“Strengthening and Studying Community-Based, Integrated Primary Health Care Systems in Rural Rwanda”
Grantee Institution:
Brigham and Women’s Hospital, Inc.
Team Leaders:
- Peter Drobac, M.D.
Partners in Health, Rwanda
- Paulin Basinga, M.D., M.Sc., Ph.D.
School of Public Health, National University of Rwanda
Project Summary:
In 2009, Brigham and Women's hospital, Partners In Health, PIH Rwanda (IMB) and the Rwandan Ministry of Health (MOH) received funding through a grant from the Doris Duke Charitable Foundation (DDCF) to strengthen health systems in two districts (pop = 460,000) in eastern Rwanda over a 5 year period. The approach includes interventions aimed at making significant improvements to each of the six health systems building blocks described by the World Health Organization. Rwanda’s second Health System Strategy Plan (HSSP-II) outlines a number of goals that correlate directly with these six domains, thus facilitating our effort to offer an approach to improving population health that integrates both WHO and Rwandan MOH priorities.
Within each of our intervention districts, implementation takes place across four distinct levels: (1) community health worker, (2) health center, (3) district hospital, and (4) district leadership. Our intervention’s five primary activities are designed to strengthen all of the domains outlined by the WHO across each of these four levels, with varying degrees of intensity.
The first of these five activities is the implementation of a novel training program called “Mentoring and Enhanced Supervision of Healthcare” (MESH). The goal of MESH is to improve the overall quality and effectiveness of health center-based care through an improved training module. With MESH, health center nurses receive an enhanced training through ongoing mentoring to supplement the traditional didactic teaching, and also receive ongoing supervision. A new MESH manager, as well as Associate Director of Training have been appointed since the summer of 2010 to lead these efforts, and teams are already providing mentoring and supervision at health centers throughout the two districts.
Our next two activities focus on strengthening the district hospitals and health centers within our intervention area. Strengthening activities at these two levels contribute to improvements in each of the six building blocks described earlier. These activities include: strengthening human resources and service delivery support; making improvements to infrastructure; improving access to medical equipment and products; providing social and financial risk protection; increasing nutritional and informational support; improving communication; and, providing ongoing training, supervision, and transportation support. IMB has developed as of October of 2010 a Health Center Strengthening Guide, a final draft of which we hope to make available to the MOH and district officials by early 2011.
Our fourth activity focuses on implementing an enhanced network of community health workers (CHWs). CHWs provide a number of services and activities not offered by those CHWs trained by the Rwandan MOH, with the goal of increasing effectiveness and quality of care. CHW activities include: regular home visits at least once per month (active case finding); a fair system of compensation for all CHWs; an enhanced system of supervision; an enhanced training; an enhanced M&E reporting system; use of a household chart; a system of accompaniment for HIV, TB, and chronic disease patients; support for CHW cooperative activities; and a system of CHW distribution that is based on the geographical size of a village area.
Our fifth strengthening activity is the implementation of a robust M&E system with feedback systems to improve care at all four district intervention levels. We are building upon and strengthening existing MOH data systems through training and are continuing to support existing data quality audits and integrated data feedback for continuous quality improvement (CQI). The systems support a rigorous impact evaluation and costing of the intervention with DDCF funds. PIH has built up the human resource capacity of the M&E Department drastically in the past year: we now have an Associate Director of M&E and Research, as well as a M&E Manager and two district teams of data collectors and data coordinators.
In addition, existing health information systems and other national surveys, in combination with data collected by the project, are being used to measure the impact of the intervention. Initial results confirm the potential of this approach to strengthen health systems. Ongoing evaluation will measure its longer term impact on improving coverage and overall population health.