PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) Comprehensive case study from Rwanda

PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) Comprehensive case study from Rwanda

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PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) Contents

Abbreviations 1 Background to PRIMASYS case studies 2 1. Introduction to Rwanda PRIMASYS case study 3 2. Methods 4 3. Overview of Rwanda PHC system 5 3.1 Transitional period: 1994–2003 5 3.2 Development phase based on strategic planning and Economic Development and Poverty Reduction Strategy: 2005 to date 6 4. Timeline 9 5. Components of the PHC system in Rwanda 10 6. Governance and structure of PHC in Rwanda 12 7. Hierarchy of health service provision in Rwanda 14 8. Financing 15 9. Human resources 18 10. Quality of health care services in Rwanda 20 11. Regulatory processes 23 12. Monitoring and information systems 25 13. Challenges, policy considerations and ways forward 27 14. Conclusion 28 Annex 1. Profiles of key informants interviewed for case study 29 References 30

COMPREHENSIVE CASE STUDY FROM RWANDA Figures Figure 1. Relevant policies on the PHC system in Rwanda, by date 9 Figure 2. Representation of the health care system of Rwanda 13 Figure 3. Architecture of Rwanda health financing 15 Figure 4. Human resources for health planning framework 18 Figure 5. Aligning performance-based financing with accreditation 21 Figure 6. Data flows between Rwandan entities involved in data collection and dissemination 26

Tables Table 1. Key demographic, macroeconomic and health indicators for Rwanda 7 Table 2. Relevance of key demographic, macroeconomic and health indicators for improved provision of PHC 8 Table 3. Summary of components of PHC system in Rwanda 10 Table 4. Existing health financing strategies ...... 15 Table 5. Health financing policy directives 16 Table 6. Human resources for health baseline and targets for HSSP IV 19 Table 7. Supportive measures for improving quality of health care at central and district levels 21 Table 8. Key missions and functions of Rwandan professional councils 23

PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) iv Abbreviations

CAMERWA Central Procurement Agency for NCD noncommunicable disease Essential Medicines in Rwanda PHC primary health care (Central d’Achat des Medicaments Essentiels de Rwanda) PPCP public, private and community partnership GDP gross domestic product SISCOM Community Health Information System HMIS Health Management Information System TRAC Plus Centre for Treatment and Research on AIDS, Malaria, Tuberculosis and Other HSSP Health Sector Strategic Plan Epidemics IT information technology WHO World Health Organization

COMPREHENSIVE CASE STUDY FROM RWANDA 1 Background to PRIMASYS case studies

Health systems around the globe still fall short of and efficiency of primary health care interventions providing accessible, good-quality, comprehensive worldwide. The PRIMASYS case studies cover key and integrated care. As the global health community aspects of primary health care systems, including is setting ambitious goals of universal health policy development and implementation, coverage and health equity in line with the 2030 financing, integration of primary health care into Agenda for Sustainable Development, there is comprehensive health systems, scope, quality and increasing interest in access to and utilization of coverage of care, governance and organization, and primary health care in low- and middle-income monitoring and evaluation of system performance. countries. A wide array of stakeholders, including The Alliance has developed full and abridged versions development agencies, global health funders, policy of the 20 PRIMASYS case studies. The abridged planners and health system decision-makers, require version provides an overview of the primary health a better understanding of primary health care care system, tailored to a primary audience of policy- systems in order to plan and support complex health makers and global health stakeholders interested in system interventions. There is thus a need to fill the understanding the key entry points to strengthen knowledge gaps concerning strategic information primary health care systems. The comprehensive case on front-line primary health care systems at national study provides an in-depth assessment of the system and subnational levels in low- and middle-income for an audience of researchers and stakeholders who settings. wish to gain deeper insight into the determinants The Alliance for Health Policy and Systems and performance of primary health care systems Research, in collaboration with the Bill & Melinda in selected low- and middle-income countries. Gates Foundation, is developing a set of 20 case Furthermore, the case studies will serve as the basis studies of primary health care systems in selected for a multicountry analysis of primary health care low- and middle-income countries as part of an systems, focusing on the implementation of policies initiative entitled Primary Care Systems Profiles and programmes, and the barriers to and facilitators and Performance (PRIMASYS). PRIMASYS aims to of primary health care system reform. Evidence from advance the science of primary health care in low- the case studies and the multi-country analysis will and middle-income countries in order to support in turn provide strategic evidence to enhance the efforts to strengthen primary health care systems performance and responsiveness of primary health and improve the implementation, effectiveness care systems in low- and middle-income countries.

PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) 2 1. Introduction to Rwanda PRIMASYS case study

The present case study provides a comprehensive, monitoring and evaluation of system performance, in-depth assessment of the national primary health and important gaps in policy and research. care (PHC) system of Rwanda in order to understand The case study is commissioned by WHO and the key entry points to strengthen PHC systems funded by the Alliance for Health Policy and Systems and foster the implementation and efficiency of Research in collaboration with the Bill & Melinda health interventions. It covers key aspects of PHC Gates Foundation, working together with researchers systems in Rwanda, including policy development from University of Rwanda, College of Medicine and implementation, human resources financing, and Health Sciences, School of Public Health, in quality of PHC, governance and organization, partnership with the Rwandan Ministry of Health.

COMPREHENSIVE CASE STUDY FROM RWANDA 3 2. Methods

The Rwanda case study used qualitative methods informants who participated in this study is provided to achieve its objective. It was implemented in two in Annex 1. phases: a desk review followed by key informant Identified stakeholders were contacted by phone interviews with a wide range of stakeholders at and an invitation was sent to them through national, regional and district levels. The desk their institutions. High-level key informants were review was done through an extensive analysis of contacted by email to schedule an appointment documentation, including reports at national and for interview, explain the rationale and objectives global levels; national strategic documents, such as of the study. All interviews and meetings with policies and strategic plans from official websites stakeholders (including the focus group discussion) and documents from the Rwandan Ministry of were conducted in English and digitally audio- Health; and research reports from affiliated agencies, recorded unless the participants did not consent research institutions, and bilateral and international to be recorded. Before each interview, participants organizations. were given an informed consent form asking for In the second phase, key informant interviews were their permission to participate and to be recorded. conducted with stakeholders purposively selected Only participants who consented to voice recording based on their current roles and positions in the were recorded; if they refused, the interviews were health sector. Participating institutions included reported in writing. The PRIMASYS case study was the Ministry of Health, public and private health approved by the Rwanda National Ethics Committee facilities, referral and district hospitals, district health on 12 December 2017. directorates, and development partners providing All data from interviews and the stakeholder focus technical and financial support to the health sector in group discussion were summarized and transcribed Rwanda. In addition, representatives of the Rwanda using recordings and field notes by the research Social Security Board, Rwanda Health Insurers team. Summaries were analysed manually for Association, and Rwanda Surgical Society were content according to the conceptual framework recruited, along with health system researchers. One underpinning the development of the PRIMASYS mixed focus group discussion was also conducted case studies. Main themes included PHC structure with stakeholders and health experts, including (governance, financing, and human resources), Ministry of Health leadership, politicians, health processes (policies, innovations, challenges, and authorities, health professionals, insurance specialists, recommendations), and outcomes (health service representatives of development partner institutions quality and accessibility). and community organizations. Information on key

PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) 4 3. Overview of Rwanda PHC system

Rwanda is a landlocked East African country with With regard to nutrition status, chronic malnutrition a green, mountainous landscape. Its population is stood at 48%, with underweight at 29% and acute estimated at 12 089 720, with a density of 467 per malnutrition at 4%. The proportion of attended square kilometre, making it one of the most densely deliveries in health facilities was 26%; the proportion populated countries in Africa (1). The Rwandan health of children aged 0–23 months that were fully sector has undergone a fundamental transition immunized was 79%; and the rates of antenatal care during the last century. visits were 94% (for one visit) and 12% (for four visits). Before the colonial period, health care consisted of 3.1 Transitional period: 1994–2003 traditional medicine using native African healing methods. During the German and later Belgian An emergency plan for rehabilitation of the health colonial period, faith-based health care emerged, system was prepared and implemented with the accompanied by the introduction of modern collaboration of government partners. A priority medicine. of the plan was to fill the enormous gap in human resources. In 1996, only 112 doctors were working In the second half of the 20th century, before the in the public health sector, and only 742 nurses, 7 1994 Genocide against the Tutsi, the Rwandan pharmacists and 77 laboratory technicians were health system was characterized by a high degree of operational. centralization and free provision of health services. During the Genocide, most of the infrastructure was In order to fill the gap, the Faculty of Medicine of the destroyed and many of the health staff were killed or National University of Rwanda reopened very quickly, fled the country. Following the Genocide, during the along with 12 nursing schools. Another consequence transitional period 1994–2003, efforts were made to of the 1994 Genocide was the significant impact on rebuild basic health care and human resources. After mental health; accordingly, a mental health service the transitional period, the health system entered a was established and a trauma centre was opened to developmental phase through the introduction of handle the mental health issues generated by that strategic planning and major reforms. tragedy. In 1990, the health system had a total of 34 hospitals, During the transitional period, a National Health 186 health centres, 69 dispensaries, 179 private Policy was developed. The policy was focused on the pharmacies and 17 private medical clinics. In terms former region sanitaire, which was provided with the of human resources, only 261 medical doctors were means to implement all health activities at regional working in the public sector. There were also 23 level. However, several programmes and projects pharmacists, 949 graduated nurses (A1, A2, and A3) remained centralized and were operationalized from and 240 auxiliaries (2). the central level. Between 2000 and 2003, a number of important reforms took place within the health According to the Rwandan Demographic and Health system. One of the reforms was the establishment Survey of 1992 (3), average life expectancy was 51 of the National AIDS Control Commission as an years; the under-5 mortality rate was 150 per 1000 advocacy body to fight HIV/AIDS, including through live births; the infant mortality rate was 72 per 1000 resource mobilization and coordination of partners. live births; and the maternal mortality rate was 500 per 100 000 live births. The total fertility rate was Programmes on malaria, HIV/AIDS and tuberculosis 6.2, and the modern contraceptive rate was 13%. were merged in the Centre for Treatment and

COMPREHENSIVE CASE STUDY FROM RWANDA 5 Research on AIDS, Malaria, Tuberculosis and Other objectives: availability of human resources; availability Epidemics (TRAC Plus), and resources were allocated of drugs, vaccines and consumables; geographical to the prevention, treatment and control of those accessibility to health services; improvement of three major diseases. Another important innovation financial accessibility to health services; increase in was the creation of the Central Procurement the quality of and demand for services for disease Agency for Essential Medicines in Rwanda (Central control; strengthening the referral system and d’Achat des Medicaments Essentiels de Rwanda – research; and institutional capacity strengthening. CAMERWA), responsible for the procurement, storage Since 2005, three Health Sector Strategic Plans and distribution of drugs and consumables for the (HSSPs) have been developed and implemented: public sector. HSSP I (2005–2009), HSSP II (2009–2012), and In 2003, community-based health insurance was HSSP III (2013–2018) (4–6). They were developed institutionalized and a health insurance policy in line with Rwanda Vision 2020, and Economic developed. The related law was enacted in 2007. Development and Poverty Reduction Strategy I During this transitional period, the Government and II. The upcoming HSSP IV (2018–2024) builds of Rwanda approved and started implementing a on lessons learned and progress made during decentralization policy. The ensuing decentralization implementation of HSSP III, and is fully aligned with of health services started with the strengthening of Rwanda Vision 2050 and the National Strategy for district hospitals and health centres, promotion of Transformation 2018–2019. It has been informed community participation, development of human by global and regional development agendas that resources, and allocation of more resources to districts. Rwanda has committed to, especially the Sustainable Development Goals. Strategic planning is evidence 3.2 Development phase based on based, with baselines provided by various censuses strategic planning and Economic and surveys. Targets are set in accordance with Development and Poverty Reduction available means, and a monitoring and evaluation Strategy: 2005 to date framework is in place (7). Given the health status of Rwanda at that time, the Table 1 provides key demographic, macroeconomic period 2003–2005 was used to consider the priorities and health indicators for Rwanda; Table 2 presents of the health sector. As provided in the Health Sector information on the relevance of those indicators for Policy, the priorities were defined in seven policy improved provision of PHC.

PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) 6 Table 1. Key demographic, macroeconomic and health indicators for Rwanda

Indicator Results Source of information Total population of country 12 089 720 Fourth Population and Housing Census, 2012 (1)

Sex ratio: male/female 92:100 Fourth Population and Housing Census, 2012 (1)

Population growth rate 2.6% Fourth Population and Housing Census, 2012 (1)

Population density (people/square kilometre) 467 Fourth Population and Housing Census, 2012 (1)

Distribution of population (rural/urban) 67% / 33% Rwanda Demographic and Health Survey, 2015 (8)

Gross domestic product (GDP) per capita US$ 720 Statistical yearbook, 2016 edition (9)

Income or wealth inequality (Gini coefficient) 0.448 Statistical yearbook, 2016 edition (9); Integrated Household Living Conditions Survey, 2013–2014 (10)

Life expectancy at birth 64.5 years Rwanda Demographic and Health Survey, 2015 (8)

Top five main cause of death (ICD-10 Neonatal illness (41%) Statistical yearbook, 2016 edition (9) classification) Gynaeco-obstetrical complications (8%) Cardiovascular disease (8%) Acute respiratory diseases (8%) HIV/AIDS opportunistic infections (6%)

Infant mortality rate 31 per 1000 live births UNICEF/WHO, countdown to 2015 report (11, 12)

Under-5 mortality rate 42 per 1000 live births UNICEF/WHO, countdown to 2015 report (11, 12)

Maternal mortality rate 210 per 100 000 live births Rwanda Demographic and Health Survey, 2015 (8)

Immunization coverage under 1 year 98% UNICEF/WHO, countdown to 2015 report (11, 12) (including pneumococcal and rotavirus)

Total health expenditure as proportion of GDP 15.5% (2012–2013) Health Financing Sustainability Policy, March 2015

PHC expenditure as % of total health 38.1% World Bank, Global Health Expenditure database, expenditure 2014

% total public sector expenditure on health 9.9% World Bank, Global Health Expenditure database, care 2014

