Evaluation of PEPFAR's Contribution (2012-2017) to Rwanda's Human Resources for Health Program (2020) / Chapter Skim
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6 Health Worker Production
6 Health Worker Production
Pages 167-200
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. It also has one of the highest rates of female labor force participation and is the only low-income country of the five countries (Iceland, Finland, Norway, Sweden, and Rwanda)
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. Between 2009 and 2015, as Figure 6-1 illustrates, the number of health workers in Rwanda remained relatively consistent, with 7.8 to 8.9 doctors, nurses, and midwives per 10,000 people (MOH, 2015)
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. As one approach to help alleviate the shortage of HRH and linked to decentralization of the health system, the health sector introduced task shifting1 in 2009, shifting many clinical decisions and activities to nurses and community health workers (CHWs)
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Publicly available data from the MOH's Annual Statistics Booklet, Annual Report, and the Master Facility List demonstrate an increase in health workers across type during a period concurrent with the HRH Program (see Table 6-1)
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. The Master Facility list counts health workers in the following categories: General Practitioner, Specialist, A1 Nurse, A2 Nurse, Midwife, Lab Technician, Physiotherapist, Anesthetist, Pharmacist, and Dentist.
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. Data provided by the MOH indicated most medical specialists were distributed with high numbers at Rwanda Military Hospital, CHUK (University Teaching Hospital, Kigali)
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TABLE 6-2 University of Rwanda Medical Student Graduation Numbers by Program Department 2010 2011 2012 2013 2014 2015 2016 2017 2018 Bachelor of Medicine and Surgery 117 42 88 130 75 96 72 83 103 Postgraduate Anesthesiology 2 2 1 2 3 2 5 -- -- Internal Medicine 3 3 6 1 6 10 14 12 17 Pediatrics 5 5 8 -- 1 6 14 13 11 Obstetrics/Gynecology 6 -- 7 -- 5 6 14 10 13 Ear, Nose, and Throat -- -- -- -- 2 3 3 1 -- Family and Community Medicine -- -- -- -- 2 -- -- -- -- Surgery 4 -- 4 -- 4 5 9 5 4 Neurosurgery -- -- -- -- -- -- -- 1 1 Orthopedics -- -- -- -- -- -- -- -- 1 Urology -- -- -- -- -- -- -- 1 -- Anatomical Pathology -- -- -- -- -- -- -- 4 4 Psychiatry -- -- -- -- -- -- -- 3 2 Emergency and Critical Care -- -- -- -- -- -- -- -- 6 SOURCE: Graduation data provided by the University of Rwanda.
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The National Council of Nurses and Midwives registers and licenses nurses and midwives in the public 25 21 20 17 17 15 14 14 13 10 8 7 5 0 Critical Care & Education, Medical Neonatal Nephrology Oncology Pediatrics Perioperative Trauma Leadership & Surgical Management FIGURE 6-3 Total nursing specialists graduated under the HRH Program by specialty. NOTES: The MSN program's first cohort matriculated in 2015.
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Respondents also credited the establishment of postgraduate specialty training programs in medicine and nursing under the HRH Program with producing more health workers with specialized skills. However, there were conflicting opinions on the distribution of these new specialists in medicine and nursing.
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Per the Master Facility List, only 51 percent of all facilities in Rwanda are in the public sector, meaning a large portion of providers work in private, nongovernmental, and faith-based facilities. SOURCE: Licensure data provided by the Rwanda Medical and Dental Council and National Council of Nurses and Midwives.
