Anatole Manzi

Clinical mentorship to improve pediatric quality of care at the health centers in rural Rwanda: a qualitative study of perceptions and acceptability of health care workers

BackgroundDespite evidence supporting Integrated Management of Childhood Illness (IMCI) as a strategy to improve pediatric care in countries with high child mortality, its implementation faces challenges related to lack of or poor post-didactic training supervision and gaps in necessary supporting systems. These constraints lead to health care workers’ inability to consistently translate IMCI knowledge and skills into practice. A program providing mentoring and enhanced supervision at health centers (MESH), focusing on clinical and systems improvement was implemented in rural Rwanda as a strategy to address these issues, with the ultimate goal of improving the quality of pediatric care at rural health centers. We explored perceptions of MESH from the perspective of IMCI clinical mentors, mentees, and district clinical leadership.MethodsWe conducted focus group discussions with 40 health care workers from 21 MESH-supported health centers. Two FGDs in each district were carried out, including one for nurses and one for director of health centers. District medical directors and clinical mentors had individual in-depth interviews. We performed a hermeneutic analysis using Atlas.ti v5.2.ResultsStudy participants highlighted program components in five key areas that contributed to acceptability and impact, including: 1) Interactive, collaborative capacity-building, 2) active listening and relationships, 3) supporting not policing, 4) systems improvement, and 5) real-time feedback. Staff turn-over, stock-outs, and other facility/systems gaps were identified as barriers to MESH and IMCI implementation.ConclusionHealth care workers reported high acceptance and positive perceptions of the MESH model as an effective strategy to build their capacity, bridge the gap between knowledge and practice in pediatric care, and address facility and systems issues. This approach also improved relationships between the district supervisory team and health center-based care providers. Despite some challenges, many perceived a strong benefit on clinical performance and outcomes. This study can inform program implementers and policy makers of key components needed for developing similar health facility-based mentorship interventions and potential barriers and resistance which can be proactively addressed to ensure success.

Assessing predictors of delayed antenatal care visits in Rwanda: a secondary analysis of Rwanda demographic and health survey 2010.

BackgroundEarly initiation of antenatal care (ANC) can reduce common maternal complications and maternal and perinatal mortality. Though Rwanda demonstrated a remarkable decline in maternal mortality and 98% of Rwandan women receive antenatal care from a skilled provider, only 38% of women have an ANC visit in their first three months of pregnancy. This study assessed factors associated with delayed ANC in Rwanda.MethodsThis is a cross-sectional study using data collected during the 2010 Rwanda DHS from 6,325 women age 15–49 that had at least one birth in the last five years. Factors associated with delayed ANC were identified using a multivariable logistic regression model using manual backward stepwise regression. Analysis was conducted in Stata v12 applying survey commands to account for the complex sample design.ResultsSeveral factors were significantly associated with delayed ANC including having many children (4–6 children, OR = 1.42, 95% CI: 1.22, 1.65; or more than six children, OR = 1.57, 95% CI: 1.24, 1.99); feeling that distance to health facility is a problem (OR = 1.20, 95% CI: 1.04, 1.38); and unwanted pregnancy (OR = 1.41, 95% CI: 1.26, 1.58). The following were protective against delayed ANC: having an ANC at a private hospital or clinic (OR = 0.29, 95% CI: 0.15, 0.56); being married (OR = 0.85, 95% CI: 0.75, 0.96), and having public mutuelle health insurance (OR = 0.81, 95% CI: 0.71, 0.92) or another type of insurance (OR = 0.33, 95% CI: 0.23, 0.46).ConclusionThis analysis revealed potential barriers to ANC service utilization. Distance to health facility remains a major constraint which suggests a great need of infrastructure and decentralization of maternal ANC to health posts and dispensaries. Interventions such as universal health insurance coverage, family planning, and community maternal health system are underway and could be part of effective strategies to address delays in ANC.

Roadmap to an effective quality improvement and patient safety program implementation in a rural hospital setting

Implementation lessons: (1) implementation of an effective quality improvement and patient safety program in a rural hospital setting requires collaboration between hospital leadership, Ministry of Health and other stakeholders. (2) Building Quality Improvement (QI) capacity to develop engaged QI teams supported by mentoring can improve quality and patient safety.