Per capita public sector expenditure on PHC US$ 52 (2014) World Bank, Global Health Expenditure database, 2014

Out-of-pocket payments as proportion of 18% UNICEF/WHO, countdown to 2015 report (11, 12) total expenditure on health

Public expenditure on health as proportion of Data not available total expenditure on health

Voluntary health insurance as proportion of Data not available total expenditure on health

Proportion of households experiencing Data not available catastrophic health expenditure

COMPREHENSIVE CASE STUDY FROM RWANDA 7 Table 2. Relevance of key demographic, macroeconomic and health indicators for improved provision of PHC

Source of Profile Summary Relevant area for PHC information Demographic Population of 12 089 720 Promote informed policy formulation and Fourth Population profile Densely populated, with high density of 467 per decision- making and Housing Census, square kilometre Enable effective planning, monitoring, and 2012. Thematic report: population Sex ratio is 92 males per 100 females evaluation of existing programmes related to health in general, and reproductive health in projections Annual population growth rate of 2.6% particular, at both the national and regional Total fertility rate of 4.0 children per woman levels Population is mostly rural, at 67% Helps in resource mobilization to respond to the Life expectancy of 64.5 years needs of the population Informs equitable distribution of resources Facilitates decentralization of services as well as engagement of community in PHC activities

Macroeconomic Rwanda’s economy has been growing steadily A mirror on how Rwanda is fulfilling its mission Ministry of Finance profile at about 8% per year since 2001, with GDP to provide sustainable growth and economic and Economic per capita increasing from US$ 211 in 2001 to opportunities, and raise the living standards of Planning, Rwanda: US$ 720 in 2016 all Rwandans within the vision of developing annual report, 2016 Rwanda into a country free of poverty Contributes to increased living standards of the population and human development within a sustainable environment Enables identification and prioritization of less advantaged areas Helps in planning and availing equitable resources for effective service provision to all

Health profile Top five causes of mortality are neonatal Guides the design of preventive, curative, Demographic and illness, gynaeco-obstetrical complications, rehabilitative and promotive strategies Health Survey, cardiovascular disease, respiratory diseases, and Promotes measures to identify priority health 2014–2015 HIV/AIDS opportunistic infections problems Population census, Infant mortality rate is 31 per 1000 live births Offers basis for allocation of appropriate 2012 Under-5 mortality rate is 42 per 1000 live births. resources to combat priority health problems, HSSP IV Maternal mortality rate is 210 per 100 000 live especially at the decentralized and primary level births Immunization coverage under 1 year is 98%

Rwanda is among the few countries to have According to data from the Integrated Household achieved universal health coverage due to its vision Living Conditions Survey 2013–2014, there was a of inclusiveness, equity, and comprehensive and significant increase in service utilization between 2005 integrated quality service delivery, with a focus on and 2012, especially within the lowest socioeconomic PHC. Rwanda’s health sector has made tremendous category. The proportion of the population reporting progress in improving the health status of the an illness or accident who consulted a medical population. These improvements are mirrored by the practitioner increased from 31% to 40%. These improvements in access to health care services and achievements are largely attributable to good utilization of those services. According to Rwanda governance and, on the demand side, to financial annual health statistics, the PHC utilization rate innovations, such as community-based health increased from 0.81 to 1.43 visits per inhabitant from insurance and performance-based financing (9, 10). 2009 to 2016 (11, 12).

PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) 8 4. Timeline

The Rwandan health system has seen an improved to respond to the population’s health care needs and performance in recent years, based on quality of care to align the health system with the global health and decentralization of health care systems. Policies agenda (Figure 1). and programmes have been developed in an effort

Figure 1. Relevant policies on the PHC system in Rwanda, by date

2005 • National Policy for the Control of HIV 2005 • National Policy on TB and HIV • National Medical Laboratory Policy 2006 • Health Financing Policy • National Pharmaceutical Policy 2006 • Behaviour Change Communication Policy • Blood Transfusion Policy 2007 • National Policy on Health Quality Assurance • National Nutrition Policy 2008 • Environmental Health Policy • Community Health Policy 2009 National Policy for Child Health 2010 • National Policy on Traditional Medicine • National Policy for Palliative Care • National Health Promotion Policy

2010 • National Health Insurance Policy • Community-Based Health Insurance Policy 2011 • National Mental Health Policy 2011 • National Adolescent Sexual and Reproductive Health and Rights Policy • Human Resources for Health Policy 2012 • Rwanda Family Planning Policy • Medical Research Centre Policy 2012 • Health Sector Research Policy • Health Sector Data Sharing and Confidentiality Policy • Pre-hospital Emergency Care: Policy and Legal Framework 2014 • National Food and Nutrition Policy • Human Resources for Health Policy 2015 • Noncommunicable Diseases Policy • National Community Health Policy 2015 • Health Sector Policy • Health Financing Sustainability Policy 2016 • National Pharmacy Policy 2017 National Policy for Traditional Complementary and Alternative Medicine

COMPREHENSIVE CASE STUDY FROM RWANDA 9 5. Components of the PHC system in Rwanda

Table 3 summarizes the components of the PHC system in Rwanda.

Table 3. Summary of components of PHC system in Rwanda

Thematic Health system category component Strength and achievements Areas for further improvement Structure Governance Decentralization of health services to the lower level Improved coverage of primary health facilities is (community health workers, health posts, health needed in order to have a health centre per sector centres, district hospitals) and health post per cell Political will and commitment Health district: enforcing the decentralization of Well structured local government monitoring and supply of drugs Collaboration with partners Access to specialized services such as cardiology, nephrology, urology Sustained community health programme Review of service package of activities to include Community participation in management of health additional needs of the community (for NCDs, etc.) facilities Home-Based Care Practitioners Programme being piloted to provide noncommunicable disease (NCD) and palliative care services at community level

Financing Poverty reduction strategies such as social Financial access: community-based health mechanisms protection programmes (Vision 2020 Umurenge insurance heavily subsidized Programme, Ubudehe) Sustainability mechanisms to be explored and Pooling of resources in Rwanda improved over time implemented Health insurance: compulsory contributions for Need for financial management skills at peripheral civil servants (Rwanda Social Security Board), health facilities premiums for community-based health insurance, government resources (Ministry of Health) Single Project Implementation Unit (donor resources pooling): budget support (direct support) + project budget Subsidies: socioeconomic stratifications (Ubudehe system); indigents are fully subsidized by the government; special protection programmes for targeted groups (HIV, TB, malnutrition) Electronic health finance tools across the country

Human resources Quality and quantity of human resources for health Need for additional human resources: specialists Training programmes in different fields, general practitioners, nurses, midwives, allied health professionals, health care Performance-based financing managers, replacement, training and refresher courses for community health workers Staff retention plan at all levels Private sector engagement

PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) 10 Thematic Health system category component Strength and achievements Areas for further improvement Process Vision and Two new structures at community level, namely It is planned to have at least one health centre per policies Home-Based Care Practitioners Programme at sector and a health post per cell, expect for cells village level and health posts at cell level where there is already a health centre, by 2019. There are three types of health post: extension of Resources are still being mobilized at district level health centres serving a permanent outreach site to and priority needs to be given to remote areas get services closer to the population; public health posts; and health posts operating in a public– private partnership model Introduction of chronic diseases screening and treatment at community and health centre levels

Planning and Improve mechanisms for monitoring client Continue private sector engagement in PHC implementation satisfaction, quality assurance of insurance, efficient strategic purchasing, automation, and availability of information Governance improvement to include community involvement and address impoverishment due to out-of-pocket payments (co-payment, transport)

Regulation of Government will health care Accountability structure system

Monitoring and Community health information system Improvement of central- and local-level information Daily incident flash reports from health facilities involvement in supervision of community health systems are newly introduced in the information system, workers including verbal autopsies E-health system at all levels and for all packages

Outcomes Accessibility People-centred services Geographical accessibility: need for health centre of health care Access to the full package provided by health posts per sector and health post per cell services and health centres, mainly curative and preventive Burden of environment-related disease (ambulance, consultation, laboratory tests, medication, minor procedures) Community-based health insurance, indigents are fully subsidized by the government Poverty reduction programmes (Vision 2020 Umurenge Programme, etc.)