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. RECRUITMENT AND RETENTION OF HEALTH WORKERS Retention of adequately trained graduates is among the ubiquitous challenges facing the region and is key to addressing an imbalanced health workforce (WHO, 2013)
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NOTE: HRH = human resources for health; MHA = Master of Health Administration; MSN = Master of Science in Nursing; UR = University of Rwanda. TABLE 6-4 Distribution of All Physician Specialists and General Practitioners by Health Facility Level Level General Practitioners Physician Specialists National Referral and Teaching Hospitals 85 (10.9%)
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. However, challenges persist in meeting this goal, including high health worker turnover rates that result in insufficient staff to provide training for new health care providers (MOH, 2013a)
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However, the challenges are more complex than volume alone. The health sector is suffering from geographic imbalances in the distribution of qualified health workers who favor urban areas, preference of workers for the private sector, and low levels of motivation and performance in the public sector (Lievens et al., 2010)
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The entire continent faces a shortage of health workers, gaps in service coverage, high rates of attrition, and migration of skilled personnel to more favorable work environments (USAID, 2014)
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. For example, Kenya has bilateral agreements with Rwanda, Namibia, and Lesotho for collaborative health workforce training and the promotion of circular migration of health workers (Taylor et al., 2011)
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Some respondents made the link to broader HIV-prevention goals, even in the discussion of retaining health workers in the Rwandan public health
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Program administration respondents viewed the MOH as providing a work environment that would increase health workers' job satisfaction and thus improve retention. This environment included regularly paid and acceptable salaries,3 opportunities for career progression, and equipment necessary to provide health care services, which had an interactive effect with increased health worker skills produced through the HRH Program: There are two parts of retention, one is to increase the salary.
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, especially for staff with families; the practice also prompted health workers to seek opportunities outside the public health system. UPGRADING AND PROCURING EQUIPMENT Across the region, issues of infrastructure permeate health professional education.
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-supported HRH Program expenditures totaled $59.1 million, including $17.9 million on health professional education-related equipment procurement, almost $2 million more than the $16.1 million budgeted for equipment. Equipment procured with PEPFAR funds included a range of items: teaching and reference books, thermometers and stethoscopes, teaching simulators, and larger equipment for clinical services, such as echocardiograph machines and portable blood testing machines.
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Rwandan respondents reported that equipment was procured under the HRH Program, while non-Rwandan respondents were largely skeptical about whether teaching sites actually received such equipment. Government of Rwanda HRH Program administrators reported positive achievements in the increased procurement of equipment to fill gaps at the health facilities (e.g., ultrasound machines, autoclaves, anesthesia machines, pediatric monitors, radiotherapy and other heavy equipment, equipment to facilitate training at the simulation center, wireless Internet connections, computers, and other similar devices)
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of the pieces of equipment were missing a value in the database, including high-priced equipment such as backup generators. SOURCE: HRH Program Equipment Master List provided by the MOH.
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Equipment Value CHUK 1 ,138 $4,020,767 25.0 CHUB 996 $3,127,022 19.4 RMH 242 $1,312,212 8.2 Kibungo 48 $1,197,401 7.4 Kibuye 81 $928,974 5.8 King Faisal Hospital 364 $802,954 5.0 Rwamagana 71 $539,005 3.4 All other sites (38) 1,769 $4,155,082 25.8 Total 4,709 $16,083,568 100 NOTE: CHUB = Centre Hospitalier Universitaire de Butare/University Teaching Hospital, Butare; Centre Hospitalier Universitaire de Kigali/CHUK = University Teaching Hospital, Kigali; RMH = Rwanda Military Hospital.
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* Includes items for pediatrics, pediatric critical care, pediatric anesthesia, and pediatric emergency medicine.
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CONCLUSIONS The HRH Program succeeded in expanding Rwanda's health workforce, with particular success in increasing the qualifications of nurses (both general and specialty) and increasing the number of physician specialists.
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Furthermore, distribution of health workers throughout the country remains inequitable. The geographic imbalances in the distribution of qualified health workers is exacerbated by those who favor urban areas, preference of workers for the private sector, and low levels of motivation and performance in the public sector (Lievens et al., 2010)
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. Despite the increase in health workers and the upgrading of skills, there was a tension between the perceived need for specialized care and advanced practice skills and the perceived need for more general practice and primary care.
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2014. The impact of health worker migration on development dynamics: Evidence of wealth effects from Africa.
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2013. Labor market for health workers in Africa : New look at the crisis.
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2010. Diversity in career preferences of future health workers in Rwanda: Where, why, and for how much?
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2018b. A report of development of Rwanda master facility list: Final report November.
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2017. Rwanda community health workers programme: 1995–2015; 20 years of building healthier communities.
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2016. Health workforce requirements for universal health coverage and the Sustainable Development Goals.
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