DEL “BIG BANG” AL UNIVERSO INFLACIONARIO.

Table 38. Baseline and targets for the Referral System

EXPECTED OUTPUTS / OUTCOMES BASELINE 2011 TARGETS 2015 TARGETS 2018 # Ground ambulances/district 5/DH catchment 5/DH catchment 6/DH catchment % HF with effective ambulance

maintenance plans

40% 80% 100%

The country has established a well-functioning referral and counter referral system, starting from the community to health centers, and from health centers to hospitals. CHWs have been trained to treat common conditions and identify cases that need to be taken to the health post or health center. Community-level ―Smart SMS‖ by CHWs has helped to link the demand (community emergencies) with supply side (the health centers and ambulatory services). A training program is being developed to ensure that all health workers are skilled in pre-hospital (emergency) care during their pre-service training.

From the health center, patients with pathologies that cannot be handled at the primary care level are referred to the district hospital. This geographic access is further enhanced through the Pre-Hospital Care Services (PHCS, also known as SAMU, for Service d’Aide Médicale d’Urgence). This service is now fully operational in all districts with 168 ambulances (five ambulances per district as per standard, all fitted with a tracking system) and a call center managing the flow. SAMU staff, together with DH staff working in emergency departments, underwent periodic advanced life-support trainings in various emergency fields.

6.4.1 Referral systems strategy to upgrade five hospitals

According to the MOH referral systems strategy, five district hospitals will be upgraded to the provincial level to diminish the burden placed on referral hospitals by the high demand from district hospitals. At all levels, the transfer to a higher-level institution has to be approved by the competent health staff of the referring health facility.

This referral system is reinforced by the non-reimbursement of costs by the CBHI system, if patients do not respect the rules. The referral hospitals therefore do receive mainly serious (referred) cases that cannot be treated elsewhere. This triage system appears effective, even in the capital, Kigali.

6.4.2 Current challenges to the referral system and SAMU

The following challenges are the main ones limiting the functioning of the referral system as a whole and, more specifically, of the Pre-Hospital Care Services:

 Inadequate attention to ambulance maintenance by district hospitals;

 Insufficient number of ambulances, and some are not well equipped, especially in DHs;

 Concentration of policy, regulation, control, and operational functions in the maintenance unit; lack of a legal framework for SAMU;

 Several medical emergencies do not reach health facilities on time;  Poor equipment and need of upgrading the 912 call center.;

 Lack of sufficiently trained staff for SAMU and emergency care providers;  Lack of sufficient anesthesia technicians;

 Lack of emergency teams in provinces outside Kigali;

 Lack of infrastructure for SAMU services: drug and equipment storage, training room.

6.4.3 Strategies and interventions to strengthen emergency medical services

The following priority strategies and key interventions will strengthen emergency medical services. 1. Leadership and governance

 Define Pre-Hospital Care Services National Policy and legal framework;

 Define regulation framework (related PHCS policies, procedures, and guidelines);  Establish an operational framework (implementation, M&E);

 Update the guidelines in order to strengthen the referral system;  Improve compliance on referral system guidelines;

2. Quality Pre-Hospital Care Services delivery and customer care:  Increase number of skilled staff (regulation and operational);  Recruit nurses and anesthetist technicians;

 Recruit communication operators;

 Improve the school curriculum for pre-service training;

 Strengthen capacity-building by trainings (clinical and supporting staff);  Emergency simulation exercises with different emergency providers;

 Strengthen SAMU staff skills through local, regional, and international courses. 3. Infrastructures and equipment:

 Construct modern emergency medical services call center and SAMU HQ;  Acquire new communication equipment to upgrade 912 call center;

 Make available sufficient pre-hospital and emergency medicines and equipment;  Put in place standards for pre-hospital equipment, with maintenance plan;  Install four offices of PHCS (one in each province).

4. Strengthening medic transport:

 Review ground ambulance distribution/HF criteria (rational deployment);  Review ambulance deployment plan/management (with emphasis on HCs);  Purchase new ambulances;

 Set up air ambulance;

 Strengthen deployment of ambulance boats in Kivu Lake;  Review PHC services tariffs.

5. Reimbursement procedures:

 Put in place appropriate reimbursement mechanism for both public and private entities. 6. Procurement process:

C

7.

HSSPIIIC

4:G

Overall Objective of Component 3:

Strengthen the Health Sector Governance mechanisms (decentralization, partnership, aid effectiveness, and financial management) to ensure optimal performance of the health sub-programs.

Governance refers to ―strategic policy frameworks that are combined with effective oversight, coalition building, regulation, attention to system design, and accountability‖ and ―the provision of appropriate regulations and incentives.‖ Related to this definition is the question: What are the main objectives of governance in the health sector? WHO distinguishes five objectives that are discussed in different sections of this document, as follows:

1. Regulation and legal frameworks: discussed in Section 7.1;

2. Standards and quality assurance (including M&E): presented in Chapters 5 and 8; 3. Internal and external coordination: presented in this chapter;

4. Voice and participation: presented in several places under the Imihigo system; 5. Efficiency and effectiveness: discussed under Health Financing in section 3.3.6.

Closely related to Governance is the issue of decentralization, which is discussed in Section 7.1.