HEALTH IN THE RWANDAN LABOR MARKET

In 2018, Rwanda's population was recorded at more than 12 million, with a working age population of 6.9 million and a labor force of approximately 3.9 million (NISR, 2018). It also has one of the highest rates of female labor force participation and is the only low-income country of the five countries (Iceland, Finland, Norway, Sweden, and Rwanda) that has closed at least 80 percent of the gender gap (Thomson, 2017; World Bank, 2018). The latest Labor Force Survey from the National Institute of Statistics of Rwanda (NISR) reported that of the population of 3,207,336 employed individuals, 49,072 (1.5 percent) are working in the field of human health and social work activities (NISR, 2018). The health workforce has increased in both number and proportion at a rate of 6.9 percent since 2002; data from the Rwanda Population and Housing Census reported that the health workforce numbered 15,084 (0.46 percent) in 2002, and 29,413 (0.7 percent) in 2012 (NISR, 2014).

Health Workforce by Cadre

The 1994 genocide against the Tutsi nearly destroyed the health infrastructure and resulted in acute shortages of a supply of qualified and specialized health workforce, which hindered health service delivery and served as a major barrier to HIV care and treatment. In 2009, it was estimated that a 14.2 percent rate of health workforce growth per annum was required, according to Rwanda's population growth rate at that time (Kinfu et al., 2009).

Between 2009 and 2015, as Figure 6-1 illustrates, the number of health workers in Rwanda remained relatively consistent, with 7.8 to 8.9 doctors, nurses, and midwives per 10,000 people (MOH, 2015). When disaggregated by cadre, the majority of these health professionals were nurses (7.27 to 8.31), with significantly fewer doctors (0.58 to 0.64) and midwives (0.05 to 0.8). More recently, Rwanda was reported to have 1 physician (2018), 7 nurses and midwives (2018), and 3 other health workers per 10,000 population density (Open Data for Africa, 2018).

FIGURE 6-1

Doctors, nurses, and midwives per 10,000 population. SOURCE: MOH, 2015.

However, this was still far below the World Health Organization (WHO) recommended critical minimum threshold of 23 doctors, nurses, and midwives per 10,000 people in 2006, and even farther below the newer (2016) threshold of 44.5 per 10,000 (WHO, 2016). This shortfall represents a production challenge, meaning there is an insufficient number of trained health professionals relative to the need.

In 2011, 625 medical doctors, 8,273 nurses, and 240 midwives were providing care in Rwanda's referral and district hospitals and health centers (MOH, 2012a). In 2015, it was reported that there were 114 pharmacists, 1,545 laboratory technicians, and 263 anesthesia practitioners in Rwanda (MOH, 2015). Most doctors in Rwanda are general practitioners and perform a majority of the surgical care; 82 percent of the general surgery and obstetric procedures are performed at district hospitals (Kansayisa et al., 2018). Only about 50 fully trained surgeons and 170 anesthesia technicians were reported in Rwanda in 2012 (Petroze et al., 2012).

Compounding the shortage of doctors are absenteeism and the presence of “ghost workers,” people who draw a salary from the public sector although they are mostly absent. Doctors in urban areas combine public- and private-sector work, and usually at the cost of public-sector health service delivery through their lack of attendance (Lievens et al., 2010). Patients and health facility staff alike benefit from the doctors' time and expertise, but absenteeism leads to low quality and inadequate health care due to low output and productivity (Lievens and Serneels, 2006; Scheffler et al., 2016). The Rwandan government initiated a pay-for-performance strategy to improve the quantity and quality of health services provided in the public sector, making positive contributions to health worker performance (Ngo et al., 2016; Sekabaraga et al., 2011; Suthar et al., 2017; Zeng et al., 2014).

Rwanda is relatively better resourced with nurses, who predominantly staff health centers, where 85 percent to 89 percent of the mostly rural population receives care (Iyer et al., 2017; Uwizeye et al., 2018). As one approach to help alleviate the shortage of HRH and linked to decentralization of the health system, the health sector introduced task shifting¹ in 2009, shifting many clinical decisions and activities to nurses and community health workers (CHWs), including in the delivery of HIV care. With a deficit of physicians, task shifting would increase the ability to care for patients and would also decrease labor costs of the HIV program. The Ministry of Health (MOH) transferred the ability to prescribe antiretroviral therapy and provide routine follow-up care of HIV-positive patients on first-line drugs without complications to nurses (MOH, 2009b). The program trained more than 500 nurses to deliver HIV care and has achieved high levels of retention and improved patient health outcomes (Nsanzimana et al., 2015). The 2013 HIV and AIDS National Strategic Plan reemphasized task shifting of routine HIV care to nurses and the upgrading of nursing skills to equip them to care for pediatric patients and those on second-line prescriptions (MOH, 2013c).

