Increasing health system synergies in low-income settings: Lessons learned from a qualitative case study of Rwanda

ABSTRACT

Building synergies is seen as an effective strategy to address and decrease existing fragmentation in health systems of low-and middle-income countries (LMICs). To that end, different programmes, such as the Sector Wide Approach, have been adopted to increase health system synergies. Despite these efforts, fragmentation remains an enduring problem, hampering health system performance in LMICs. This study is part of the Lancet Commission on synergies between Universal Health Coverage, Health Security, and Health Promotion; we aimed to document synergising strategies adopted by Rwanda. Data for this paper came from a qualitative study including in-depth interviews of 15 key informants and a document review. A thematic analysis embracing deductive and inductive approaches was used to analyse the data. We found that Rwanda adopted three main strategies to increase health system synergies: (1) alignment of health programmes with national health policies and strategies, (2) increased coordination across national health institutions, and (3) effective monitoring and evaluation frameworks. Achieving synergies in a low-resource country is challenging but not impossible. To meet the target of global health agendas such as the Sustainable Development Goals and the prevention of future global pandemics, efforts to increase health system synergies in LMICs need to be strengthened.

KEYWORDS:

• Synergies
• fragmentation
• health system
• sub-saharan Africa
• health policy

Acknowledgements

We would like to express our sincere gratitude to the Lancet Commission and Wellcome Trust for selecting and funding this research. Moreover, we would like to thank all key informants who agreed to be part of this research and provided our study much valuable information. Lastly, we would like to express our gratitude to Regis Hitimana for supporting the Rwanda country case study report which informed this paper and also Maureen McGowan for her critical perspective on the material.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Declarations

Ethics approval and consent to participate

Ethical approval was obtained from the Rwanda National Ethics Committee (Reference No. 933/RNEC/2019) and by the National Health Research Committee (Ref. No. NHRC/2019/PROT/038). All participants were informed about the study objectives and provided written and verbal consent to participate in the study and prior to the beginning of the interviews. Participants knew and agreed to voluntarily participate. They were informed about their right to withdraw from the study at any given time without providing reasons. They knew that their responses would be audio-taped and that the produced data would be anonymised and used for analysis and publication.

Consent for publication

The consent for publication of anonymised quotes in peer reviewed journal publications was obtained from all participants.

Availability of data and material

All data and material produced and used for analytical purposes in this study can be requested from the corresponding author within reasonable terms.

Notes

1 WHO Triple Billion Targets – 13th General Programme of Work 2019–2023: 1 billion more people benefitting from universal health coverage; 1 billion more people better protected from health emergencies; 1 billion more people enjoying better health and well-being (https://www.who.int/news-room/questions-and-answers/item/the-triple-billion-targets)

Additional information

Funding

This study was funded by the Wellcome Trust, U.K., with Grant 214686/Z/18/Z under the umbrella of the Lancet Commission on Synergies between Universal Health Coverage, Health Security, and Health Promotion.