Primary health care systems (primasys): comprehensive case study from Rwanda

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

Comprehensive case study from Rwanda PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) Kigali, June 2018 PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) 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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If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. 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 COMPREHENSIVE CASE STUDY FROM RWANDA 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 iv PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) 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 1 COMPREHENSIVE CASE STUDY FROM RWANDA Abbreviations CAMERWA Central Procurement Agency for Essential Medicines in Rwanda (Central d’Achat des Medicaments Essentiels de Rwanda) GDP gross domestic product HMIS Health Management Information System HSSP Health Sector Strategic Plan IT information technology NCD noncommunicable disease PHC primary health care PPCP public, private and community partnership SISCOM Community Health Information System TRAC Plus Centre for Treatment and Research on AIDS, Malaria, Tuberculosis and Other Epidemics WHO World Health Organization 2 PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) Background to PRIMASYS case studies Health systems around the globe still fall short of providing accessible, good-quality, comprehensive and integrated care. As the global health community is setting ambitious goals of universal health coverage and health equity in line with the 2030 Agenda for Sustainable Development, there is increasing interest in access to and utilization of primary health care in low- and middle-income countries. A wide array of stakeholders, including development agencies, global health funders, policy planners and health system decision-makers, require a better understanding of primary health care systems in order to plan and support complex health system interventions. There is thus a need to fill the knowledge gaps concerning strategic information on front-line primary health care systems at national and subnational levels in low- and middle-income settings. The Alliance for Health Policy and Systems Research, in collaboration with the Bill & Melinda Gates Foundation, is developing a set of 20 case studies of primary health care systems in selected low- and middle-income countries as part of an initiative entitled Primary Care Systems Profiles and Performance (PRIMASYS). PRIMASYS aims to advance the science of primary health care in low- and middle-income countries in order to support efforts to strengthen primary health care systems and improve the implementation, effectiveness and efficiency of primary health care interventions worldwide. The PRIMASYS case studies cover key aspects of primary health care systems, including policy development and implementation, financing, integration of primary health care into comprehensive health systems, scope, quality and coverage 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. Furthermore, the case studies will serve as the basis for a multicountry analysis of primary health care systems, focusing on the implementation of policies and programmes, and the barriers to and facilitators of primary health care system reform. Evidence from the case studies and the multi-country analysis will in turn provide strategic evidence to enhance the performance and responsiveness of primary health care systems in low- and middle-income countries. 3 COMPREHENSIVE CASE STUDY FROM RWANDA 1. Introduction to Rwanda PRIMASYS case study The present case study provides a comprehensive, in-depth assessment of the national primary health care (PHC) system of Rwanda in order to understand the key entry points to strengthen PHC systems and foster the implementation and efficiency of health interventions. It covers key aspects of PHC systems in Rwanda, including policy development and implementation, human resources financing, quality of PHC, governance and organization, monitoring and evaluation of system performance, and important gaps in policy and research. The case study is commissioned by WHO and funded by the Alliance for Health Policy and Systems Research in collaboration with the Bill & Melinda Gates Foundation, working together with researchers from University of  Rwanda, College of Medicine and Health Sciences, School of Public Health, in partnership with the Rwandan Ministry of Health. 4 PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) 2. Methods The Rwanda case study used qualitative methods to achieve its objective. It was implemented in two phases: a desk review followed by key informant interviews with a wide range of stakeholders at national, regional and district levels. The desk review was done through an extensive analysis of documentation, including reports at national and global levels; national strategic documents, such as policies and strategic plans from official websites and documents from the Rwandan Ministry of Health; and research reports from affiliated agencies, research institutions, and bilateral and international organizations. In the second phase, key informant interviews were conducted with stakeholders purposively selected based on their current roles and positions in the health sector. Participating institutions included the Ministry of Health, public and private health facilities, referral and district hospitals, district health directorates, and development partners providing technical and financial support to the health sector in Rwanda. In addition, representatives of the Rwanda Social Security Board, Rwanda Health Insurers Association, and Rwanda Surgical Society were recruited, along with health system researchers. One mixed focus group discussion was also conducted with stakeholders and health experts, including Ministry of Health leadership, politicians, health authorities, health professionals, insurance specialists, representatives of development partner institutions and community organizations. Information on key informants who participated in this study is provided in Annex 1. Identified stakeholders were contacted by phone and an invitation was sent to them through their institutions. High-level key informants were contacted by email to schedule an appointment for interview, explain the rationale and objectives of the study. All interviews and meetings with stakeholders (including the focus group discussion) were conducted in English and digitally audio- recorded unless the participants did not consent to be recorded. Before each interview, participants were given an informed consent form asking for their permission to participate and to be recorded. Only participants who consented to voice recording were recorded; if they refused, the interviews were reported in writing. The PRIMASYS case study was approved by the Rwanda National Ethics Committee on 12 December 2017. All data from interviews and the stakeholder focus group discussion were summarized and transcribed using recordings and field notes by the research team. Summaries were analysed manually for content according to the conceptual framework underpinning the development of the PRIMASYS case studies. Main themes included PHC structure (governance, financing, and human resources), processes (policies, innovations, challenges, and recommendations), and outcomes (health service quality and accessibility). 