Paulin Basinga

Comprehensive and integrated district health systems strengthening: the Rwanda Population Health Implementation and Training (PHIT) Partnership

BackgroundNationally, health in Rwanda has been improving since 2000, with considerable improvement since 2005. Despite improvements, rural areas continue to lag behind urban sectors with regard to key health outcomes. Partners In Health (PIH) has been supporting the Rwanda Ministry of Health (MOH) in two rural districts in Rwanda since 2005. Since 2009, the MOH and PIH have spearheaded a health systems strengthening (HSS) intervention in these districts as part of the Rwanda Population Health Implementation and Training (PHIT) Partnership. The partnership is guided by the belief that HSS interventions should be comprehensive, integrated, responsive to local conditions, and address health care access, cost, and quality. The PHIT Partnership represents a collaboration between the MOH and PIH, with support from the National University of Rwanda School of Public Health, the National Institute of Statistics, Harvard Medical School, and Brigham and Women’s Hospital.Description of interventionThe PHIT Partnership’s health systems support aligns with the World Health Organization’s six health systems building blocks. HSS activities focus across all levels of the health system — community, health center, hospital, and district leadership — to improve health care access, quality, delivery, and health outcomes. Interventions are concentrated on three main areas: targeted support for health facilities, quality improvement initiatives, and a strengthened network of community health workers.Evaluation designThe impact of activities will be assessed using population-level outcomes data collected through oversampling of the demographic and health survey (DHS) in the intervention districts. The overall impact evaluation is complemented by an analysis of trends in facility health care utilization. A comprehensive costing project captures the total expenditures and financial inputs of the health care system to determine the cost of systems improvement. Targeted evaluations and operational research pieces focus on specific programmatic components, supported by partnership-supported work to build in-country research capacity.DiscussionBuilding on early successes, the work of the Rwanda PHIT Partnership approach to HSS has already seen noticeable increases in facility capacity and quality of care. The rigorous planned evaluation of the Partnership’s HSS activities will contribute to global knowledge about intervention methodology, cost, and population health impact.

High Levels of Adherence and Viral Suppression in a Nationally Representative Sample of HIV-Infected Adults on Antiretroviral Therapy for 6, 12 and 18 Months in Rwanda

Background Generalizable data are needed on the magnitude and determinants of adherence and virological suppression among patients on antiretroviral therapy (ART) in Africa. Methods We conducted a cross-sectional survey with chart abstraction, patient interviews and site assessments in a nationally representative sample of adults on ART for 6, 12 and 18 months at 20 sites in Rwanda. Adherence was assessed using 3- and 30-day patient recall. A systematically selected sub-sample had viral load (VL) measurements. Multivariable logistic regression examined predictors of non-perfect (<100%) 30-day adherence and detectable VL (>40 copies/ml). Results Overall, 1,417 adults were interviewed and 837 had VL measures. Ninety-four percent and 78% reported perfect adherence for the last 3 and 30 days, respectively. Eighty-three percent had undetectable VL. In adjusted models, characteristics independently associated with higher odds of non-perfect 30-day adherence were: being on ART for 18 months (vs. 6 months); younger age; reporting severe (vs. no or few) side effects in the prior 30 days; having no documentation of CD4 cell count at ART initiation (vs. having a CD4 cell count of <200 cells/µL); alcohol use; and attending sites which initiated ART services in 2003–2004 and 2005 (vs. 2006–2007); sites with ≥600 (vs. <600 patients) on ART; or sites with peer educators. Participation in an association for people living with HIV/AIDS; and receiving care at sites which regularly conduct home-visits were independently associated with lower odds of non-adherence. Higher odds of having a detectable VL were observed among patients at sites with peer educators. Being female; participating in an association for PLWHA; and using a reminder tool were independently associated with lower odds of having detectable VL. Conclusions High levels of adherence and viral suppression were observed in the Rwandan national ART program, and associated with potentially modifiable factors.

Approaches to ensuring and improving quality in the context of health system strengthening: a cross-site analysis of the five African Health Initiative Partnership programs

BackgroundIntegrated into the work in health systems strengthening (HSS) is a growing focus on the importance of ensuring quality of the services delivered and systems which support them. Understanding how to define and measure quality in the different key World Health Organization building blocks is critical to providing the information needed to address gaps and identify models for replication.Description of approachesWe describe the approaches to defining and improving quality across the five country programs funded through the Doris Duke Charitable Foundation African Health Initiative. While each program has independently developed and implemented country-specific approaches to strengthening health systems, they all included quality of services and systems as a core principle. We describe the differences and similarities across the programs in defining and improving quality as an embedded process essential for HSS to achieve the goal of improved population health. The programs measured quality across most or all of the six WHO building blocks, with specific areas of overlap in improving quality falling into four main categories: 1) defining and measuring quality; 2) ensuring data quality, and building capacity for data use for decision making and response to quality measurements; 3) strengthened supportive supervision and/or mentoring; and 4) operational research to understand the factors associated with observed variation in quality.ConclusionsLearning the value and challenges of these approaches to measuring and improving quality across the key components of HSS as the projects continue their work will help inform similar efforts both now and in the future to ensure quality across the critical components of a health system and the impact on population health.

