Evaluation of PEPFAR's Contribution (2012-2017) to Rwanda's Human Resources for Health Program (2020) / Chapter Skim
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Recognizing HRH capabilities as a foundational challenge for the health system and the response to HIV, the Government of Rwanda worked with PEPFAR and other partners to develop a program to strengthen institutional capacity in health professional education and thereby increase the production of high-quality health workers. The HRH Program was origi 1 This summary does not include references.
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3. Examine the impact of PEPFAR funding for the HRH Program on HRH outcomes and on patient- or population-level HIV-related outcomes.
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The posited pathway to impact is that a stronger health workforce that is able to meet the health needs of the population can be expected, along with other factors, to generate improved public health and health care delivery systems. The combination of a functioning health system with an effective workforce results in better-quality services.
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In addition, the report can inform other stakeholders in Rwanda engaged in that work, such as other funders, health professional educational institutions, professional societies, patient advocacy groups, and other civil society organizations. Furthermore, there are lessons for stakeholders in other countries aiming to strengthen health systems and the health workforce through professional education.
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faculty who had of Rwanda faculty experience in the • Some unsuitable or unqualified USI faculty who did not region and/or were meet experience requirements or technical needs from the region • Insufficient transfer of teaching skills from USI faculty to • Increased skills in Rwandan faculty management of academic curricula • Insufficient resources and unclear expectations among and programs Rwandan actors and USIs affected processes related to issuing contract, recruitment, and onboarding + 5 Institutional Capacity for Health Professional Education Ch • Exposure of trainees to high-quality • Variations by specialty in quality of teaching methodologies, new or updated trainee experience and exposure curricula, and evidence-based medicine • Emphasis on individual twinning did • Increased motivation, confidence, and not translate to increased capacity at professionalism among trainees University of Rwanda to continually • Increased research skills and strengthen and grow academic competencies at University of Rwanda, programming with some continued research • Inability to institutionalize Master of collaboration after USI faculty left Hospital and Healthcare • Well developed and institutionalized Administration program Master of Science in Nursing program • Mixed results in retaining faculty at the University of Rwanda + FIGURE S-1 Key findings: successes and challenges. continued
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Concurrent with the HRH Program, Rwanda experienced decreasing prevalence, increasing access to and coverage of ART, and increasing percentages of adults who know their status, are on ART, and have reached
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The complexity of the HRH Program and the system it aimed to strengthen meant these successes were accompanied by challenges, which together offer lessons for future programming. Challenges with respect to the ambitious goals of increasing institutional capacity for health professional education included operational issues, variable implementation of
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Unmet HRH needs remain, in terms of both sheer numbers of professionals and their geographic distribution. When it was funded, the Program represented an uncommon, although not unique, donor approach to strengthening HRH capacity through a large investment in building capacity in health professional education institutions.
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Recommendation 1: Funders investing in strengthening human re sources for health should support a codesign model through a process that engages representatives from diverse stakeholders as the designers,2 including funders, program administrators, implementers, regulatory bodies, and those who will use or benefit from the funded activities. To ensure a feasible program that reflects reality and responds to the need, a collaborative, bottom-up design process that includes funders, government representatives across relevant sectors, implementers, and beneficia 2 Latter recommendations that actions be taken by HRH program designers refer to this group of diverse stakeholders.
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Recommendation 2: Designers of programs to strengthen human re sources for health should employ a complex systems thinking lens, including multisectoral approaches that mix top-down and bottom-up models with long-term flexible funding that can support both the im mediate needs of a health system and longer-term issues, such as the retention of health workers. Applying complex systems thinking can change how program designers conceive of health system challenges, the questions they ask about how to improve the system, and their understanding of the factors that support or hinder improvement.
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Program design should not only create new health workers but also redress factors that undermine the capacity of the existing workforce. A labor market lens that considers both supply and demand can leverage existing investments in health professional education and correct imbalances in supply, which are often due to the dominance of demand-side forces.
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Models for Improving Health Professional Education Building capacity in the HRH Program occurred predominantly through an academic consortium comprising U.S. institutions that contracted faculty to be paired in "twinning" relationships with University of Rwanda faculty.
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The HRH Program used an individual twinning model to build faculty and institutional capacity for health professional education. Other models are available and should be evaluated before selection, based on the programmatic goals and vision and the needs of the health workforce.
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, the European Union's ESTHER4 Alliance for Global Health Partnerships, and the United Kingdom's Tropical Health Education Trust (THET) have all employed institutional twinning partnerships and have well-developed definitions, practices, processes, and tools for designing, implementing, and assessing the effectiveness of institutional twinning models.
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With respect to HIV/AIDS, a long-term design for HRH investments needs to reflect the anticipated future of the epidemic -- strengthening a health system to be able to care for an aging PLHIV population. The design of HRH programs should consider the anticipated evolution of workforce needs as the burden of disease shifts over time.
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If there is an expectation that a program should demonstrate a contribution to both systemwide and disease-specific effects, each of these areas of monitoring, evaluation, and learning needs to be designed from the outset to document and assess that dual intent. CONCLUSION The HRH Program, funded by PEPFAR from 2012 to 2017, represented an opportunity for a vertical, HIV-focused external donor to invest in horizontal systems change by strengthening Rwandan health professional education institutions to produce a workforce of sufficient quantity and quality to meet the needs of the Rwandan population, including PLHIV.
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