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Evaluation of PEPFARâs Contribution (2012â2017) to RWANDAâS HUMAN RESOURCES FOR HEALTH PROGRAM Committee on the Evaluation of Strengthening Human Resources for Health Capacity in the Republic of Rwanda Under the Presidentâs Emergency Plan for AIDS Relief (PEPFAR) Board on Global Health Health and Medicine Division A Consensus Study Report of
THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW, Washington, DC 20001 This activity was supported by a contract between the National Academy of Sci- ences and the U.S. Centers for Disease Control and Prevention. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project. International Standard Book Number-13:â 978-0-309-67205-4 International Standard Book Number-10:â 0-309-67205-8 Digital Object Identifier:â https://doi.org/10.17226/25687 Additional copies of this publication are available from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. Copyright 2020 by the National Academy of Sciences. All rights reserved. Printed in the United States of America Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2020. Evaluation of PEPFARâs contribution (2012â2017) to Rwandaâs Human Resources for Health Program. Washington, DC: The National Academies Press. https://doi.org/10.17226/25687.
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Consensus Study Reports publishedÂ by the National Academies of Sciences, Engineering, and MedicineÂ document the evidence-based consensusÂ on the studyâs statement of task by an authoring committee of experts.Â Reports typi- cally include findings, conclusions, and recommendations based on information gathered by the committee and the committeeâs deliberations. Each report has been subjected to a rigorous and independent peer-review process, and it representsÂ theÂ positionÂ ofÂ the National Academies on the statement of task. ProceedingsÂ publishedÂ by the National Academies of Sciences, Engineering, and MedicineÂ chronicle the presentations and discussions at a workshop, symposium, or otherÂ eventÂ convened by the National Academies. The statements and opin- ions contained in proceedings are those of the participants and are not endorsed by other participants, the planning committee, or the National Academies. For information about other products and activities of the National Academies, please visitÂ www.nationalacademies.org/about/whatwedo.
COMMITTEE ON THE EVALUATION OF STRENGTHENING HUMAN RESOURCES FOR HEALTH CAPACITY IN THE REPUBLIC OF RWANDA UNDER THE PRESIDENTâS EMERGENCY PLAN FOR AIDS RELIEF (PEPFAR) ANN E. KURTH (Chair), Linda Koch Lorimer Professor and Dean, Yale School of Nursing TILL BÃRNIGHAUSEN, Alexander von Humboldt University Professor and Director, Heidelberg Institute of Global Health, University of Heidelberg, Germany; Adjunct Professor of Global Health, Harvard T.H. Chan School of Public Health ERAN BENDAVID, Associate Professor of Medicine, Stanford University CARLA CASTILLO-LABORDE, Assistant Professor, Centro de EpidemiologÃa y PolÃticas de Salud, Facultad de Medicina ClÃnica Alemana, Universidad del Desarrollo, Santiago, Chile ELVIN H. GENG, Professor of Medicine, Division of Infectious Diseases, and Director of the Center for Dissemination and Implementation at the Institute for Public Health, Washington University in St. Louis FASTONE M. GOMA, Dean and Associate Professor, University of Zambia School of Medicine, Lusaka, Zambia LAURA HOEMEKE, Global Health Policy Consultant; Adjunct Professor, Gillings School of Global Public Health, University of North Carolina at Chapel Hill ANGELINA KAKOOZA-MWESIGE, Senior Lecturer and Pediatric Neurologist, Department of Pediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda EMMANUEL B. K. LUYIRIKA, Executive Director, African Palliative Care Association, Kampala, Uganda MOSA MOSHABELA, Dean and Head, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa DENIS NASH, Distinguished Professor and Executive Director, CUNY Institute for Implementation Science in Population Health, City University of New York Graduate School of Public Health and Health Policy CHARLES OK PANNENBORG, Retired Chief Health Advisor and Chief Health Scientist, The World Bank Group DEREK J. SLOAN, Senior Clinical Lecturer and Consultant Infectious Diseases Physician, University of St. Andrews, Scotland SHEILA D. TLOU, Chair, Global HIV Prevention Coalition; Former Director of the Regional Support Team for Eastern and Southern Africa, UNAIDS (until May 2019) v
Study Staff SUSAN F. E. MILNER, Study Director CECILIA MUNDACA SHAH, Senior Program Officer (until December 2018) KATYE M. MAGEE, Associate Program Officer (until February 2019) EMMA FINE, Associate Program Officer (from May 2019) T. ANH TRAN, Research Associate (until March 2020) ZARIA FYFFE, Senior Program Assistant (from March 2020) MICHELLE KVALSUND, National Academy of Medicine Fellow in Osteopathic Medicine JULIE A. PAVLIN, Senior Director, Board on Global Health Consultant BRIDGET B. KELLY, Principal Consultant, Burke Kelly Consulting EnCompass LLC Consulting Team SARAH SMITH LUNSFORD, Team Lead and Senior Evaluation Specialist SIMON HILTEBEITEL, Monitoring and Evaluation Specialist II KELSEY SIMMONS, Evaluation Specialist II AMY BHOPAL, Special Projects Associate REBECCA K. CATHCART, Rwanda-Based Consultant SYLVESTRE MUSENGIMANA, Rwanda-Based Consultant vi
