Rethinking how development assistance for health can catalyse progress on primary health care

Global campaigns to control HIV, tuberculosis, malaria, and vaccine-preventable illnesses showed that large-scale impact can be achieved by using additional international financing to support selected, evidence-based, high-impact investment areas and to catalyse domestic resource mobilisation. Building on this paradigm, we make the case for targeting additional international funding for selected high-impact investments in primary health care. We have identified and costed a set of concrete, evidence-based investments that donors could support, which would be expected to have major impacts at an affordable cost. These investments are in: (1) individuals and communities empowered to engage in health decision making, (2) a new model of people-centred primary care, and (3) next generation community health workers. These three areas would be supported by strengthening two cross-cutting elements of national systems. The first is the digital tools and data that support facility, district, and national managers to improve processes, quality of care, and accountability across primary health care. The second is the educational, training, and supervisory systems needed to improve the quality of care. We estimate that with an additional international investment of between US$1·87 billion in a low-investment scenario and $3·85 billion in a high-investment scenario annually over the next 3 years, the international community could support the scale-up of this evidence-based package of investments in the 59 low-income and middle-income countries that are eligible for external financing from the World Bank Group's International Development Association.

Punching above their weight: a network to understand broader determinants of increasing life expectancy

Background

Life expectancy initially improves rapidly with economic development but then tails off. Yet, at any level of economic development, some countries do better, and some worse, than expected – they either punch above or below their weight. Why this is the case has been previously researched but no full explanation of the complexity of this phenomenon is available.

New research network

In order to advance understanding, the newly formed Punching Above Their Weight Research Network has developed a model to frame future research. It provides for consideration of the following influences within a country: political and institutional context and history; economic and social policies; scope for democratic participation; extent of health promoting policies affecting socio-economic inequities; gender roles and power dynamics; the extent of civil society activity and disease burdens.

Conclusion

Further research using this framework has considerable potential to advance effective policies to advance health and equity.

Exogenous factors matter when interpreting the results of an impact evaluation: a case study of rainfall and child health programme intervention in Rwanda

OBJECTIVE

Public health interventions are often implemented at large scale, and their evaluation seems to be difficult because they are usually multiple and their pathways to effect are complex and subject to modification by contextual factors. We assessed whether controlling for rainfall-related variables altered estimates of the efficacy of a health programme in rural Rwanda and have a quantifiable effect on an intervention evaluation outcomes.

METHODS

We conducted a retrospective quasi-experimental study using previously collected cross-sectional data from the 2005 and 2010 Rwanda Demographic and Health Surveys (DHS), 2010 DHS oversampled data, monthly rainfall data collected from meteorological stations over the same period, and modelled output of long-term rainfall averages, soil moisture, and rain water run-off. Difference-in-difference models were used.

RESULTS

Rainfall factors confounded the PIH intervention impact evaluation. When we adjusted our estimates of programme effect by controlling for a variety of rainfall variables, several effectiveness estimates changed by 10% or more. The analyses that did not adjust for rainfall-related variables underestimated the intervention effect on the prevalence of ARI by 14.3%, fever by 52.4% and stunting by 10.2%. Conversely, the unadjusted analysis overestimated the intervention's effect on diarrhoea by 56.5% and wasting by 80%.

CONCLUSION

Rainfall-related patterns have a quantifiable effect on programme evaluation results and highlighted the importance and complexity of controlling for contextual factors in quasi-experimental design evaluations.

Impact of a district-wide health center strengthening intervention on healthcare utilization in rural Rwanda: Use of interrupted time series analysis

Background

Evaluations of health systems strengthening (HSS) interventions using observational data are rarely used for causal inference due to limited data availability. Routinely collected national data allow use of quasi-experimental designs such as interrupted time series (ITS). Rwanda has invested in a robust electronic health management information system (HMIS) that captures monthly healthcare utilization data. We used ITS to evaluate impact of an HSS intervention to improve primary health care facility readiness on health service utilization in two rural districts of Rwanda.