5 COMPREHENSIVE CASE STUDY FROM RWANDA 3. Overview of Rwanda PHC system Rwanda is a landlocked East African country with a green, mountainous landscape. Its population is estimated at 12 089 720, with a density of 467 per square kilometre, making it one of the most densely populated countries in Africa (1). The Rwandan health sector has undergone a fundamental transition during the last century. Before the colonial period, health care consisted of traditional medicine using native African healing methods. During the German and later Belgian colonial period, faith-based health care emerged, accompanied by the introduction of modern medicine. In the second half of the 20th century, before the 1994 Genocide against the Tutsi, the Rwandan health system was characterized by a high degree of centralization and free provision of health services. During the Genocide, most of the infrastructure was destroyed and many of the health staff were killed or fled the country. Following the Genocide, during the transitional period 1994–2003, efforts were made to rebuild basic health care and human resources. After the transitional period, the health system entered a developmental phase through the introduction of strategic planning and major reforms. In 1990, the health system had a total of 34 hospitals, 186 health centres, 69 dispensaries, 179 private pharmacies and 17 private medical clinics. In terms of human resources, only 261 medical doctors were working in the public sector. There were also 23 pharmacists, 949 graduated nurses (A1, A2, and A3) and 240 auxiliaries (2). According to the Rwandan Demographic and Health Survey of 1992 (3), average life expectancy was 51 years; the under-5 mortality rate was 150 per 1000 live births; the infant mortality rate was 72 per 1000 live births; and the maternal mortality rate was 500 per 100 000 live births. The total fertility rate was 6.2, and the modern contraceptive rate was 13%. With regard to nutrition status, chronic malnutrition stood at 48%, with underweight at 29% and acute malnutrition at 4%. The proportion of attended deliveries in health facilities was 26%; the proportion of children aged 0–23 months that were fully immunized was 79%; and the rates of antenatal care visits were 94% (for one visit) and 12% (for four visits). 3.1 Transitional period: 1994–2003 An emergency plan for rehabilitation of the health system was prepared and implemented with the collaboration of government partners. A priority of the plan was to fill the enormous gap in human resources. In 1996, only 112 doctors were working in the public health sector, and only 742 nurses, 7 pharmacists and 77 laboratory technicians were operational. In order to fill the gap, the Faculty of Medicine of the National University of Rwanda reopened very quickly, along with 12 nursing schools. Another consequence of the 1994 Genocide was the significant impact on mental health; accordingly, a mental health service was established and a trauma centre was opened to handle the mental health issues generated by that tragedy. During the transitional period, a National Health Policy was developed. The policy was focused on the former region sanitaire, which was provided with the means to implement all health activities at regional level. However, several programmes and projects remained centralized and were operationalized from the central level. Between 2000 and 2003, a number of important reforms took place within the health system. One of the reforms was the establishment of the National AIDS Control Commission as an advocacy body to fight HIV/AIDS, including through resource mobilization and coordination of partners. Programmes on malaria, HIV/AIDS and tuberculosis were merged in the Centre for Treatment and 6 PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) Research on AIDS, Malaria, Tuberculosis and Other Epidemics (TRAC Plus), and resources were allocated to the prevention, treatment and control of those three major diseases. Another important innovation was the creation of the Central Procurement Agency for Essential Medicines in Rwanda (Central d’Achat des Medicaments Essentiels de Rwanda – CAMERWA), responsible for the procurement, storage and distribution of drugs and consumables for the public sector. In 2003, community-based health insurance was institutionalized and a health insurance policy developed. The related law was enacted in 2007. During this transitional period, the Government of Rwanda approved and started implementing a decentralization policy. The ensuing decentralization of health services started with the strengthening of district hospitals and health centres, promotion of community participation, development of human resources, and allocation of more resources to districts. 3.2 Development phase based on strategic planning and Economic Development and Poverty Reduction Strategy: 2005 to date Given the health status of Rwanda at that time, the period 2003–2005 was used to consider the priorities of the health sector. As provided in the Health Sector Policy, the priorities were defined in seven policy objectives: availability of human resources; availability of drugs, vaccines and consumables; geographical accessibility to health services; improvement of financial accessibility to health services; increase in the quality of and demand for services for disease control; strengthening the referral system and research; and institutional capacity strengthening. Since 2005, three Health Sector Strategic Plans (HSSPs) have been developed and implemented: HSSP I (2005–2009), HSSP II (2009–2012), and HSSP III (2013–2018) (4–6). They were developed in line with Rwanda Vision 2020, and Economic Development and Poverty Reduction Strategy I and II. The upcoming HSSP IV (2018–2024) builds on lessons learned and progress made during implementation of HSSP III, and is fully aligned with Rwanda Vision 2050 and the National Strategy for Transformation 2018–2019. It has been informed by global and regional development agendas that Rwanda has committed to, especially the Sustainable Development Goals. Strategic planning is evidence based, with baselines provided by various censuses and surveys. Targets are set in accordance with available means, and a monitoring and evaluation framework is in place (7). Table 1 provides key demographic, macroeconomic and health indicators for Rwanda; Table  2 presents information on the relevance of those indicators for improved provision of PHC. 7 COMPREHENSIVE CASE STUDY FROM RWANDA 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 classification) Neonatal illness (41%) Gynaeco-obstetrical complications (8%) Cardiovascular disease (8%) Acute respiratory diseases (8%) HIV/AIDS opportunistic infections (6%) Statistical yearbook, 2016 edition (9) 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 (including pneumococcal and rotavirus) 98% UNICEF/WHO, countdown to 2015 report (11, 12) Total health expenditure as proportion of GDP 15.5% (2012–2013) Health Financing Sustainability Policy, March 2015 PHC expenditure as % of total health expenditure 38.1% World Bank, Global Health Expenditure database, 2014 % total public sector expenditure on health care 9.9% World Bank, Global Health Expenditure database, 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 total expenditure on health 18% UNICEF/WHO, countdown to 2015 report (11, 12) Public expenditure on health as proportion of total expenditure on health Data not available Voluntary health insurance as proportion of total expenditure on health Data not available Proportion of households experiencing catastrophic health expenditure Data not available 8 PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) Table 2. Relevance of key demographic, macroeconomic and health indicators for improved provision of PHC Profile Summary Relevant area for PHC Source of information Demographic profile Population of 12 089 720 Densely populated, with high density of 467 per square kilometre Sex ratio is 92 males per 100 females Annual population growth rate of 2.6% Total fertility rate of 4.0 children per woman Population is mostly rural, at 67% Life expectancy of 64.5 years Promote informed policy formulation and decision- making Enable effective planning, monitoring, and evaluation of existing programmes related to health in general, and reproductive health in particular, at both the national and regional levels Helps in resource mobilization to respond to the needs of the population Informs