent border incursions from the génocidaires 2 in eastern DRC contributing to instability in Rwanda. The RPA defended its borders as well as actively fighting the génocidaires and other rebel groups in eastern DRC which resulted in tens of thousands killed by the different parties involved in the conflict (UN Office of the High Commissioner for Human Rights, 2010). Rwanda required significant humanitarian aid as well as substantial support in rebuilding basic state institutions, both physically and in terms of human capacity given that many of the most educated people had either been killed or fled the country. The ongoing fighting in eastern DRC and frequent border incursions also contributed to instability. 2 This is a French term that is commonly used to refer to those guilty of the mass killings during the 1994 genocide in Rwanda. 6

7 Politically, the RPF led a coalition Government of National Unity (GoNU) and formed a Transitional National Assembly. Under the GoNU, a process of demobilisation and reintegration took place which was important for national security and stability (Shyaka, undated), and in 1999, a National Unity and Reconciliation Commission (NURC) was set up to reinforce the institutional framework and put in place mechanisms for building a culture of peace and reconciliation (RoR, 2007a: 17). This was coupled with the re-establishment of a system of community-based reconciliatory justice known as gacaca to help process those accused of crimes during the genocide which could not be undertaken by the formal legal system due to the fact that there were very few trained lawyers and judges left in the country as they had either been killed or had fled during the genocide. The NURC conducted a survey on social cohesion in 2008 and found that 99 per cent of the general population, 92 per cent of genocide survivors and 79 per cent of the prisoner population believed that gacaca is an essential step toward peace and reconciliation in Rwanda (NURC, 2008: 6). By contrast, McDoom (2011) argues that gacaca does not have strong support from the population and has had low levels of community participation. Ethnic identities are now no longer used publicly and the GoR has encouraged people to think of themselves as Rwandans. Whilst this has resulted in what at a superficial level seems to be a much more peaceful society, ethnicity remains an elephant in the room that is not talked about openly and beneath the surface there still lie many tensions and inter-ethnic grievances (Beswick, 2010). Due to the Government s position on ethnicity, there is no disaggregation of data on access to services by different ethnic groups. McDoom (2011) argues that there is not genuine peace and unity between the main ethnic groups in Rwanda, but rather a non-violent co-existence. Beswick (2010: 4) notes that: Following the failures of the international community during the genocide, the RPF-led Government has made it clear that issues of ethnicity and security are off-the-table as far as donors are concerned. He further points out that donors have largely remained silent about the ethnicity issue and instead have focused on the positive progress the Government is making in other areas, particularly that of good governance. Political Progress Since the early years of transition into a post-conflict state, Rwanda has made considerable progress and has not descended back into large-scale ethnic hatred and civil war but rather has achieved greater stability, focusing strongly on building state capacity and institutions. Public sector reforms (including reforming the civil service) were put in place from 1998 with the intention to improve the quality of service to the public, increase effectiveness, eliminate corruption and to ensure equity, transparency and 7

8 accountability (RoR: 2007a: 12). In 2001, public financial management reforms were also undertaken leading to the introduction of the Medium Term Expenditure Framework for government budgeting and spending. The National Constitution was enacted into law in 2003 after a referendum with 93 per cent of the population voting in favour (OECD, 2009). This was followed by parliamentary and presidential elections in August and September 2003 respectively which took place peacefully with the RPF candidate Paul Kagame winning the presidential election with over 95 per cent of the vote. Rwanda s constitution allocates 30 per cent of seats in the Chamber of Deputies to women (Shyaka, undated) which has had a strong impact on gender empowerment and equity. Despite these important achievements, there is a concern about the lack of political space with a relatively weak and co-opted political opposition and limitations on political activism which curtail the activities of civil society organisations, particularly in human rights (Beswick, 2010: 12). Donors have also been largely unwilling to challenge the Government on political space, human rights and press freedom; and Beswick (2010) points out that this does not send out a supportive message to civil society groups and others wanting to challenge government and whose work is likely to lead to improved state-society relations, a more inclusive and sustainable political settlement and more responsive state-building. There have also been concerns over Rwanda s ongoing military involvement in the DRC, which is another area that donors have not challenged consistently. McDoom (2011: 38) argues that long-term peace and stability in Rwanda depend on: the gradual opening of political space and de-concentration of power in the hands of the ruling