Methods

We used controlled ITS analysis to compare changes in healthcare utilization at health centers (HC) that received the intervention (n = 13) to propensity score matched non-intervention health centers in Rwanda (n = 86) from January 2008 to December 2012. HC support included infrastructure renovation, salary support, medical equipment, referral network strengthening, and clinical training. Baseline quarterly mean outpatient visit rates and population density were used to model propensity scores. The intervention began in May 2010 and was implemented over a twelve-month period. We used monthly healthcare utilization data from the national Rwandan HMIS to study changes in the (1) number of facility deliveries per 10,000 women, (2) number of referrals for high risk pregnancy per 100,000 women, and (3) the number of outpatient visits performed per 1,000 catchment population.

Results

PHIT HC experienced significantly higher monthly delivery rates post-HSS during the April-June season than comparison (3.19/10,000, 95% CI: [0.27, 6.10]). In 2010, this represented a 13% relative increase, and in 2011, this represented a 23% relative increase. The post-HSS change in monthly rate of high-risk pregnancies referred increased slightly in intervention compared to control HC (0.03/10,000, 95% CI: [-0.007, 0.06]). There was a small immediate post-HSS increase in outpatient visit rates in intervention compared to control HC (6.64/1,000, 95% CI: [-13.52, 26.81]).

Conclusion

We failed to find strong evidence of post-HSS increases in outpatient visit rates or referral rates at health centers, which could be explained by small sample size and high baseline nation-wide health service coverage. However, our findings demonstrate that high quality routinely collected health facility data combined with ITS can be used for rigorous policy evaluation in resource-limited settings.

Rainfall variation and child health: effect of rainfall on diarrhea among under 5 children in Rwanda, 2010

Background

Diarrhea among children under 5 years of age has long been a major public health concern. Previous studies have suggested an association between rainfall and diarrhea. Here, we examined the association between Rwandan rainfall patterns and childhood diarrhea and the impact of household sanitation variables on this relationship.

Methods

We derived a series of rain-related variables in Rwanda based on daily rainfall measurements and hydrological models built from daily precipitation measurements collected between 2009 and 2011. Using these data and the 2010 Rwanda Demographic and Health Survey database, we measured the association between total monthly rainfall, monthly rainfall intensity, runoff water and anomalous rainfall and the occurrence of diarrhea in children under 5 years of age.

Results

Among the 8601 children under 5 years of age included in the survey, 13.2 % reported having diarrhea within the 2 weeks prior to the survey. We found that higher levels of runoff were protective against diarrhea compared to low levels among children who lived in households with unimproved toilet facilities (OR = 0.54, 95 % CI: [0.34, 0.87] for moderate runoff and OR = 0.50, 95 % CI: [0.29, 0.86] for high runoff) but had no impact among children in household with improved toilets.

Conclusion

Our finding that children in households with unimproved toilets were less likely to report diarrhea during periods of high runoff highlights the vulnerabilities of those living without adequate sanitation to the negative health impacts of environmental events.

The effect of performance-based financing on illness, care-seeking and treatment among children: an impact evaluation in Rwanda

Background

Performance-based financing (PBF) strategies are promoted as a supply-side, results-based financing mechanism to improve primary health care. This study estimated the effects of Rwanda’s PBF program on less-incentivized child health services and examined the differential program impact by household poverty.

Methods

Districts were allocated to intervention and comparison for PBF implementation in Rwanda. Using Demographic Health Survey data from 2005 to 2007–08, a community-level panel dataset of 5781 children less than 5 years of age from intervention and comparison districts was created. The impacts of PBF on reported childhood illness, facility care-seeking, and treatment received were estimated using a difference-in-differences model with community fixed effects. An interaction term between poverty and the program was estimated to identify the differential effect of PBF among children from poorer families.

Results

There was no measurable difference in estimated probability of reporting illness with diarrhea, fever or acute respiratory infections between the intervention and comparison groups. Seeking care at a facility for these illnesses increased over time, however no differential effect by PBF was seen. The estimated effect of PBF on receipt of treatment for poor children is 45 percentage points higher (p = 0.047) compared to the non-poor children seeking care for diarrhea or fever.

Conclusions

PBF, a supply-side incentive program, improved the quality of treatment received by poor children conditional on patients seeking care, but it did not impact the propensity to seek care. These findings provide additional evidence that PBF incentivizes the critical role staff play in assuring quality services, but does little to influence consumer demand for these services. Efforts to improve child health need to address both supply and demand, with additional attention to barriers due to poverty if equity in service use is a concern.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-015-1033-7) contains supplementary material, which is available to authorized users.

