Evaluation of PEPFAR's Contribution (2012-2017) to Rwanda's Human Resources for Health Program (2020) / Chapter Skim
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3 Human Resources for Health Program Context, Vision, and Design
3 Human Resources for Health Program Context, Vision, and Design
Pages 55-108
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From page 55... ...
3 Human Resources for Health Program Context, Vision, and Design Key Findings: + Successes and - Challenges 3 Vision and Design Ch • Concurrence among • Lack of clarity around the mechanisms and pathway interview participants for the vision and intent of achieving a world-class on a high-level vision health care system and intent that aligned • Tension between the perceived needs for and with broader health prioritization of specialized versus primary care sector goals providers • Program management • Insufficient planning and funding to systematically led by the Government learn from the Program by establishing rigorous MEL of Rwanda, in line with processes and supportive mechanisms at the outset emerging global principles for donor • Insufficient time for operational management, both at assistance the outset of implementation and continuously, as unexpected circumstances arose + CONTEXT IN RWANDA LEADING UP TO THE PROGRAM The Costs of Conflict Rwanda's recent history of conflict is essential context for the Human Resources for Health (HRH) Program's origin and implementation progress.
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The release of the Health Sector Policy in 2005 outlined an overhaul of the sector, in light of decentralization efforts under way and in pursuit of more significant health gains (MOH, 2005a)
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framework of health systems building blocks served as a foundation for the third Health Sector Strategic Plan (2012–2018) , in which the MOH started to orient toward objectives in the post-MDG era and increasingly considered health resource management and governance mechanisms (MOH, 2012d)
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. This shortfall comes from an insufficient number of trained health professionals relative to the need.
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NOTES: Gross national expenditure is the sum of household final consumption expenditure, general government final consumption expenditure, and gross capital formation. General government final consumption expenditure includes all government current expenditures for purchases of goods and services (including compensation of employees)
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NOTE: Domestic "all sources" comprises out-of-pocket voluntary health insurance and domestic public expenditures. SOURCES: WHO Global Health Expenditure Database; WHO, 2019.
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2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 FIGURE 3-4 PEPFAR Rwanda planned funding by program area and percent allocation for HSS. NOTES: The bar graph shows amounts allocated to each program area indicated and the percentage of funding dedicated to health systems strengthening (HSS)
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cooperative agreement with the MOH called "Strengthening the Capacity of the Ministry of Health to Respond to the HIV/AIDS Epidemic in the Republic of Rwanda under PEPFAR" (also known as the Clinical Services 2 The other East African Community countries include Kenya, Tanzania, and Uganda. In Kenya, PEPFAR-planned funding for HSS activities has ranged from 1 percent to 3 percent of total planned funding between FY 2009 and FY 2019.
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From page 63... ...
. In addition to PEPFAR funding, the Program had a diversified funding base, evidenced by the engagement of the Global Fund to Fight AIDS, Tuberculosis and Malaria.3 Starting in FY 2014, CDC used a separate cooperative agreement with the MOH, "Strengthening Human Resources for Health Capacity in the Republic of Rwanda under PEPFAR," to fund the HRH Program (Mtiro, 2018)
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From page 64... ...
Therefore, the proportion of the amount that was specific to the HRH Program is not known in FY 2012 to FY 2014, when the HRH Program was funded as a component of the cooperative agreement, "Strengthening Capacity to Respond to the HIV/AIDS Epidemic," that started in FY 2009. Starting in FY 2015, the HRH Program was funded through its own cooperative agreement, "Strengthening Human Resources for Health Capacity in the Republic of Rwanda Under PEPFAR," and the amounts reported in TAGGS are reflective of the amounts disbursed for the HRH Program: $11 million in FY 2015 and $10.5 million in FY 2016.
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government, through PEPFAR, and from the Global Fund. The total funding amount from these external sources, as provided by the MOH, was just under $100 million, with approximately 60 percent coming from the U.S.
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Fiscal Year U.S. Government Global Fund Total Annual Budget 2012–2013 12,300,163 6,775,325 19,075,488 2013–2014 14,971,013 6,775,325 21,746,338 2014–2015 12,976,798 6,775,325 19,752,123 2015–2016 11,000,000 5,729,026 16,729,026 2016–2017 10,500,000 5,847,111 16,347,111 2017–2018 0 5,519,856 5,519,856 2018–2019 0 362,246 362,246 Total HRH 61,747,974 37,784,214 99,532,188 Program Budget NOTES: Amounts and totals are reported as provided by the MOH in current U.S.
