Kirehe District Research Articles

Non-Obstetric Surgical Care at Three Rural District Hospitals in Rwanda: More Human Capacity and Surgical Equipment May Increase Operative Care.

BackgroundMost mortality attributable to surgical emergencies occurs in low- and middle-income countries. District hospitals, which serve as the first-level surgical facility in rural sub-Saharan Africa, are often challenged with limited surgical capacity. This study describes the presentation, management, and outcomes of non-obstetric surgical patients at district hospitals in Rwanda.MethodsThis study included patients seeking non-obstetric surgical care at three district hospitals in rural Rwanda in 2013. Demographics, surgical conditions, patient care, and outcomes are described; operative and non-operative management were stratified by hospitals and differences assessed using Fisher’s exact test.ResultsOf the 2660 patients who sought surgical care at the three hospitals, most were males (60.7 %). Many (42.6 %) were injured and 34.7 % of injuries were through road traffic crashes. Of presenting patients, 25.3 % had an operation, with patients presenting to Butaro District Hospital significantly more likely to receive surgery (57.0 %, p < 0.001). General practitioners performed nearly all operations at Kirehe and Rwinkwavu District Hospitals (98.0 and 100.0 %, respectively), but surgeons performed 90.6 % of the operations at Butaro District Hospital. For outcomes, 39.5 % of all patients were discharged without an operation, 21.1 % received surgery and were discharged, and 21.1 % were referred to tertiary facilities for surgical care.ConclusionSignificantly more patients in Butaro, the only site with a surgeon on staff and stronger surgical infrastructure, received surgery. Availing more surgeons who can address the most common surgical needs and improving supplies and equipment may improve outcomes at other districts. Surgical task sharing is recommended as a temporary solution.

The race to the top initiative: towards excellence in health-care service delivery

Abstract Background Since 2006, Rwanda has adopted performance-based incentives to boost the motivation of health-care workers and improve Millennium Development Goal (MDG) health indicators. However, performance-based incentives will often create a focus on final outcomes rather than the improvement of processes. Furthermore, national evaluation of district health facilities uses the same indicators irrespective of district-level differences in burden of disease and health priorities. In 2013, Partners In Health, in collaboration with the Rwandan Ministry of Health, launched the “race to the top” initiative (RTT), a new district-based approach to performance incentives, which strengthens process and outcomes through engagement of community and health-care workers, the setting of priority targets, and peer-to-peer learning to speed up changes in the way care is delivered. Ongoing technical support is provided throughout RTT's action periods to foster local innovations and make the most of local resources, and support data-driven quality improvement. Here, we describe results from a health district in rural Rwanda, 18 months after implementation of the RTT initiative. Methods We did a baseline assessment of population health indicators at 13 health centres in the Kirehe district hospital catchment area between January, 2013, and June, 2014. We set ambitious targets and success required a coordinated effort by health centres, local leaders, and community. We measured progress towards targets and gave feedback to health centres 6 months, 12 months, and 18 months after implementation. Health centres were given monetary rewards (to be invested in quality improvement) on the attainment of three pre-set goals: a minimum 90% coverage of community-based health insurance (CBHI); a 70% contraceptive prevalence rate; and complete elimination of severe acute malnutrition cases. Findings At 6 months' follow up, four of 13 health centres had met one target. At 12 months, seven had met one target, and by 18 months, six centres had met two targets and two centres had achieved all three indicators. At 18 months, average performance had improved significantly across the district for all three targets. The mean CBHI coverage across facilities increased by 35% from 68% at baseline to 92%. The mean number of malnutrition cases per facility per 6 month period identified at the health centres fell by 78% from 24 at baseline to 5·2 at 18 months. Finally, the contraceptive prevalence rate increased by 55% from 42% to 65%. RTT also provided opportunity for health centres to develop innovative strategies to address identified performance gaps. Interpretation The strength of the RTT intervention resides in its combination of the performance-based incentive and provision of technical support. RTT is being implemented in a neighbouring district and ongoing efforts including site visits and district level meetings are being implemented in Kirehe to understand the challenges that these health centres are facing. Funding RTT was jointly funded by Partners In Health through Doris Duke foundation and Kirehe district.

Mentoring and quality improvement strengthen integrated management of childhood illness implementation in rural Rwanda

ObjectiveIntegrated Management of Childhood Illness (IMCI) is the leading clinical protocol designed to decrease under-five mortality globally. However, impact is threatened by gaps in IMCI quality of care (QOC). In...