elite to allow Rwanda s state institutions and civil and political society to evolve into responsible and independent counterweights to the regime. Economic Progress Rwanda has made good economic progress since Real GDP growth between 1996 and 2000 averaged more than 10 per cent annually, slowing to around 6.4 per cent a year between 2001 and 2006 (OECD, 2009).The GoR has also taken a tough stance on corruption, removing from office and imprisoning corrupt officials. This has led it to have a strong reputation in the region for its zero tolerance for corruption (OECD, 2009). Despite impressive and sustained levels of economic growth, there has not been the same progress in reducing poverty, with extreme poverty falling by just over 4 per cent between 2000/01 and 2005/06 and those living below the poverty line falling by only 0.5 percentage points (OECD, 2009). Levels of inequality (measured by the Gini coefficient) increased from 0.47 in 2000 to 0.51 in 2005 with strong horizontal inequalities between urban and rural areas the latter consisting of largely Hutu smallholders (McDoom, 2011). McDoom argues that such inequalities create ethnic grievances. 8

9 Governance is one of six priority areas in the latest Poverty Reduction Strategy Paper (known in Rwanda as the Economic Development and Poverty Reduction Strategy (EDPRS)) (RoR, 2007b). There has been greater consultation by the Government with its citizens in the process of developing the EDPRS, especially through the ubudehe community-based participatory approach. This is a change from the past where state-society relations have been strongly authoritarian. This has led donors to claim that in driving the poverty reduction agenda, they have positively influenced state-society relations, but the Government to reject this idea as they believe poverty is strongly related to insecurity (OECD, 2009). Rwanda created a Ministry of Local Government (MINALOC) in 1999 and then introduced a Decentralisation and Community Development Policy in 2000 which devolved planning and spending to local levels with the ministries having a policy coordination role (Musoni, 2004; RoR, 2007a). Legitimacy Rwanda s score for legitimacy of the state on the Failed States Index stood at 7.5 in 2010 (where 10 is the worst score and 1 is the best) having improved from 8.7 in Its score for public services was 7.4 in 2010 having worsened from 6.9 in This demonstrates a trajectory of improvement for legitimacy but a worsening of performance in relation to service delivery. The OECD (2009) argues that the RPF Government s prioritisation of peace and security in Rwanda has been the major issue contributing to state legitimacy in the eyes of Rwandan citizens. They argue that evidence from this is demonstrated by the results of a World Attitudes Survey which showed that the Rwandan population placed more trust in the police than in their neighbours. Other important issues include the GoR s focus on rule of law, anti-corruption, strong macroeconomic management and the performance of state bureaucracy. Donor assistance in building state capacity for the delivery of services has also been critical (OECD, 2009). 3. Progress on Service Delivery During and immediately after the genocide, service delivery had more or less stopped and post-genocide, the GoNU faced a big challenge in restarting service delivery and returning some degree of normality to the population. Schools were opened rapidly with the GoR prioritising the delivery of education and UNICEF assisting in the payment of salaries (Obura, 2003). The re-establishment of other services followed. In 2005, the Government produced a report entitled Making Decentralized Service Delivery Work in Rwanda: Putting People at the Center of Service Provision. Building on this, the 2007 government report Capacity Development and Building a Capable State: Rwanda Country Report states that: a capable state needs to be able to 3 and 9

10 provide efficient and effective services to the people and that this include[s] mechanisms for citizens participation, community-based healing and reconciliatory justice and effective service delivery and social inclusion (RoR, 2007a: 5-6). The purpose of the decentralisation reforms was to give citizens a greater say in their own development. Reforms in the judicial sector, public service and local government were intended to bring governance closer to the people, reinforce good governance and ensure efficient and effective service delivery. Initiatives geared at achieving accountable and inclusive governance include accountability and transparency policies, accompanied by appropriate institutions to monitor their implementation. (RoR, 2007a: 5) Coverage of Services 4 Rwanda has made a commitment to increase access to services in its various sector policies (for example, one of the principles of Rwanda s Health Policy is to expand geographical accessibility to health services (MINSANTE, 2005)) as well as in the EDPRS. It has made considerable progress in increasing access to services since the genocide although challenges remain in all four sectors including disparities in access and performance/quality especially between rich and poor and between urban and rural areas. There is near gender equity in access to all services. See Table 1 on the following page and Annex 1 for more information and full references. The near universal coverage of education and health services demonstrates the provision of more inclusive services to a wider group of the population which is likely to have a positive effect on state-society relations, social