Through further task shifting and a reformation of the national community health system, care for 80 percent of the disease burden was offloaded to CHWs at the village level through health promotion activities as well as preventive, diagnostic, and curative care (Binagwaho et al., 2012; Condo et al., 2014; MOH, 2013b). The Rwanda CHW Program was established in 1995, growing from 12,000 CHWs to now approximately 45,000 (RGB, 2017). Each village has three CHWs—a pair of general CHWs (binomes), who provide community health, nutrition, and HIV/AIDS prevention services, and a maternal health worker (animatrice de santé maternelle), who provides infant and pre- and postnatal maternity care. CHWs are elected by the communities they serve and undergo at least 6 years of education (Condo et al., 2014). Although task shifting has positively contributed to the supply of adequately trained health professionals, there are still significant shortages of physicians and physician specialists in the health workforce.

Publicly available data from the MOH's Annual Statistics Booklet, Annual Report, and the Master Facility List demonstrate an increase in health workers across type during a period concurrent with the HRH Program (see Table 6-1). These numbers encompass the newly trained health workers who participated in the HRH Program, those who were already working in the health system, and those who entered the Rwandan health system after being trained elsewhere. The committee was unable to disaggregate these data by source or career stage.

Including physician specialists and general practitioners, there were 1,350 physicians in Rwanda in 2018, which translates to 1 doctor per 8,919 population—below the Fourth Health Sector Strategic Plan (HSSP IV) national target of 1 doctor per 7,000 population by 2024 (MOH, 2018a,b).² Physician specialists, before embarking on specialization training, become general practitioners. Although trend data provide the number of health practitioners by level, these data do not highlight the number of general practitioners who became specialists, which might have some implications for achieving targets for generalists.

TABLE 6-1Number of Health Practitioners in Rwanda by Level

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	2010	2011	2012	2013	2014	2015	2016	2017	2018	HRH Target
General Practitioners	604	625	683	684	709	742			783*	1,182**
Physician Specialists		150**				197**			567*	551**
Nurses and Midwives	8,202	8,513	9,230	9,607	9,590	9,661			10,758*	11,384**
Community Health Workers***		~60,000	~60,000						~45,000

*

Ministry of Health: Rwanda Master Facility List, 2018 (MOH, 2018b). The Master Facility list counts health workers in the following categories: General Practitioner, Specialist, A1 Nurse, A2 Nurse, Midwife, Lab Technician, Physiotherapist, Anesthetist, Pharmacist, and Dentist.

**

Midterm review of the HRH Program (MOH, 2016). The definition of specialists according to the midterm review was “of specialized physicians in public-sector workforce with an M.Med., excluding those in exclusively administrative roles,” which may differ from “specialist physicians” as used in the Master Facility List, which did not include a definition.

***

Comprehensive Evaluation of the Community Health Program in Rwanda (LSTM, 2016).

SOURCES: MOH Annual Statistics Booklets or MOH Annual Reports unless otherwise noted. MOH, 2010, 2012a, 2013a, 2014a, 2015.

As of 2018, 5 of Rwanda's 30 districts had more than 1 doctor per 7,000 population and 8 districts had fewer than 1 doctor per 25,000 population (MOH, 2018b). Likewise, Rwanda's 9,551 nurses equate to 1 nurse per 1,261 population, below the HSSP IV target of 1 nurse per 800 population, and the 1,207 midwives equate to 1 midwife per 2,504 women of childbearing age, close to the national target of 1 midwife per 2,500 women of childbearing age (MOH, 2018a,b). In total in 2018, there were 10.5 doctors, nurses, and midwives per 10,000 population, an increase from 8.8 in 2011, before the start of the HRH Program and a 19 percent increase in total, led by a per population increase of 176 percent in physician specialists, a 10 percent increase in general practitioners, and 10 percent increase in nurses and midwives. However, Rwanda remains well below the Sustainable Development Goal index threshold of 4.45 doctors, nurses, and midwives per 1,000 population established by WHO as necessary to deliver essential health services (WHO, 2016). If Rwanda meets its HSSP IV targets, it will have 15 doctors, nurses, and midwives per 10,000 population by 2024.