Reviewers This Consensus Study Report was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published report as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the study charge. The review comments and draft manu- script remain confidential to protect the integrity of the deliberative process. We thank the following individuals for their review of this report: PAULIN BASINGA, Bill & Melinda Gates Foundation MOLLY COOKE, University of California, San Francisco SUNDEEP K. GUPTA, Partners in Hope, Malawi WILLIAM HOLZEMER, Rutgers University SANGEETA MOOKHERJI, The George Washington University KHAMA ROGO, World Bank KIMBERLY A. SCOTT, Virginia Department of Health JEAN N. UTUMATWISHIMA, Rwamagana Provincial Hospital Although the reviewers listed above provided many constructive com- ments and suggestions, they were not asked to endorse the conclusions or recommendations of this report nor did they see the final draft be- fore its release. The review of this report was overseen by KRISTINE M. GEBBIE, Flinders University School of Nursing and Midwifery, and ANN M. ARVIN, Stanford University School of Medicine. They were responsible vii
viii REVIEWERS for making certain that an independent examination of this report was car- ried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the authoring committee and the National Academies.
Preface The world needs more health workers. The need is acute in low-income country settings with the highest burden of HIV disease, including in sub- Saharan Africa. With 11 percent of the worldâs population, 24 percent of the global disease burden, and more than 70 percent of HIV disease,1 yet only 3 percent of the worldâs health workforce, this region is ripe for in- novation and investment to improve human resources for health (HRH).2 Given this context, the Rwanda HRH Program was an important experi- ment, one that arose from a unique set of circumstancesâa postgenocide need to rebuild, impressive advancement in addressing baseline HIV met- rics, and a government dedicated to improving Rwandan health via creation of a stronger and more self-sustaining health system. The Presidentâs Emergency Plan for AIDS Relief (PEPFAR) and its leadership in the Office of the U.S. Global AIDS Coordinator are man- dated to address HIV, and the Government of Rwanda has a commitment to improve the health of all of its people. These goals may seem to be in conflictâa vertical focus on a single disease and a horizontal approach to building a health system able to address all citizensâ basic health needs. The debate over vertical versus horizontal programming has been an ongoing 1â Kharsany, A. B. M., and Q. A. Karim. 2016. HIV infection and AIDS in sub-Saharan Africa: Current status, challenges and opportunities. Open AIDS 10. 2ââââ IFC (International Finance Corporation). 2019. Sub-Saharan Africa: Health and education. https://www.ifc.org/wps/wcm/connect/REGION__EXT_Content/IFC_External_ Corporate_Site/Sub-Saharan+Africa/Priorities/Health+and+Education (accessed November 6, 2019). ix
x PREFACE one; however, given the growing burden of noncommunicable diseases (ac- counting for 71 percent of global mortality)3 and the evolution of managing HIV disease as a chronic care model with multiple comorbidities, there may be increasing congruence. In this context, we must admire the creativity of PEPFAR and the Government of Rwanda in partnering to launch this distinctive program. The Rwanda HRH Program experiment is one from which we believe salient lessons can be drawn for the design and implementation of work- force capacity building that advances both HIV prevention and care and country attainment of universal health access and coverage. Many countries and collaborations can learn from the way the HRH Program was con- ceived, executed, and evaluated. These lessons are especially timely given the commitment made at the United Nationâs first high-level meeting on universal health coverage (UHC) on September 23, 2019, which recognized the substantial shortfall of workers in low- and middle-income countries and âthe need to train, build, and retain a skilled health workforce,â noting in particular ânurses, midwives, and community health workers.â4Â Perhaps a primary lesson of the Rwanda HRH paradigm is the limited time line of the Program, foreshortened as it was by a 2-year reduction in PEPFAR funding. Even the original conception of a program designed for less than a decade was arguably too brief to create cohorts of expert clini- cians who could be educated, practice and have an impact on care, and educate the next generation of clinicians in turn. Another key lesson is that the degree of structural change needed for sustained gains in institutional capacity for health professional education was underestimated. Likewise, faculty development to take on this work at the University of Rwanda was not as grounded in partnership engagement as it could have been. Given the vertical mission of PEPFAR, the goal to understand whether the HRH Program funding improved outcomes for people living with HIV (PLHIV) is logical. As a committee, we thought deeply about how one might attempt to answer this as an overarching evaluation question, given the lack of baseline and time-series data, the too brief period of funded work, and the challenges of navigating between a vertical focus on HIV outcomes and a more horizontal nation-building program of health work- force advancement. The committeeâs final conclusion was that it would not be possible to determine attribution. But given the continued HIV epidemic in sub-Saharan Africa, as well as the issue of how best to achieve UHC 3â WHO (World Health Organization). 2018. Noncommunicable diseases. https://www.who. int/news-room/fact-sheets/detail/noncommunicable-diseases (accessed November 6, 2019). 4â United Nations. 2019. Political declaration of the high-level meeting on universal health coverage: âUniversal health coverage: Moving together to build a healthier world.â New York: United Nations. https://undocs.org/en/A/RES/74/2 (accessed January 28, 2020).
