LA GALAXIA ENANA DE SAGITARIO

Table 36. Baseline and targets for District Health Services

EXPECTED OUTPUTS / OUTCOMES BASELINE

2011

TARGETS 2015

TARGETS 2018

% HF with electricity / water 56 / 66 80 / 80 95/98

% Functional DHMT in all districts (based on TOR)

NA 100 100

# of health Facilities (DH, RH) under accreditation and on trach as planned

0 13 45

% HF using clinical protocols 0 80 100

The health infrastructure in Rwanda is a three-tiered system in the public sector composed of a large network of health facilities. In this document, the term health facility (HF) refers to health institutions offering health care services (not including dispensaries, who report through health centers). As of March 2012, there were 495 nonprivate health facilities in Rwanda (see Table 2). Public health facilities represent 64 percent of the total number of health facilities in Rwanda; of the remaining HFs, 28 percent are run by faith-based organizations (FBOs), referred to as “Agréé”, 1 percent are parastatal; an

estimated 5 percent are private; and 2 percent are run by communities.

6.2.1 District Health Services status and accomplishments

The initiation and implementation of community services has taken the health service closer to the community. This is further enhanced by bringing the qualified health staff from district hospitals to health centers at least once a month on pre-arranged and notified visits. The establishment of a quasi-universal (89% coverage) system of Community-Based Health Insurance has largely contributed to the improved accessibility to health care services.

For each level of health facility, a standard package of services has been established ensuring the availability of minimum requirement of human resources, equipment, drugs, and commodities. The procurement and distribution system has been decentralized through a network of district pharmacies to bring the supply of medical products closer to the service delivery level. To motivate health care providers to offer quality services to the population, a Performance-Based Financing system has been put in place, and local leaders are accountable to fulfill their commitments through Imihigo contracts.

The MOH has produced various protocols, guidelines, and standards for quality health services. Notable examples are the financial management procedures manual for HF, the standard operating procedures for health management information systems, and the district health system guidelines, which clarify the organizational structure for district health services. But some documents need updating (for example, new guidelines for provincial or regional hospitals as an intermediary referral level between district hospitals and tertiary hospitals, and as training centers).

A District Health Unit (DHU) and DHMT have recently been put in place to coordinate the different actors of the health sector at the decentralized level (DH, HC, NGOs, DPs, and community-based interventions), to clarify and allocate the tasks of the different actors, and ensure an adequate integration of the multidimensional determinants of the health status of the population. (An organization chart of the DHMT and DHU appears in Annex 3.)

Another area of focus is ensuring that all health facilities have access to electricity and water during HSSP III. Furthermore, a curriculum for biomedical technicians has been developed (training has already started) to reduce the skills gap in the area of equipment maintenance. Efforts are ongoing to strengthen the mobility of the technicians from DHs to health centers.

6.2.2 District Health Services challenges

Even with the impressive achievements described above, there are areas that require further work. These challenges include:

1. HR management

 Human resources are insufficient in quality and quantity.  There is high turnover of qualified staff and of local authorities.

 There is an inadequate number of biomedical engineers (for the maintenance unit) and limited skills among the biomedical technicians.

2. Infrastructure and equipment

 It still takes more than an hour for 27 percent of the population to reach the closest health facility (<5km). Around 51 out of 416 sectors (12%) are still without a HC.

 The budget for decentralized infrastructures is insufficient, causing poor quality building materials.

 Fifteen percent of health centers still have no electric power.  There is a disparity of communication resources (Internet).

 The minimum package of services provided at different levels has been expanded from time to time without a concomitant infrastructural expansion.

 There is inadequate dissemination of protocols and guidelines.

 Detailed norms and standards for infrastructure and equipment, including maintenance, are lacking.

 Many districts don’t have appropriate infrastructure for their pharmacies. 3. Equipment

 Procurement of medical equipment is not adequately standardized, which causes disparate medical equipment brands within hospitals.

 Inadequate funding for equipment maintenance at facility levels is exacerbated by the lack of a separate budget line for this activity.

 Specialized training on equipment that requires special skills (i.e., radiographic units) is lacking.

4. Regarding DHU and DHMT coordination with all actors, there is a lack of:  Supportive supervision from the district;

 Health coordination at the operational level (district);  Collaboration with the private sector.

6.2.3 District Health Services strategies and interventions

To respond to these and other challenges in the District Health Services provision and management, a number of priority strategies and key interventions have been identified in the following areas:

1. HR management

 Increase number of clinical and support staff

 Reinforce implementation of retention strategies from the central level to the district level  Strengthen performance management system (CPD)

2. Infrastructure and equipment

 Increase the number of health facilities and renovate the existing ones  Provide the inventory of the existing equipment and conduct need assessment  Development of national quality control system for the main equipment  Provide standardized equipment and strengthen their maintenance system  Ensure extension of infrastructure (HCs)

 Recruit and train biomedical engineers and biomedical technical staff.

 Support local educational institute at Kigali Institute of Science and Technology and KHI to develop and improve a specific curricula for biomedical technicians.

 Construct maintenance workshops at the provincial level.

 Create a decentralized procurement and maintenance unit in each DH.  Train hospital managers.

 Acquire tools and equipment needed for maintenance. 3. Drugs and medical supply chain

 Create a decentralized procurement office in each DH (see infrastructure/equipment strategy above).

4. Transport (supervision and supplies)  Provide sufficient means of transport  Maintain existing means of transport 5. Data collection and ICT tools

 Harmonize data collection tools and provide electronic data management system  Assure data quality system (training, monitoring and evaluation)

 Include data from private practitioners. 6. DHU and DHMT coordination with all actors

 Put in place the DHU and DHMT team to coordinate health services delivery  Strengthen leadership in district hospitals.

 Strengthen integration of health system at all levels  Define roles / resp. for district coordination