equitable distribution of resources Facilitates decentralization of services as well as engagement of community in PHC activities Fourth Population and Housing Census, 2012. Thematic report: population projections Macroeconomic profile Rwanda’s economy has been growing steadily at about 8% per year since 2001, with GDP per capita increasing from US$ 211 in 2001 to US$ 720 in 2016 A mirror on how Rwanda is fulfilling its mission to provide sustainable growth and economic opportunities, and raise the living standards of all Rwandans within the vision of developing 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 Ministry of Finance and Economic Planning, Rwanda: annual report, 2016 Health profile Top five causes of mortality are neonatal illness, gynaeco-obstetrical complications, cardiovascular disease, respiratory diseases, and HIV/AIDS opportunistic infections Infant mortality rate is 31 per 1000 live births Under-5 mortality rate is 42 per 1000 live births. Maternal mortality rate is 210 per 100 000 live births Immunization coverage under 1 year is 98% Guides the design of preventive, curative, rehabilitative and promotive strategies Promotes measures to identify priority health problems Offers basis for allocation of appropriate resources to combat priority health problems, especially at the decentralized and primary level Demographic and Health Survey, 2014–2015 Population census, 2012 HSSP IV Rwanda is among the few countries to have achieved universal health coverage due to its vision of inclusiveness, equity, and comprehensive and integrated quality service delivery, with a focus on PHC. Rwanda’s health sector has made tremendous progress in improving the health status of the population. These improvements are mirrored by the improvements in access to health care services and utilization of those services. According to Rwanda annual health statistics, the PHC utilization rate increased from 0.81 to 1.43 visits per inhabitant from 2009 to 2016 (11, 12). According to data from the Integrated Household Living Conditions Survey 2013–2014, there was a significant increase in service utilization between 2005 and 2012, especially within the lowest socioeconomic category. The proportion of the population reporting an illness or accident who consulted a medical practitioner increased from 31% to 40%. These achievements are largely attributable to good governance and, on the demand side, to financial innovations, such as community-based health insurance and performance-based financing (9, 10). 9 COMPREHENSIVE CASE STUDY FROM RWANDA 4. Timeline The Rwandan health system has seen an improved performance in recent years, based on quality of care and decentralization of health care systems. Policies and programmes have been developed in an effort to respond to the population’s health care needs and to align the health system with the global health agenda (Figure 1). Figure 1. Relevant policies on the PHC system in Rwanda, by date 2015 • Health Sector Policy • Health Financing Sustainability Policy 2017 National Policy for Traditional Complementary and Alternative Medicine 2014 • National Food and Nutrition Policy • Human Resources for Health Policy 2012 • Rwanda Family Planning Policy • Medical Research Centre Policy 2011 • National Mental Health Policy 2010 • National Policy on Traditional Medicine • National Policy for Palliative Care • National Health Promotion Policy 2008 • Environmental Health Policy • Community Health Policy 2006 • Behaviour Change Communication Policy • Blood Transfusion Policy 2005 • National Policy for the Control of HIV • National Policy on TB and HIV 2006 • Health Financing Policy • National Pharmaceutical Policy 2005 • National Medical Laboratory Policy 2011 • National Adolescent Sexual and Reproductive Health and Rights Policy • Human Resources for Health Policy 2007 • National Policy on Health Quality Assurance • National Nutrition Policy 2009 National Policy for Child Health 2010 • National Health Insurance Policy • Community-Based Health Insurance Policy 2012 • Health Sector Research Policy • Health Sector Data Sharing and Confidentiality Policy • Pre-hospital Emergency Care: Policy and Legal Framework 2015 • Noncommunicable Diseases Policy • National Community Health Policy 2016 • National Pharmacy Policy 10 PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) 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 category Health system component Strength and achievements Areas for further improvement Structure Governance Decentralization of health services to the lower level (community health workers, health posts, health centres, district hospitals) Political will and commitment Well structured local government Collaboration with partners Sustained community health programme Community participation in management of health facilities Home-Based Care Practitioners Programme being piloted to provide noncommunicable disease (NCD) and palliative care services at community level Improved coverage of primary health facilities is needed in order to have a health centre per sector and health post per cell Health district: enforcing the decentralization of monitoring and supply of drugs Access to specialized services such as cardiology, nephrology, urology Review of service package of activities to include additional needs of the community (for NCDs, etc.) Financing mechanisms Poverty reduction strategies such as social protection programmes (Vision 2020 Umurenge Programme, Ubudehe) Pooling of resources in Rwanda improved over time Health insurance: compulsory contributions for civil servants (Rwanda Social Security Board), 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 Financial access: community-based health insurance heavily subsidized Sustainability mechanisms to be explored and implemented Need for financial management skills at peripheral health facilities Human resources Quality and quantity of human resources for health Training programmes Performance-based financing Need for additional human resources: specialists in different fields, general practitioners, nurses, midwives, allied health professionals, health care managers, replacement, training and refresher courses for community health workers Staff retention plan at all levels Private sector engagement 11 COMPREHENSIVE CASE STUDY FROM RWANDA Thematic category Health system component Strength and achievements Areas for further improvement Process Vision and policies Two new structures at community level, namely Home-Based Care Practitioners Programme at village level and health posts at cell level There are three types of health post: extension of health centres serving a permanent outreach site to 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 It is planned to have at least one health centre per sector and a health post per cell, expect for cells where there is already a health centre, by 2019. Resources are still being mobilized at district level and priority needs to be given to remote areas Planning and implementation Improve mechanisms for monitoring client 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) Continue private sector engagement in PHC Regulation of health care system Government will Accountability structure Monitoring and information systems Community health information system Daily incident flash reports from health facilities are newly introduced in the information system, including verbal autopsies Improvement of central- and local-level involvement in supervision of community health workers E-health system at all levels and for all packages Outcomes Accessibility of health care services People-centred services Access to the full package provided by health posts and health centres, mainly curative and preventive (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.) Geographical accessibility: need for health centre per sector and health post per cell Burden of environment-related disease Quality of health care services Accreditation process at all