Evaluation of PEPFAR's Contribution (2012-2017) to Rwanda's Human Resources for Health Program (2020) / Chapter Skim
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7 Effects on Human Resources for Health and Quality of Care
7 Effects on Human Resources for Health and Quality of Care
Pages 201-226
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7 Effects on Human Resources for Health and Quality of Care Key Findings: + Successes and - Challenges 7 Effects on HRH and Quality of Care Ch • Described as having a • The potential for health professional education positive effect on the safety, and increased production of providers to improve effectiveness, timeliness, quality of care was limited by systems factors, and accessibility of services such as infrastructure, equipment, diagnostics, for PLHIV and beyond and geographic distribution of referral services • Seen by those in both • Given prior gains from Rwanda's response to health professional HIV, any specific HRH Program contribution to education and health HIV outcomes would be relatively small and service delivery roles as difficult to discern. Moreover, with HIV services contributing to improved integrated in the health system, disentangling the quality of care for all Program's impact on HIV outcomes is Rwandans, including complicated PLHIV, through direct and • Sustainability and institutionalization of the HRH indirect pathways such as Program were hampered by its design and greater provider availability, implementation, and by changes in PEPFAR's improved skills for basic funding priorities and HIV-specific care, and improved skills to address • HRH Program lacked sufficient time to act on the HIV-related complications midterm review recommendation related to sustainability planning + 201
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services, from 4 facilities in 2002 to 552 in 2016, as reported in the Rwanda Integrated Health Management Information System. The increase in output and distribution of high-quality trained health professionals across Rwanda as a result of the HRH Program was seen by all respondent groups in this evaluation as having a positive impact on the quality of care as an outcome of increased access, although that is not explicitly noted in the overall design of the Program.
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estimated HIV prevalence among adults aged 15–49 as 2.6 percent and 3 percent among adults aged 15–64 years, totaling approximately 210,200 adults in Rwanda living with HIV (RPHIA, 2019)
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HIV/AIDS Outcomes The RPHIA and UNAIDS both estimate that approximately 74 percent of PLHIV have achieved viral suppression (RPHIA, 2019; UNAIDS, 2018b) ; however, estimates of the three 90-90-90 elements are different (see Table 7-1)
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and almost 80 percent of HIV-positive women have achieved viral load suppression, a key indicator of effective HIV treatment in a population (RPHIA, 2019)
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Impact on HIV/AIDS Care The design of the HRH Program emphasized developing a quality health care system through an increased output and cadre of high-quality trained health professionals who would in turn increase the quality of care. As mentioned above, the increase in output and distribution across Rwanda was seen to have had a positive impact on the quality of care as an outcome of increased access, although that is not explicitly noted in the overall design of the program.
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. For program administrators, the impact on HIV was observed through the increases in the quality of care and management at health facilities by HRH trainees, reinforcing the integrated HIV service delivery Rwanda had been working toward since 2009.
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. Although the incidence rate has continued to decline since 2008 and is reflective of a successful national HIV program, the discrepancies in these data are notable, with implications for assessing the nature of the HIV epidemic in Rwanda even with methodological differences.
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The estimated increases in coverage were seen throughout the years of the HRH Program implementation, although its estimations of coverage vary significantly in comparison to PEPFAR, likely pointing to methodological differences. This drop in coverage percentage occurred as the estimated need for PMTCT coverage rose from 9,416 pregnant women in 2011 to 11,000 in 2016, while the number of pregnant women who were provided antiretrovirals (ARVs)
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Improving clinicians' time management, triage practices, and scheduling rosters, and improved clinical guidelines (although the ever-changing HIV-related clinical guidelines were seen as challenging) were all seen as contributing to reduced patient waiting times and flow through the hospitals (30, Former Government of Rwanda HRH Program Administrator; 58 and 59, University of Rwanda Former Students in Nursing)
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A strong program of community-based HIV service delivery by community health workers was seen as having an impact on patient-level outcomes (Abbott et al., 2017)
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Conditions in rural and remote areas made them undesirable locales to work and live, impeding health worker retention and contributing to a situation in which there were insufficient human resources for health at the facility level, creating a more burdensome workload for health workers who stayed. Linking Quality of Care to Patient Outcomes Data from this evaluation suggest revisions to the theoretical causal pathway that guided the evaluation design, presented in Chapter 1, that more clearly link HRH Program activities and outputs to the domains of quality presented in Figure 7-5.
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Although this view was not widespread, one USI faculty member noted that there had been some improvements in treatment for and reduction in stigmatization of HIV-positive cervical cancer patients, which may point to small inroads in improving equity. Therefore, the committee revised the causal pathway to highlight the role of improved quality of care as a longer-term outcome that is required to effectively impact health outcomes for all and HIV-related outcomes.
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The clear outset of the Program, its defined set of training activities, and the distribution of HRH trainees across Rwanda mean that a quantitative assessment of impact with reasonable potential for causal attribution could, in principle, be carried out as follows: The design would conceptualize Rwandan districts that received HRH trainees as independent units with their own trajectories of health outcomes such as HIV testing, treatment, and viral suppression rates. The new infusion of HRH trainees would then be tested as an "intervention" that is applied to each district at a unique "dose" that is represented by the quantity and type of HRH trainees who enter each district, ideally characterizing dose in relation to population or disease burden.
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University of Rwanda and USI respondents alike expressed confusion about the future of the HRH Program. University of Rwanda respondents were unclear as to whether additional USI faculty would be coming and were concerned about being able to continue their programs without the support: We have been twinning until June, but we are promised to get other faculty to assist in August, next month, because we are still run ning the programs, and some of them have been getting the Ph.D.
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(03, Government of Rwanda HRH Program Administrator) That the health workers trained under the HRH Program brought higher skill levels and qualifications to the health sector was viewed as another measure of sustainability.
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Another Government of Rwanda respondent expressed that having a university capable of producing more health workers was an unplanned benefit of the Program, making it "even more sustainable than what we believe" (18, Former Government of Rwanda HRH Program administrator)
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(17, USI Faculty in Obstetrics and Gynecology) The midterm review also reported there were no formal planning exercises to facilitate the phasing out of USI faculty and ensure a permanent faculty pipeline for a sustainable health system as the HRH Program time lines evolved (MOH, 2016b)
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However, there is evidence pointing to community health workers' role in the provision of HIV care and improved outcomes for PLHIV, including psychosocial support and viral load suppression, yet these were not a part of the HRH Program (Han et al., 2018; Kenya et al., 2013)
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Evidence points to the need for future HRH planning to ensure the evolving health needs of an HIV population are met. Recent population-based surveys from Tanzania and Uganda have shown that cardiovascular risk factors, including hypertension and other components of metabolic syndrome, are at least as prevalent in HIV populations as in the general population (Gaziano et al., 2017; Kavishe et al., 2015)
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Sustainability and Institutionalization Sustainability and institutionalization of the HRH Program were significantly hampered by the Program's design and implementation, and by PEPFAR's changes in funding priorities. There was general agreement among respondents that prolonged engagement of USI faculty in an intensive twinning program was not the desired outcome, but there was also recognition that there had been insufficient time to institutionalize the ability to continually update curricula and teaching methodologies at the University of Rwanda.
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2018. Renal outcomes in patients initi ated on tenofovir disoproxil fumarate-based antiretroviral therapy at a community health centre in Malawi.
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2013. Using community health workers to improve clinical outcomes among people living with HIV: A randomized controlled trial.
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2008. Baseline renal insufficiency and risk of death among HIV-infected adults on antiretroviral therapy in Lusaka, Zambia.
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2017. Maternal mortality ratio (per 100,000 live births)
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