PIEDRAS QUE CAEN DEL CIELO

Table 29. Baseline and targets for Health Infrastructure

EXPECTED OUTPUTS / OUTCOMES BASELINE 2011 TARGETS 2015 TARGETS 2018 % Adequate infrastructure in HF based on norms and standards

8 27 50

% DH with effective maintenance workshops

<5 50 80

Infrastructure systems include the fixed assets like buildings, as well as their control systems and software required to operate, manage, and monitor them. They also include communication facilities, plants and vehicles and other utilities.

The overall objective under HSSP III for infrastructure and maintenance is to:

 Improve access to functional health infrastructure and equipment that comply with international standards and norms:

 Develop maintenance systems;

 Strengthen relevant HRH capacity for infrastructure development and maintenance.

5.5.1 Improve access to a functional health infrastructure that complies with international standards

The availability and access to health services have greatly improved during HSSP II through constructing and equipping four district hospitals and five health centers. A developed network of public sector health facilities exists to meet the health needs of Rwanda’s population. This network is structured as a pyramid with four referral hospitals at the apex followed by 40 district hospitals and 450 health centers. Each district has at least one district hospital and an average of one health center per 20,000 populations. The initiation and implementation of community health services has increased outreach and brought health services closer to the people they serve. The referral system from community to health centers and from health centers to hospitals has greatly improved with PBF. In addition, the emergency medical assistance service (SAMU) is now fully operational in all districts with 154 ambulances (five ambulances in each district fitted with tracking systems as the standard requirement) and a call center managing the flow.

According to the Rwanda District Health System Strengthening Tool, a web-based database maintained by all of the districts with data on 465 health facilities, 19 percent of health centers and 2 percent of district hospitals had no access to power in 2009, a figure that has been decreased to 15 percent of health centers and 0 percent of district hospitals in 2010. HSSP III will endeavor to bring power to the remaining health centers by installation of solar power where HFs are not part of the power grid. Even where HFs are connected to the power grid, back-up will be installed in the form of generators.

Despite these achievements, around 5 percent of the sectors (20 / 416) remained without a HC. Approximately 23 percent of the population is estimated to live more than 5 kilometers from the nearest HF, while on average the population needs one hour to visit the HF (Integrated Household Living Conditions Survey [EICV], 2010). Furthermore, the minimum package of services provided at different

levels has been expanded from time to time without requisite infrastructural expansion. Other challenges include lack of or insufficient diagnostic equipment and standardized medical equipment.

During HSSP III, emphasis will be given to (1) developing and operationalizing health infrastructure standards, norms, and guidelines in line with international standards and (2) using a central procurement system for medical equipment to ensure harmonized and standardized medical equipment procurement. In addition to provision of equipment, each health facility will be provided with appropriate transportation, energy source (grid / generator), adequate water supply and drainage systems, appropriate sewage disposal system, and a good solid waste and hazardous waste management system. They will also be equipped with an appropriate communications infrastructure (telephone, Internet, or both).

A health map will be prepared to guide infrastructure investment. Completion of ongoing construction and equipping of health facilities will be done, as well as construction of an additional two new hospitals (Nyabikenke and Rutare) and 15 new health centers. An inspection team will periodically assess the state of both public and private health facilities, including their equipment. HFs will be virtually linked with telephone, Internet, and video networks to enable long-distance support from higher levels of expertise.

5.5.2 Develop a maintenance system

The maintenance of medical equipment has been complicated by various factors, including the absence of a HF maintenance tracking system, lack of adherence to national equipment donation standards by DPs, NGOs, and other actors, as well as by health facilities. Inadequate funding for equipment maintenance at facility levels is complicated by the absence of a separate budget line for this activity. To address these challenges, focus during HSSP III will be on preparing and implementing a physical infrastructure development and maintenance plan, as well as the establishment of a procurement and maintenance plan for medical and energy equipment. In this regard, ten maintenance workshops (two in each province) will be constructed and provided with appropriate tools and equipment. A national quality control system for the main equipment office will be established, and all managers will be sensitized on maintenance. A maintenance fund will be created in the budget for the health sector. This budget will be decentralized to allow each DH to have a budget line for medical equipment maintenance. Central procurement of spare parts for equipment will form an integral part of medical equipment investment in HSSP III. To facilitate maintenance of physical assets, including medical and transport equipment, the MOH will explore a greater role in maintenance on the part of the private sector.

5.5.3 Develop the technical capacity of HR

A curriculum for biomedical technicians has been developed and training has already started to reduce the skills gap in the maintenance area. In addition, efforts are ongoing to strengthen support by technicians from district hospitals to health centers. However, there is inadequate number of biomedical engineers to staff the maintenance units. Skills for biomedical technicians remain limited. More specifically, there is lack of specialized training on equipment that needs special skills, such as radiographic units. The HR capacity development needs for infrastructure and maintenance will be determined and appropriate investment integrated into the overall health sector human resources plan. To ensure adherence to the Medical Equipment Policy during HSSP III, the necessary biomedical engineers and biomedical technicians will be trained, ensuring that at least 70 percent of all maintenance staff will be trained by end of HSSP III.