PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) Comprehensive case study from Rwanda PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) Comprehensive case study from Rwanda Kigali, June 2018 WHO/HIS/HSR/17.44 © World Health Organization 2017 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. 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The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. The named authors alone are responsible for the views expressed in this publication. Editing and design by Inís Communication – www.iniscommunication.com 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