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Systems approach to monitoring and evaluation guides scale up of the Standard Days Method of family planning in Rwanda

Igras, S., Sinai, I., Mukabatsinda, M., et al. , Eds.: Global Health: Science and Practice, (2014)

There is no guarantee that a successful pilot program introducing a reproductive health innovation can also be expanded successfully to the national or regional level, because the scaling-up process is complex and multilayered. This article describes how a successful pilot program to integrate the Standard Days Method (SDM) of family planning into existing Ministry of Health services was scaled up nationally in Rwanda. Much of the success of the scale-up effort was due to systematic use of monitoring and evaluation (M&E) data from several sources to make midcourse corrections. Four lessons learned illustrate this crucially important approach. First, ongoing M&E data showed that provider training protocols and client materials that worked in the pilot phase did not work at scale; therefore, we simplified these materials to support integration into the national program. Second, triangulation of ongoing monitoring data with national health facility and population-based surveys revealed serious problems in supply chain mechanisms that affected SDM (and the accompanying CycleBeads client tool) availability and use; new procedures for ordering supplies and monitoring stockouts were instituted at the facility level. Third, supervision reports and special studies revealed that providers were imposing unnecessary medical barriers to SDM use; refresher training and revised supervision protocols improved provider practices. Finally, informal environmental scans, stakeholder interviews, and key events timelines identified shifting political and health policy environments that influenced scale-up outcomes; ongoing advocacy efforts are addressing these issues. The SDM scale-up experience in Rwanda confirms the importance of monitoring and evaluating programmatic efforts continuously, using a variety of data sources, to improve program outcomes.

Rwanda’s evolving community health worker system: a qualitative assessment of client and provider perspectives

Condo J, et al., Eds.: Human Resources for Health, (2014)

This study highlights the challenges and areas in need of improvement as perceived by CHWs and beneficiaries, in regards to a nationwide scale-up of CHW interventions in a resource-challenged country. Identifying and understanding these barriers, and addressing them accordingly, particularly within the context of performance-based financing, will serve to strengthen the current CHW system and provide key guidance for the continuing evolution of the CHW system in Rwanda.

Plausible role for CHW peer support groups in increasing care-seeking in an integrated community case management project in Rwanda: a mixed methods evaluation

Langston, A., Weiss, J., Landegger, J., et al. , Eds.: Global Health: Science and Practice, (2014)

The Kabeho Mwana project (2006–2011) supported the Rwanda Ministry of Health (MOH) in scaling up integrated community case management (iCCM) of childhood illness in 6 of Rwanda’s 30 districts. The project trained and equipped community health workers (CHWs) according to national guidelines. In project districts, Kabeho Mwana staff also trained CHWs to conduct household-level health promotion and established supervision and reporting mechanisms through CHW peer support groups (PSGs) and quality improvement systems. The iCCM model implemented by Kabeho Mwana resulted in greater improvements in care-seeking than those seen in the rest of the country. Intensive monitoring, collaborative supervision, community mobilization, and CHW PSGs contributed to this success. The PSGs were a unique contribution of the project, playing a critical role in improving care-seeking in project districts. Effective implementation of iCCM should therefore include CHW management and social support mechanisms. Finally, re-analysis of national survey data improved evaluation findings by providing impact estimates.

Pathways to progress: a multi-level approach to strengthening health systems

Samuels, F., Amaya, A.B., Rodríguez Pose, R. and Balabanova, D., Eds.: Overseas Development Institute, (2014)

Findings on maternal and child health in Nepal, Mozambique and Rwanda, and neglected tropical diseases in Cambodia and Sierra Leone | This report synthesises findings from five country case studies from the health dimension of this project, which focus on maternal and child health (MCH) (Mozambique,Nepal, Rwanda) and neglected tropical diseases (NTDs)(Cambodia, Sierra Leone). MCH was selected given its centrality in two of the Millennium Development Goals (MDGs) and its ability to act as a proxy for strengthened health systems. NTDs, while until recently relatively neglected in global policy debates, are now attracting more interest, not least because they are viewed as diseases of the poor whose treatment could positively impact on most of the other MDGs.

Impact of health systems strengthening on coverage of maternal health services in Rwanda, 2000–2010: a systematic review

Maurice Bucagu, Jean M. Kagubare, Paulin Basinga, Fidèle Ngabo, Barbara K Timmons & Angela C Lee, Eds.: Reproductive Health Matters, (2012)

From 2000 to 2010, Rwanda implemented comprehensive health sector reforms to strengthen the public health system, with the aim of reducing maternal and newborn deaths in line with Millennium Development Goal 5, among many other improvements in national health. Based on a systematic review of the literature, national policy documents and three Demographic & Health Surveys (2000, 2005 and 2010), this paper describes the reforms and the policies they were based on, and provides data on the extent of Rwanda’s progress in expanding the coverage of four key women’s health services. Progress took place in 2000–2005 and became more rapid after 2006, mostly in rural areas, when the national facility-based childbirth policy, performance-based financing, and community-based health insurance were scaled up. Between 2006 and 2010, the following increases in coverage took place as compared to 2000–2005, particularly in rural areas, where most poor women live: births with skilled attendance (77% increase vs. 26%), institutional delivery (146% increase vs. 8%), and contraceptive prevalence (351% increase vs. 150%). The primary factors in these improvements were increases in the health workforce and their skills, performance-based financing, community-based health insurance, and better leadership and governance. Further research is needed to determine the impact of these changes on health outcomes in women and children.

Identifying characteristics associated with performing recommended practices in maternal and newborn care among health facilities in Rwanda: a cross-sectional study

Sipsma, H.L., Curry, L.A., Kakoma, J.P., Linnander, E.L., & Bradley, E.H., Eds.: Human Resources for Health, (2012)

This study examined the quality of facility-based maternal and newborn health care by describing the implementation of recommended practices for maternal and newborn care among health care facilities to determine whether increased training, supervision, and incentives for health workers were associated with implementing these recommended practices.

Using Performance Incentives to Improve Health Outcomes

Gertler, P. & Vermeersch, C., Eds.: The World Bank, (2012)

Policy Research Working Paper 6100 | Impact Evaluation Series No. 60 | This study examines the effect of performance incentives for health care providers to provide more and higher quality care in Rwanda on child health outcomes. The authors find that the incentives had a large and significant effect on the weight-for-age of children 0–11 months and on the height-for-age of children 24–49 months. They attribute this improvement to increases in the use and quality of prenatal and postnatal care. Consistent with theory, They find larger effects of incentives on services where monetary rewards and the marginal return to effort are higher. The also find that incentives reduced the gap between provider knowledge and practice of appropriate clinical procedures by 20 percent, implying a large gain in efficiency. Finally, they find evidence of a strong complementarity between performance incentives and provider skill .

Workplace violence and gender discrimination in Rwanda’s health workforce: Increasing safety and gender equality

Newman, C.J., de Vries, D.H., Kanakuze, J., et al. , Eds.: Human Resources for Health, (2011)

This article reexamines a set of study findings that directly relate to the influence of gender on workplace violence, synthesizes these findings with other research from Rwanda, and examines the subsequent impact of the study on Rwanda’s policy environment.

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