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Rwanda Population Health Implementation & Training Partnership

Thursday, December 18, 2014

For the past decade, Rwanda has brought a singular focus to rebuilding a still fragile public health system crippled by devastation in the wake of the country’s 1994 genocide, which claimed at least 800,000 lives and left 2 million people homeless. Among these efforts to rehabilitate and strengthen the nation’s health system is a powerful project called the Rwanda Population Health Implementation and Training (PHIT) Partnership, which was formed in 2009 with funding from the Doris Duke Charitable Foundation’s African Health Initiative. The project, which is now in its sixth year, builds upon an existing partnership between the Rwandan Ministry of Health and Partners In Health that began in 2005 during an effort to strengthen health systems in two of Rwanda’s most impoverished districts.

A boy proudly displays his health card outside a Rwandan clinicToday, the partnership consists of six institutions, whose contributions are distinct but united by a single goal—improving the lives of Rwandans by improving their health outcomes. Partners In Health’s lead partner on the project, the Rwanda Ministry of Health, is led by Minister of Health Agnes Binagwaho, M.D PhD., and sets national health policies while overseeing research, data sharing, data management and system capacity-building efforts. The ministry partners with Inshuti Mu Buzima, Partners In Health’s Rwandan sister organization, for implementation on the ground. The other partners include: the University of Rwanda School of Public Health, which leads the research capacity-building program; the National Institute of Statistics of Rwanda, which coordinates and implements key data collection activities; and Harvard Medical School and Brigham and Women’s Hospital, which both support evaluation and capacity-building activities. Because of the organizations’ shared priorities and coordinated operations, the project has made significant progress in monitoring, evaluation, research and improvement activities.

“This was really implementing the Rwandan Ministry of Health’s vision of district health systems strengthening,” Lisa Hirschhorn, M.D., M.P.H., one of the principal investigators from the Harvard Medical School, Harvard School of Public Health and Partners In Heath, Rwanda, said of the project. “But to do so, each institution and individual within the PHIT team works in deep collaboration. As a group of organizations, we really are true partners in building capacity.”

With scalability in mind, the PHIT partnership’s work targets the World Health Organization’s six health system building blocks[1], under the belief that comprehensive, integrated health system improvement efforts should be responsive to the local context and sustainable through capable institutions. One of the key tools for addressing issues of access, quality and cost at all levels is a health information system that can reliably produce timely data and facilitate feedback to inform decision making around policy and service delivery. This way of using data is critical to building an effective and efficient health system. Health professionals can also track activity throughout the health system, which allows for a replicable, evidence-based road map for district-level health care delivery across rural Africa.

The PHIT partnership applies its model of health system strengthening in two rural districts in eastern Rwanda, Southern Kayonza and Kirehe, with strategies reinforcing the four levels of district health infrastructure: community health workers (CHWs), local health centers, the district hospital and district leadership. In order to build capacity across all levels of the district health systems, the PHIT partners decided to focus on targeted, facility-specific infrastructure support, innovative quality-improvement initiatives and strengthening the network of community health workers. These strategies are now being implemented at all 21 health centers and two district hospitals within the targeted area, where they are improving the overall quality of health care.

The partnership’s data-oriented strategy brought a specific focus to data monitoring, data use and feedback both nationally and locally within the affected regions. The partnership has focused on improving the quality of routinely collected data within the national health information system as well as from the existing, open source electronic medical record. Co-developed by the Ministry of Health and Partners In Health, the electronic medical record was primarily designed to track the health of patients with HIV and chronic diseases, including cardiac disease, diabetes and cancer. Additional work has included training to develop data interpretation and communication skills as well as incorporating data-driven discussions and resource allocation dring existing facility and district-wide meetings. Patient registration data is also being used to identify geographic areas with low access to acute outpatient services. This kind of data-driven activity was of foremost importance to the partnership and has seen successful integration.