Toward a Systematic Approach to Generating Demand for Voluntary Medical Male Circumcision: Insights and Results From Field Studies

By the end of 2014, an estimated 8.5 million men had undergone voluntary medical male circumcision (VMMC) for HIV prevention in 14 priority countries in eastern and southern Africa, representing more than 40% of the global target. However, demand, especially among men most at risk for HIV infection, remains a barrier to realizing the program's full scale and potential impact. We analyzed current demand generation interventions for VMMC by reviewing the available literature and reporting on field visits to programs in 7 priority countries. We present our findings and recommendations using a framework with 4 components: insight development; intervention design; implementation and coordination to achieve scale; and measurement, learning, and evaluation. Most program strategies lacked comprehensive insight development; formative research usually comprised general acceptability studies. Demand generation interventions varied across the countries, from advocacy with community leaders and community mobilization to use of interpersonal communication, mid- and mass media, and new technologies. Some shortcomings in intervention design included using general instead of tailored messaging, focusing solely on the HIV preventive benefits of VMMC, and rolling out individual interventions to address specific barriers rather than a holistic package. Interventions have often been scaled-up without first being evaluated for effectiveness and cost-effectiveness. We recommend national programs create coordinated demand generation interventions, based on insights from multiple disciplines, tailored to the needs and aspirations of defined subsets of the target population, rather than focused exclusively on HIV prevention goals. Programs should implement a comprehensive intervention package with multiple messages and channels, strengthened through continuous monitoring. These insights may be broadly applicable to other programs where voluntary behavior change is essential to achieving public health benefits.

Motivations and Constraints to Family Planning: A Qualitative Study in Rwanda's Southern Kayonza District

Community members and health workers recognized the value of spacing and limiting births but a variety of traditional and gender norms constrain their use of contraception. Limited method choice, persistent side effects, transportation fees, stock-outs, long wait times, and hidden service costs also inhibit contraceptive use.

Background:

While Rwanda has achieved impressive gains in contraceptive coverage, unmet need for family planning is high, and barriers to accessing quality reproductive health services remain. Few studies in Rwanda have qualitatively investigated factors that contribute to family planning use, barriers to care, and quality of services from the community perspective.

Methods:

We undertook a qualitative study of community perceptions of reproductive health and family planning in Rwanda’s southern Kayonza district, which has the country’s highest total fertility rate. From October 2011 to December 2012, we conducted interviews with randomly selected male and female community members (n = 96), community health workers (n = 48), and health facility nurses (n = 15), representing all 8 health centers’ catchment areas in the overall catchment area of the district’s Rwinkwavu Hospital. We then carried out a directed content analysis to identify key themes and triangulate findings across methods and informant groups.

Results:

Key themes emerged across interviews surrounding: (1) fertility beliefs: participants recognized the benefits of family planning but often desired larger families for cultural and historical reasons; (2) social pressures and gender roles: young and unmarried women faced significant stigma and husbands exerted decision-making power, but many husbands did not have a good understanding of family planning because they perceived it as a woman’s matter; (3) barriers to accessing high-quality services: out-of-pocket costs, stock-outs, limited method choice, and long waiting times but short consultations at facilities were common complaints; (4) side effects: poor management and rumors and fears of side effects affected contraceptive use. These themes recurred throughout many participant narratives and influenced reproductive health decision making, including enrollment and retention in family planning programs.

Conclusions:

As Rwanda continues to refine its family planning policies and programs, it will be critical to address community perceptions around fertility and desired family size, health worker shortages, and stock-outs, as well as to engage men and boys, improve training and mentorship of health workers to provide quality services, and clarify and enforce national policies about payment for services at the local level.

Toward utilization of data for program management and evaluation: quality assessment of five years of health management information system data in Rwanda

BACKGROUND

Health data can be useful for effective service delivery, decision making, and evaluating existing programs in order to maintain high quality of healthcare. Studies have shown variability in data quality from national health management information systems (HMISs) in sub-Saharan Africa which threatens utility of these data as a tool to improve health systems. The purpose of this study is to assess the quality of Rwanda's HMIS data over a 5-year period.

