Speaker 1: Developing Public Health Policy, Family Planning in Rwanda, presented by me, Hannah Amann. In this presentation we will discuss the development of public health policy, why policy regarding family planning is important, the chosen case study of family planning in Rwanda and the opportunities and challenges associated with this form of health promotion. Developing Public Health Policy. Healthy public policy is created to address the structural and environmental determinants of health. Its main aim is to create a supportive environment in which healthy choices are the easier choices, or, in the case of legislated policy, the only choice. There is an abundance of evidence to show that healthy public policy has a profound and positive effect on the health status of populations. The Ottawa Charter highlights the government's responsibility to create the conditions to support health through putting it on the agenda of all policy makers in all sectors. This requires governments to consider the health implications of all their decisions. There is a variety of scientific, social, economic and political forces that influence local, state and national governments building healthy public policy. So, what is policy? Policy can be defined as a broad pattern or framework of collective action in a particular field based on specific decisions that aim to realise the visions and goals of that field. Policy is usually about problem solving, but it can also be about preventing or minimising problems. The focus of policy is usually reform, establishing priority goals and accomplishing policy objectives. It also refers to the decisions taken at a government level to run, fund, support, regulate or ban certain services or activities. Before we discuss why family planning is important and how policy in Rwanda has increased access to such services, it is important to understand the country. Rwanda is located in Central Africa and has a population of 12 million people. The average life expectancy is 64.3 years and 39.1% of people live below the poverty line. Another important indicator relevant to family planning is the age structure in Rwanda. A mass genocide caused a major shift in the age of the population with 41.38% of people between 0 to 14 years old, 19.34% between 15 and 24 years old, 32.77% between 25 and 54 years old, 4.09% between 55 to 64 years old and 2.43% at 65 years old or above. Family planning, why it's important. Promotion of family planning and ensuring access to preferred contraceptive methods for women and couples is essential to securing the wellbeing and autonomy of women while supporting the health and development of communities. A woman's ability to choose if and when to become pregnant has a direct impact on her health and wellbeing. Family planning allows spacing of pregnancies and can delay pregnancies in young women at increased risk of health problems and death from early childbearing. It prevents unintended pregnancies including those of older women who face increased risks related to pregnancy. Family planning enables women who wish to limit the size of their families to do so. Evidence suggests that women who have more than four children are at increased risk of maternal mortality. By reducing rates of unintended pregnancies, family planning also reduces the need for unsafe abortion. Family planning enables people to make informed choices about their sexual and reproductive health. Family planning represents an opportunity for women to pursue additional education and participate in public life, including paid employment in non-family organisations. Additionally, having smaller families allows parents to invest more in each child. Children with fewer siblings tend to stay in school longer than those with many siblings. Rwanda experienced a devastating genocide in 1994 which claimed the lives of at least 800,000 people and left 2 million homeless. Rwanda's health system was left extremely fragile across much of the country. Mortality rates, which had skyrocketed in the mid-1990s, did not return to pre-1994 levels until 2005. In 2005, 57% of the population were living in poverty and only 30% of those experiencing an illness or accident reported seeking help from a medical practitioner. By 2009, the Rwandan government had improved access to primary health services mainly through infrastructure development and expansion of a community-based health insurance program. The country instituted a voluntary health insurance plan that offers health insurance for the entire population. It's based on a pooling of resources at the community level. For an annual premium of less than $2 per child, health services are almost free. In 2003, only 7% of Rwandans had health insurance. By 2008, 85% of Rwandans were participating in the program. By 2009, geographic access to care was relatively well distributed, with 75% of the nation's population living within 5 kilometres of a health facility. 96% of pregnant women received some antenatal care and 45% delivered at a health facility, an increase from 26% who delivered at a health facility in 2000. In an address to a World Health Organization sponsored meeting of health ministers and delegations back in 2009, Rwanda's President Paul Kagame challenged other African leaders to also commit to the strategic investments in the health of their people. He said, It is not preordained that our continent must remain impoverished, illiterate and in poor health and if we can make the noted modest achievements in Rwanda, a country that is by no means rich, we can do better regionally and continentally. Rwanda is divided into 30 districts and 85% of the country's 12 million people live in rural areas. The architecture of the district health system is typical for a developing country setting. Each district is served by a network of community health workers offering health education, basic preventative and curative services and family planning. Community health workers are supported by local health centres which serve approximately 20,000 people and are staffed by nurses, most of whom have a secondary school education level. Health centres provide vaccinations, reproductive and child health services, acute care and diagnosis and treatment of HIV, tuberculosis and malaria. District hospitals staffed in part by 10 to 15 general practice doctors provide more advanced care, including basic surgical services such as caesarean sections. District pharmacies acquire essential medicines and consumables from a central agency and distribute them to all health facilities within the district. District health units are responsible for