Improving district facility readiness: a 12-month evaluation of a data-driven health systems strengthening intervention in rural Rwanda

Figures & data

Table 1 Facility survey mapped to WHO building blocks

WHO building block	Facility readiness domain	Data elements	Examples of investment to fill identified gap
Service delivery	Infrastructure	Facility repair, availability of electricity, availability of safe water	Building renovations (such as re-roofing, re-painting, re-flooring), provision of utilities such as power and water supply through purchase of a backup generator, fuel or solar power, construction of rainwater collection containers
Service delivery	Clinical services	Services offered as expected, range of services offered	Trainings/mentorship in clinical areas through MESH program (28, 29)
Health workforce	Human resources	Number of clinical and non-clinical staff, staff retention	Salary support to ensure that health centers had staffing levels more in line with MOH norms
Health information systems, leadership/governance	M&E/information use	Data use, information availability	Provision of salaries for EMR data officers, trainings in monitoring and evaluation and data quality, laptop computers
Service delivery	Laboratory	Availability of gloves, needles, laboratory tests and reagents	Provision of laboratory equipment and reagents
Service delivery	Infection and sanitation control	Availability of hand washing stations, latrine functionality	Build latrines and toilets
Service delivery	Medical equipment	Availability and functionality of 15 essential pieces of equipment, presence of functional equipment	Provision of medical durables, such as hospital beds, neonatal warming lamps, delivery tables, and mosquito nets
Access to essential medicines	Pharmacy	Pharmaceuticals in stock, management of supplies	Provision of technical support, refrigerators, essential medicines, free specialty non-formulary medicines to district pharmacies
Financing	Social services	Support for patients unable to pay, social services	Assistance with the payment of mutuelle (Rwandan national health insurance) and ticket moderateur fees (co-payment for medical visits and treatment) for indigent patients
Service delivery	Referral	Ambulance availability, communication systems	Communications funding, purchase of ambulance to meet goal of five ambulances per district, dedicated nurse to follow referrals to reference hospitals
Leadership/governance	Management	Management practices	Technical assistance to GoR district leadership in implementing district health systems strengthening plan, coordination of regular meetings to review health center's functioning

Table 2 Change in domain scores from baseline to 12 months among intervention facilities compared to prior supported facilities

		Reference facilities	Intervention facilities
		N=6	N=14
WHO building blocks	Facility domain	Baseline score	Baseline score	Endline score	Difference^a	p ^b
Service delivery	Infrastructure	6.7	2.9	7.0	4.0	0.001
	Clinical services	8.6	8.7	9.9	1.2	0.03
	Lab services	8.1	7.1	7.6	0.5	0.58
	Infection and sanitation control	7.8	8.1	8.7	0.6	0.03
	Medical equipment	7.8	7.5	8.5	1.0	0.02
	Social services	3.3	2.1	4.6	2.5	0.20
	Referral	8.3	5.0	4.3	−0.7	0.73
	Management	6.7	7.9	8.3	0.5	0.63
Health workforce	Human resources	8.9	5.0	6.1	1.1	0.51
Health information systems	M&E/information use	7.6	6.3	8.4	2.0	0.002
Access to essential medicines	Pharmacy	7.1	7.9	8.4	0.5	0.11
Composite score (all domains)	Total	7.4	6.2	7.4	1.2	0.002

^aNumbers may not add up due to rounding; ^bWilcoxon signed rank test for non-parametric paired samples. Bold text refers to p-value<0.05.

Fig. 1 Per capita HS investments* in 2011 USD by funding source among intervention facilities (N=14) over a 12-month period to reference facilities (N=6) at baseline. *Includes in-kind donations.

Fig. 2 Sustainability in Facility Readiness Improvement among Intervention Facilities (N=14) after 36 months.

Table 3 Correlation between difference in composite facility score over 12 months and other covariates among 14 intervention facilities

	r	95% CI	p^a
Difference in composite facility score
Baseline score	−0.71	−0.90, −0.28	0.003
Baseline PHIT HSS direct funding	−0.16	−0.64, 0.41	0.58
Change in PHIT HSS direct funding	0.40	−0.16, 0.77	0.14
Change in equipment score	0.46	−0.09, 0.80	0.09
Change in HR score	0.52	−0.02, 0.82	0.049
Change in infrastructure score	0.14	−0.42, 0.63	0.62
Change in M&E/information score	−0.17	−0.65, 0.39	0.54
Change in laboratory score	0.51	−0.03, 0.82	0.054
Change in management score	0.33	−0.24, 0.73	0.24
Change in pharmacy score	0.19	−0.37, 0.66	0.50
Change in referral score	0.46	−0.09, 0.80	0.09
Change in sanitation score	0.06	−0.48, 0.57	0.83
Change in clinical services score	0.59	0.09, 0.86	0.02
Change in social services score	0.68	0.23, 0.89	0.005

^aBold text denotes p-value<0.05.

Fig. 3 Correlation between change in composite facility score and change in direct PHIT HSS funding among intervention facilities (N=14). Number in cells is the rank based on baseline composite score (lowest to highest).

Fig. 4 Standardized comparisons of intervention facilities (N=14) at baseline and 12 months to baseline facility scores for reference facilities.

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