Strengthening health systems Evidence-informed approaches and lessons learned from Rwanda ‘Institutional Support to Ministry of Health – Phase IV’ (Minisanté IV) Program Capitalization and Knowledge Management: generating lessons from program implementation and translating them into concrete actions at managerial and technical levels for increased ownership, evidence-based policy development and sharing of good practices This booklet is a product of the Ministry of Health in Rwanda in collaboration with the ‘Institutional Support to Ministry of Health – Phase IV’ (Minisanté IV) Program through support from the Belgian Development Agency. The book capitalizes on the work done within the BTC- Rwanda partnership and reflects on different components such as health system strengthening, Strengtheningmaternal health, mental health, urban health, health health technologies and ecologicalsystems interventions, decentralization and aid modalities reflections. It is also a reflection on the value of results achieved and the progress made through the whole institutional support process while providing an appreciation of the relevance, efficiency, effectiveness, sustainability and impact of planned Evidence-informedinterventions. In addition, this book is seen approaches as an intensive sharing and and learning lessons opportunity in order to draw useful lessons for other similar interventions, new policies and strategies in other learnedcountries and future from partnerships Rwanda in Rwanda. Strengthening health systems Evidence-informed approaches and lessons learned from Rwanda ‘Institutional Support to Ministry of Health – Phase IV’ (Minisanté IV) Program Capitalization and Knowledge Management: generating lessons from program implementation and translating them into concrete actions at managerial and technical levels for increased ownership, evidence-based policy development and sharing of good practices This booklet is a product of the Ministry of Health in Rwanda in collaboration with the ‘Institutional Support to Ministry of Health – Phase IV’ (Minisanté IV) Program through support from the Belgian Development Agency. The book capitalizes on the work done within the BTC- Rwanda partnership and reflects on different components such as health system strengthening, maternal health, mental health, urban health, health technologies and ecological interventions, decentralization and aid modalities reflections. It is also a reflection on the value of results achieved and the progress made through the whole institutional support process while providing an appreciation of the relevance, efficiency, effectiveness, sustainability and impact of planned interventions. In addition, this book is seen as an intensive sharing and learning opportunity in order to draw useful lessons for other similar interventions, new policies and strategies in other countries and future partnerships in Rwanda. REPUBLIC OF RWANDA MINISTRY OF HEALTH Authors Gilbert Biraro, Vincent Tihon, Daniel Ngamije, Fidèle Nsengimana, Frederick Fundi, Jean Baptiste Habimana, Innocent Hakizimana, Ina Kalisa Rukundo, Mathieu Niyonkuru, Vestine Mukagatesi, Théogène Mbonyeyezu, Sophie Mukandikumana, Avite Mutaganzwa, Victor Ndaruhutse , Alfred Rutagengwa, Prince Rwaburindi, Edith Musabyimana, Achour Ait Mohand, Yvonne Kayiteshonga, Nancy Claire Misago, Jeanne D’ Arc Dusabeyezu, Jean Damascene Iyamuremye, Bernard Ngabo Rwabufigiri, Judith Mukamurigo, Félicien Rusagara, Jean Baptiste Habimana, Régis Kazindu, Alexis Maniraho, Sankaran Narayanan, Hope Tumukunde, Blaise Uhagaze, Erick Vladescu Ayirwanda, Jean-Marie Sinari, Jean D’Amour Manirafasha, Gervais Baziga, M ecthilde Kamukunzi, Alypio Nyandwi, Donatien Bajyanama, Parfait Uwaliraye, Janvière Uwamahoro, Gad Sibomana, Abdallah Utumatwishima, Patrick Uwihanganye Editors Anke van der Kwaak and Judith Mathijssen © 2017, Republic of Rwanda, Ministry of Health Graphic design: Ad van Helmond, Amterdam, The Netherlands Production: High Trade BV, Zwolle, The Netherlands ISBN 978-94-6022-408-9 Abbreviations and Acronyms Contents ANC Antenatal care Preface 7 BoD Board of Directors BTC Belgian Development Agency Acknowledgements 9 CBHI Community-Based Health Insurance CHWs Community Health Workers DALYs Disability-Adjusted Life Years Introduction 9 DELCO Délégué à la Cogestion DHMT District Health Management Team Part one: Towards a good quality of care for women and children EDPRS II Second Economic Development and Poverty Reduction Strategy in Rwanda EmOC Emergency Obstetric Care EmONC Emergency Obstetrical and Neonatal Care GDP Gross Domestic Product 1. First antenatal care visit as a prerequisite to reduce maternal and child HC Health Centre health mortality: a case study from Rulindo District, Rwanda 23 HIV Human