levels Quality audit of services Performance-based financing Roll-out accreditation process at all levels, especially health centres 12 PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) 6. Governance and structure of PHC in Rwanda The overall administrative head of the Rwanda health system is the Ministry of Health, which governs all health facilities, both public and private. In Rwanda, public health facilities represent 64% of the total number of non-private health facilities, with 28% run by faith-based organizations. Currently the system is organized in four levels (Figure 2) (13). Central level. The Ministry of Health has a mission to provide and continually improve affordable promotive, preventive, curative and rehabilitative health care services of the highest quality, thereby contributing to the reduction of poverty and enhancing the general well-being of the population. The following are core functions: • to develop, disseminate and coordinate the implementation of health policies, strategies and programmes; • to regulate the health sector; • to monitor and evaluate the implementation of policies, strategies and programmes of the health sector and related sectors; • to develop institutional and human resource capacities in the health sector; • to develop innovative health financing approaches for accessibility to quality health services; • to oversee the institutions under supervision; • to mobilize resources for the development of the health sector and related programmes; • to develop medical cooperation and coordinate health sector development partners. In order to oversee the implementation of policies, strategies and health-related programmes, the Rwanda Biomedical Centre was established in 2011 with the following functions (14): • to coordinate and follow up the implementation of programmes aiming at improving health pro- motion, disease prevention, diagnosis, treatment and care for communicable and noncommunica- ble diseases; • to coordinate health care technology manage- ment and engineering of infrastructure for all public health facilities in Rwanda; • to prevent and control epidemic diseases and other public health emergencies in Rwanda through the implementation of an effective and efficient national epidemiological surveillance and response system; • to contribute to efficiency promotion and finan- cial sustainability of the health sector through income-generating biomedical-related activities and research; • to establish and strengthen collaboration with local, regional and international institutions hav- ing related missions. National referral hospitals. There are five national referral and teaching hospitals whose mission is to provide specialized health service provision, undertake teaching in medical and health sciences schools, and conduct research in health-related fields. These are the King Faisal Hospital, Rwanda Military Hospital, Kigali University Teaching Hospital, Butare University Teaching Hospital and Ndera Neuropsychiatric Hospital. Intermediary level. The referral and provincial hospitals form an intermediary level of referral hospitals at the province level. Three referral and four provincial hospitals are being gradually upgraded to decrease the pressure of demand for services in the national referral hospitals. Peripheral level. This level is represented by an administrative office (district health unit), district hospital, and a network of health centres, health posts and community health workers. The district health unit is an administrative unit in charge of the provision of health services, and is responsible for planning, monitoring and supervision of the implementing agencies. It reports to the vice-mayor for social affairs. There are 36 district hospitals, 499 health centres at 13 COMPREHENSIVE CASE STUDY FROM RWANDA sector level, and around 45  516 community health workers serving the population at village level (7). In addition, Rwanda has a national blood transfusion service, national medical procuring and storing service, national referral laboratory, and health professional councils for supervising and monitoring professional practices. District hospitals District hospitals District hospitals District hospitalsTertiary hospitals 8 4 36 503 501 45 516 Province (5) District (30) Sector (416) Cell (2148) Village (14 837) • Specialized hospitals serving the entire country • Medical training National (~ 12 m) ~ 255 000 ~ 250 • Provide government-defined complementary package of activities (caesarean, treatment of complicated cases, etc.) • Provide care to patients referred by the primary health centres • Carry out planning activities for the health district and supervise district health personnel • Provide government-defined minimum package of activities at the peripheral level • This includes complete and integrated services such as 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 health centres • Established in areas that are far from health centres • Services include curative outpatient care, certain diagnostic tests, child immunization, growth monitoring for children under 5 years, antenatal consultation, family planning, and health education Community-based • Prevention, screening and treatment of malnutrition • Integrated management of child illness • Provision of family planning • Maternal and newborn health • HIV, tuberculosis, and other chronic illnesses • Behaviour change and communication District hospitals District hospitalsDistrict hospitalsHealth centres District hospitalsDistrict hospitalsHealth posts District hospitalsDistrict hospitals Community health workers (CHWs) 80% of burden of disease addressed at this level Administrative structure Health care delivery system No. of public facilities / CHWs Av. catchment area pop. Type of service offered Figure 2. Representation of the health care system of Rwanda Source: Ministry of Health (15). ~ 23 000 14 PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) 7. Hierarchy of health service provision in Rwanda The hierarchy of health service provision in Rwanda can be summarized as follows. At village level (14 837 villages) the following services are offered in the community: • prevention, screening and treatment of malnutrition • integrated management of child illness • provision of family planning • maternal and newborn health • HIV, tuberculosis and other major illnesses • behaviour change and communication. In addition to the classic community health workers, the Ministry of Health started the Home-Based Care Practitioners Programme in March 2017 in nine hospitals in nine districts, whereby 206 home-based care practitioners are working in their communities to deliver services in three components, as follows: Palliative care at community level: • providing basic nursing care among patients with end-of-life conditions • follow-up of all patients with life-limiting condi- tions, including NCDs • providing bereavement counselling to the family. NCD prevention: • screening of NCDs • raising awareness of prevention of NCDs • linking patients with NCDs to health facilities. Verbal autopsy: • conduct verbal autopsy • notification of deaths in civil registration and vital statistics system • data reporting • raising awareness of civil registration of vital events. At cell level (2148 cells) there are health posts with the following package of services: • PHC services including promotional, preventive and primary curative services • basic diagnostics with rapid testing • basic package of services for those areas that are far from health centres. At sector level (416 sectors) there are health centres providing the following services: • government-defined minimum package of activ- ities at the peripheral level; • complete, integrated services, such as cura- tive, preventive, promotional, and rehabilitation services; • supervision of health posts and community health workers operating in their catchment area. At district level (30 districts) there are 36 district hospitals, with the following services: • government-defined complementary package of activities (for example caesarean section, treat- ment of complicated cases); • provision of care to patients referred by the pri- mary health centres; • carrying out planned activities for the health dis- trict and supervision of district health personnel. At province level (4 provinces) the facilities provide the following package: • Gradually upgraded from secondary health care to specialized services to serve the population in the respective provinces. They provide the com- plementary package of activities and specialized care, including internal medicine, paediatrics, sur- gery, obstetrics and gynaecology. 