cohesion and thus statebuilding 5 as compared with, for example, the pre-1994 quota system in education which was both ethnically divisive, detracting from social cohesion and peacebuilding, and far from offering universal access. Access to sanitation and water services still lag quite far behind education and health. In the case of sanitation, it is not clear what impact, if any, this is likely to have on state-building as the sector is largely self-supplied. Access to water and to improved water sources has slightly decreased over the last two decades which reflects the fact that population growth has outstripped supply growth. There is some way to go to approach universal access. The fact that women have equal access to men in relation to all services is significant and along with the constitution s requirement that 30 per cent of seats in the Chamber of Deputies are allocated to women, is a clear demonstration of the commitment of the Government to gender equity and the building of a more genderinclusive political settlement. Reducing rural-urban and income disparities could help to strengthen the political settlement further. 4 See Table 1 on page 11 for a summary of coverage, disparities and performance/quality of all four key services. Full references and additional information are given at Annex 1. 5 See State-Building, Peace-Building and Service Delivery in Fragile and Conflict-Affected States: Literature Review produced as the first output of this research programme for more evidence of this linkage (especially page 46). 10

11 Table 1: Summary of Access to Basic Services in Education, Health, Sanitation and Water Coverage Disparities Performance/ Quality Achieved MDG3, eliminating gender disparities in access to primary by 2005 Access disparities between income groups especially at secondary Access disparities between rural and urban areas due to the opportunity and cost of attending school for some rural children Education Primary net enrolment rate (NER) 94.2% in 2008 Secondary NER only 13.9% in 2008, but with average 11% annual growth rate in access during the previous decade Health 40% of patients travel more than 1 hour (5 km) to nearest health centre Infant mortality, under-five mortality and maternal mortality rates may have been declining in recent years 27% of population covered by mutuelles in 2004 and this increased to 74% by 2008 Sanitation 54% of population has access to improved sanitation services 47.5% of national population served by private disposal systems Water 65% of population has access to improved water services 68.1% of households spent more than 15 minutes travelling to nearest water source in 2008 Access to improved water sources has slightly decreased over the last two decades Significant access disparities between income groups Almost no appreciable difference between wealth quintiles of women accessing antenatal care Various disadvantaged groups receive full subsidisation of their membership of mutuelles Disparities in access between rural and urban areas Geographical disparities in access Rwanda is one of the few countries where access to improved sanitation is higher in rural areas compared to urban areas Burden of water collection falls more heavily on women Piped water is an urban phenomenon scarcely occurring in rural areas Peri-urban and rural areas less well served by water services than urban areas Access to water services significantly decreased in urban areas and marginally decreased in rural areas Rural households generally travel further to water points than urban households Geographical and income disparities in access Retention rates at all levels worsened between 2002/03 and 2008 largely due to high drop-out and repetition rates Drop-out is a particular problem amongst girls, those with disabilities, the poor and those living in rural areas (World Bank, 2011) Girls are not performing as well as boys in examinations Significant discrepancies exist between urban and rural health outcomes, with rural areas lagging behind Under 50% of health centres are meeting staffing requirements which has negative impact on service delivery 10% of schools and 38% of rural households have latrines that comply with health norms More than doubling of percentage of the country s population using improved sanitation since 1990 Approximately 30% of drinking water supply facilities are in need of rehabilitation; a situation that has not changed significantly for some years 77% of urban population and 62% of rural population have access to improved drinking water 11

12 Modes of Delivery of Services Under decentralisation, districts have the main responsibility for overseeing the provision of primary and secondary education and healthcare services. In the education sector, there are three main types of school public, private and government-subsidised (libre subsidie). Under the latter category, the Government pays salaries but faith-based or community-based organisations (FBOs and CBOs) manage and run the school and may also contribute financially to the school. The private sector plays a very small role in the provision of primary education, with 2.4 per cent of students enrolled in private schools in The share is more significant at secondary level where 37.1 per cent of enrolments are in private schools (27.6 per cent at lower secondary and a more significant 53.8 per cent at upper secondary) (World Bank, 2011). Public provision is increasing at tronc commun level whilst it is predominantly private sector provision in upper secondary (RoR, 2007b and World Bank, 2011). All