PREFACE xi worldwide, this evaluation was an opportunity to highlight the importance of HRH and how it can affect not only PLHIV, but ultimately everyoneâs health. The study was completed in a relatively accelerated time frame, but with thoughtfulness and methodologic depth. Following from our com- mitment to learn as much as possible, despite the limitations due to the circumstances of this Program and this evaluation, the committee offers not only findings about this Program, but also suggestions for how future endeavors such as this could be designed to more explicitly enable learning to follow from innovation. We are deeply grateful for the work of the dedicated staff, consultants, and committee members, and most of all to the Rwandan government representatives and university employees, faculty who participated through U.S. partner institutions, and others throughout the country who partici- pated in this evaluation. We invite the reader to consider ways to apply the lessons to their own work to improve the health of people and populations. Ann E. Kurth, Chair Committee on the Evaluation of Strengthening Human Resources for Health Capacity in the Republic of Rwanda Under the Presidentâs Emergency Plan for AIDS Relief (PEPFAR)
Acknowledgments This Consensus Study Report and program evaluation would not have been possible without the invaluable contributions of many individuals. First and foremost, the committee, consultants, and study staff wish to express their sincere appreciation to the 87 anonymous respondents who so generously gave their time to provide their insights during the studyâs qualitative interviews. We also wish to express our sincere thanks to the speakers, listed in Appendix B, and other participants at the committeeâs public sessions in Washington, DC, and Kigali, Rwanda, for their time and their willingness to share with us their various perspectives. In addition, we are grateful to Dr. Khama Rogo and Dr. Daniel Yumbya for providing insight and guidance on the health professional education systems and accreditation processes in East Africa. We are profoundly grateful to the leadership and staff at the Rwandan Ministry of Health, Rwanda Biomedical Center, University of Rwanda, Rwanda Medical Association, and Rwanda Nurses and Midwives Union for providing the data presented in this study and for their thoughtful input and cooperation. Without the support and commitment, at every juncture, of Dr. Diane Gashumba, Dr. Jean Pierre Nyemazi, Dr. Sabin Nsanzimana, Mr. Joseph Shema, Dr. Parfait Uwaliraye, Dr. Patrck Ndimubanzi, Dr. Jeanine Condo, Dr. Phil Cotton, Dr. David Ntirushwa, and Mr. Andre Gitembagara this report would not have been possible. We are extremely appreciative of the efforts of Dr. Kristine Gebbie, who twice oversaw reviews of this study, first at the protocol stage and later as a xiii
xiv ACKNOWLEDGMENTS final manuscript. In addition, we are indebted to the following individuals who gave generously of their time and expertise to review the studyâs pro- tocol in December 2018: Dr. Sangeeta Mookherji, The George Washington University; Dr. Sam Phiri, Lighthouse Trust, Malawi; Dr. Shoshanna Sofaer, City University of New York; Dr. Allison P. Squires, New York University; and Dr. Kathryn Whetten, Duke University. We also wish to thank staff with the Presidentâs Emergency Plan for AIDS Relief (PEPFAR) and the U.S. Centers for Disease Control and Pre- vention (CDC) Rwanda and with CDC Atlanta, most especially Ms. Emma Mtiro, for their support and guidance over the course of the study. Finally, many within the National Academies of Sciences, Engineer- ing, and Medicine also provided assistance with the study. We would like to thank Rebecca Morgan with the National Academiesâ Research Center staff for her assistance with research. We also wish to thank Ron Brown, Daniel Cesnalis, Anna Isabel Camilo Javier, Julie Wiltshire, and Skip Day (Office of the Chief Financial Officer); Lauren Shern, Taryn Young, and Bet- tina Seliber (HMD Executive Office); Maryjo Oster and Dorothy Zolandz (Report Review Committee); Marc Gold (Office of the General Counsel); Andrew Grafton, Greta Gorman, Nicole Joy, Jeanay Butler, and Sadaf Faraz (Office of Communications); and Stephanie Miceli (Office of News and Public Information).
