| Table of contents |
Contents ......................................................................................................................................................iii
Tables and Figures ......................................................................................................................................ix
Preface ......................................................................................................................................................xiii
Acknowledgements....................................................................................................................................xv
Key Findings and Recommendations .......................................................................................................xvii
Abbreviations..........................................................................................................................................xxiii
Chapter 1 Survey Methodology
1.1 Overview................................................................................................................... 1
1.2 Institutional Framework and Objectives of the Study............................................... 1
1.3 Data Collection Instruments...................................................................................... 1
1.4 Sample....................................................................................................................... 2
1.4.1 Sample of Facilities .................................................................................. 2
1.4.2 Sample of Health Service Providers ......................................................... 3
1.4.3 Sample for Observations........................................................................... 5
1.5 Study Implementation ............................................................................................... 6
1.5.1 Training and Supervision of Data Collectors............................................ 6
1.5.2 Methods for Data Collection..................................................................... 6
1.5.3 Data Analysis............................................................................................ 6
1.6 Process for Data Management and Report Writing .................................................. 7
Chapter 2 Overview of the Health System in Rwanda
2.1 General Organization of the Health System.............................................................. 9
2.2 Overview of Operating Authorities for Health Services........................................... 9
2.2.1 Public Sector............................................................................................. 9
2.2.2 Government-assisted Health Facilities ................................................... 10
2.2.3 Private Sector.......................................................................................... 10
2.2.4 Traditional Medicine............................................................................... 11
2.3 Geographic Distribution and Populations Served by Health Facilities................... 11
2.4 Package of Health Services..................................................................................... 11
2.4.1 Minimum Package of Activities for the Peripheral Level ...................... 12
2.4.2 Complementary Package of Activities for District Hospitals................. 12
2.4.3 Complementary Package of Activities for National Referral
Hospitals ................................................................................................. 13
2.5 Progress in Implementing the Minimum Package of Activities and the
Complementary Package of Activities.................................................................... 13
2.6 Use of Curative Consultation Services ................................................................... 14
iv CONTENTS
2.7 Issues Related to Quality of Care............................................................................ 14
2.8 Supervision.............................................................................................................. 14
2.9 System of Supply and Distribution of Medications ................................................ 15
2.10 Availability of Human Resources ........................................................................... 15
2.11 Basic Qualifications for Health Personnel .............................................................. 16
2.12 Health-sector Financing .......................................................................................... 16
Chapter 3 Facility-level Infrastructure, Resources, and Systems
3.1 Basic Infrastructure and Resources Supportive of Utilization of Services ............. 17
3.1.1 Availability of a Range of Services and Qualified Staff......................... 17
3.1.2 Availability of Services through Community Outreach ......................... 20
3.1.3 Facility Infrastructure Supportive of Client Utilization and
Quality Services...................................................................................... 21
3.1.4 Infrastructure and Resources to Support Quality 24-hour
Emergency Services................................................................................ 23
3.2 Management Systems to Support and Maintain Quality and Appropriate
Utilization of Health Services ................................................................................. 26
3.2.1 Routine Management Meetings .............................................................. 27
3.2.2 Supportive Supervision Activities .......................................................... 27
3.2.3 Management Practices Supporting Community Involvement ................ 30
3.2.4 Funding Mechanisms That Decrease Financial Barriers to
Utilization of Health Services................................................................. 32
3.3 Logistics Systems for Vaccines, Contraceptives, and Medicines
(Pharmaceutical Commodities)............................................................................... 32