Mentorship and coaching to support strengthening healthcare systems: lessons learned across the five Population Health Implementation and Training partnership projects in sub-Saharan Africa

BackgroundDespite global efforts to increase health workforce capacity through training and guidelines, challenges remain in bridging the gap between knowledge and quality clinical practice and addressing health system deficiencies preventing health workers from providing high quality care. In many developing countries, supervision activities focus on data collection, auditing and report completion rather than catalyzing learning and supporting system quality improvement. To address this gap, mentorship and coaching interventions were implemented in projects in five African countries (Ghana, Mozambique, Rwanda, Tanzania, and Zambia) as components of health systems strengthening (HSS) strategies funded through the Doris Duke Charitable Foundation’s African Health Initiative. We report on lessons learned from a cross-country evaluation.MethodsThe evaluation was designed based on a conceptual model derived from the project-specific interventions. Semi-structured interviews were administered to key informants to capture data in six categories: 1) mentorship and coaching goals, 2) selection and training of mentors and coaches, 3) integration with the existing systems, 4) monitoring and evaluation, 5) reported outcomes, and 6) challenges and successes. A review of project-published articles and technical reports from the individual projects supplemented interview information.ResultsAlthough there was heterogeneity in the approaches to mentorship and coaching and targeted areas of the country projects, all led to improvements in core health system areas, including quality of clinical care, data-driven decision making, leadership and accountability, and staff satisfaction. Adaptation of approaches to reflect local context encouraged their adoption and improved their effectiveness and sustainability.ConclusionWe found that incorporating mentorship and coaching activities into HSS strategies was associated with improvements in quality of care and health systems, and mentorship and coaching represents an important component of HSS activities designed to improve not just coverage, but even further effective coverage, in achieving Universal Health Care.

Impact of a health system strengthening intervention on maternal and child health outputs and outcomes in rural Rwanda 2005–2010

Introduction Although Rwanda’s health system underwent major reforms and improvements after the 1994 Genocide, the health system and population health in the southeast lagged behind other areas. In 2005, Partners In Health and the Rwandan Ministry of Health began a health system strengthening intervention in this region. We evaluate potential impacts of the intervention on maternal and child health indicators. Methods Combining results from the 2005 and 2010 Demographic and Health Surveys with those from a supplemental 2010 survey, we compared changes in health system output indicators and population health outcomes between 2005 and 2010 as reported by women living in the intervention area with those reported by the pooled population of women from all other rural areas of the country, controlling for potential confounding by economic and demographic variables. Results Overall health system coverage improved similarly in the comparison groups between 2005 and 2010, with an indicator of composite coverage of child health interventions increasing from 57.9% to 75.0% in the intervention area and from 58.7% to 73.8% in the other rural areas. Under-five mortality declined by an annual rate of 12.8% in the intervention area, from 229.8 to 83.2 deaths per 1000 live births, and by 8.9% in other rural areas, from 157.7 to 75.8 deaths per 1000 live births. Improvements were most marked among the poorest households. Conclusion We observed dramatic improvements in population health outcomes including under-five mortality between 2005 and 2010 in rural Rwanda generally and in the intervention area specifically.

Race to the Top: evaluation of a novel performance-based financing initiative to promote healthcare delivery in rural Rwanda

Background Performance-based financing (PBF) has demonstrated a range of successes and failures in improving health outcomes across low- and middle-income countries. Evidence indicates that the success of PBF depends, in large part, on the model selected, in relation to a variety of contextual factors. Objective Partners In Health∣Inshuti Mu Buzima aimed to evaluate health outcomes associated with a novel capacity-building model of PBF at health centers throughout Kirehe district, Rwanda. Design Thirteen health centers in Kirehe district, which provide healthcare to a population of over 300,000 people, agreed to participate in a PBF initiative scheme that integrated data feedback, quality improvement coaching, peer-to-peer learning, and district-level priority setting. Health centers’ progress toward collectively agreed upon site-specific health targets was assessed every 6 months for 18 months. Incentives were awarded only when health centers met goals on all three priorities health centers had collectively agreed upon: 90% coverage of community-based health insurance, 70% contraceptive prevalence rate, and zero acute severe malnutrition cases. Improvement across all four time points and facilities was measured using mixed-effects linear regression. Findings At 6-month follow-up, 4 of 13 health centers had met 1 target. At 12-month follow-up, 7 centers had met 1 target, and by 18-month follow-up, 6 centers had met 2 targets and 2 centers had met all 3. Average health center performance had improved significantly across the district for all three targets: mean insurance coverage increased from 68% at baseline to 93% (p<0.001); mean number of acute malnutrition cases in the previous 6 months declined from 24 to 5 per facility (p<0.001); and contraceptive prevalence increased from 42 to 59% (p<0.001). A number of innovative improvement initiatives were identified. Conclusion The combining of PBF, district engagement/support, and peer-to-peer learning resulted in significant improvements despite resource constraints and is now being considered as a model for scale-up in other districts of Rwanda.