“All health facilities in the catchment area that we are working in are really trying to use data to make their decisions along the way, and they have the support they need to analyze them,” said Felix Cyamatare Rwabukwisi, M.D., one of the partnership’s principal investigators with Partners In Health, Rwanda. “That’s really a gain, and we are working to share lessons we have learned across the health system in Rwanda and other countries.”

Because Rwandan health centers are staffed almost exclusively by nurses and play a pivotal role in the health system, the PHIT project developed a specialized training program called the Mentoring and Enhanced Supervision of Health (MESH) program. Through a focus on ongoing mentoring and on systems, the MESH program is able to enhance the Rwandan Ministry of Health’s existing nurse training program by building staff technical skills and providing tools for clinical and programmatic mentorship through MOH supervisors trained in clinical mentoring and quality improvement of health service delivery. MESH was initially applied to outpatient pediatric and adult HIV and maternal health service delivery in order to further develop the quality and effectiveness of health center-based care.

The MESH Team reviews clinic data for quality improvement projectsOutside of health facilities, rural communities can access health services provided by local networks of CHWs. The standard CHW conducts regular home visits within his or her villages, provides health education, screens for specific diseases, encourages use of health facilities, and monitors child growth and development. However, the strengthened CHW role that is being tested by the PHIT project involves more rigorous data collection surrounding household visit activities—in addition to supervisory support to improve quality of care, ongoing training and expansion of home-based care for patients with HIV and other chronic diseases. This additional CHW network support (only provided in the district of South Kayonza for logistical reasons) reflects the importance to the Rwandan government that communities be able to manage their own health needs, promote prevention activities and increase public awareness of available health services.

The PHIT partnership’s project design also supports building capacity for the consumption and production of research and data collection to ensure that health care professionals have the ability to learn from those changes. A graduate level research training program, known as Rwanda PHIT Scholars, is one form of that support. The effort, which addresses a critical skills gap in Rwanda and is led by the National University of Rwanda School of Public Health and Harvard Medical School provides scholarships to health professionals to pursue advanced degrees while completing research projects. Candidates are required to develop operational research proposals that complement the PHIT impact evaluation and intervention component evaluations during the selection process, and each of the chosen candidates is assigned to a team of advisors from the PHIT project leadership team. Examples of student-led operation projects include assessing family planning uptake, the quality of information in the electronic medical record, HIV care delivery’s effect on maternal and child health services, and childhood nutritional status, among other aspects of the health system.

With two years left in the project, the Rwanda PHIT partnership’s work in health system strengthening has already seen a noticeable increase in facilities’ capacity for and quality of care, and some of the initiatives are being scaled up nationally. For example, the MESH model is now being implemented in health centers and hospitals beyond the two intervention districts for HIV care. The program has also resulted in an increase of resources and personnel devoted to research—reflecting the Rwandan government’s broad interest in ongoing development of Rwandan leadership in research.

“The lessons that we’ve learned have started to be adopted and adapted both within Rwanda and across other countries,” Hirschhorn said. “We have successfully launched a number of Rwandan health professionals on their research careers and expanded the consumption of research and data across different management levels. We’ve also strengthened the platforms for data monitoring and evaluation in these districts, so that they can be centers of innovation and capacity building well beyond the grant.”

By 2017, the Rwanda PHIT partnership—along with the four other PHIT projects—also looks forward to releasing end-line data sharing the impact of their interventions on population health and health system improvements. The hope is that this data-sharing effort will contribute to the development of effective health system interventions—both more broadly in the countries where the projects are taking place as well as worldwide.

A major priority moving forward, according to Cyamatare, involves monitoring sustainability in the districts as the health system progresses. “Our next step is to see how district-level health care in Rwanda is being sustained. While we share strategies, like MESH, nationwide, the district’s health unit still needs to be able to function at high capacity and continue innovating.”

[1] The World Health Organization defines the six building blocks of health systems as service delivery, health workforce, information, medicines, financing and governance.