private schools are fee-paying and therefore predominantly serve richer households, although some students at private secondary schools are supported by the Genocide Survivors Fund. The GoR introduced fee-free primary education in 2003 and has since introduced fee-free basic education (primary cycle and the first three years of the secondary cycle known as tronc commun). Fees have been offset by a capitation grant paid to schools so that schools were not disadvantaged financially by this policy decision. The decision to abolish school fees did not have a significant positive effect on enrolment in primary education which was already over 90 per cent, but it has had a greater impact on enrolment in tronc commun which has nearly trebled between 1998/99 and 2008 (World Bank, 2011). At basic education level, given that services are predominantly provided by the GoR (even if they are managed by FBOs and CBOs), this is likely to be contributing positively to citizens perception of the state in relation to service delivery, and where done well, positively contribute to the state s performance legitimacy and thus to state-building, but this inference will need to be tested during the Phase 2 fieldwork. Health services are provided at central, district and sector levels by a range of providers including public, private for-profit, NGOs and FBOs. FBOs own around 40 per cent of health facilities with most of these being health centres. The private sector is much smaller and generally providing services in urban areas accounting for around 15 per cent of all health workers (Saskena et al., 2009) but private sector involvement in the provision of healthcare services is encouraged (RoR, 2007b). Voluntary risk-sharing groups know as mutuelles enable members to have better access to health services by guaranteeing lower out-of-pocket prices at the time of purchase. Households which are part of mutuelles pay an annual membership fee which covers all services and drugs provided at health centres (known as a minimum package of activities 6 ) and a limited number of hospital-based services (known as the 6 This covers care provided at health centres: prenatal consultation, postnatal consultation, vaccination, family planning, nutritional service, curative consultations, nursing care, hospitalisation, 12

13 complementary package of activities 7 ) (MINISANTE, 2004). By comparison, households which are not part of mutuelles pay fees to healthcare providers every time they access services. The greater mix of providers in the health sector both public and private (including FBOs) along with the coordination and regulation role that the Ministry of Health is playing is ensuring services are delivered irrespective of the type of provider. This is very unlikely to be undermining state-building in any way. The Government s focus on increasing access to mutuelles has been an important step in ensuring a larger proportion of the population has access to affordable health services thus meeting expectations and improving state-society relations. Sanitation services are largely self-supplied. RECO-RWASCO is the state-owned utility company responsible for water and electricity infrastructure and service delivery in urban areas including providing drinking water to Kigali City and all major urban centres in Rwanda. RECO-RWASCO charges its customers for electricity and water consumption and uses its profits to invest in new infrastructure and services. There is a strong focus on private sector investment for the development of infrastructure and public-private partnership in the provision of water services with the proportion of schemes managed by private operators at district level growing rapidly (MINITERRE, 2004 and MININFRA, 2010). However, there are some concerns about the current capacity of RECO-RWASCO in 2008, it failed to collect around 47 per cent of potential revenue by not billing or collecting revenues from its customers and it is current cross-subsidising water services from electricity tariffs (Chacha, Ruzibuka and Birungi, 2010). There are also concerns about the financial and accounting skills capacity of private operators (Water and Sanitation Program, 2010). The 2010 National Policy and Strategy for Water Supply and Sanitation Services encourages community participation in water and sanitation services and focuses on provision around grouped settlements. It assumes that users will pay for services to ensure sustainability, with affordability being linked to using appropriate technology rather than providing public subsidies. The delivery of services will be via private companies which will be encouraged to invest in infrastructure and services. The document also highlights the prioritisation of strengthening accountability and efficiency with a focus on inclusion, particularly recognising the needs of women and children (MININFRA, 2010). The fact that users are charged for water makes access for the poorest households very difficult, which has the potential to create tension between those who can afford access and those who cannot thus lowering social cohesion and undermining statebuilding. However, give RECO-RWASCO s poor performance on revenue collection, in addition to affordability there are also wider issues about the GoR s capacity to simple childbirth, essential and generic drugs, laboratory analyses, minor surgical operations, health information, education and communication, transportation of the patient to the district hospital. 7 This covers care provided in district hospitals: consultation by a doctor, hospitalisation in rooms, normal and complicated deliveries, caesarean operations, minor and major surgical operation, referred serious malaria, all diseases of children from 0 to 5 years, medical imaging, laboratory analyses, etc. 13