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* Workforce comprises in-service training and workshops, incentives for community health workers, pre-service training and workshops, salaries for contracted government personnel, salaries for government personnel, salaries for nongovernmental personnel, salaries for short term consultants, service provision, technical assistance, and performance-based financing.
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Incentives 24,435,334 In-service Training and 40,200,881 Workshops Incentives for Community 29,381,321 Health Workers Pre-service Training and 8,064,948 Workshops Salaries (Contracted 35,049,224 Government Personnel) Salaries (Government 27,784,464 Personnel)
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(09, University of Rwanda Administrator in Obstetrics and Gynecology) These achievements built on years of previous engagements by and with the United States and other partners in Rwanda, which created energy and interest in continuing to develop the health sector: From the beginning, USAID and CDC were on board….
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(22, Non-Government of Rwanda HRH Program Administrator from an International NGO) The perceived political will, on the part of the United States at the time and the Government of Rwanda, also created enabling conditions to develop and fund a holistic HSS program such as the HRH Program: [T]
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HRH Program Vision At the time of the HRH Program's design and funding, Rwanda was implementing the Health Sector Strategic Plan 2009–2012 and the HIV/ AIDS National Strategic Plan 2009–2012, both of which had goals around the availability, quality, and rational use of HRH in service of improved health outcomes, in alignment with Vision 2020 goals of health equity, universal health coverage, and increased access to and delivery of quality health care (CDC, 2014; MOH, 2011b; Uwizeye et al., 2018)
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(01, Government of Rwanda HRH Program Administrator) Thus, the HRH Program "was fully integrated into the health system" with potential impacts beyond "just one disease" such as HIV (87, Government of Rwanda Program Administrator)
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(25, Non-Government of Rwanda HRH Program Administrator and U.S. Government Donor)
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Program documents illustrated that developing the Rwandan health education system remained a principal component of the HRH Program. Throughout the Program, the MOH noted that focusing on health education was a mechanism for filling the gap between the supply and demand of highly qualified health professionals in Rwanda (MOH, 2011b, 2015b, 2016b)
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For example, the 2015 programmatic/technical work plan emphasized "internationally benchmarked curricula" in one of the areas TABLE 3-6 Evolution of the HRH Program's Goals and Approaches 2015 Project 2016 Rwanda 2011 2014 Narrative and HRH Program Rwanda HRH HRH Monitoring Programmatic/ Midterm Review Program, 2011–2019, and Evaluation Plan, Technical Work Report (October Funding Proposal March 2014 Plan 2015–June 2016) Aim: Build the health education infrastructure and health workforce necessary to create a high-quality, sustainable health care system in Rwanda Identified Challenges to Achieving Aim Critical shortage of Reduce the critical Critical shortage skilled health workers shortage of skilled of skilled health health professionals workers Poor quality of health Improve the quality Poor quality of worker education of health professional health worker education education Inadequate Increase and diversify Sustainability of infrastructure and health care worker health education equipment in health specialties system facilities Inadequate Enhance management of health infrastructure facilities and equipment in health facilities and educational sites Improve health facilities and educational site management continued
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; Core Program Expectations (2014) ; or Complete Results Framework Objectives (2016)
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continued Introduce the role Introduce the role of Introduce the role of of health manager health manager and health manager at into the Rwandan increase their number district hospital level health system and from 7 to 157 increase the number (introduce trained of trained health health manager managers from 7 to position in district 157 hospital and develop a job description) Launch the Rwanda Launch the school of Increase the number School of Dentistry, dentistry and increase of oral health and increase the the number of health professionals number of oral professionals from health professionals 122 to 424 from 122 to 424 Build the institutional Create teaching capacity of the hospitals and medical medical, nursing, schools that have oral health, health the infrastructure, management schools, equipment, and and clinical teaching institutional capacity hospitals to sustain to sustain highhigh-quality health quality education education continued