administrative management of the district health system, while district hospitals are responsible for clinical supervision and monitoring and evaluation of all district health facilities. Rwanda has increased its contraceptive prevalence rate more than tenfold in less than a decade. In the year 2000, the Demographic and Health Survey found only 4% of married women of reproductive age were using modern contraceptive methods. This low contraceptive prevalence rate was most likely a result of the destroyed infrastructure after the 1994 genocide. In 2005, the rate had increased to 10% and by 2010 to 45% for this group. The President of the Senate and former Minister of Health spoke to his interview team in the Senate office shortly before the 2011 International Conference of Family Planning. He said, Yes, we have achieved good results in terms of the contraceptive prevalence rate increase, but we can't stop to celebrate. We have a lot more work to do with respect to family planning. One of the key supportive groups in helping making family planning central to the government policy was the Parliamentary Network on Population and Sustainable Development, established in 2002, and still a key champion that works closely with the National Assembly. In 2005, the Parliamentary Network on Population and Sustainable Development members received a presentation of the RAPID model, a forecasting tool developed by the Futures Group Health Policy Initiative, with support from USAID. The model combines socioeconomic indicators such as labour force participation, primary school enrolment, and number of nurses per capita, with demographic information and population projections to estimate impacts up to 30 years into the future. Different scenarios are projected so that policymakers can compare the consequences if the country or region continues to have high fertility, thus the benefits of reducing fertility, in part through family planning programs. When this model was presented in 2005, it showed that without substantial support for family planning policies, services, and support systems, the population of Rwanda would increase threefold at the current fertility levels, compared to only doubling at reduced fertility levels. An extra 30,000 primary school teachers would be needed, and more than 40% more metric tonnes of food would be required to feed the population. Potential savings in the health sector would be 384 million US dollars. This presentation had a powerful impact and motivated Rwanda's leadership to take the leap and advance a national family planning agenda that would promote smaller families, thereby improving health, education, and economic opportunities for the country. This consensus by the President and Prime Minister, along with the parliamentarians, leveraged political support for family planning at the highest levels, including the finance, education, and health ministries, determining family planning as integral to their work. At a district and community level, local government officials also became family planning champions. The Minister of Health, Dr Jean Demmesine, stated, We, with the President and Prime Minister, came to a consensus at the very highest level, around 2005. We agreed that the rapid population growth rate was an issue that needed to be dealt with. If we didn't deal with it, we most certainly would have problems with achieving our vision. After that, every leader began advocating for family planning. Local government officials have the authority and are expected to talk about health issues, including family planning at public events. These local officials also encourage male involvement and promote Maternal and Child Health Week, which is organised quarterly and includes immunisation campaigns and services for family planning. Gradually, this process led to a desire for smaller families, as evidenced by the fact that the mean desired number of children decreased from 4.6 in 2005 to 3.6 children in 2010. Since 2005, Rwanda has diligently been working towards a decentralised health system. The country expanded the number of health centres at the sector level and hospitals at district level, strengthened overall training of medical personnel and improved the availability of data for decision making. Ministries are also integrating family planning into all health services to ensure no missed opportunities. For example, integration of family planning into immunisation and HIV or AIDS programs. In 2005, 73% of women received their contraceptive methods from government services. In 2010, this figure jumped to 92%. This table illustrates an even more important aspect of this shift to public services, the shifting of service delivery closer to the client, away from hospitals to health centres, health posts and the community. Rwanda also worked with development partners to ensure availability of trained service providers at the health facilities to provide a wider method mix of contraceptive methods, including long acting methods such as implants. Community health workers are the people on the front lines delivering family planning services. The CHW program was first implemented in 1995 with the aim to increase the uptake of essential maternal and child clinical services through education of pregnant women, promotion of healthy behaviours and linkages to health services. Three CHWs with clearly defined roles and responsibilities operate in each village of approximately 100 to 150 households. The CHW in charge of maternal health identifies pregnant women, makes regular follow-ups during and after pregnancy and ensures deliveries in health facilities where skilled health workers are available. Male and female CHW pairs provide assessment, classification and treatment or referral of diarrhoea, pneumonia, malaria and malnutrition in children younger than five years of age, community-based provision of contraceptives and more. The CHWs are elected by their community and are therefore highly trusted and respected. Although CHWs in Rwanda are volunteers, in 2009 the Rwandan Ministry of Health introduced community performance-based financing to motivate community health workers. CHW cooperatives are organised groups of CHWs that receive and share funds from the Ministry of Health based on the achievement of specific targets established by the Ministry of Health. By linking incentives to performance there has been a dramatic improvement in maternal health indicators. CHW program has played an important role in expanding coverage of basic services, particularly community-based family planning services and treatment of childhood malaria and pneumonia.