Contents ACRONYMS AND ABBREVIATIONS xxiii SUMMARY1 1 INTRODUCTION: EVALUATION SCOPE AND APPROACH 17 Background, 17 Rwanda Human Resources for Health Program, 18 Charge to the Committee, 21 Committeeâs Approach to the Charge, 23 Use of the Evaluation, 31 Organization of the Report, 31 References, 32 2 EVALUATION DESIGN, METHODS, AND LIMITATIONS 37 Design, 37 Limitations, 51 References, 53 3 HUMAN RESOURCES FOR HEALTH PROGRAM CONTEXT, VISION, AND DESIGN 55 Context in Rwanda Leading Up to the Program, 55 Human Resources for Health Program Vision and Design, 69 Design Process, 84 Financial Management, 88 xv
xvi CONTENTS Programmatic Management Approaches and Challenges, 91 Monitoring and Evaluation, 96 Sustainability Planning, 98 Conclusions, 101 References, 103 4 FACULTY TWINNING 109 Successes of Twinning, 112 Challenges with Twinning, 115 Conclusions, 119 References, 122 5 INSTITUTIONAL CAPACITY FOR HEALTH PROFESSIONAL EDUCATION 125 Quality of Teaching, 127 Recruitment and Retention of Health Professional Educators, 132 Curricula and Programs for Health Professional Education, 136 Accreditation and Specialty Programs, 150 Research and Professional Development, 152 Conclusions, 157 References, 161 6 HEALTH WORKER PRODUCTION 167 Health in the Rwandan Labor Market, 167 Recruitment and Retention of Health Workers, 177 Upgrading and Procuring Equipment, 185 Conclusions, 191 References, 194 7 EFFECTS ON HUMAN RESOURCES FOR HEALTH AND QUALITY OF CARE 201 Overall Effect of the Human Resources for Health Program, 202 The HIV Epidemic in Rwanda, 202 Sustainability and Institutionalization, 214 Conclusions, 219 References, 222 8 RECOMMENDATIONS 227 Overarching Evaluation Conclusions, 227 Implications for HIV and Human Resources for Health Programming, 228 Recommendations, 229 References, 246
CONTENTS xvii APPENDIXES A COMMITTEE MEMBER, CONSULTANT, AND STAFF BIOGRAPHIES 251 B PUBLIC SESSION AGENDAS 267
Box, Figures, and Tables BOX 1-1 Statement of Task, 22 FIGURES S-1 Key findings: successes and challenges, 5 1-1 HRH Program framework, 20 1-2 Theoretical causal pathway for the evaluation, 26 2-1 Evaluation process, 38 3-1 The size of the Rwandan economy from 2000â2018 in current U.S. dollars, 59 3-2 Health expenditures in Rwanda from 2000â2016 (in purchasing power parity per capita), 60 3-3 Proportion of health expenditure in Rwanda by revenue source, 60 3-4 PEPFAR Rwanda planned funding by program area and percent allocation for HSS, 61 3-5 MOH expenditures FY 2010/2011âFY 2014/2015 (U.S. dollars), 67 3-6 HRH Program time line, 85 xix
xx BOX, FIGURES, AND TABLES 6-1 Doctors, nurses, and midwives per 10,000 population, 168 6-2 Total physician specialists graduated under the HRH Program by year, 174 6-3 Total nursing specialists graduated under the HRH Program by specialty, 174 6-4 Career trajectory of interviewed HRH Program graduates following graduation, 178 6-5 Career trajectory of interviewed HRH Program trained nursing respondents, 179 6-6 Distribution of sites receiving health professional education equipment through PEPFAR support under the HRH Program by district, 187 7-1 HIV prevalence among Rwandan adults aged 15â49, 203 7-2 Antiretroviral therapy coverage, 2010â2017, 204 7-3 New HIV infections, 1990â2018, 209 7-4 PMTCT need and number of pregnant women on ARVs, 2011â2016, 210 7-5 Data-driven causal pathway, 213 TABLES 1-1 HIV Prevalence and ART Coverage in Surrounding Countries in the Eastern and Southern African Regions, 2012, 29 2-1 HIV Prevalence and ART Coverage in Facility Microsystem Districts, 41 2-2 Interview Respondent Sample, 42 2-3 Interview Topics by Respondent Type, 46 3-1 PEPFAR Funding Sources That Contributed to the HRH Program, 64 3-2 HRH Program Budget by Year (U.S. Dollars), 66 3-3 CDC Disbursements for the HRH Program by Year (U.S. Dollars), 66 3-4 Ministry of Health Budget and Expenditures Reported Preceding and During the HRH Program (U.S. Dollars, Rounded to Millions), 67 3-5 MOH Health Workforce Expenditures with Category Breakdowns by Year (U.S. Dollars), 68 3-6 Evolution of the HRH Programâs Goals and Approaches, 75 3-7 HRH Program Expenditures of PEPFAR Investments (U.S. Dollars), 89