Quality of health Accreditation process at all levels Roll-out accreditation process at all levels, especially care services Quality audit of services health centres Performance-based financing

COMPREHENSIVE CASE STUDY FROM RWANDA 11 6. Governance and structure of PHC in Rwanda

The overall administrative head of the Rwanda health • to coordinate health care technology manage- system is the Ministry of Health, which governs all ment and engineering of infrastructure for all health facilities, both public and private. In Rwanda, public health facilities in Rwanda; public health facilities represent 64% of the total • to prevent and control epidemic diseases and number of non-private health facilities, with 28% run other public health emergencies in Rwanda by faith-based organizations. Currently the system is through the implementation of an effective and organized in four levels (Figure 2) (13). efficient national epidemiological surveillance and response system; Central level. The Ministry of Health has a mission • to contribute to efficiency promotion and finan- to provide and continually improve affordable cial sustainability of the health sector through promotive, preventive, curative and rehabilitative income-generating biomedical-related activities health care services of the highest quality, thereby and research; contributing to the reduction of poverty and • to establish and strengthen collaboration with enhancing the general well-being of the population. local, regional and international institutions hav- The following are core functions: ing related missions. • to develop, disseminate and coordinate the National referral hospitals. There are five national implementation of health policies, strategies and referral and teaching hospitals whose mission is programmes; to provide specialized health service provision, • to regulate the health sector; undertake teaching in medical and health sciences • to monitor and evaluate the implementation of schools, and conduct research in health-related policies, strategies and programmes of the health fields. These are the King Faisal Hospital, Rwanda sector and related sectors; Military Hospital, Kigali University Teaching Hospital, • to develop institutional and human resource Butare University Teaching Hospital and Ndera capacities in the health sector; Neuropsychiatric Hospital. • to develop innovative health financing approaches for accessibility to quality health services; Intermediary level. The referral and provincial • to oversee the institutions under supervision; hospitals form an intermediary level of referral • to mobilize resources for the development of the hospitals at the province level. Three referral and four health sector and related programmes; provincial hospitals are being gradually upgraded to • to develop medical cooperation and coordinate decrease the pressure of demand for services in the health sector development partners. national referral hospitals. In order to oversee the implementation of policies, Peripheral level. This level is represented by an strategies and health-related programmes, the administrative office (district health unit), district Rwanda Biomedical Centre was established in 2011 hospital, and a network of health centres, health posts with the following functions (14): and community health workers. The district health unit is an administrative unit in charge of the provision • to coordinate and follow up the implementation of health services, and is responsible for planning, of programmes aiming at improving health pro- monitoring and supervision of the implementing motion, disease prevention, diagnosis, treatment agencies. It reports to the vice-mayor for social affairs. and care for communicable and noncommunica- There are 36 district hospitals, 499 health centres at ble diseases;

PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) 12 sector level, and around 45 516 community health service, national referral laboratory, and health workers serving the population at village level (7). professional councils for supervising and monitoring professional practices. In addition, Rwanda has a national blood transfusion service, national medical procuring and storing

Figure 2. Representation of the health care system of Rwanda

Administrative Health care No. of public Av. catchment structure delivery system facilities / CHWs area pop. Type of service offered

• Specialized hospitals serving the entire country Province (5) 8 National (~ 12 m) • Medical training TertiaryDistrict hospitalshospitals District hospitals 4

~ 255 000 • Provide government-defined complementary package of 36 activities (caesarean, treatment of complicated cases, etc.) District (30) DistrictDistrictDistrict hospitals hospitals hospitals • Provide care to patients referred by the primary health centres • Carry out planning activities for the health district and supervise district health personnel

503 ~ 23 000 • Provide government-defined minimum package of activities at the peripheral level • This includes complete and integrated services such as Sector (416) DistrictHealth centreshospitals District hospitals curative, preventive, promotional, and rehabilitation services • Supervise health posts and CHWs operating in their catchment area

• Services provided are similar, albeit reduced from that of 501 health centres • Established in areas that are far from health centres Health posts Cell (2148) DistrictDistrict hospitals hospitals • Services include curative outpatient care, certain diagnostic tests, child immunization, growth monitoring for children under 5 years, antenatal consultation, family planning, and health education

45 516 ~ 250 Community-based • Prevention, screening and treatment of malnutrition Community health • Integrated management of child illness DistrictworkersDistrict hospitals hospitals(CHWs) Village (14 837) • Provision of family planning • Maternal and newborn health • HIV, tuberculosis, and other chronic illnesses • Behaviour change and communication

80% of burden of disease addressed at this level

Source: Ministry of Health (15).

COMPREHENSIVE CASE STUDY FROM RWANDA 13 7. Hierarchy of health service provision in Rwanda

The hierarchy of health service provision in Rwanda At cell level (2148 cells) there are health posts can be summarized as follows. with the following package of services: At village level (14 837 villages) the following • PHC services including promotional, preventive services are offered in the community: and primary curative services • basic diagnostics with rapid testing • prevention, screening and treatment of malnutrition • basic package of services for those areas that are • integrated management of child illness far from health centres. • provision of family planning • maternal and newborn health At sector level (416 sectors) there are health • HIV, tuberculosis and other major illnesses centres providing the following services: • behaviour change and communication. • government-defined minimum package of activ- In addition to the classic community health workers, ities at the peripheral level; the Ministry of Health started the Home-Based Care • complete, integrated services, such as cura- Practitioners Programme in March 2017 in nine tive, preventive, promotional, and rehabilitation hospitals in nine districts, whereby 206 home-based services; care practitioners are working in their communities • supervision of health posts and community health to deliver services in three components, as follows: workers operating in their catchment area. Palliative care at community level: At district level (30 districts) there are 36 district • providing basic nursing care among patients with hospitals, with the following services: end-of-life conditions • government-defined complementary package • follow-up of all patients with life-limiting condi- of activities (for example caesarean section, treat- tions, including NCDs ment of complicated cases); • providing bereavement counselling to the family. • provision of care to patients referred by the pri- NCD prevention: mary health centres; • screening of NCDs • carrying out planned activities for the health dis- • raising awareness of prevention of NCDs trict and supervision of district health personnel. • linking patients with NCDs to health facilities. At province level (4 provinces) the facilities Verbal autopsy: provide the following package: • conduct verbal autopsy • Gradually upgraded from secondary health care • notification of deaths in civil registration and vital to specialized services to serve the population in statistics system the respective provinces. They provide the com- • data reporting plementary package of activities and specialized • raising awareness of civil registration of vital care, including internal medicine, paediatrics, sur- events. gery, obstetrics and gynaecology.

PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) 14 8. Financing

The Rwanda Vision 2020 (16) considers health finance services. Progress has been facilitated by political accessibility as a key priority of its strategic direction. commitment and development of a legal framework The current Health Financing Sustainability Policy is that made health insurance compulsory for all aligned with the Health Sector Policy 2015 (15) and Rwandans in 2016. the second Economic Development and Poverty Table 4 provides information on existing health Reduction Strategy (17), which aims to develop financing strategies. a wide-ranging financing framework for health systems based on best practices in global health care financing. The vision is to ensure that Rwandans have Figure 3. Architecture of Rwanda health universal financial access to quality health services financing in an equitable, efficient and sustainable manner. Figure 3 presents a diagrammatic representation of the architecture of health financing in Rwanda. Universal financial access to This framework is built on two main pillars: (a) quality health services Risk pooling – health insurance on the supply side, the implementation of fiscal decentralization with increased transfers from value for money – Efficiency resources Increase of domestic health insurance pooling – Risk central government to local governments and peripheral health facilities on the basis of needs and performance; (b) on the demand side, the establishment of a health insurance system including cross-subsidies from higher-income to lower-income populations. These mechanisms have enabled achievement of a number of major health sector targets, including reduction of unmet needs, Institutional environment for sustainable increased use of health care services, decreased health financing and accountability incidence of catastrophic health expenditures and decreased inequality in access to health care Source: Ministry of Health (13).

Table 4. Existing health financing strategies

Risk pooling – health insurance Efficiency – value for money Increase of domestic resources

Community-based health insurance: a risk Performance-based financing: links Community health cooperatives, performance- pooling mechanism that is based on ability measurable indicators with financial based financing: transfers investments to to pay incentives village level, creates local development Social health insurance: Rwanda Social Security Decentralization: shifted job positions and projects and provides sustainable resources for Board: Rwanda Health Insurance Fund (for related budget to the health facility level community health services public servants) and Military Medical Insurance to improve the equitable distribution of Public, private and community partnerships Voluntary health insurance: Corar, SORAS, health personnel towards rural areas (PPCPs): increased number of community Radiant, UAP, etc. Performance contract system (imihigo): health posts through PPCPs implemented a system whereby Self-sustaining health facilities: have begun commitments are made to deliver on key establishing a self-sustaining health facility development projects model

Source: Ministry of Health (13).

COMPREHENSIVE CASE STUDY FROM RWANDA 15 Government spending on health has surpassed the In 2015, Rwanda spent 11.2% of its GDP on the health 15% required under the Abuja Declaration, showing sector, while total public sector expenditure on PHC a high level of commitment to and support for was 9.9% in 2015. Health expenditure per capita was health sector financing, within the limits of national US$ 44.6 in 2015, and out-of-pocket expenditure as resources. In the 2015/2016 fiscal year, the health a proportion of total expenditure on health was 8.8% sector accounted for 16.52% of total government in 2015 (19). Funds for PHC come from government spending (18). contributions, development partners, health insurance contributions, social solidarity funding and Risk pooling has been greatly improved as a result of cross-subsidizing among the community. the extension of community-based health insurance schemes, which give the majority of the population Table 5 presents a summary of health financing access to health care services and drugs. Social policy directives. and private health insurance schemes now cover approximately 80% of the population.

Table 5. Health financing policy directives

Policy element Objective Directives

Efficiency – value for Reduction of administrative costs, Apply electronic mechanisms in place of paper-based administration processes money transaction costs and sharing Improve efficiency of drug and other medical product supply chains management costs Improve management of medical equipment and infrastructures, including good maintenance strategies Utilize innovations in common information technology (IT) platforms for health information systems, including reporting and billing across all different pools of money – Rwanda Social Security Board, community-based health insurance, performance-based financing, etc. Reduce management and transaction costs across all levels of the health system

Development of performance- Improve integration of performance-based financing and accreditation process to based financing and ensure more sustainable outputs and outcomes for health results-based financing Strengthen and utilize country-led systems for external financing

Other efficiency opportunities Improve financial management performance, including financial recording, accounting, expenditure tracking and compliance with procurement rules

Risk pooling – health Strengthen health insurance and Strengthen insurance schemes for universal health coverage, especially insurance risk pooling systems community-based health insurance Improve cross-subsidization for low-income categories by increasing contribution of private and public insurance provision Expand the benefit package of health insurance based on changes in the burden of disease (NCDs) Enhance financial health protection through the reduction of co‑payments

Increase of domestic Enhance strategies and Engage with the private sector in order to increase investment in health for both resources interventions increasing domestic supply of health services (including development of hospitals, clinics, diagnostic revenue for health, including centres, and education institutions) and demand for health services community and private entities, Create public–private partnerships for projects such as provision of medical to monetize available expertise infrastructure, leasing of equipment, and maintenance of medical equipment Strengthen PPCPs, such as health posts and community health worker cooperatives Sustain government resources invested in health Promote corporate social health responsibility of private companies Develop cost recovery and cost saving plans for health products, including blood products

Source: Ministry of Health (13).

PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) 16 There is a Single Project Implementation Unit in the different actors in the health financing system and Ministry of Health, with the mandate of reducing the to decrease transaction costs. number of separate projects and the administrative Key challenges and gaps in health financing include burden of the Ministry of Health in managing and the following: reporting on the various projects with off-budget resources. Funds flow into the Rwandan health • disease burden, including the emerging problem sector from numerous sources and through many of NCDs and associated higher costs of care, and different channels. The systems of pooling, allocation the cost of sustaining progress in the manage- and purchasing are complex, with potential for ment of infectious diseases, such as malaria; duplication of activities and inefficient administrative • resource generation, including the high depend- costs. There are numerous direct resource streams ency on external public financing with a projected to district hospitals and health centres, including decline of external funding, and the low contribu- funds from the general government budget, donor tion of the private sector in health; support, insurance schemes and co-payments, as • resource pooling, allocation and purchasing, well as out-of-pocket payments from those not including linkages between purchasing mecha- covered by insurance. Nevertheless, strategies and nisms (results-based financing), programmes and future reforms are needed to increase efficiency and health system functions. create clearer value for money incentives for the

COMPREHENSIVE CASE STUDY FROM RWANDA 17 9. Human resources

Human resources for health are viewed as the accountability (for example, through proximity backbone of the Rwandan health system, as they management). The specific objectives are: consume the biggest share of the budget (35% • to strengthen the autonomy of facilities in the of the total expenditure on health in 2015) and planning and management of all resources (client are responsible for managing other resources and responsibility); running the health service system, as well as being • to strengthen the harmonization and integration a critical factor for health service development (20) of health personnel management; (Figure 4). • to create a conducive framework for equitable dis- The general objective of the Human Resources tribution of resources to rural areas. for Health Programme is to ensure an equitable Recently, Rwanda has developed strategies and distribution of health personnel (especially to serve interventions to overcome shortages in human in rural areas) and to involve beneficiaries for citizen resources for health and to ensure the population has access to affordable quality health care.