METHODS

The World Health Organization (WHO) data quality report card framework was used to assess the quality of HMIS data captured from 2008 to 2012 and is a census of all 495 publicly funded health facilities in Rwanda. Factors assessed included completeness and internal consistency of 10 indicators selected based on WHO recommendations and priority areas for the Rwanda national health sector. Completeness was measured as percentage of non-missing reports. Consistency was measured as the absence of extreme outliers, internal consistency between related indicators, and consistency of indicators over time. These assessments were done at the district and national level.

RESULTS

Nationally, the average monthly district reporting completeness rate was 98% across 10 key indicators from 2008 to 2012. Completeness of indicator data increased over time: 2008, 88%; 2009, 91%; 2010, 89%; 2011, 90%; and 2012, 95% (p<0.0001). Comparing 2011 and 2012 health events to the mean of the three preceding years, service output increased from 3% (2011) to 9% (2012). Eighty-three percent of districts reported ratios between related indicators (ANC/DTP1, DTP1/DTP3) consistent with HMIS national ratios. Conclusion and policy implications: Our findings suggest that HMIS data quality in Rwanda has been improving over time. We recommend maintaining these assessments to identify remaining gaps in data quality and that results are shared publicly to support increased use of HMIS data.

Low risk of attrition among adults on antiretroviral therapy in the Rwandan national program: a retrospective cohort analysis of 6, 12, and 18 month outcomes

Background

We report levels and determinants of attrition in Rwanda, one of the few African countries with universal ART access.

Methods

We analyzed data abstracted from health facility records of a nationally representative sample of adults [≥18 years] who initiated ART 6, 12, and 18 months prior to data collection; and collected facility characteristics with a health facility assessment questionnaire. Weighted proportions and rates of attrition [loss to follow-up or death] were calculated, and patient- and health facility-level factors associated with attrition examined using Cox proportional hazard models.

Results

1678 adults initiated ART 6, 12 and 18 months prior to data collection, with 1508 person-years [PY] on ART. Attrition was 6.8% [95% confidence interval [CI] 6.0-7.8]: 2.9% [2.4-3.5] recorded deaths and 3.9% [3.4-4.5] lost to follow-up. Population attrition rate was 7.5/100PY [6.1-9.3]. Adjusted hazard ratio [aHR] for attrition was 4.2 [3.0-5.7] among adults enrolled from in-patient wards [vs 2.2 [1.6-3.0] from PMTCT, ref: VCT]. Compared to adults who initiated ART 18 months earlier, aHR for adults who initiated ART 12 and 6 months earlier was 1.8 [1.3-2.5] and 1.3 [0.9-1.9] respectively. Male aHR was 1.4 [1.0-1.8]. AHR of adults enrolled at urban health facilities was 1.4 [1.1-1.8, ref: rural health facilities]. AHR for adults with CD4+ ≥200 cells/μL vs <200 cells/μL was 0.8 [0.6-1.0]; and adults attending facilities with performance-based financing since 2004–2006 [vs. 2007–2008] had aHR 0.8 [0.6-0.9].

Conclusions

Attrition was low in the Rwandan national program. The above patient and facility correlates of attrition can be the focus of interventions to sustain high retention.

Approaches to ensuring and improving quality in the context of health system strengthening: a cross-site analysis of the five African Health Initiative Partnership programs

BACKGROUND

Integrated into the work in health systems strengthening (HSS) is a growing focus on the importance of ensuring quality of the services delivered and systems which support them. Understanding how to define and measure quality in the different key World Health Organization building blocks is critical to providing the information needed to address gaps and identify models for replication.

DESCRIPTION OF APPROACHES

We describe the approaches to defining and improving quality across the five country programs funded through the Doris Duke Charitable Foundation African Health Initiative. While each program has independently developed and implemented country-specific approaches to strengthening health systems, they all included quality of services and systems as a core principle. We describe the differences and similarities across the programs in defining and improving quality as an embedded process essential for HSS to achieve the goal of improved population health. The programs measured quality across most or all of the six WHO building blocks, with specific areas of overlap in improving quality falling into four main categories: 1) defining and measuring quality; 2) ensuring data quality, and building capacity for data use for decision making and response to quality measurements; 3) strengthened supportive supervision and/or mentoring; and 4) operational research to understand the factors associated with observed variation in quality.