BOX, FIGURES, AND TABLES xxi 5-1 Comparative Analysis of MHA and MSN Programs, 146 5-2 Required CPD Credits by Profession, 156 6-1 Number of Health Practitioners in Rwanda by Level, 171 6-2 University of Rwanda Medical Student Graduation Numbers by Program, 173 6-3 Number of Practitioners Receiving Their License, 176 6-4 Distribution of All Physician Specialists and General Practitioners by Health Facility Level, 178 6-5 Equipment by District Procured with PEPFAR Support Under the HRH Program, 2013â2017, 188 6-6 Equipment by Site Procured with PEPFAR Support Under the HRH Program, 2013â2017, 189 6-7 Types of Equipment Procured with PEPFAR Support Under the HRH Program, 2013â2017, 190 7-1 Progress Toward 90-90-90 Treatment Cascade Targets in Rwanda, 205 7-2 UNAIDS and PEPFAR Estimates of PMTCT Coverage in Rwanda, 2011â2016, 209
Acronyms and Abbreviations APEFE Association pour la Promotion de lâÃducation et de la Formation Ã lâEtranger ART antiretroviral therapy ARV antiretroviral (drug) BSN Bachelor of Science in Nursing CD4 cluster of differentiation 4 CDC U.S. Centers for Disease Control and Prevention CHAI Clinton Health Access Initiative CHUB Centre Hospitalier Universitaire de Butare/University Teaching Hospital, Butare CHUK Centre Hospitalier Universitaire de Kigali/University Teaching Hospital, Kigali CHW community health worker CMHS College of Medicine and Health Sciences COP country operational plan COSECSA College of Surgeons of East, Central, and Southern Africa CPD continuing professional development ESTHER pour une solidaritÃ© thÃ©rapeutique Ensemble hospitaliÃ¨re en rÃ©seau/Network for Therapeutic Solidarity in Hospitals xxiii
xxiv ACRONYMS AND ABBREVIATIONS FCS(ECSA) Fellowship of the College of Surgeons of East, Central, and Southern Africa FY fiscal year GDP gross domestic product GHWA Global Health Workforce Alliance GP general practitioner HRH human resources for health HSS health systems strengthening HSSP IV Health Sector Strategic Plan 4 LMIC low- and middle-income country M&E monitoring and evaluation MDG Millennium Development Goal MHA Master of Hospital and Healthcare Administration MIFOTRA Ministry of Public Service and Labour MINECOFIN Ministry of Finance and Economic Planning M.Med. Master of Medicine MOE Ministry of Education MOH Ministry of Health MOU memorandum of understanding MSN Master of Science in Nursing NGO nongovernmental organization NISR National Institute of Statistics of Rwanda PEPFAR Presidentâs Emergency Plan for AIDS Relief PLHIV people living with HIV PMTCT prevention of mother-to-child transmission PrEP preexposure prophylaxis RBC Rwanda Biomedical Center RPHIA Rwanda Population-Based HIV Impact Assessment RWF Rwandan Francs Sida Swedish International Development Cooperation Agency SMART specific, measurable, achievable, relevant, and time- based SPH School of Public Health SPIU Single Project Implementation Unit
ACRONYMS AND ABBREVIATIONS xxv TAGGS Tracking Accountability in Government Grants TDF tenofovir disoproxil fumarate THET Tropical Health Education Trust UGHE University of Global Health Equity UHC universal health coverage UNAIDS Joint United Nations Programme on HIV/AIDS USAID United States Agency for International Development USD U.S. dollar USI U.S. institution WHO World Health Organization