14 delivery water services to the population. These are areas which will need further exploration during Phase 2. Financing of Services The GoR has prioritised education as a sector, with between 15 and 20 per cent of the national budget being allocated for education in recent years. Donors, led by DFID, have been assisting MINEDUC to follow a Sector Wide Approach (SWAp) which is now fully operational and has led to very close cooperation between MINEDUC and its development partners, with MINEDUC taking a strong leadership role (Latham, Ndaruhutse and Smith, 2006). Out of this approach, it has developed a comprehensive costed Education Sector Strategic Plan. This has been a rolling process with several such plans having been produced. The majority of donor funding is now provided to support this plan with a number of donors having provided sector budget support in recent years. School fees have been abolished at primary and tronc commun (lower secondary) levels and replaced with a capitation grant that MINEDUC pays directly to schools. Household expenditure contributed to 26 per cent of total health expenditure with public and donor resources contributing to the rest (Saskena, Antunes, Xu, Musango and Carrin, 2011). External resources fund around 62 per cent of the Health Sector Strategic Plan, government resources around 29 per cent and facility-based revenue the remaining 9 per cent (MINISANTE, 2009). Belgium is the lead donor for the health sector. Mutuelles are publicly subsidised by the Government and donors which has helped contribute to increased coverage. The fact that donors are largely supporting the education and health sectors through general and sector budget support, pooled funds or earmarked funding for the mutuelles, has meant that a significant proportion of donor funding in these sectors has contributed to increased service delivery through both the mutuelles and the implementation of fee-free basic education with capitation grants given to schools. There is unlikely to be any perception from citizens that it is not the state that is providing these services, as the money is flowing through established government systems and processes so it is difficult to separate out the GoR and the donor financial inputs. Thus, if evidence can be found to show that increased service delivery has led to perceptions of greater legitimacy of the state, it can be concluded that the approach that donors have used has contributed to this. However, given Rwanda s history of donors largely supporting the ruling government rather than the wider state, McDoom (2011) argues that it is important that donors make the difficult distinction between ensuring that they are supporting the state rather than being seen to be supporting the rule of the RPF. Individuals and households bear most of the costs of water and sanitation services. Other funding for water and sanitation has mostly come from external sources 8 in 8 One of the largest programmes of improving sanitation, the Rwanda National Rural Drinking Water Supply and Sanitation Project, is managed by the African Development Bank (AfDB, 2009). It is a large programme in 15 districts covering a population of 5 million. The programme sees private sector participation to construct and maintain the sanitation systems as a route to improved income and employment and has a plan to construct 16,000 new individual latrines. It uses the ubudehe approach to community construction and remuneration, using pipes and material routes to bring districts together and formation of common user committees. 14

15 recent years with the percentage of overall donor funding allocated to water and sanitation increasing from 4.3 per cent in 2004 to 5.7 per cent in However, in 2008 the GoR spent more than the donors for the first time. NGOs are also key players in the provision of water and sanitation services, with their financial contribution estimated at 3,500m Rwandan francs (around UK 3.5m) between 2006 and 2009 (Chacha et al., 2010). International donors have generally been supportive of the Kagame government not only because Kagame was responsible for stopping the genocide but also because studies of aid prior to the genocide (notably Uvin, 1998) indicated that donors had inadvertently exacerbated tensions within Rwanda that led to the genocide. This has perhaps made donors unusually cautious about the role of aid and the danger of bypassing the state. This perception, coupled with Rwanda s improving public financial management systems, has resulted in a shift towards the provision of budget support. A significant amount of aid (nearly 28 per cent in 2007) is channelled via the government budget through general and sector budget support, having a direct link to state-building: Overall, donor assistance has been pivotal to the state s progress in providing services, which ultimately is crucial to both its legitimacy and its overall efforts to advance economic development. (OECD, 2009: 25) The OECD goes on to state that donors conditionalities, especially the focus on regular reports from the auditor s office and accountability and transparency in tendering have been constructive. 