3.3.1 Storage and Management Systems for Vaccines .................................... 33
3.3.2 Storage and Management Systems for Contraceptive methods
and Medicines......................................................................................... 35
3.4 Systems for Preventing Transmission of Infection ................................................. 37
3.4.1 Capacity for Processing Equipment for Reuse ....................................... 37
3.4.2 Infection Prevention and Hazardous Waste Control in Service
Delivery Area.......................................................................................... 41
Chapter 4 Child Health Services
4.1 Background ............................................................................................................. 43
4.1.1 SPA Approach to Collection of Child Health Information..................... 43
4.1.2 Health Situation of Children in Rwanda................................................. 43
4.2 Availability of Child Health Services ..................................................................... 44
4.3 Capacity to Provide Quality Immunization Services .............................................. 45
4.3.1 Capacity to Maintain the Quality of Vaccines........................................ 46
CONTENTS v
4.3.2 Availability of Vaccines ......................................................................... 47
4.3.3 Availability of Equipment and Supplies for Vaccination Sessions ........ 47
4.3.4 Availability of Administrative Components for Monitoring
Immunization Activities ......................................................................... 48
4.4 Capacity to Provide Quality Consultation Services for Sick Children ................... 49
4.4.1 Infrastructure and Resources to Support Quality of Sick
Child Services......................................................................................... 50
4.4.2 Equipment and Supplies for Assessing the Sick Child........................... 52
4.4.3 Essential Medicines for Sick Child Services .......................................... 53
4.4.4 Management Practices Supportive of Quality Services.......................... 55
4.5 Adherence to IMCI Guidelines for Sick Child Service Provision .......................... 57
4.5.1 Full Assessment of Illness ...................................................................... 58
4.5.2 Reducing Missed Opportunities for Promoting Child Health Care ........ 63
4.5.3 Counseling on Child Health Issues......................................................... 65
4.5.4 Supporting Continuity of Care................................................................ 65
4.5.5 Caretaker Opinion from Exit Interviews................................................. 66
Chapter 5 Family Planning Services
5.1 Background ............................................................................................................. 67
5.1.1 SPA Approach to Collection of Family Planning Service
Information ............................................................................................. 67
5.1.2 Family Planning Services in Rwanda ..................................................... 67
5.2 Availability of Family Planning Services ............................................................... 68
5.3 Components Supporting Quality Family Planning Services................................... 72
5.3.1 Infrastructure and Resources for Quality Counseling............................. 72
5.3.2 Equipment and Resources for Quality Family Planning Services .......... 74
5.3.3 Management Practices Supportive of Quality Services.......................... 75
5.4 Family Planning Programs for Special Groups....................................................... 77
Chapter 6 Maternal Health Services
6.1 Background ............................................................................................................. 79
6.1.1 SPA Approach to Collection of Maternal Health Information ............... 79
6.1.2 Maternal Health and the Utilization of Services in Rwanda................... 80
6.2 Availability of ANC Services ................................................................................. 81
6.3 Capacity to Provide Quality ANC........................................................................... 82
6.3.1 Infrastructure and Resources to Support Quality Counseling for
ANC........................................................................................................ 82
vi CONTENTS
6.3.2 Equipment and Resources for Quality ANC and PNC
Examinations .......................................................................................... 84
6.3.3 Equipment and Resources for Quality ANC and PNC Services............. 86
6.3.4 Management Practices Supportive of Quality ANC Services ................ 90
6.4 Adherence to Standards for Providing Quality ANC Service................................. 93
6.4.1 Assessment for Early Identification of Risk Signs or Symptoms........... 93
6.4.2 Counseling to Promote Healthy Outcome .............................................. 96
6.4.3 Supporting Continuity of Care................................................................ 98
6.4.4 Identification of Areas for Improvement in Service Delivery ................ 99
6.5 Delivery Services and Emergency Obstetric Care: Capacity to Provide
Quality Delivery and Newborn Care....................................................................... 99
6.5.1 Availability of Components of CEOC Services ..................................... 99
6.5.2 Support for Safe Home Deliveries........................................................ 101
6.5.3 Infrastructure and Resources to Support Quality Delivery
Services................................................................................................. 102
6.5.4 Equipment and Resources to Allow Quality Delivery Services ........... 103
6.6 Newborn Care Practices........................................................................................ 106
6.7 Management Practices Supportive of Quality Delivery Services ......................... 108