15 COMPREHENSIVE CASE STUDY FROM RWANDA 8. Financing The Rwanda Vision 2020 (16) considers health finance accessibility as a key priority of its strategic direction. The current Health Financing Sustainability Policy is aligned with the Health Sector Policy 2015 (15) and the second Economic Development and Poverty Reduction Strategy (17), which aims to develop 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 universal financial access to quality health services in an equitable, efficient and sustainable manner. Figure 3 presents a diagrammatic representation of the architecture of health financing in Rwanda. This framework is built on two main pillars: (a) on the supply side, the implementation of fiscal decentralization with increased transfers from 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, increased use of health care services, decreased incidence of catastrophic health expenditures and decreased inequality in access to health care services. Progress has been facilitated by political commitment and development of a legal framework that made health insurance compulsory for all Rwandans in 2016. Table 4 provides information on existing health financing strategies. Table 4. Existing health financing strategies Risk pooling – health insurance Efficiency – value for money Increase of domestic resources Community-based health insurance: a risk pooling mechanism that is based on ability to pay Social health insurance: Rwanda Social Security Board: Rwanda Health Insurance Fund (for public servants) and Military Medical Insurance Voluntary health insurance: Corar, SORAS, Radiant, UAP, etc. Performance-based financing: links measurable indicators with financial incentives Decentralization: shifted job positions and related budget to the health facility level to improve the equitable distribution of health personnel towards rural areas Performance contract system (imihigo): implemented a system whereby commitments are made to deliver on key development projects Community health cooperatives, performance- based financing: transfers investments to village level, creates local development projects and provides sustainable resources for community health services Public, private and community partnerships (PPCPs): increased number of community health posts through PPCPs Self-sustaining health facilities: have begun establishing a self-sustaining health facility model Source: Ministry of Health (13). Figure 3. Architecture of Rwanda health financing Source: Ministry of Health (13). Risk pooling – health insurance Universal financial access to quality health services Effi ciency – value for m oney Risk pooling – health insurance Institutional environment for sustainable health financing and accountability Increase of dom estic resources 16 PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) Government spending on health has surpassed the 15% required under the Abuja Declaration, showing a high level of commitment to and support for health sector financing, within the limits of national resources. In the 2015/2016 fiscal year, the health sector accounted for 16.52% of total government spending (18). Risk pooling has been greatly improved as a result of the extension of community-based health insurance schemes, which give the majority of the population access to health care services and drugs. Social and private health insurance schemes now cover approximately 80% of the population. In 2015, Rwanda spent 11.2% of its GDP on the health sector, while total public sector expenditure on PHC was 9.9% in 2015. Health expenditure per capita was US$ 44.6 in 2015, and out-of-pocket expenditure as a proportion of total expenditure on health was 8.8% in 2015 (19). Funds for PHC come from government contributions, development partners, health insurance contributions, social solidarity funding and cross-subsidizing among the community. Table 5 presents a summary of health financing policy directives. Table 5. Health financing policy directives Policy element Objective Directives Efficiency – value for money Reduction of administrative costs, transaction costs and sharing management costs Apply electronic mechanisms in place of paper-based administration processes Improve efficiency of drug and other medical product supply chains 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- based financing and results-based financing Improve integration of performance-based financing and accreditation process to ensure more sustainable outputs and outcomes for health 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 insurance Strengthen health insurance and risk pooling systems Strengthen insurance schemes for universal health coverage, especially 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 resources Enhance strategies and interventions increasing domestic revenue for health, including community and private entities, to monetize available expertise Engage with the private sector in order to increase investment in health for both supply of health services (including development of hospitals, clinics, diagnostic centres, and education institutions) and demand for health services Create public–private partnerships for projects such as provision of medical 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). 17 COMPREHENSIVE CASE STUDY FROM RWANDA There is a Single Project Implementation Unit in the Ministry of Health, with the mandate of reducing the number of separate projects and the administrative burden of the Ministry of Health in managing and reporting on the various projects with off-budget resources. Funds flow into the Rwandan health sector from numerous sources and through many different channels. The systems of pooling, allocation and purchasing are complex, with potential for duplication of activities and inefficient administrative costs. There are numerous direct resource streams to district hospitals and health centres, including funds from the general government budget, donor support, insurance schemes and co-payments, as well as out-of-pocket payments from those not covered by insurance. Nevertheless, strategies and future reforms are needed to increase efficiency and create clearer value for money incentives for the different actors in the health financing system and to decrease transaction costs. Key challenges and gaps in health financing include the following: • disease burden, including the emerging problem of NCDs and associated higher costs of care, and the cost of sustaining progress in the manage- ment of infectious diseases, such as malaria; • resource generation, including the high depend- ency on external public financing with a projected decline of external funding, and the low contribu- tion of the private sector in health; • resource pooling, allocation and purchasing, including linkages between purchasing mecha- nisms (results-based financing), programmes and health system functions. 