Figure 4. Human resources for health planning framework

Employment: Socioeconomic ––job analysis planning ––job description ––recruitment and selection ––personnel records and Health planning databases ––induction ––distribution of personnel Retention and change: Estimating supply and requirements Human ––career structure Estimating numbers, categories, ––promotion resource planning competencies, skills, attitudes ––grievance and dismissal ––procedures ––working and living conditions ––reward system incentives Health service Support: development ––forms of supervision ––forms of communication and Undergraduate education consultation Health Health Postgraduate training ––employer–employee resource resource management production relations and collective Continuing education representation Development: ––individual performance review

Source: Ministry of Health (20).

PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) 18 As indicated by the HSSP IV (2018–2024) baseline collaboration with development partners, has figures (7), the doctor–population ratio (including initiated a human resources for health project general practitioners and specialists) is 1:10 055, that includes a postgraduate training programme the nurse–population ratio is 1:1094, and the for ensuring quality health care for patients at midwife–population ratio (women aged 15–49 provincial and national referral hospitals. A Human years) is 1:4064 (Table 6). Nevertheless, the shortage Resources for Health Strategic Plan (2016–2021) of human resources in the health sector is one of is being implemented with a focus on innovative the biggest challenges facing the government. models of health training, increasing health In order to fill the gaps, the government has personnel productivity, strengthening the capacity invested significant resources in implementing pre- of employment, improving data management for service training programmes and strengthening decision-making, and mobilizing the necessary institutions. The Government of Rwanda, in sustainable financing (20).

Table 6. Human resources for health baseline and targets for HSSP IV

Baseline Indicator targets Indicator output indicator value Means of verification (2016/17) Target 2020/21 Target 2023/24

Doctor–population ratio (including 1:10 055 1:9 000 1:7 000 Health professional bodies statistics, general practitioners and specialists) reports, annual statistical booklets

Nurse–population ratio 1:1 094 1:900 1:800 Health professional bodies statistics, reports, annual statistical booklets

Midwife–population ratio 1:4 064 1:3 500 1:2 500 Health professional bodies statistics, (women aged 15–49 years) reports, annual statistical booklets

Pharmacist–population ratio 1:16 871 1:16 000 1:15 500 Health professional bodies statistics, reports, annual statistical booklets

Laboratory technicians–population 1:10 500 1:9 000 1:7 500 Health professional bodies statistics, ratio reports, annual statistical booklets

Doctor attrition rate – > 10% > 5% Survey

Source: Ministry of Health (7).

COMPREHENSIVE CASE STUDY FROM RWANDA 19 10. Quality of health care services in Rwanda

Rwanda recognizes the right to quality health services • In 1995, resolution AFR/RC45/R3 of the World in its national Constitution. The Ministry of Health is Health Organization (WHO) Regional Committee responsible for the quality and safety of health care for Africa urged Member States to establish qual- services. In order to carry out this responsibility, ity assurance programmes. the Ministry of Health assesses the needs of the • In 2006, the Ministry of Health introduced accredi- population, sets priorities, and develops health care tation programmes in three hospitals – King Faisal policy and strategies to meet the identified needs. Hospital, Butare University Teaching Hospital and The quality of health care services in Rwanda is Kigali University Teaching Hospital – using the continuously and regularly monitored through Council for Health Service Accreditation of South- health facilities accreditation, performance-based ern Africa to achieve accreditation. financing and integrated supportive supervision. • Laboratory accreditation was launched in 2009, when Rwanda adopted the Strengthening Lab- Performance-based financing is one of the pillars oratory Management towards Accreditation of health financing to strengthen the health system programme of the WHO Regional Office for Africa. in Rwanda. This approach was introduced in order • In 2012, the Ministry of Health launched the to strengthen the motivation of care providers and National Health Care Accreditation System, with produce results (output) that traditional financing key documentation including the Rwanda Hos- (for input) had not previously yielded. Performance- pital Accreditation Standards, an accreditation based financing started in 2002 as a pilot and has performance assessment toolkit, and surveyor and been integrated in the HSSP since 2005. Health facilitator manuals. In the same year, the Ministry facilities are evaluated twice a year (20). of Health disseminated accreditation standards in Health facility accreditation has been identified by all 42 hospitals, followed by a baseline assessment the Government of Rwanda, through its Ministry of for all hospitals completed in 2013–2014. Health, as a priority strategy towards improving the • In 2013, five new referral and provincial hospi- quality and safety of health care, and creating a sus- tals first enrolled in the accreditation programme, tainable process for implementing and measuring following which 37 other hospitals were also achievement of standards. Notable progress has been enrolled. recorded in improving the health outcomes of the • In 2013, the Ministry of Health resolved to link population, and health is among the main priorities of performance-based financing to accreditation in the country’s political and development agenda and order to increase the effectiveness and efficiency strategic development planning. With the same logic, of continuous quality improvement of health care the Ministry of Health has developed guidance doc- services, enhance the performance-based financ- uments, including the National Policy for Quality and ing quality assessment tool using accreditation Accreditation, the National Strategy for Quality and standards, harmonize assessment tools and teams Accreditation, and the Rwanda Hospital Accreditation (to have one tool and one team), use existing per- Standards. All quality-related programmes are coordi- formance-based financing incentives to support nated by the Health Services and Quality Assurance continuous quality improvement, align indicators Division of the Ministry of Health. from different programmes with accreditation standards, and avoid duplication of efforts and Some milestones in Rwanda’s journey in pursuit of resources. Performance progress assessments are quality health care services include the following. carried out twice a year to measure compliance

PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) 20 with quality-driven standards, followed by inte- Table 7 indicates supportive measures that have grated supportive supervision coupled with data taken place at central and district levels. quality audit to reduce gaps identified during Performance contracts (imihigo). Each year assessment (Figure 5). performance contracts (including health targets) are • Since 2013, there has been in-country capacity- signed between the President of Rwanda and local building in quality improvement and accreditation government institutions and line ministries. These by training accreditation surveyors and facilitators bind respective institutions to targets they set for to enable both central-level organizations and themselves. Performance indicators provide a clear hospitals to conduct self and external evaluation framework to establish domestic accountability and facilitation. This has been supported by estab- at a level directly relevant to citizens. Performance lishment of an Accreditation Steering Committee contracts are measured against an agreed set of and a Quality and Safety Technical Working Group, governance, economic, health and social indicators and of hospital accreditation support committees, known as performance indicators. Local authorities enabling institutionalization of quality of care. are held accountable to their targets, and civil servants can be fired for below-average performance.

Figure 5. Aligning performance-based financing with accreditation

Performance-based financing Accreditation assessment tool evaluation tool • Leadership • Clinical care • Administration • Clinical activities • Workforce • Quality • Health centre • HIV • Safe improvement coaching, • TB environment supportive supervision

Merge in one performance assessment tool 60% aligned 40% not aligned • Leadership • Health centre coaching • Workforce • HIV • Safe environment • TB • Clinical care • Quality improvement

Source: Ministry of Health presentation in Health Financing International Conference, March 2016.