Chapter 7 Services for Sexually Transmitted Infections and HIV/AIDS
7.1 Background ........................................................................................................... 111
7.1.1 SPA Approach to Collection of Information on STI and
HIV/AIDS Services .............................................................................. 111
7.1.2 Health Situation Related to STIs and HIV/AIDS in Rwanda ............... 111
7.1.3 Government Policies and Programs Related to STIs and
HIV/AIDS............................................................................................. 112
7.2 Availability of STI Services.................................................................................. 113
7.3 Components Supporting Quality STI Services ..................................................... 114
7.3.1 System Components to Support utilization of Services........................ 114
7.3.2 Infrastructure and Resources for Quality Counseling........................... 115
7.3.3 Availability of Equipment and Resources to Permit Quality
Diagnosis and Treatment for STIs ........................................................ 117
7.3.4 Management Practices Supportive of Quality Services for STIs.......... 120
7.4 Availability of Services Related to HIV/AIDS ..................................................... 123
7.4.1 SPA Approach to Collection of Information on HIV/AIDS
Services................................................................................................. 123
7.4.2 Overview of MoH Strategy for HIV/AIDS in Rwanda ........................ 123
7.4.3 Availability of Services for HIV/AIDS ................................................ 124
7.5 Capacity to Provide Quality Services for HIV/AIDS Clients ............................... 126
CONTENTS vii
7.5.1 Infrastructure and Resources to Support Quality Services Related
to HIV/AIDS......................................................................................... 126
7.5.2 Facility-level Implementation of Universal Precautions ...................... 127
7.5.3 Resources for Diagnosis and Management of
HIV/AIDS-Related Illnesses................................................................. 128
7.5.4 Management Practices Supportive of Quality Services........................ 131
References ..............................................................................................................................................135
Appendix A: Additional Tables ............................................................................................................139
Appendix B: Survey Personnel ............................................................................................................. 185
Appendix C: Questionnaires................................................................................................................. 187
TABLES AND FIGURES ix
Tables and Figures
Chapter 1 Survey Methodology
Table 1.1 Rwanda SPA facility sample, actual and weighted numbers ................................................. 3
Table 1.2 Sample of interviewed health care providers and weighted values for providers.................. 4
Table 1.3 Sample of observed and interviewed clients .......................................................................... 5
Chapter 2 Overview of the Health System in Rwanda
Table 2.1 Trends in utilization of curative consultation services......................................................... 14
Table 2.2 Trends in manpower in the Ministry of Health .................................................................... 15
Chapter 3 Facility-level Infrastructure, Resources, and Systems
Table 3.1 Availability of services and qualified staff to meet basic client needs ................................ 19
Table 3.2 Service and facility infrastructure to support utilization and quality of services ................. 22
Table 3.3 Service and facility infrastructure to support quality 24-hour emergency services ............. 25
Table 3.4 Supportive management practices at the facility level......................................................... 29
Table 3.5 Management practices supporting community feedback and access to services ................. 31
Table 3.6 Storage conditions and stock monitoring systems for vaccines, contraceptives, and
medicines ............................................................................................................................. 34
Table 3.7 Infection prevention and hazardous waste control............................................................... 40
Figure 3.1 Availability of services and staff to meet basic client needs................................................ 20
Figure 3.2 Availability of specific health services through community outreach ................................. 21
Figure 3.3 Availability of items to support quality 24-hour emergency services.................................. 24
Figure 3.4 Facilities reporting routine management committee meetings............................................. 27
Figure 3.5 Supervision by persons external to facility .......................................................................... 28
Figure 3.6 Client feedback systems....................................................................................................... 31
Figure 3.7 Elements for monitoring vaccine storage conditions ........................................................... 34
Figure 3.8 Elements for management of vaccine stock......................................................................... 35
Figure 3.9 Elements for storing and managing contraceptive methods................................................. 36
Figure 3.10 Elements for storing and managing medicine stock............................................................. 36
Figure 3.11 Highest level of sterilization or HLD for which there is functioning equipment................. 38
Figure 3.12 Components to support quality sterilization or HLD ........................................................... 39