18 PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) 9. Human resources Human resources for health are viewed as the backbone of the Rwandan health system, as they consume the biggest share of the budget (35% of the total expenditure on health in 2015) and are responsible for managing other resources and running the health service system, as well as being a critical factor for health service development (20) (Figure 4). The general objective of the Human Resources for Health Programme is to ensure an equitable distribution of health personnel (especially to serve in rural areas) and to involve beneficiaries for citizen accountability (for example, through proximity management). The specific objectives are: • to strengthen the autonomy of facilities in the planning and management of all resources (client responsibility); • to strengthen the harmonization and integration of health personnel management; • to create a conducive framework for equitable dis- tribution of resources to rural areas. Recently, Rwanda has developed strategies and interventions to overcome shortages in human resources for health and to ensure the population has access to affordable quality health care. Socioeconomic planning Health planning Employment: – job analysis – job description – recruitment and selection – personnel records and databases – induction – distribution of personnel Retention and change: – career structure – promotion – grievance and dismissal – procedures – working and living conditions – reward system incentives Support: – forms of supervision – forms of communication and consultation – employer–employee relations and collective representation Development: – individual performance review Estimating supply and requirements Estimating numbers, categories, competencies, skills, attitudes Undergraduate education Postgraduate training Continuing education Health service development Health resource production Human resource planning Health resource management Figure 4. Human resources for health planning framework Source: Ministry of Health (20). 19 COMPREHENSIVE CASE STUDY FROM RWANDA As indicated by the HSSP IV (2018–2024) baseline figures (7), the doctor–population ratio (including general practitioners and specialists) is 1:10  055, the nurse–population ratio is 1:1094, and the midwife–population ratio (women aged 15–49 years) is 1:4064 (Table 6). Nevertheless, the shortage of human resources in the health sector is one of the biggest challenges facing the government. In order to fill the gaps, the government has invested significant resources in implementing pre- service training programmes and strengthening institutions. The Government of Rwanda, in collaboration with development partners, has initiated a human resources for health project that includes a postgraduate training programme for ensuring quality health care for patients at provincial and national referral hospitals. A Human Resources for Health Strategic Plan (2016–2021) is being implemented with a focus on innovative models of health training, increasing health personnel productivity, strengthening the capacity of employment, improving data management for decision-making, and mobilizing the necessary sustainable financing (20). Table 6. Human resources for health baseline and targets for HSSP IV Indicator output Baseline indicator value (2016/17) Indicator targets Means of verification Target 2020/21 Target 2023/24 Doctor–population ratio (including general practitioners and specialists) 1:10 055 1:9 000 1:7 000 Health professional bodies statistics, 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 (women aged 15–49 years) 1:4 064 1:3 500 1:2 500 Health professional bodies statistics, 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 ratio 1:10 500 1:9 000 1:7 500 Health professional bodies statistics, reports, annual statistical booklets Doctor attrition rate – > 10% > 5% Survey Source: Ministry of Health (7). 20 PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) 10. Quality of health care services in Rwanda Rwanda recognizes the right to quality health services in its national Constitution. The Ministry of Health is responsible for the quality and safety of health care services. In order to carry out this responsibility, the Ministry of Health assesses the needs of the population, sets priorities, and develops health care policy and strategies to meet the identified needs. The quality of health care services in Rwanda is continuously and regularly monitored through health facilities accreditation, performance-based financing and integrated supportive supervision. Performance-based financing is one of the pillars of health financing to strengthen the health system in Rwanda. This approach was introduced in order to strengthen the motivation of care providers and produce results (output) that traditional financing (for input) had not previously yielded. Performance- based financing started in 2002 as a pilot and has been integrated in the HSSP since 2005. Health facilities are evaluated twice a year (20). Health facility accreditation has been identified by the Government of Rwanda, through its Ministry of Health, as a priority strategy towards improving the quality and safety of health care, and creating a sus- tainable process for implementing and measuring achievement of standards. Notable progress has been recorded in improving the health outcomes of the population, and health is among the main priorities of the country’s political and development agenda and strategic development planning. With the same logic, the Ministry of Health has developed guidance doc- uments, including the National Policy for Quality and Accreditation, the National Strategy for Quality and Accreditation, and the Rwanda Hospital Accreditation Standards. All quality-related programmes are coordi- nated by the Health Services and Quality Assurance Division of the Ministry of Health. Some milestones in Rwanda’s journey in pursuit of quality health care services include the following. • In 1995, resolution AFR/RC45/R3 of the World Health Organization (WHO) Regional Committee for Africa urged Member States to establish qual- ity assurance programmes. • In 2006, the Ministry of Health introduced accredi- tation programmes in three hospitals – King Faisal Hospital, Butare University Teaching Hospital and Kigali University Teaching Hospital – using the Council for Health Service Accreditation of South- ern Africa to achieve accreditation. • Laboratory accreditation was launched in 2009, when Rwanda adopted the Strengthening Lab- oratory Management towards Accreditation programme of the WHO Regional Office for Africa. • In 2012, the Ministry of Health launched the National Health Care Accreditation System, with key documentation including the Rwanda Hos- pital Accreditation Standards, an accreditation performance assessment toolkit, and surveyor and facilitator manuals. In the same year, the Ministry of Health disseminated accreditation standards in all 42 hospitals, followed by a baseline assessment for all hospitals completed in 2013–2014. • In 2013, five new referral and provincial hospi- tals first enrolled in the accreditation programme, following which 37 other hospitals were also enrolled. • In 2013, the Ministry of Health resolved to link performance-based financing to accreditation in order to increase the effectiveness and efficiency of continuous quality improvement of health care services, enhance the performance-based financ- ing quality assessment tool using accreditation standards, harmonize assessment tools and teams (to have one tool and one team), use existing per- formance-based financing incentives to support continuous quality improvement, align indicators from different programmes with accreditation standards, and avoid duplication of efforts and resources. Performance progress assessments are carried out twice a year to measure compliance 21 COMPREHENSIVE CASE STUDY FROM RWANDA with quality-driven standards, followed by inte- grated supportive supervision coupled with data quality audit to reduce gaps identified during assessment (Figure 5). • Since 2013, there has been in-country capacity- building in quality improvement and accreditation by training accreditation surveyors and facilitators to enable both central-level organizations and hospitals to conduct self and external evaluation and