4. Mechanisms for State Responsiveness Governance and Accountability Mechanisms In 2006 the GoR introduced imihigo, a performance contract with targets identified by the local population of a district and the contract signed between the President and the district mayors with regular reporting to the President. In the health sector, imihigo contracts include district coverage of community health insurance (mutuelles) and involve community participation (Pose and Samuels, 2011). In the education sector, District Education Committees are responsible for implementing the national education sector policy and include representatives from PTAs as well as headteachers and teachers. These examples from the health and education sectors seem to indicate inclusive representation and participation in governance and accountability bodies which, if they are empowering rather than just for public image or elite capture 9, are likely to contribute to greater results and more responsive state-building. 9 Elite capture is an issue identified in the Literature Review undertaken as the first output of this research programme. 15

16 It is argued by the Government that this has greatly enhanced people s participation in their own development and reinforced the concept of results-oriented governance. (RoR: 2007a: 29; MINALOC, 2006). However, imihigo is still in its early stages so it is difficult to say how effective it is. The Rwanda Joint Governance Assessment (2008) pointed out that there is good accountability between local and central government but a need for more citizen participation especially around planning, budgeting and service delivery. User participation in the management and accountability of services is encouraged through Parent-Teacher Associations (PTAs) 10, Hospital Management Boards and Water Committees and all government funding to the sectors is audited by the relevant Ministry or District as well as overall Ministry and District audits undertaken by the National Audit Office. However, the focus of these audits is mostly on financial compliance rather than on sector performance and whether the sector is responding to the expectations of its citizens. There is a joint review of the education sector and one of the health sector, which take place annually. In the education sector, it is expected that such a review will also take place at district level so that there can be upwards and downwards information flows during the annual review process (MINEDUC, 2008). In the health sector, there are plans for this review to produce a report of key findings and recommendations which will be widely distributed to all partners and stakeholders, on the national and district levels. (MINISANTE, 2009: 60). Upwards accountability and accountability to development partners through the annual joint reviews seems strong, but downwards accountability is less well established. This suggests that there is some room for improvement in downwards accountability to strengthen state-society relations. Rwanda piloted citizen report cards and community scorecards in health and education during 2005 to seek the views of beneficiaries on how effective, inclusive, participatory and accountable government programmes and actions are, how knowledgeable citizens are about their rights, and how responsive officials and service providers are to the expressed views and needs of ordinary citizens. (Rwanda Joint Governance Assessment, 2008: 62). The surveys for education and health revealed a lack of knowledge amongst potential beneficiaries about their entitlements to primary schooling and basic healthcare, indicating a need for better upwards and downwards flows of information. The community scorecards indicated a willingness amongst participants to talk about both positive and negative aspects of service provision (Rwanda Joint Governance Assessment, 2008). This demonstrates a level of openness and dialogue between citizens and the state which has the potential for making a positive contribution to state-building, but also a need for greater information flows to strengthen dialogue. In 2009, the Rwanda citizen report and community scorecard covered sanitation. It found that there was very high use of latrines where they are available with no differences between urban and rural areas in terms of usage, although there were fewer latrines available in rural areas. 63 per cent of rural Rwandans and 75 per cent of urban Rwandans acknowledged having a hygienic latrine. The three main reasons 10 All schools have PTAs and they are encouraged to play a key role in strengthening school management and accountability (MINEDUC, 2008; MINALOC, 2006). 16

17 cited for low availability of latrines across the country were (i) lack of finances to buy materials that are not locally available; (ii) lack of access to adequate materials for construction in rural areas; and (iii) limited knowledge of the health risks of not using latrines. The citizen report stressed that there was a need for more sensitisation on healthy latrines and greater access to building materials (trees) through afforestation, and that the state should impose penalties on households without latrines (Chacha et al., 2010) though to date, the state has not started issuing fines. This could indicate a lack of responsiveness of the Government, or that it is an issue that has low priority for the Government given that sanitation services are largely self-supplied. In the water sector, the GoR has recently established the Energy, Water and Sanitation Authority to have oversight of energy, water and sanitation in rural and urban areas (Chacha et al., 2010). CBOs including users associations (régies associatives) play an important role in the governance of piped water which is increasingly provided by private