Figure 3.13 Percentage of facilities reporting use of reusable syringes and capacity for
appropriate HLD processing ................................................................................................ 39
Figure 3.14 Facilities with stored sterile or HLD items .......................................................................... 41
Figure 3.15 Infection prevention items in all assessed service delivery areas and facility
hazardous waste control ....................................................................................................... 42
Chapter 4 Child Health Services
Table 4.1 Availability of child health services..................................................................................... 44
Table 4.2 Health system components required for childhood vaccination services............................. 46
Table 4.3 Essential components to support quality consultation services for sick children ................ 51
Table 4.4 Essential components to support quality consultation services for sick children ................ 56
Table 4.5 Assessments, examinations, and treatment for sick children, classified by diagnosis
or major symptom ................................................................................................................ 61
x TABLES AND FIGURES
Table 4.6 Provider practices related to health education and continuity of care.................................. 65
Figure 4.1 Availability of child health services the day of the survey, among facilities offering
sick child (SC) services, growth monitoring (GM), and immunization (EPI) ..................... 45
Figure 4.2 Availability of vaccine among facilities that store vaccines ................................................ 47
Figure 4.3 Availability of materials for a quality EPI program among facilities offering EPI
services................................................................................................................................ 48
Figure 4.4 Availability of items to support quality counseling services for sick children among
facilities offering sick child services.................................................................................... 50
Figure 4.5 Availability of equipment and supplies for examination and treatment among
facilities offering sick child services.................................................................................... 52
Figure 4.6 Availability of first-line medicines for treating sick children among facilities
offering sick child services................................................................................................... 53
Figure 4.7 Availability of prereferral medicines (injectables) among facilities offering sick
child services....................................................................................................................... 54
Figure 4.8 Availability of other essential medicines among facilities offering sick child
services................................................................................................................................ 55
Figure 4.9 In-service education received by interviewed child health service providers, by
topic and timing of most recent education ........................................................................... 57
Figure 4.10 Major danger signs assessed during observed sick child consultations ............................... 58
Figure 4.11 Major symptoms assessed during observed sick child consultations................................... 59
Figure 4.12 Elements of physical examination conducted during observed sick child
consultations........................................................................................................................ 59
Figure 4.13 Nutritional elements assessed for observed sick children under 24 months of age ............. 60
Figure 4.14 Essential advice observed being provided to caretakers of sick children ............................ 61
Figure 4.15 Events reported by caretakers of observed sick children ..................................................... 63
Figure 4.16 Preventive interventions observed for sick children ............................................................ 64
Chapter 5 Family Planning Services
Table 5.1 Availability of family planning services .............................................................................. 69
Table 5.2 Frequency of availability of temporary family planning services........................................ 70
Table 5.3 Availability of infrastructure and resources to support quality services for
temporary methods of family planning ................................................................................ 72
Table 5.4 Management practices to support quality services for temporary methods of family
planning............................................................................................................................... 76
Table 5.5 Family planning activities targeted toward special groups .................................................. 78
Figure 5.1 Method of contraception offered, and availability of method on the day of the
survey .................................................................................................................................. 71
Figure 5.2 Conditions for quality examination of family planning clients............................................ 73
Figure 5.3 Percentage of facilities offering family planning that have equipment relevant to
safe provision of combined oral contraceptives, IUDs, and implants available .................. 74
Figure 5.4 In-service education received by interviewed family planning health providers, by
topic and timing of most recent education ........................................................................... 77
Chapter 6 Maternal Health Services
Table 6.1 Availability of antenatal care and tetanus toxoid vaccinations ............................................ 81
Table 6.2 Availability of infrastructure and resources to support quality counseling and