facilitation. This has been supported by estab- lishment of an Accreditation Steering Committee and a Quality and Safety Technical Working Group, and of hospital accreditation support committees, enabling institutionalization of quality of care. Table 7 indicates supportive measures that have taken place at central and district levels. Performance contracts (imihigo). Each year performance contracts (including health targets) are signed between the President of Rwanda and local government institutions and line ministries. These bind respective institutions to targets they set for themselves. Performance indicators provide a clear framework to establish domestic accountability at a level directly relevant to citizens. Performance contracts are measured against an agreed set of governance, economic, health and social indicators known as performance indicators. Local authorities 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 evaluation tool • Administration • Health centre coaching, supportive supervision • Clinical activities • HIV • TB Accreditation assessment tool • Leadership • Workforce • Safe environment • Clinical care • Quality improvement Merge in one performance assessment tool 60% aligned • Leadership • Workforce • Safe environment • Clinical care • Quality improvement 40% not aligned • Health centre coaching • HIV • TB 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 Health Services and Quality Assurance Unit in the Ministry of Health Quality Standards Technical Working Group In-country capacity-building by training surveyors and facilitators at central and district levels Collaboration with district health units Establishment of district health management teams Quality and accreditation supportive committees at hospital level Quality assurance committee at health centre level 22 PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) District mayors utilize performance contracts (imihigo) with health facilities to encourage fulfilment of standards, with subsidies and financing contingent on performance. Health performance targets include indicators for declining morbidity and mortality associated with prevention and curative care, as well as access to care. Performance against indicators is monitored with quarterly evaluations and through analysis of results in annual reports. The system aims to: • ensure geographical and financial access to health care services (especially numbers of health posts); • establish and institutionalize a quality improve- ment (accreditation) mechanism or framework; • ensure access to safe surgical care in health facili- ties at secondary and tertiary levels; • strengthen the management of health care technology; • ensure availability of IT infrastructure to improve health services delivery; • support and sustain the cost of care for constant improvement of the health system (including access to quality treatment of cancer, kidney, car- diovascular disease, drug addiction and abuse); • improve pre-hospital and emergency services. 23 COMPREHENSIVE CASE STUDY FROM RWANDA 11. Regulatory processes 1 Official Gazette No. Special of 28/02/2015. The general mission of the Ministry of Health is to promote the health of the population through the delivery of preventive, curative and rehabilitative health services. Specifically, one of the core functions of the Ministry of Health is to regulate the health sector through (a) drafting and disseminating laws, regulations and instructions to promote health sector performance; (b) setting and disseminating standards applicable to the health sector; and (c) authorizing private health institutions.1 The Ministry of Health ensures regulation of the health sector in collaboration with the health professional councils – the Rwanda Medical and Dental Council, the Rwanda Nursing and Midwifery Council, the Rwanda Allied Health Professions Council, and the Rwanda Pharmacy Council. A number of codes and regulations have been put in place for health sector actors, for example the code for the allied health professions, the code of ethics for the pharmacy profession, and codes for the nursing profession. 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 Dental Council Established under Law No. 30/2001 of 12 June 2001, revised to Law No. 44/2012 of 14 January 2013. 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 Midwifery Council Established under Law No. 25/2008 of 25 July 2008. 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… 24 PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) The Ministry of Health adopted a national Traditional, Complementary and Alternative Medicine Policy in 2017 as a step towards regulation of this area, while a specific law regulating its practice is also in the pipeline (21). The Ministry of Health defines service packages at each level of the health system in Rwanda – from the community to university teaching hospitals – in terms of the types of services offered, the description and qualifications of staff that provide the services, and the infrastructure and equipment required to carry out the services. The health service packages support the clinical and managerial standards by which the health care facilities operate. The Ministry of Health also defines effective referral processes, linking each level of health care services to provide a smooth transition for the patients to navigate. There is an established mechanism for licensing private health facilities in close collaboration with district authorities and technical teams. Processes are summarized in the Citizen Service Charter of the Ministry of Health (22). The regulation of prices and tariffs for medical services in both the public and private sector is done periodically in collaboration with health insurance entities. The quality of health services is monitored via continuous supportive supervision at different levels, performance-based incentives, and an accreditation system that has been instigated at hospital level and will soon be implemented at health centre level as well. Decentralized governance structures such health committees or boards are also mandated to oversee the quality of services provided to citizens. Council Relevant information, including mission and functions Rwanda Allied Health Professions Council Established under Law No. 46/2012 of 14 January 2013 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/ Continued… 25 COMPREHENSIVE CASE STUDY FROM RWANDA 12. Monitoring and information systems The Ministry of Health requires that data management, validation and verification be conducted routinely after report submission. The routine data quality review is retrospectively conducted on all data submitted to the centralized Health Management Information System (HMIS) during the previous reporting period and any other reporting periods deemed necessary by the review team. The findings from the data validation and verification review must be submitted to the Ministry of Health within five working days after each review and discussed by the institution reviewed within two working days after the review (23). The main source of data is the HMIS. Data are recorded in health centres and hospitals on patient files, collated in registers, and then compiled monthly and transmitted to the centralized HMIS server on the fifth day of the reporting month. Other routine web-based information management solutions include the Integrated Disease Surveillance and Response system (which monitors a number of diseases, including HIV and tuberculosis), performance-based financing and data warehouse systems, and the Community Health Information System (SISCOM), which collects, stores, retrieves and disseminates critical programme and patient information related to care and treatment. Figure 6 shows how information flows between the entities involved in data collection. Data-driven decision-making and policy formulation have increased the efficiency of health programme management and enhanced the government’s