CONCLUSIONS

Learning the value and challenges of these approaches to measuring and improving quality across the key components of HSS as the projects continue their work will help inform similar efforts both now and in the future to ensure quality across the critical components of a health system and the impact on population health.

Comprehensive and integrated district health systems strengthening: the Rwanda Population Health Implementation and Training (PHIT) Partnership

Background

Nationally, health in Rwanda has been improving since 2000, with considerable improvement since 2005. Despite improvements, rural areas continue to lag behind urban sectors with regard to key health outcomes. Partners In Health (PIH) has been supporting the Rwanda Ministry of Health (MOH) in two rural districts in Rwanda since 2005. Since 2009, the MOH and PIH have spearheaded a health systems strengthening (HSS) intervention in these districts as part of the Rwanda Population Health Implementation and Training (PHIT) Partnership. The partnership is guided by the belief that HSS interventions should be comprehensive, integrated, responsive to local conditions, and address health care access, cost, and quality. The PHIT Partnership represents a collaboration between the MOH and PIH, with support from the National University of Rwanda School of Public Health, the National Institute of Statistics, Harvard Medical School, and Brigham and Women’s Hospital.

Description of intervention

The PHIT Partnership’s health systems support aligns with the World Health Organization’s six health systems building blocks. HSS activities focus across all levels of the health system — community, health center, hospital, and district leadership — to improve health care access, quality, delivery, and health outcomes. Interventions are concentrated on three main areas: targeted support for health facilities, quality improvement initiatives, and a strengthened network of community health workers.

Evaluation design

The impact of activities will be assessed using population-level outcomes data collected through oversampling of the demographic and health survey (DHS) in the intervention districts. The overall impact evaluation is complemented by an analysis of trends in facility health care utilization. A comprehensive costing project captures the total expenditures and financial inputs of the health care system to determine the cost of systems improvement. Targeted evaluations and operational research pieces focus on specific programmatic components, supported by partnership-supported work to build in-country research capacity.

Discussion

Building on early successes, the work of the Rwanda PHIT Partnership approach to HSS has already seen noticeable increases in facility capacity and quality of care. The rigorous planned evaluation of the Partnership’s HSS activities will contribute to global knowledge about intervention methodology, cost, and population health impact.

Utilizing community health worker data for program management and evaluation: systems for data quality assessments and baseline results from Rwanda

Community health workers (CHWs) have and continue to play a pivotal role in health services delivery in many resource-constrained environments. The data routinely generated through these programs are increasingly relied upon for providing information for program management, evaluation and quality assurance. However, there are few published results on the quality of CHW-generated data, and what information exists suggests quality is low. An ongoing challenge is the lack of routine systems for CHW data quality assessments (DQAs). In this paper, we describe a system developed for CHW DQAs and results of the first formal assessment in southern Kayonza, Rwanda, May-June 2011. We discuss considerations for other programs interested in adopting such systems. While the results identified gaps in the current data quality, the assessment also identified opportunities for strengthening the data to ensure suitable levels of quality for use in management and evaluation.

High levels of adherence and viral suppression in a nationally representative sample of HIV-infected adults on antiretroviral therapy for 6, 12 and 18 months in Rwanda

Background

Generalizable data are needed on the magnitude and determinants of adherence and virological suppression among patients on antiretroviral therapy (ART) in Africa.

Methods

We conducted a cross-sectional survey with chart abstraction, patient interviews and site assessments in a nationally representative sample of adults on ART for 6, 12 and 18 months at 20 sites in Rwanda. Adherence was assessed using 3- and 30-day patient recall. A systematically selected sub-sample had viral load (VL) measurements. Multivariable logistic regression examined predictors of non-perfect (<100%) 30-day adherence and detectable VL (>40 copies/ml).