examinations for antenatal care............................................................................................ 84
TABLES AND FIGURES xi
Table 6.3 Management support for quality antenatal care services ..................................................... 91
Table 6.4 General assessments, examinations, and interventions for assessment of current
health status for observed antenatal care clients .................................................................. 94
Table 6.5 Availability of maternal health services............................................................................. 100
Table 6.6 Availability of elements for quality delivery services........................................................ 103
Table 6.7 Management support for quality delivery services ............................................................ 109
Figure 6.1 Availability of items for quality ANC counseling among facilities offering ANC ............. 83
Figure 6.2 Topics routinely included in group maternal health education sessions, among
facilities offering ANC......................................................................................................... 83
Figure 6.3 Items for physical examination and infection prevention .................................................... 85
Figure 6.4 Essential materials for basic ANC ....................................................................................... 87
Figure 6.5 Oral medicines for managing common problems during ANC ........................................... 88
Figure 6.6 Percentage of facilities offering ANC where indicated item is routine component of
ANC, and medicine or test was available the day of the survey .......................................... 89
Figure 6.7 In-service education received by interviewed ANC service providers, by topic and
timing of most recent education........................................................................................... 92
Figure 6.8 Percentage of observed ANC clients for whom indicated assessment was
component of ANC .............................................................................................................. 95
Figure 6.9 Percentage of observed first-visit ANC clients and follow-up visit clients who were
given, referred for, or prescribed indicated test or intervention........................................... 95
Figure 6.10 Health education provided to observed ANC client who received indicated
interventions........................................................................................................................ 97
Figure 6.11 Health education topics discussed with first-visit ANC clients ........................................... 97
Figure 6.12 Risk signs discussed with either first or follow-up visit ANC clients.................................. 98
Figure 6.13 Basic supplies for delivery................................................................................................. 104
Figure 6.14 Treatment interventions for common complications of labor and delivery ....................... 104
Figure 6.15 Availability of injectable emergency medicines among facilities providing delivery
services.............................................................................................................................. 105
Figure 6.16 Routine practices for newborns among facilities offering delivery services ..................... 107
Figure 6.17 In-service educatino received by interviewed delivery service providers, by topic
and timing of most recent education .................................................................................. 110
Chapter 7 Services for Sexually Transmitted Infections and HIV/AIDS
Table 7.1 Availability of services for sexually transmitted infections............................................... 113
Table 7.2 Availability of infrastructure and resources to support quality counseling and
examinations for sexually transmitted infections............................................................... 116
Table 7.3 Management support for quality services for sexually transmitted infections................... 121
Table 7.4 Availability of HIV/AIDS services .................................................................................... 125
Table 7.5 Availability of services related to HIV/AIDS .................................................................... 129
Figure 7.1 Availability of items to support quality counseling for STIs ............................................. 115
Figure 7.2 Availability of items to support quality physical examination for STIs ............................ 117
Figure 7.3 Laboratory testing among facilities reporting the use of etiological diagnosis.................. 119
Figure 7.4 Availability of at least one medicine to treat indicated STI ............................................... 120
Figure 7.5 In-service education received by interviewed STI service providers, by topic and
timing of most recent education......................................................................................... 122
Figure 7.6 Items for quality counseling for HIV/AIDS clients ........................................................... 127
Figure 7.7 Availability of HIV/AIDS tests at facilities offering HIV/AIDS services ......................... 130
xii TABLES AND FIGURES
Figure 7.8 Resources for providing TB services at facilities that offer both HIV/AIDS and TB
services.............................................................................................................................. 130
Figure 7.9 Facilities where at least half of interviewed providers of HIV/AIDS services
received indicated support.................................................................................................. 132
Figure 7.10 In-service education received by interviewed HIV/AIDS service providers, by topic
and timing of most recent education .................................................................................. 133 |
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