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to conducive to facilitate improved facilitating health professional improved health education professional education By 2019, have a Established a sustainable, skilled, sustainable, skilled and specialized and specialized health professional health professional workforce in workforce in Rwanda Rwanda
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HRH PROGRAM CONTEXT, VISION, AND DESIGN 79 TABLE 3-6 Continued 2015 2011 Project 2016 Rwanda HRH Rwanda HRH 2014 Narrative and Program Midterm Program, 2011– HRH Monitoring Programmatic/ Review Report 2019, Funding and Evaluation Plan, Technical Work (October 2015–June Proposal March 2014 Plan 2016) Aim: Build the health education infrastructure and health workforce necessary to create a high-quality, sustainable health care system in Rwanda Areas of Work Increase skill levels Increase skills Increase skill levels and specialization levels and and specialization of health care specialization of health care professionals and of health care professionals and educators professionals and educators educators Establish high-quality Establish high- Establish high-quality clinical training sites quality clinical clinical training and schools training sites and sites and schools schools through procurement of infrastructure and equipment and improvement of health management capacity Accelerate Support Accelerate recruitment and recruitment recruitment and support student and retention support student retention of trainees retention and students in nursing and midwifery, biomedical laboratory sciences, medicine and surgery, and health management programs Implement Develop Implement integrated, and deliver integrated, competency-based internationally competency-based curricula benchmarked curricula curricula continued
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80 EVALUATION OF PEPFAR'S CONTRIBUTION TO RWANDA TABLE 3-6 Continued 2011 2015 2016 Rwanda HRH Rwanda HRH 2014 Project Narrative Program Midterm Program, 2011– HRH Monitoring and Programmatic/ Review Report 2019, Funding and Evaluation Plan, Technical Work (October 2015–June Proposal March 2014 Plan 2016) Aim: Build the health education infrastructure and health workforce necessary to create a high-quality, sustainable health care system in Rwanda Areas of Work continued Increase the Increase the Increase the importance of engagement importance of teaching and careers of health teaching and careers in health professions professionals in in health professions learning, teaching, and scholarships Build institutional Recruit to and Build institutional capacity for health retain faculty capacity for health education in Rwanda by education working with USIs Increase collaboration between health professional education stakeholders Enhance the recruitment and retention of graduates in the health care and health education sectors Development of faculty for health professional education Expand research Expand scientific Expand research partnerships and partnerships partnerships and academic exchange and academic academic exchange exchange Monitoring and evaluation
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Among Government of Rwanda respondents, the Program's main objective was unequivocally to build a larger cadre of health care workers across specialties: The vision of the MOH was to improve the shortage of HRH, improve their quality in terms of skills and knowledge, and how to deal with some of the major issues that we had here in Rwanda. (48, Government of Rwanda HRH Program Administrator)
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(18, Former Government of Rwanda HRH Program Administrator) Some USI faculty reported that the objectives and design of specific specialties changed significantly over the course of the Program.
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(22, Non-Government of Rwanda HRH Program Administrator)
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be provided by very few specialists. (45, Government of Rwanda HRH Program Administrator)
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institution involvement Academic programs ‘11 Government of Rwanda 18 USIs submit letters 1 USI partnership ends submits unsolicited of intent to join Academic before HRH Program proposal Consortium launch ‘12 1 USI exits Expansion of "Strengthening the HRH 10 USIs USI faculty Academic Ministry of Health's Capacity to Program join begin Consortium Respond to the HIV/AIDS Launch Academic arriving in Epidemic in the Republic of Consortium Rwanda Rwanda under PEPFAR" Cooperative Agreement ‘13 MHA program launched ‘14 "Strengthening Human Resources M&E plan Management of Clinical for Health Capacity in the Republic developed HRH Program Services of Rwanda under PEPFAR" transitioned to CoAg ends Cooperative Agreement issued MOH ‘15 1 USI joins 3 USIs exit MSN MGHD PEPFAR Academic Academic program program decides to Consortium Consortium launched launched cease funding ‘16 3 USIs exit Academic Consortium Midterm review conducted ‘17 1 USI exits Academic Consortium PEPFAR funding ends ‘18 5 USIs exit Academic Consortium 1 USI joins Academic Consortium ‘19 5 USIs exit Academic Consortium FIGURE 3-6 HRH Program time line. NOTE: HRH = human resources for health; MGHD = Master of Global Health Delivery; MSN = Master of Science in Nursing; PEPFAR = President's Emergency Plan for AIDS Relief; USI = U.S.