Applied statistical training to strengthen analysis and health research capacity in Rwanda

BackgroundTo guide efficient investment of limited health resources in sub-Saharan Africa, local researchers need to be involved in, and guide, health system and policy research. While extensive survey and census data are available to health researchers and program officers in resource-limited countries, local involvement and leadership in research is limited due to inadequate experience, lack of dedicated research time and weak interagency connections, among other challenges. Many research-strengthening initiatives host prolonged fellowships out-of-country, yet their approaches have not been evaluated for effectiveness in involvement and development of local leadership in research.MethodsWe developed, implemented and evaluated a multi-month, deliverable-driven, survey analysis training based in Rwanda to strengthen skills of five local research leaders, 15 statisticians, and a PhD candidate. Research leaders applied with a specific research question relevant to country challenges and committed to leading an analysis to publication. Statisticians with prerequisite statistical training and experience with a statistical software applied to participate in class-based trainings and complete an assigned analysis. Both statisticians and research leaders were provided ongoing in-country mentoring for analysis and manuscript writing.ResultsParticipants reported a high level of skill, knowledge and collaborator development from class-based trainings and out-of-class mentorship that were sustained 1 year later. Five of six manuscripts were authored by multi-institution teams and submitted to international peer-reviewed scientific journals, and three-quarters of the participants mentored others in survey data analysis or conducted an additional survey analysis in the year following the training.ConclusionsOur model was effective in utilizing existing survey data and strengthening skills among full-time working professionals without disrupting ongoing work commitments and using few resources. Critical to our success were a transparent, robust application process and time limited training supplemented by ongoing, in-country mentoring toward manuscript deliverables that were led by Rwanda’s health research leaders.

A Clinical Mentorship and Quality Improvement Program to Support Health Center Nurses Manage Type 2 Diabetes in Rural Rwanda

Introduction The prevalence of diabetes mellitus is rapidly rising in SSA. Interventions are needed to support the decentralization of services to improve and expand access to care. We describe a clinical mentorship and quality improvement program that connected nurse mentors with nurse mentees to support the decentralization of type 2 diabetes care in rural Rwanda. Methods This is a descriptive study. Routinely collected data from patients with type 2 diabetes cared for at rural health center NCD clinics between January 1, 2013 and December 31, 2015, were extracted from EMR system. Data collected as part of the clinical mentorship program were extracted from an electronic database. Summary statistics are reported. Results The patient population reflects the rural settings, with low rates of traditional NCD risk factors: 5.6% of patients were current smokers, 11.0% were current consumers of alcohol, and 11.9% were obese. Of 263 observed nurse mentee-patient encounters, mentor and mentee agreed on diagnosis 94.4% of the time. Similarly, agreement levels were high for medication, laboratory exam, and follow-up plans, at 86.3%, 87.1%, and 92.4%, respectively. Conclusion Nurses that receive mentorship can adhere to a type 2 diabetes treatment protocol in rural Rwanda primary health care settings.

Economic evaluation of a mentorship and enhanced supervision program to improve quality of integrated management of childhood illness care in rural Rwanda

Background Integrated management of childhood illness (IMCI) can reduce under-5 morbidity and mortality in low-income settings. A program to strengthen IMCI practices through Mentorship and Enhanced Supervision at Health centers (MESH) was implemented in two rural districts in eastern Rwanda in 2010. Methods We estimated cost per improvement in quality of care as measured by the difference in correct diagnosis and correct treatment at baseline and 12 months of MESH. Costs of developing and implementing MESH were estimated in 2011 United States Dollars (USD) from the provider perspective using both top-down and bottom-up approaches, from programmatic financial records and site-level data. Improvement in quality of care attributed to MESH was measured through case management observations (n = 292 cases at baseline, 413 cases at 12 months), with outcomes from the intervention already published. Sensitivity analyses were conducted to assess uncertainty under different assumptions of quality of care and patient volume. Results The total annual cost of MESH was US

Advancing the health of women and newborns: predictors of patient satisfaction among women attending antenatal and maternity care in rural Rwanda

27,955.74 and the average cost added by MESH per IMCI patient was US