Results

Overall, 1,417 adults were interviewed and 837 had VL measures. Ninety-four percent and 78% reported perfect adherence for the last 3 and 30 days, respectively. Eighty-three percent had undetectable VL. In adjusted models, characteristics independently associated with higher odds of non-perfect 30-day adherence were: being on ART for 18 months (vs. 6 months); younger age; reporting severe (vs. no or few) side effects in the prior 30 days; having no documentation of CD4 cell count at ART initiation (vs. having a CD4 cell count of <200 cells/µL); alcohol use; and attending sites which initiated ART services in 2003–2004 and 2005 (vs. 2006–2007); sites with ≥600 (vs. <600 patients) on ART; or sites with peer educators. Participation in an association for people living with HIV/AIDS; and receiving care at sites which regularly conduct home-visits were independently associated with lower odds of non-adherence. Higher odds of having a detectable VL were observed among patients at sites with peer educators. Being female; participating in an association for PLWHA; and using a reminder tool were independently associated with lower odds of having detectable VL.

Conclusions

High levels of adherence and viral suppression were observed in the Rwandan national ART program, and associated with potentially modifiable factors.

An equity analysis of performance-based financing in Rwanda: are services reaching the poorest women?

Maternal health services continue to favour the wealthiest in lower and middle income countries. Debate about the potential of performance-based financing (PBF) to address these disparities continues. As PBF is adopted by countries, it is critical to understand the equity effects for maternal services. The aim of this study is to examine the effects of PBF on equity in maternal health service use when no specific provisions target the poorest in the population. In Rwanda, PBF was designed to increase health service use, which was universally low. Paired districts were randomly assigned to intervention and control for PBF implementation. Using Rwanda's Demographic Health Survey data from 2005 (pre-intervention) and 2007-8 (post-intervention), a cluster-level panel dataset of 7899 women 15-49 years of age from intervention (4477) and control districts (3422) was created. The impact of PBF on reported use of facility deliveries, antenatal care (ANC) and modern contraceptive use was estimated using a difference-in-differences model with community fixed effects. Interaction terms between wealth quintiles and PBF were estimated to identify the differential effect of PBF among poorer women. The probability of a facility delivery increased by 10 percentage points in the intervention when compared with the control districts (P = 0.014), while no significant effects were noted for ANC visits or modern contraceptive use. Service use increased for intervention and control populations and across all wealth quintiles from 2005 to 2007, with no evidence that PBF was a pro-poor or a pro-rich strategy. Insurance remained a positive predictor of service use. This research suggests that if service use is uniformly low then a PBF programme that incentivizes select services, such as facility deliveries, may improve service use overall. However, if the equity gap is extreme, then a PBF programme without equity targets will do little to alleviate disparities.

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

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.

Towards universal health coverage: an evaluation of Rwanda Mutuelles in its first eight years

BACKGROUND

Mutuelles is a community-based health insurance program, established since 1999 by the Government of Rwanda as a key component of the national health strategy on providing universal health care. The objective of the study was to evaluate the impact of Mutuelles on achieving universal coverage of medical services and financial risk protection in its first eight years of implementation.

METHODS AND FINDINGS

We conducted a quantitative impact evaluation of Mutuelles between 2000 and 2008 using nationally-representative surveys. At the national and provincial levels, we traced the evolution of Mutuelles coverage and its impact on child and maternal care coverage from 2000 to 2008, as well as household catastrophic health payments from 2000 to 2006. At the individual level, we investigated the impact of Mutuelles' coverage on enrollees' medical care utilization using logistic regression. We focused on three target populations: the general population, under-five children, and women with delivery. At the household level, we used logistic regression to study the relationship between Mutuelles coverage and the probability of incurring catastrophic health spending. The main limitation was that due to insufficient data, we are not able to study the impact of Mutuelles on health outcomes, such as child and maternal mortalities, directly. The findings show that Mutuelles improved medical care utilization and protected households from catastrophic health spending. Among Mutuelles enrollees, those in the poorest expenditure quintile had a significantly lower rate of utilization and higher rate of catastrophic health spending. The findings are robust to various estimation methods and datasets.

CONCLUSIONS

Rwanda's experience suggests that community-based health insurance schemes can be effective tools for achieving universal health coverage even in the poorest settings. We suggest a future study on how eliminating Mutuelles copayments for the poorest will improve their healthcare utilization, lower their catastrophic health spending, and affect the finances of health care providers.

Effect on maternal and child health services in Rwanda of payment to primary health-care providers for performance: an impact evaluation

BACKGROUND

Evidence about the best methods with which to accelerate progress towards achieving the Millennium Development Goals is urgently needed. We assessed the effect of performance-based payment of health-care providers (payment for performance; P4P) on use and quality of child and maternal care services in health-care facilities in Rwanda.