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(45, Government of Rwanda HRH Program Administrator) The Third Health Sector Strategic Plan makes reference to an extensive situation analysis and comprehensive midterm review conducted in 2011, which informed the plan's priority to "improve quantity and quality of human resources for health (planning, quantity, quality, management)
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Embassy" (20, Government of Rwanda HRH Program Administrator)
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(48, Government of Rwanda HRH Program Administrator) FINANCIAL MANAGEMENT The 2011 HRH Program proposal indicated that a Single Project Implementation Unit would be established "to centralize programmatic, financial, and administrative management functions" (MOH, 2011b)
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According to MOH data, the bulk of the expenditures from PEPFAR investments in the HRH Program went to USIs, followed by equipment procured for health professional education and clinical training (see Table 3-7)
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(45, Government of Rwanda HRH Program Administrator) There are too many specialties that these fund were not really able to support and for us, I can see how [HIV]
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that was even more difficult because it pushes the quarter to another one, so from October you will see that it comes to the other year and all this payment to universities was done quarterly. (20, Government of Rwanda HRH Program Administrator)
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, although respondents knew of other faculty members who were not aware of the Program: I was a little bit ahead of my colleagues who had those challenges of not being informed ahead, but for me, I knew that the program was there. (80, USI Faculty in Nursing)
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(37, University of Rwanda Administrator) MOH respondents also mentioned the value of the steering committee as the entity "in charge of giving the guidance and making the policies" (20, Government of Rwanda HRH Program Administrator)
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(26, International NGO Representative) MOH–USI Relations The 2016 midterm review highlighted challenges in contracting processes: lack of clarity around leave and other policies, time line and processes for obtaining work permits and licenses for USI faculty, and funding and reporting requirements that resulted in delays in drafting MOUs; delays in annual revising and reissuing MOUs; late award notification, which delayed program funding and USI reimbursements; and a need to accommodate USI and HRH Program processes delaying submission of invoices and payment (MOH, 2016b)
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Program administrators who worked outside of the Government of Rwanda shared that some USI faculty "pulled out" of the HRH Program because the financial gap (due to these contract conditions) "was putting enormous pressure … so it was too much risk" (22, Non-Government of Rwanda HRH Program Administrator)
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Communication from USIs to the MOH about the physician specialists, nurses, and midwives selected to travel to Rwanda, specifically their experience and seniority, also affected the relationship, although this was seen as having improved "over time as we went on mentioning this challenge the profiles changed and I think they would send even better people" (48, Government of Rwanda HRH Program Administrator)
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. Under the new cooperative agreement, CDC required the MOH to revise and submit a more detailed evaluation and performance measurement plan within the first 6 months of the award (CDC, 2014)
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Another respondent stated that there was "a high-level M&E document [referring to the 2014 M&E plan] , but it's not specific to actual activities on a yearly basis" (22, Non-Government of Rwanda HRH Program Administrator from an International NGO)
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The proposal included a rationale for the availability of the financial resources that would be needed to absorb the newly trained health workers and maintain equipment purchased under the HRH Program. It argued that the government's commitment to allocating 15 percent of the total national budget to health, as agreed to in the Abuja Declaration, combined with the projected 5 percent annual increase in the total Rwandan budget due to GDP growth, would generate enough funds to cover the estimated $43 million per year for Rwandan health professionals produced by the HRH Program, $9 million per year for tuition support, $13 million (over several years)
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(20, Gov ernment of Rwanda HRH Program Administrator) In contrast, for another respondent, who had expressed that the objective of the HRH Program was to build capacity of Rwandan health education institutions, most directly the University of Rwanda, the Program failed to clearly understand and build on the capacity of local institutions: [L]
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And that's fine, but not re ally long-term planning. (22, Non-Government of Rwanda HRH Program Administrator)
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The relative importance of building health education capacity, including enhancing the skills of Rwandan faculty and the learning environment at the University of Rwanda, was inconsistent during the life of the Program. In particular, it was unclear whether activities for building institutional capacity for health professional education were prioritized simply as a mechanism to produce the desired number of health professionals across cadres, or viewed as complementary goals to having a sustainable, skilled, and specialized workforce, as expressed in the later strategic outcomes (MOH, 2011b, 2014b, 2015b)
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. The original program objectives were incorporated into various indicators for the M&E plan and midterm review; however, the development of an M&E plan after implementation had begun resulted in a lack of baseline data for some cadres and program areas, as well as unexplained differences in baseline and target values (MOH, 2011b, 2014b, 2016b)
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(Available by request from the National Academies Public Access Records Office [paro@nas.edu] or via https:// www8.nationalacademies.org/pa/managerequest.aspx?
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2009a. Health Sector Strategic Plan, July 2009–June 2012.
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2012d. Third Health Sector Strategic Plan, July 2012–June 2018.
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2015. Rwanda country operational plan (COP)
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2016. Health workforce requirements for universal health coverage and the Sustainable Development Goals.
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