suppliers nearly 50 per cent of operators are selfemployed entrepreneurs. A 2010 Water Sanitation Program report states that: the PPP [public-private partnership] process is often seen as an opportunity for local governments to offload their water service responsibilities. Local governments generally put more emphasis on the development of new infrastructure than on the quality of existing services (Water Sanitation Program, 2010: 16). Whether or not citizens perceive self-employed entrepreneurs active in the water sector as the GoR offloading their water service responsibilities is an area which needs further investigation. This would enable evidence-based conclusions to be drawn to see if the increasing privatisation of the water sector is undermining statebuilding. Dialogue and Information Flows According to the 2008 NURC survey on social cohesion, 85 per cent of citizens claimed to have been consulted by local decision makers in 2004, rising to 93 per cent in per cent of citizens claimed to have been participating in the management of social, cultural and political affairs in 2004, rising slightly to 37 per cent in However, it is unclear how voluntary participation is and there are significant differences between the perception that citizens are taking part in decision-making and the proportion of people actually reported to have attended a community meeting recently (NURC, 2008). Membership in civil society groups is relatively limited and there are capacity weaknesses amongst civil society groups an area that needs strengthening (RoR, 2007b). The GoR claims that it is responsive in the education sector: The education system has been restructured to fill the enormous skills and competence gaps and enable the public sector to meet the expectations of the people. (RoR, 2007b: 5) 11 These opinions reflect the views of nearly 10,000 individuals surveyed. 17

18 A specific example of this is that in response to the increasing demand for secondary education, given that so many of the population have access to primary education, the GoR has prioritised significant growth in the tronc commun or lower secondary schools, with a rapid programme of school construction having taken place in the past few years resulting in a doubling of public secondary schools between 2002/03 and 2008 (World Bank, 2011). In the health sector, the user fees introduced in 1996 to cover the costs of health service provision resulted in a decrease in the utilisation of health services from 0.6 cases per person in 1995 to 0.3 between 1997 and 2001 due to the high cost for households (Save the Children, 2005; Musoni, 2004). The GoR responded by introducing pre-payment schemes and in 1999, piloting mutuelles. 12 According to analysis by MINISANTE and WHO, health insurance has decreased by four times the percentage of poor households experiencing catastrophic expenditure (Saskena et al., 2009). Mutuelles were also seen by the Government as instruments of social cohesion. Under decentralisation, 100 per cent of health centres and 75 per cent of hospitals have set up governance bodies and the first line of service delivery is provided by voluntary Community Health Workers who are not formal health professionals but have undertaken some training through the public health system and are the key players in sensitisation (Saskena and Antunes, 2009; Pose and Samuels, 2011). Immunisation rates are higher in rural areas than in urban areas with the urban rate having dropped. This is thought to be largely due to sustained sensitisation in rural areas giving people greater access to information (RoR, 2007b). Having greater access to information, and this resulting in higher immunisation rates (and as a result, lower disease incidence) is likely to give citizens the perception that the GoR is delivering appropriate health services which are responding to their health needs. It will be important to investigate in Phase 2 whether this is in fact improving citizens perception of the performance legitimacy of the Government in relation to delivering health services. There is strong evidence to show that significant improvements have been made in sanitation in rural areas in recent years, with a near halving of the rural population using traditional pit latrines and shifting to improved pit latrines, an indication that significant efforts have been made to create awareness in rural areas about the importance of sanitation and usage of sanitation facilities (Chacha et al., 2010: viii). By contrast, in urban areas there has been a decrease in the percentage of the population using flush toilets from 5.4 per cent in 2005 to 3.2 per cent in 2005 and a larger proportion of people using traditional pit latrines (deemed sub-standard) than those in rural areas. In addition, there has been a decline in the percentage of the population in urban areas using improved sanitation facilities from 52.5 per cent in 2005 to 44.1 per cent in 2008 (Chacha et al., 2010). This seems to highlight that 12 These are voluntary risk-sharing groups that enable their members to have better access to health services by guaranteeing lower out-of-pocket prices at the time of purchase. Households which are part of mutuelles pay an annual membership fee which covers all services and drugs provided at health centres (known as a minimum package of activities) and a limited number of hospital-based services (known as the complementary package of activities) (MINISANTE, 2004). By comparison, households which are not part of mutuelles pay fees to healthcare providers every time they access services. 18