METHODS

166 facilities were randomly assigned at the district level either to begin P4P funding between June, 2006, and October, 2006 (intervention group; n=80), or to continue with the traditional input-based funding until 23 months after study baseline (control group; n=86). Randomisation was done by coin toss. We surveyed facilities and 2158 households at baseline and after 23 months. The main outcome measures were prenatal care visits and institutional deliveries, quality of prenatal care, and child preventive care visits and immunisation. We isolated the incentive effect from the resource effect by increasing comparison facilities' input-based budgets by the average P4P payments made to the treatment facilities. We estimated a multivariate regression specification of the difference-in-difference model in which an individual's outcome is regressed against a dummy variable, indicating whether the facility received P4P that year, a facility-fixed effect, a year indicator, and a series of individual and household characteristics.

FINDINGS

Our model estimated that facilities in the intervention group had a 23% increase in the number of institutional deliveries and increases in the number of preventive care visits by children aged 23 months or younger (56%) and aged between 24 months and 59 months (132%). No improvements were seen in the number of women completing four prenatal care visits or of children receiving full immunisation schedules. We also estimate an increase of 0·157 standard deviations (95% CI 0·026-0·289) in prenatal quality as measured by compliance with Rwandan prenatal care clinical practice guidelines.

INTERPRETATION

The P4P scheme in Rwanda had the greatest effect on those services that had the highest payment rates and needed the least effort from the service provider. P4P financial performance incentives can improve both the use and quality of maternal and child health services, and could be a useful intervention to accelerate progress towards Millennium Development Goals for maternal and child health.

FUNDING

World Bank's Bank-Netherlands Partnership Program and Spanish Impact Evaluation Fund, the British Economic and Social Research Council, Government of Rwanda, and Global Development Network.

Effect of applying a treatment threshold in a population. An example of pulmonary tuberculosis in Rwanda

PURPOSE

Clinicians often think treatment thresholds should be adapted to the setting. We intended to explore the effect in terms of harm because of false negatives and true and false positives of the application of a treatment threshold for pulmonary tuberculosis from a patient's perspective at different prevalence levels in a developing country.

METHODS

In a cohort of 300 patients with chronic cough, we estimated the prevalence of pulmonary tuberculosis, and the sensitivity and specificity of key predictors with latent class analysis (LCA). We computed the post-test probability of individual patients based on these data. With disease- and treatment-related mortality and morbidity, and without cost or regret, we calculated the break-even point of disease probability where treating versus not treating resulted in similar total harm from the patient's perspective. We estimated the total harm of applying this threshold to the cohort, and to hypothetical settings with different disease prevalence.

RESULTS

The threshold was computed at 0.026, suggesting treatment for all patients of the cohort. Hypothetically lowering the prevalence showed that the lowest total harm in the cohort always coincides with this threshold, but that numbers of treated patients drop considerably.

CONCLUSION

For pulmonary tuberculosis a decision threshold solely based on utilities without cost or regret leads to a very low threshold. The lowest total harm is found always at this disease probability, irrespective of the distribution of the patients. Although these findings might suggest an excess prescription at reference level, this is not the case in settings with lower prevalence.

Weighing harm in therapeutic decisions of smear-negative pulmonary tuberculosis

PURPOSE

To relate the intuitive weight of harm by commission and harm by omission in therapeutic decisions for pulmonary tuberculosis, and to compare it with a weight based on probabilities.

METHODS

Clinicians were asked for an estimation of probabilities related with the outcome of treated and nontreated pulmonary tuberculosis and for the toll of wrong decisions. Three ratios of the weight of forgoing a treatment in false-negative patients against the weight of treating false-positives were calculated. The first was based on intuitive estimations, whereas the second and third were based on calculated, either through intuitive estimations of probabilities or through literature data. The association between experience and the difference between the intuitive and the calculated ratios was assessed.

RESULTS

Eighty-one participants from Ecuador, Laos, Nepal, and Rwanda responded. The ratio of intuitive weights was 2.0 (interquartile range [IQR], 1.0-4.0) and the ratio of calculated weights based on intuitive probabilities was 64 (IQR, 25.0-169.6; P < 0.001). The ratio of calculated weight based on literature probabilities was 30 (IQR, 17.9-59.2). No association (R(2) = 0.03) was found between experience and accuracy in estimating the weight of errors.

