Evaluation of PEPFAR's Contribution (2012-2017) to Rwanda's Human Resources for Health Program (2020) / Chapter Skim
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1 Introduction: Evaluation Scope and Approach
1 Introduction: Evaluation Scope and Approach
Pages 17-36
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From page 17... ...
. The Joint Learning Initiative, the World Health Report 2006, and the Global Health Workforce Alliance all highlighted the increasing HRH shortage, most acute in countries heavily affected by HIV, and called for greater investments in health workers.
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. Among HRH initiatives that emerged as a result, three PEPFAR-funded efforts -- the Medical Education Partnership Initiative, the Nursing Education Partnership Initiative, and the General Nursing Project -- played important roles in expanding the workforce of physicians, nurses, and midwives and the capacity of health professional education institutions in Africa.
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U.S. medical and health professional universities provided instructors for Rwanda's new health educational and training programs, filled gaps in teaching rosters for existing programs, and supported Rwandan educators in the development of new curricula and professional training programs (Cancedda et al., 2017, 2018; Uwizeye et al., 2018)
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comptency-based health and quality to health professional professional meet national USI faculty twin with and Output D: College faculty education workforce in needs support College (CMHS) twinned with and Rwanda faculty supported by USI faculty Hospital Management Output E: Administration Mentors twin with hospital and management senior management teams Outcome 2: support provided to To establish an Administrative assistants Rwanda's health enabling assigned to health education education institutions environment in institutions and facilities and sites CMHS schools Output F: Equipment and training sites Procure and distribute (e.g., referral equipment and materials to and materials provided to Rwanda's health hospitals)
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The committee was a multidisciplinary group of experts, selected based on their relevant knowledge and experience, expressly for the purpose of conducting this evaluation. Members had expertise in health workforce and health professional education, HIV clinical care and service delivery, health care quality, health services research, mixed-methods research, epidemiology, biostatistics, and health economics.
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Given the wide reach of the HRH Program in Rwanda, and overlap with most individuals in fields of expertise and professional roles related to both health professional education and health service delivery, the committee did not have any members who were from Rwanda. Members of the committee had experience in clinical care, HRH, and health professional education in Rwanda and throughout the region.
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However, consistent with National Academies' policies protecting the independence of the committee's work, the sponsor and key parties involved in the HRH Program neither reviewed preliminary findings, conclusions, and recommendations nor changed the draft report before its public release as a final document. COMMITTEE'S APPROACH TO THE CHARGE Overview In response to the Statement of Task, the evaluation applied a retrospective, concurrent mixed-methods design, drawing on literature and document review, qualitative interviews, and secondary analysis of quantitative data.
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These included building health professionals' capacity to train HRH in nine clinical and management specialties (anesthesia, emergency medicine, internal medicine, nursing and midwifery, obstetrics and gynecology, pathology, pediatrics, surgery, and hospital administration) and investments in equipment.
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Taking this holistic view of HRH and associated needs to produce improved health outcomes for PLHIV facilitates examination of the context in which the Program was implemented. As the causal pathway illustrates, a stronger health workforce that is able to meet the health needs of the population is understood, along with other factors, to generate improved public health and health care delivery systems.
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Goal Appropriate clinical and management health workforce to meet national need Outcomes Better Public Stronger Health Care Systems Health Systems ‒ Information systems ‒ Finance ‒ Health promotion ‒ Leadership and ‒ Better health facility ‒ Prevention governance management and ‒ Community ‒ Access to essential service delivery medicines Impact Better Overall Health Outcomes Better HIV-Related Outcomes including for PLHIV (incidence, morbidity, mortality) FIGURE 1-2 Theoretical causal pathway for the evaluation.
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For example, without a functioning education sector that supports general education and professional educational institutions, students may not be prepared with the knowledge, skills, and competencies they need to be trained as health workers capable of providing high-quality care. Assessment of Causality and Contribution to Impact The third objective under the Statement of Task is to examine, "to the extent feasible, … the impact of PEPFAR funding for the HRH Program on HRH outcomes and patient- or population-level HIV-related outcomes." The committee used the analytical approach of contribution to impact, the accepted standard, as an effective methodology for evaluating complex development assistance programs where an experimental design is not appropriate or feasible (IOM, 2014; Leeuw and Vaessen, 2009)
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In addition, PEPFAR's investments in the HRH Program and the subsequent request for this evaluation took place relatively recently, compared to the time frame required to develop and deploy highly qualified nurses and physicians. Effecting population-level change through investments in health professional education should be expected to take many years, if not decades, given the time required for training and for trainees to make their way as fully qualified health professionals into the service delivery system and as faculty to produce ongoing cohorts of providers.
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Rwanda's health and higher education systems -- and the political, sociocultural, and historical context in which they operate -- are key factors in the implementation of the HRH Program, just as with any other program. Rwanda's unique context relative to other countries in Eastern and Southern Africa, the singularity of the University of Rwanda as the public-sector institution for health professional education in Rwanda, and the widespread deployment of the HRH Program's trainees meant there was no appropriate comparison setting where the Program was not implemented that would allow attribution of outcomes.
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For this evaluation, the contribution analysis of the effects of the HRH Program was informed by the theory-based causal pathway, described above. This approach enabled the committee to reasonably examine, to the extent feasible, the effects of PEPFAR's investment in the Program on HRH outcomes and on HIV-specific and other HIV-related health outcomes, including (1)
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By assessing convergence and consistency among findings from different yet complementary data sources and methods, and by exploring the data to understand areas of divergence, the committee was able to develop conclusions about the HRH Program's performance and effects, and make recommendations to inform future HRH investments that support PLHIV and to advance PEPFAR's mission. The committee's hope is that the findings, conclusions, and recommendations generated from this evaluation and described in this report will be used by Rwandan, U.S., regional, and global stakeholders to inform future efforts to strengthen the health workforce in Rwanda and elsewhere.
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2017. Building workforce capacity abroad while strengthening global health programs at home: Participation of seven Harvard-affiliated institutions in a health pro fessional training initiative in Rwanda.
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2018. Health professional training and capacity strengthening through international academic partnerships: The first five years of the Human Resources for Health Program in Rwanda.
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(Available by request from the Na tional Academies Public Access Records Office [paro@nas.edu] or via https://www8.
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2008. Scaling up, saving lives: Task Force for Scaling Up Education and Training for Health Workers, Global Health Work force Alliance.
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