capacity to monitor the quality of health care. Deployment of a centralized, web-based HMIS started in 2012 with the aim of simplifying data collection and improving the timeliness of reporting. All government institutions at central and local levels use the collected data to inform planning and budgeting. However, all levels should ensure appropriate infrastructure, skilled personnel and accountability. Routine health data are sent from health facilities and the community by data managers and community health workers. Reports are sent regularly (quarterly, monthly or weekly) or on a case-by-case basis through the web-based Rwandan HMIS. 26 PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) Central level HMIS unit Referral hospital Central level programmes and divisions RHMIS-DHIS-2 Cell level CHW supervisors Community Health centres Enter data Prepare paper reports Enter data Prepare paper reports Private clinics Enter data Prepare paper reports Mutuelle de Sante sections Routine DH health and CBHI data reports Figure 6. Data flows between Rwandan entities involved in data collection and dissemination Source: Ministry of Health (23). Feedback or direct data access Manual report transmission Electronic report transmission Prepare paper reports Enter data Routine health data and TB report Direct access – dashboards and reports Feedback & error reports Quarterly bulletins Annual statistical report Provincial & district hospitals Direct access – dashboards and reports Feedback & errors reports Quarterly bulletins Annual statistical reportMost at-risk populations & orphans and vulnerable children quarterly report Routine health, TB data reports Administrative district health units Monthly feedback Monthly feedback Monthly feedback Community health worker cooperatives Enter data Aggregate data from all cells Community- based health insurance weekly & monthly reports Monthly cell level SISCOM report Monthly cell level SISCOM report Direct access – dashboards and reports Prepare paper reports Monthly feedback SISCOM data reports Routine health data reports 27 COMPREHENSIVE CASE STUDY FROM RWANDA 13. Challenges, policy considerations and ways forward To maintain the progress made in PHC service provision, Rwanda will continue to place emphasis in certain areas: • ensure geographical and financial access to health care services (especially number of health posts); • establish and institutionalize the quality improve- ment (accreditation) mechanism and framework; • ensure access to safe surgical care in health facili- ties at secondary and tertiary levels; • strengthen the management of health care technology; • ensure availability of IT infrastructure to improve health services delivery; • support and sustain the cost of care for constant improvement of the health system (for example, access to quality treatment of cancer, kidney dis- ease, cardiovascular disease, drug addiction and abuse); • improve pre-hospital and emergency services; • promote community involvement in the health care system to reinforce community ownership; • improve contributions and feedback on quality of health services, and ensure the accountability of all involved actors; • promote data use to inform policy and decision- making; • increase the domestic budget for PHC (in response to the decrease in external funding) by improve- ments in pooling finances and risk to ensure affordable care; • accelerate development of e-health through the use of advanced technology and knowledge transformation to collect available data and suc- cess stories to inform future plans; • provide continuous support for human resources for health, and avail an adequate, skilled workforce by means of training and retention plans; • strengthen the community-based health insur- ance law to improve financial access to vulnerable groups (persons with disabilities, the homeless, mental health patients, the elderly); • revise the prices of health care services; • upgrade health services to meet the expectations of various population groups, and improve the referral system. 28 PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) 14. Conclusion The Rwandan health sector follows a decentralized system, with the health district as the basic operational unit of the system, supported by reinforcement of community participation in managing and financing health services. Consideration of all factors influencing the health care system worldwide, and in Rwanda particularly, is indispensable in planning, policy-making and evidence-based decision- making. These elements – including governance, financing and human resources, policy matters, regulatory measures, planning, and access to and quality of services – are discussed in this report to inform structure, process and outcomes. The document is thus a vital foundation for further actions, including health-related decision- making, planning and prioritization to address gaps, continuation of community engagement, accountability, strengthening of the district health system, reinforcing human resource cadres, and ensuring accessible quality health services. 29 COMPREHENSIVE CASE STUDY FROM RWANDA 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 of Kigali Head of Division for Clinical Services 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 Health Lecturer, Health System Researcher 17 Dr Evrare NAHIMANA Partners in Health (PIH) PHC Researcher 30 PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) References 1. 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Integrated Household Living Conditions Survey, 2013–2014. Kigali: Government of Rwanda; 2014. 11. Partnership for Maternal, Newborn and Child Health. 2010 countdown to 2015 decade report (2000–2010). Geneva: World Health Organization; 2010 (http://www.who.int/pmnch/topics/child/2010countdown_decadereport/en/, accessed 20 July 2018). 12. Victora CG, Requejo JH, Barros AJD, Berman P, Bhutta Z, Boerma T et al. Countdown to 2015: a decade of tracking progress for maternal, newborn, and child survival. Lancet. 2016;387(10032):2049–59. 13. Health Financing Sustainability Policy. Kigali: Government of Rwanda, Ministry of Health; 2015. 14. The Constitution of the Republic of Rwanda of 2003 revised in 2015: summary. Official Gazette No. Special of 24/12/2015. Kigali: Government of Rwanda (http://www.parliament.gov.rw/fileadmin/Bills_CD/THE_CONSTITUTION_OF_THE_REPUBLIC_OF_RWANDA_ OF_2003_REVISED_IN_2015.pdf, accessed 20 July 2018). 15. Health Sector Policy. Kigali: Government of Rwanda, Ministry of Health; 2015. 16. Ministry of Finance and Economic Planning of Rwanda. Rwanda Vision 2020. Kigali: Government of Rwanda, Ministry of Finance and Economic Planning; 2012. 17. Economic Development and Poverty Reduction Strategy II: 2013–2018. Kigali: Government of Rwanda, Ministry of Finance and Economic Planning; 2013 (http://www.moh.gov.rw/fileadmin/templates/Job/EDPRS_2_Abridged_Version.pdf, accessed 20 July 2018). 18. Mid term review of the Rwanda Third Health Sector Strategic Plan. Kigali: Government of Rwanda, Ministry of Health; 2015. 19. Rwanda Health Resource Tracker: draft output report, April 2012. Government of Rwanda, Ministry of Health; 2012 (http://www.moh.gov. rw/fileadmin/templates/MOH-Reports/Final_Draft_-_Health_Resource_Tracker_Output_Report.pdf, accessed 20 July 2018). 20. Human Resources for Health Strategic Plan 2016–2021. Kigali: Government of Rwanda, Ministry of Health; 2016. 21. National Policy of Traditional, Complementary and Alternative Medicine. Kigali: Government of Rwanda, Ministry of Health; 2017. 22. Citizen Service Charter for the Ministry of Health. Kigali: Government of Rwanda, Ministry of Health; 2017. 23. Procedures manual for the Rwanda Health Management Information System. Kigali: Government of Rwanda, Ministry of Health; 2013.

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. Avenue Appia 20 CH-1211 Genève 27 Switzerland alliancehpsr@who.int http://www.who.int/alliance-hpsr World Health Organization