Abstract
BackgroundNationally, health in Rwanda has been improving since 2000, with considerable improvement since 2005. Despite improvements, rural areas continue to lag behind urban sectors with regard to key health outcomes. Partners In Health (PIH) has been supporting the Rwanda Ministry of Health (MOH) in two rural districts in Rwanda since 2005. Since 2009, the MOH and PIH have spearheaded a health systems strengthening (HSS) intervention in these districts as part of the Rwanda Population Health Implementation and Training (PHIT) Partnership. The partnership is guided by the belief that HSS interventions should be comprehensive, integrated, responsive to local conditions, and address health care access, cost, and quality. The PHIT Partnership represents a collaboration between the MOH and PIH, with support from the National University of Rwanda School of Public Health, the National Institute of Statistics, Harvard Medical School, and Brigham and Women’s Hospital.Description of interventionThe PHIT Partnership’s health systems support aligns with the World Health Organization’s six health systems building blocks. HSS activities focus across all levels of the health system — community, health center, hospital, and district leadership — to improve health care access, quality, delivery, and health outcomes. Interventions are concentrated on three main areas: targeted support for health facilities, quality improvement initiatives, and a strengthened network of community health workers.Evaluation designThe impact of activities will be assessed using population-level outcomes data collected through oversampling of the demographic and health survey (DHS) in the intervention districts. The overall impact evaluation is complemented by an analysis of trends in facility health care utilization. A comprehensive costing project captures the total expenditures and financial inputs of the health care system to determine the cost of systems improvement. Targeted evaluations and operational research pieces focus on specific programmatic components, supported by partnership-supported work to build in-country research capacity.DiscussionBuilding on early successes, the work of the Rwanda PHIT Partnership approach to HSS has already seen noticeable increases in facility capacity and quality of care. The rigorous planned evaluation of the Partnership’s HSS activities will contribute to global knowledge about intervention methodology, cost, and population health impact.
Highlights
Health in Rwanda has been improving since 2000, with considerable improvement since 2005
Evaluation design: The impact of activities will be assessed using population-level outcomes data collected through oversampling of the demographic and health survey (DHS) in the intervention districts
Employing a model of multilevel public sector health system strengthening used by Partners In Health (PIH) in rural Haiti, the Rwandan Ministry of Health (MOH) and PIH rapidly invested in health facility infrastructure, building or renovating two district hospitals and six health centers; recruited and trained health professionals from the limited available pool; and introduced community-based HIV care integrated with basic primary health care services [3].To bring the lessons of this successful collaboration to scale, the MOH, PIH, and other partners developed a detailed framework for districtlevel health systems strengthening (HSS) aligned with the World Health Organization (WHO) six building blocks: service delivery, health workforce, information, medicines, financing and governance [4]
Summary
In the context of global efforts to achieve the healthrelated Millennium Development Goals, there is a strong and growing consensus that evidence-based interventions are needed to create “robust, responsive, and efficient health systems” [23]. A robust initiative to recruit and train health workers is unlikely to succeed if those health workers are asked to perform in a setting of decrepit infrastructure, inadequate equipment, drug stock outs, and absent information systems For this reason, our intervention deliberately emphasizes capacitation across all six WHO building blocks at the district, facility, and community levels of the health system. In Rwanda, efforts to provide universal community-based health insurance — an initiative supported by the PHIT Partnership —are already bearing fruit [7] This final principle is core to the three main components which all focus on ensuring accessible quality care. An impact evaluation designed to measure the full spectrum of interventions, as well as the cost and external factors, will be able to provide the critical information needed by implementers, governments, and donors to make effective choices in efforts to improve population health through HSS. Competing interests The authors declare that they have no competing interests
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