Table 7. Supportive measures for improving quality of health care at central and district levels

Central level District level (decentralized)

Accreditation Steering Committee to oversee accreditation process Collaboration with district health units Health Services and Quality Assurance Unit in the Ministry of Health Establishment of district health management teams Quality Standards Technical Working Group Quality and accreditation supportive committees at hospital level In-country capacity-building by training surveyors and facilitators at Quality assurance committee at health centre level central and district levels

COMPREHENSIVE CASE STUDY FROM RWANDA 21 District mayors utilize performance contracts • establish and institutionalize a quality improve- (imihigo) with health facilities to encourage ment (accreditation) mechanism or framework; fulfilment of standards, with subsidies and financing • ensure access to safe surgical care in health facili- contingent on performance. Health performance ties at secondary and tertiary levels; targets include indicators for declining morbidity and • strengthen the management of health care mortality associated with prevention and curative technology; care, as well as access to care. Performance against • ensure availability of IT infrastructure to improve indicators is monitored with quarterly evaluations health services delivery; and through analysis of results in annual reports. The • support and sustain the cost of care for constant system aims to: improvement of the health system (including access to quality treatment of cancer, kidney, car- • ensure geographical and financial access to health diovascular disease, drug addiction and abuse); care services (especially numbers of health posts); • improve pre-hospital and emergency services.

PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) 22 11. Regulatory processes

The general mission of the Ministry of Health is to The Ministry of Health ensures regulation of the health promote the health of the population through the sector in collaboration with the health professional delivery of preventive, curative and rehabilitative councils – the Rwanda Medical and Dental Council, health services. the Rwanda Nursing and Midwifery Council, the Rwanda Allied Health Professions Council, and the Specifically, one of the core functions of the Ministry Rwanda Pharmacy Council. A number of codes and of Health is to regulate the health sector through (a) regulations have been put in place for health sector drafting and disseminating laws, regulations and actors, for example the code for the allied health instructions to promote health sector performance; professions, the code of ethics for the pharmacy (b) setting and disseminating standards applicable to profession, and codes for the nursing profession. the health sector; and (c) authorizing private health institutions.1 Table 8 summarizes the key missions and functions of the professional councils in Rwanda.

Table 8. Key missions and functions of Rwandan professional councils

Council Relevant information, including mission and functions Rwanda Medical and Established under Law No. 30/2001 of 12 June 2001, revised to Law No. 44/2012 of 14 January 2013. Dental Council Mission: • to safeguard the moral values of the medical and dental profession; • to encourage access to the profession, to the excellence of medical doctors’ skills and to quality medical and dental practice; • to act as the guardian of medical and dental deontology and ethics; • to give advice about medical and dental practice and health policies; • to define the standards of elementary, advanced and continuous training adapted as much to the progress of medical and dental practice as to changing society. Related laws and policies include: • law of Rwanda Medical and Dental Council • law establishing medical professional liability insurance • ministerial order establishing internship for medical doctors • registrations and licensing policy • registrations for indexing of medical and dental students • Council qualifying examinations policy. Official website: http://www.rmdc.rw/

Rwanda Nursing and Established under Law No. 25/2008 of 25 July 2008. Midwifery Council The mission of the Council is to protect the public and the integrity of the nursing and midwifery professions through the regulation of education and practice in collaboration with all stakeholders as well as the community, within available resources. Function of the Rwanda Nursing and Midwifery Council: The principal function of the Council is to protect the public from harmful or unprofessional practices by ensuring that clients receive care from competent and ethically behaved nurses and midwives. • The Council sets standards of professional education and practice, including professional conduct of nurses and midwives, and determines their scope of practice. • The Council ensures that the public receives care from only nurses and midwives who meet the required qualifications for provision of safe and effective care. In order to ensure that educational and practice standards are met, the Council carries out the following: • sets educational standards for nurses and midwives • sets standards of practice for nurses and midwives. Official website: http://ncnm.rw Continues… 1 Official Gazette No. Special of 28/02/2015.

COMPREHENSIVE CASE STUDY FROM RWANDA 23 Continued… Council Relevant information, including mission and functions Rwanda Allied Health Established under Law No. 46/2012 of 14 January 2013 Professions Council The Rwanda Allied Health Professions Council is a national regulatory body responsible for compliance with the rules, honour and dignity of allied health professions in Rwanda. It ensures compliance with the principles of morality, integrity and dedication essential to the practice of health professions and ensures that its members and registrants comply with their professional requirements, and with the laws and regulations governing the health profession. The Council’s mission is to regulate, supervise, oversee, coordinate, and control the activities of its members, enforce standards of ethics, and enhance professionalism among health institutions. Official website: http://www.rahpc.org.rw

Rwanda Pharmacy Council Established under Law No. 45/2012 of 14 January 2013 The Council is responsible for ensuring that the rules, honour and dignity of the pharmacy profession are complied with in order to protect public health. The Council ensures compliance with the principles of morality, integrity and dedication essential to the practice of the pharmacy profession and ensures that all its members comply with their professional requirements and the laws and regulations governing pharmacists. The Council has the following competencies: • to grant and revoke the authorization to practice the pharmacy profession; • to provide institutions of higher learning with advice regarding pharmacy academic programmes; • to take disciplinary measures against pharmacists, as appropriate. Related laws and policies include: • law establishing the Rwanda Pharmacy Council • law governing narcotics drugs, psychotropic substances and precursors in Rwanda • law establishing Rwanda Food and Medicines Authority • law relating to the regulation and inspection of food and pharmaceutical products • continuing professional development policy for health professional councils in Rwanda • an overview of the National Pharmacy Council • Code of Ethics for Pharmacy Professions • guidelines for grading pharmacy professionals in Rwanda. Official website: http://www.pharmacycouncil.rw/

The Ministry of Health adopted a national Traditional, There is an established mechanism for licensing Complementary and Alternative Medicine Policy in private health facilities in close collaboration with 2017 as a step towards regulation of this area, while district authorities and technical teams. Processes a specific law regulating its practice is also in the are summarized in the Citizen Service Charter of the pipeline (21). Ministry of Health (22). The Ministry of Health defines service packages at The regulation of prices and tariffs for medical each level of the health system in Rwanda – from services in both the public and private sector is done the community to university teaching hospitals – in periodically in collaboration with health insurance terms of the types of services offered, the description entities. and qualifications of staff that provide the services, The quality of health services is monitored via and the infrastructure and equipment required to continuous supportive supervision at different levels, carry out the services. The health service packages performance-based incentives, and an accreditation support the clinical and managerial standards by system that has been instigated at hospital level which the health care facilities operate. The Ministry and will soon be implemented at health centre level of Health also defines effective referral processes, as well. Decentralized governance structures such linking each level of health care services to provide a health committees or boards are also mandated to smooth transition for the patients to navigate. oversee the quality of services provided to citizens.

PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) 24 12. Monitoring and information systems

The Ministry of Health requires that data systems, and the Community Health Information management, validation and verification be System (SISCOM), which collects, stores, retrieves conducted routinely after report submission. and disseminates critical programme and patient The routine data quality review is retrospectively information related to care and treatment. conducted on all data submitted to the centralized Figure 6 shows how information flows between the Health Management Information System (HMIS) entities involved in data collection. during the previous reporting period and any other reporting periods deemed necessary by the review Data-driven decision-making and policy formulation team. The findings from the data validation and have increased the efficiency of health programme verification review must be submitted to the Ministry management and enhanced the government’s of Health within five working days after each review capacity to monitor the quality of health care. and discussed by the institution reviewed within two Deployment of a centralized, web-based HMIS working days after the review (23). started in 2012 with the aim of simplifying data collection and improving the timeliness of reporting. The main source of data is the HMIS. Data are recorded in health centres and hospitals on patient All government institutions at central and local files, collated in registers, and then compiled monthly levels use the collected data to inform planning and transmitted to the centralized HMIS server on and budgeting. However, all levels should ensure the fifth day of the reporting month. appropriate infrastructure, skilled personnel and accountability. Routine health data are sent Other routine web-based information management from health facilities and the community by data solutions include the Integrated Disease Surveillance managers and community health workers. Reports and Response system (which monitors a number are sent regularly (quarterly, monthly or weekly) or of diseases, including HIV and tuberculosis), on a case-by-case basis through the web-based performance-based financing and data warehouse Rwandan HMIS.

COMPREHENSIVE CASE STUDY FROM RWANDA 25 Figure 6. Data flows between Rwandan entities involved in data collection and dissemination

Feedback or direct data access Manual report transmission Electronic report transmission Central level Central level Referral hospital programmes and HMIS unit divisions

Routine health data and TB report Direct access – dashboards and reports Feedback & RHMIS-DHIS-2 errors reports Feedback & error reports Quarterly bulletins Quarterly bulletins Annual statistical Routine DH Most at-risk populations report Annual statistical health and CBHI & orphans and vulnerable report data reports children quarterly report

Enter data Direct access – dashboards Prepare paper and reports reports Administrative district health units

Direct access – Provincial & district hospitals dashboards and reports Community- SISCOM data based health reports insurance weekly & Routine health, Routine health monthly reports TB data reports data reports Monthly Monthly feedback feedback Enter data Enter data Enter data Enter data

Prepare paper Aggregate data Prepare paper Prepare paper reports from all cells reports reports

Community Health centres health worker Private clinics Mutuelle de Sante cooperatives sections

Monthly cell level SISCOM report

Cell level CHW supervisors

Monthly Monthly cell level feedback SISCOM report

Monthly Prepare paper feedback reports

Community

Source: Ministry of Health (23).

PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) 26 13. Challenges, policy considerations and ways forward

To maintain the progress made in PHC service • improve contributions and feedback on quality of provision, Rwanda will continue to place emphasis health services, and ensure the accountability of in certain areas: all involved actors; • promote data use to inform policy and decision- • ensure geographical and financial access to health making; care services (especially number of health posts); • increase the domestic budget for PHC (in response • establish and institutionalize the quality improve- to the decrease in external funding) by improve- ment (accreditation) mechanism and framework; ments in pooling finances and risk to ensure • ensure access to safe surgical care in health facili- affordable care; ties at secondary and tertiary levels; • accelerate development of e-health through the • strengthen the management of health care use of advanced technology and knowledge technology; transformation to collect available data and suc- • ensure availability of IT infrastructure to improve cess stories to inform future plans; health services delivery; • provide continuous support for human resources • support and sustain the cost of care for constant for health, and avail an adequate, skilled workforce improvement of the health system (for example, by means of training and retention plans; access to quality treatment of cancer, kidney dis- • strengthen the community-based health insur- ease, cardiovascular disease, drug addiction and ance law to improve financial access to vulnerable abuse); groups (persons with disabilities, the homeless, • improve pre-hospital and emergency services; mental health patients, the elderly); • promote community involvement in the health • revise the prices of health care services; care system to reinforce community ownership; • upgrade health services to meet the expectations of various population groups, and improve the referral system.

COMPREHENSIVE CASE STUDY FROM RWANDA 27 14. Conclusion

The Rwandan health sector follows a decentralized regulatory measures, planning, and access to and system, with the health district as the basic operational quality of services – are discussed in this report to unit of the system, supported by reinforcement inform structure, process and outcomes. of community participation in managing and The document is thus a vital foundation for financing health services. Consideration of all factors further actions, including health-related decision- influencing the health care system worldwide, and making, planning and prioritization to address in Rwanda particularly, is indispensable in planning, gaps, continuation of community engagement, policy-making and evidence-based decision- accountability, strengthening of the district health making. These elements – including governance, system, reinforcing human resource cadres, and financing and human resources, policy matters, ensuring accessible quality health services.

PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) 28 Annex 1. Profiles of key informants interviewed for case study

No. Key informants Institutions Function

1 Dr Patrick NDIMUBANZI Ministry of Health Minister of State in charge of Primary Health Care

2 Dr Zuberi MUVUNYI Ministry of Health Director-General of Clinical and Public Health Services

3 Dr Parfait UWALIRAYE Ministry of Health Director-General of Planning, Health Financing and Information Systems

4 Associate Professor Dr Martin NYUNDO University Teaching Hospital Head of Division for Clinical Services of Kigali

5 Dr Jean Chrysostome NYIRINKWAYA Hôpital La Croix du Sud Chief Executive Officer

6 Dr Blaise UHAGAZE Private Health Insurance Executive Secretary of Rwanda Health Insurers Association

7 Dr Elisabeth UWANYIRIGIRA USAID Health System Strengthening Specialist

8 Diane MUHONGERWA WHO Health Economist

9 Juliet BATARINGAYA WHO Country Adviser, Health System Development

10 Dr Jules MUGABO WHO HIV/AIDS/STI Officer

11 Mrs Florence MUZIGANYI Rwanda Social Security Board Medical Benefits Division Manager/Community-Based Health Insurance

12 Dr Marcel UWIZEYE Masaka District Hospital Director-General

13 Dr Avite MUTAGANZWA Kibagabaga District Hospital Director-General

14 Carine MURIGO Gasabo District Director of Health Unit

15 Gilbert UMURERWA Nyarugenge District District Monitoring and Evaluation Officer

16 Stella Matutina UMUHOZA UR/CMHS/ School of Public Lecturer, Health System Researcher Health

17 Dr Evrare NAHIMANA Partners in Health (PIH) PHC Researcher

COMPREHENSIVE CASE STUDY FROM RWANDA 29 References

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PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) 30

This case study was developed by the Alliance for Health Policy and Systems Research, an international partnership hosted by the World Health Organization, as part of the Primary Health Care Systems (PRIMASYS) initiative. PRIMASYS is funded by the Bill & Melinda Gates Foundation, and aims to advance the science of primary health care in low- and middle-income countries in order to support interventions worldwide. The PRIMASYS case studies cover key aspects of primary health care systems, including policy development of care, governance and organization, and monitoring and evaluation of system performance. The Alliance has developed full and abridged versions of the 20 PRIMASYS case studies. The abridged version provides an overview of the primary health care system, tailored to a primary audience of policy-makers and global health stakeholders interested in understanding the key entry points to strengthen primary health care systems. The comprehensive case study provides an in-depth assessment of the system for an audience of researchers and stakeholders who wish to gain deeper insight into the determinants and performance of primary health care systems in selected low- and middle-income countries.

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