CONCLUSION

The weight of a false negative is more important than the weight of a false positive for therapeutic decisions in pulmonary tuberculosis. The ratio of the intuitively estimated weights was much lower than the calculation based on intuitively estimated influencing factors. Clinicians were accurate in estimating probabilities but failed to incorporate them into therapeutic decisions.

Why are clinicians reluctant to treat smear-negative tuberculosis? An inquiry about treatment thresholds in Rwanda

PURPOSE

The diagnosis of tuberculosis remains controversial between clinicians and public health officers. Public health officials fear to treat too many patients; clinicians fear that truly diseased will be denied treatment. We wondered whether an analysis of the treatment threshold could help making the often intuitive decision to treat smear-negative cases more evidence based.

METHODS

Eighteen clinicians and 10 public health specialists were asked for an intuitive estimate of their treatment threshold for tuberculosis and of key determinant factors for this threshold: the magnitude and subjective weight of mortality and morbidity due to both the disease and the treatment and risk and cost of the latter. With these factors, the authors calculated treatment thresholds and compared them to the intuitive thresholds of the interviewees. A prescriptive threshold was calculated based on literature data, omitting cost and subjective factors.

RESULTS

The median overall intuitive treatment threshold was 52.5%, the calculated 11.9%, and the prescriptive 2.7%. For 2 factors, public health officers provided significantly lower values than clinicians: cost of treatment (median = 20 dollars v. 300 dollars; U = 2.5; P = 0.0002); cost of life (median = 500 dollars v. 5000 dollars; U = 17.5; P = 0.009).

CONCLUSION

These results suggest that clinicians and public health officers estimate wrongly the threshold even when using their own subjective estimate of influencing factors. Omitting treatment cost and subjective weight of provoked harm can result in a very low threshold. Sound training in threshold principles and providing tools to correctly assess data might help in making better decisions in tuberculosis in developing countries.

Results of a national survey on drug resistance among pulmonary tuberculosis patients in Rwanda

BACKGROUND

One of the principal objectives of tuberculosis (TB) control is to minimise the emergence of drug resistance. The first national survey was conducted in Rwanda to determine the prevalence of M. tuberculosis drug resistance.

METHODS

Sputum samples were collected from all new and retreatment cases in the health districts from November 2004 to February 2005. Drug susceptibility testing of isolates against first-line drugs was performed by the proportion method.

RESULTS

Of 616 strains from new cases, 6.2% were resistant to isoniazid, 3.9% to rifampicin and 3.9% were multidrug-resistant TB. Among 85 strains from previously treated cases, the prevalence of resistance was respectively 10.6%, 10.6% and 9.4% (MDR-TB strains). Eight MDR cases showed additional resistance to ethambutol and streptomycin.

CONCLUSION

The level of MDR-TB among TB patients in Rwanda is high. The main reasons of this emergence of MDR-TB can be attributed to the disorganisation of the health system, migration of the population during the 1994 civil war and poor success rates, with a high number of patients transferred out and lost to follow-up. On the other hand, the use of treatment regimens administered twice weekly during the continuation phase could be another important factor and merit further investigations.

Preparing for microbicide trials in Rwanda: focus group discussions with Rwandan women and men

The acceptability and feasibility of microbicide studies and future microbicide use are influenced by existing norms and values regarding sexual and contraceptive behaviour. In preparation for microbicide research in Rwanda, focus group discussions were conducted to assess sexual and contraceptive behaviour, preferences for vaginal lubrication, and hypothetical acceptability of microbicides among Rwandan women and men. Seven focus group discussions were conducted among sexually active married women, unmarried women, sex workers, female students, older women and men living in Kigali, Rwanda, and an additional group of women living in a rural area. The results indicate that condom use is low among Rwandan men and women and that condoms are mainly used by men during commercial sex. Women have limited power to negotiate condom or family planning use. Vaginal hygiene practices are very common and consist primarily of washing with water. Lubrication during sex is highly preferred by both men and women. Hypothetical microbicide acceptability after an explanation of what microbicides are and a demonstration with lubricant jelly was high.