Speaker 2: Since 2009, when we started up till now, we have reached 2830 family planning clients. Every day we serve 25 to 30 women. Secondary health ports like the one in Muhura is part of a comprehensive government plan to complement the health of the population.

Speaker 3: Secondary health ports like the one in Muhura is part of a comprehensive government plan to complement the health clinics provided by the Catholic Church with secondary health ports which offer family planning. The government and its partners such as UNFPA aim at boosting the adoption of modern family planning methods resulting in a more manageable fertility rate and sustainable development. UNFPA provides contraceptives and other support to the project.

Speaker 2: There are many benefits that I have enjoyed because of family planning. When you use contraceptives you get better health and your children's welfare becomes better. It also reduces your pain and workload.

Speaker 3: When I teach and sensitize my neighbors about family planning it is because it increases the welfare of the few children in the families. If we use family planning methods we can end the problem of street children.

Speaker 1: Increased family planning facilities provides more employment opportunities and encourages both men and women to become educated in the field of health. Rwanda is a leading third world country in regards to health public policy and remains an important model for other African countries to emulate. Practitioners benefit from the support and policy making of the government. This empowers practitioners to reach high standards of medical care with a holistic approach of prevention and treatment. The success of family planning in Rwanda and public policy in general relies on the government to create and implement healthy public policy. There is a risk that future government leaders may not be as proactive and dedicated to change in this area of policy. If practitioners are not supported with maintained supplies and up-to-date medical education and training their patients will be the ones to suffer. It is therefore vital that the government continue to advocate for family planning policy and services. Further current challenges include patients and practitioners having to travel on foot over rough terrain to reach their destination, often in urgent situations. At times a lack of medical supplies to meet demand. Reliance on charities and other countries for financial support. Resistance against promotion of modern contraceptive methods from the Catholic Church. Rwanda has been extremely successful in the implementation of healthy public policy, especially in regards to family planning. Healthy public policy requires all levels and sectors of government to be involved in the implementation of healthy public policy. This includes the public sector, the private sector, and the private sector. In regards to family planning, healthy public policy requires all levels and sectors of government to be on board and consider the health implications of all decision making. Healthy public policy provides many opportunities for the community in many areas of life, such as education, employment opportunities, reduced poverty, and an improved quality of life. The government must continue to address challenges and improve on health policies set in place to benefit the community. you