Immunodeficiency Virus 2. Prevalence and causes of neonatal death in Gakenke District: HMIS Health Management Information System lessons learned and the way forward 33 HSSP Health Sector Strategic Plan 3. A strategy to reduce postnatal deaths: the case of Bugesera District 43 iHRIS integrated Human Resources Information System IPRC Integrated Polytechnic Regional Centre LLINs Long-Lasting Impregnated Nets Part two: Specific interventions for strengthening health systems KIT Royal Tropical Institute, Amsterdam MDGs Millennium Development Goals 4. Decentralization and integration of mental health care into primary M&E Monitoring and Evaluation health care: A case study of Rwanda 55 MTI Medical Technology and Infrastructure 5. Improved Health Care Waste Management: Successes and Challenges MUAC Middle Upper Arm Circumference NCD Non-Communicable Diseases from Rural Health Facilities in Gakenke District 71 PBF Performance-Based Financing 6. Assessment of Technical Units in District Hospitals 81 DHS Demographic and Health Survey 7. Improving financial accessibility to health care: lessons learned from PTSD Post-Traumatic Stress Disorder community-based health insurance in Bugesera District 89 PMTCT Prevention of Mother-to-Child Transmission 8. Medicalization of Urban Health Centres: Coping with Emerging Health PNC Postnatal Care Challenges in the City of Kigali 101 SISCOM Système d’Information Sanitaire Communautaire SMS Short Message Service SPIU Single Project Implementation Unit Part three: Strengthening health systems management STATA data analysis and statistical software RBC Rwanda Biomedical Centre 9. Strengthening district health systems through health data management: RWF Rwandese Francs The case of Rulindo District 111 SPIU Single Project Implementation Unit UR-SPH University of Rwanda-School of Public Health 10. The role of the administrative district in the governance and management USAID United States Agency for International Development of decentralized health systems in Rwanda 121 VCT Voluntary Counselling and Testing 11. An Innovative Approach for Effective Project Management in the Ministry WHO World Health Organization of Health: Case Study of the Institutional Support Program to the WONCA World Organization of Family Doctors Ministry of Health Phase IV (Minisanté IV) 129 Annex 1 – List of authors 149 Preface Tables In the last decades Rwanda has focused strongly on strengthening the health system Table 1.1: WHO quality of care dimensions 23 that was disrupted in 1994 due to the genocide. Due to loss of lives and structure the Table 1.2: Level of service provision vis-à-vis the services received by Rwandan government has closely collaborated with donors and partners to build up pregnant women 25 specific development sectors. Table 4.1: Mental health activities in District Hospitals 60 Table 5.1: Observed protective equipment and clothing for waste collectors 68 Health is one of the three priorities of the Indicative Cooperation Program between Table 5.2: Infectious sharp waste management (number of respondents=95) 69 Belgium and Rwanda. Belgium’s development cooperation support to Rwanda’s health Table 5.3: Availability of hygiene materials/equipment within health facilities 70 sector is channeled through the Belgian Development Agency (BTC). In 2009, Belgium Table 7.1: The CBHI categories and membership fees 85 committed to supporting the Rwandan health sector for twelve years with particular Table 7.2: Characteristics of participants (N=41) 88 emphasis on Primary Health Care. Table 7.3: Opinions of local leaders and health care providers at sector level 90 Table 8.1: District-specific health care context in the City of Kigali 97 From August 2010 to June 2015, the Ministry of Health, in collaboration with the Belgium Table 8.2: Top 10 causes of morbidity in Health Centres, 2011 98 Development Cooperation (BTC), implemented the “Institutional Support Program to Table 8.3: Minimum package of activities at different health facility levels 100 the Ministry of Health – Phase IV” (Minisanté IV) Program at central level (MoH and RBC) and also in three specific districts recommended by the MoH (Rulindo, Gakenke and Figures Bugesera). Figure 0.1: Conceptual framework of HSSP III 10 Figure 4.1: Human resources available at each level of the health pyramid 58 The Minisanté IV programme support, amounting to €12.6 Million from 2010-2015, was Figure 4.2: Supervision system performed at district level 59 aligned to the Health Sector Strategic Plan II (and later HSSP III). It aimed at supporting Figure 5.1: Interim storage of health care waste in Gakenke health facilities 69 central and decentralized health sector strengthening priority interventions to assure Figure 5.2: Characteristics of dustbins (N=99) 71 quality of