Why Are Clinicians Reluctant to Treat Smear-Negative Tuberculosis? An Inquiry about Treatment Thresholds in Rwanda

Purpose. The diagnosis of tuberculosis remains controversial between clinicians and public health officers. Public health officials fear to treat too many patients; clinicians fear that truly diseased will be denied treatment. We wondered whether an analysis of the treatment threshold could help making the often intuitive decision to treat smear-negative cases more evidence based. Methods. Eighteen clinicians and 10 public health specialists were asked for an intuitive estimate of their treatment threshold for tuberculosis and of key determinant factors for this threshold: the magnitude and subjective weight of mortality and morbidity due to both the disease and the treatment and risk and cost of the latter. With these factors, the authors calculated treatment thresholds and compared them to the intuitive thresholds of the interviewees. A prescriptive threshold was calculated based on literature data, omitting cost and subjective factors. Results. The median overall intuitive treatment threshold was 52.5%, the calculated 11.9%, and the prescriptive 2.7%. For 2 factors, public health officers provided significantly lower values than clinicians: cost of treatment (median =

Performance-based financing: the need for more research

20 v.

Utilizing community health worker data for program management and evaluation: Systems for data quality assessments and baseline results from Rwanda

300; U = 2.5; P = 0.0002); cost of life (median =

Motivations and Constraints to Family Planning: A Qualitative Study in Rwanda’s Southern Kayonza District

500 v.

Toward utilization of data for program management and evaluation: quality assessment of five years of health management information system data in Rwanda

5000; U = 17.5; P = 0.009). Conclusion. These results suggest that clinicians and public health officers estimate wrongly the threshold even when using their own subjective estimate of influencing factors. Omitting treatment cost and subjective weight of provoked harm can result in a very low threshold. Sound training in threshold principles and providing tools to correctly assess data might help in making better decisions in tuberculosis in developing countries.

The trouble with likelihood ratios

While several developing countries have been implementing PBF as a strategy to finance health services, a polarized debate between the “proponents” and “opponents” of this approach is gaining prominence.1–4 Ireland et al.5 provide a critical view on the paper by Meessen et al.,6 mainly opposing the argument that PBF, on its own, can be considered as a strategy to reform health systems in developing countries. One of their main criticisms is the lack of evidence. Evidence, of course, should ideally be central to any health sector reform but applying this rule rigorously can lead to inertia. Looking back on the history of public health, we note that many important health reforms implemented in Africa – such as selective primary care for child survival or the health district strategy – were not developed based on recommendations from rigorous experimental studies.7 Health reformers should carefully consider different opportunities based on their potential to maximize the delivery and uptake of proven maternal and child health interventions.8 As African public health experts, we believe that PBF is interesting due to its potential. Having said this, we agree that implementing health reforms based on evidence is crucial. For example, some components of selective primary health care, such as growth monitoring, were implemented even though little was known about their cost-effectiveness.7 However, a recent evaluation of the primary-care approach has shown interesting results9 and the global public health community has since gained important knowledge on successful interventions in primary health care. We think that Ireland et al. minimize the growing body of evidence on PBF implementation produced in recent years. Many studies have been published providing details on how to implement PBF and one experimental study has been published on the impact of the approach.10 Clearly, rigorous research is still needed, especially more theoretical and qualitative studies that address the “how and why” and test hypotheses of potential adverse effects of PBF. Continuous checking and integration of the PBF approach is needed during implementation and this should be informed by operational research aimed at aligning PBF with the existing health system. The World Bank, through a grant from the Government of Norway, has launched several PBF initiatives in developing countries, systematically accompanied with an impact evaluation strategy using different innovative research designs.11 These initiatives should include formative research to address the rapidly changing social and political context that may influence policy implementation.12 The debate around PBF should be evidence-based with critical appraisal. Both proponents and opponents should avoid taking a dogmatic position. Both parties have agreed that PBF is not a panacea. The provision of input items and other key interventions, such as provider training, supervision and health-system strengthening, should continue with the aim of producing results. A research agenda and an effective community of practice embracing all views on PBF is critical to understanding more about its potential for helping developing countries to reach some of the United Nations Millennium Development Goals.

Can performance-based financing help reaching the poor with maternal and child health services? The experience of rural Rwanda

Community health workers (CHWs) have and continue to play a pivotal role in health services delivery in many resource-constrained environments. The data routinely generated through these programs are increasingly relied upon for providing information for program management, evaluation and quality assurance. However, there are few published results on the quality of CHW-generated data, and what information exists suggests quality is low. An ongoing challenge is the lack of routine systems for CHW data quality assessments (DQAs). In this paper, we describe a system developed for CHW DQAs and results of the first formal assessment in southern Kayonza, Rwanda, May-June 2011. We discuss considerations for other programs interested in adopting such systems. While the results identified gaps in the current data quality, the assessment also identified opportunities for strengthening the data to ensure suitable levels of quality for use in management and evaluation.