Data from the University of Rwanda indicate that although more medical students graduated from undergraduate and postgraduate training programs after the HRH Program started, there was variability by specialty (see Table 6-2). The higher numbers of graduates in 2016, 2017, and 2018 reflect the increase in enrollment rates in the first 3 years of the Program. A maximum likelihood time series analysis was performed to assess the statistical significance of this increase (see Chapter 2 section for the rationale and methodology). Results indicated that the total number of physician specialists graduating per year from 2014 through 2018 increased significantly (P < 0.001), compared to the 2007–2013 period (see Figure 6-2). Data provided by the MOH indicated most medical specialists were distributed with high numbers at Rwanda Military Hospital, CHUK (University Teaching Hospital, Kigali), and CHUB (University Teaching Hospital, Butare)—and with smaller disbursements, in comparison, in Ruhengeri and Muhima hospitals—most of whom were internists, pediatricians, obstetricians and gynecologists, and/or surgeons. The impact of reduced investments in the HRH Program on graduation rates requires more time to assess.

FIGURE 6-2

Total physician specialists graduated under the HRH Program by year. NOTES: The 2016 HRH Program midterm review indicates that in 2015 there were 197 specialists in Rwanda; the 2018 Rwanda Master Facility List indicates this increased to 567 in 2018. (more...)

Additional MOH data on nursing specialists indicated that 111 nursing specialists graduated from the first Master of Science in Nursing (MSN) cohort from 2015–2017, with the most graduates from the pediatrics specialty, followed by medical surgical, and critical care and trauma (see Figure 6-3). Although the MSN program is still in its infancy, the number of specialist nurses produced in its early years is promising and could contribute to continued specialization of nurses and the provision of specialty care, although more time would be needed to evaluate the sustained impact.

FIGURE 6-3

Total nursing specialists graduated under the HRH Program by specialty. NOTES: The MSN program's first cohort matriculated in 2015. Presented data show the first graduated cohort for the 2-year programs from 2015–2017. SOURCE: Graduation data (more...)

TABLE 6-2University of Rwanda Medical Student Graduation Numbers by Program

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Department		2010	2011	2012	2013	2014	2015	2016	2017	2018
Bachelor of Medicine and Surgery		117	42	88	130	75	96	72	83	103
Postgraduate
	Anesthesiology	2	2	1	2	3	2	5	—	—
	Internal Medicine	3	3	6	1	6	10	14	12	17
	Pediatrics	5	5	8	—	1	6	14	13	11
	Obstetrics/Gynecology	6	—	7	—	5	6	14	10	13
	Ear, Nose, and Throat	—	—	—	—	2	3	3	1	—
	Family and Community Medicine	—	—	—	—	2	—	—	—	—
	Surgery	4	—	4	—	4	5	9	5	4
	Neurosurgery	—	—	—	—	—	—	—	1	1
	Orthopedics	—	—	—	—	—	—	—	—	1
	Urology	—	—	—	—	—	—	—	1	—
	Anatomical Pathology	—	—	—	—	—	—	—	4	4
	Psychiatry	—	—	—	—	—	—	—	3	2
	Emergency and Critical Care	—	—	—	—	—	—	—	—	6

SOURCE: Graduation data provided by the University of Rwanda.

The Rwanda Medical and Dental Council, established in 2003, is responsible for registering and licensing all medical and dental professionals practicing in both the public and private sectors in Rwanda. Doctors are required to renew licenses annually after completing a minimum of 50 continuing professional development credits. The National Council of Nurses and Midwives registers and licenses nurses and midwives in the public and private sectors. Licenses must be renewed every 3 years. According to their data, the number of general practitioners, physician specialists, and dentists receiving licenses has been increasing (see Table 6-3). The number of nurses and midwives receiving their licenses peaked in 2014 when the licensing system was newer. Another peak would have been expected in 2017 or 2018 as licenses issued in 2014 came up for renewal, but this was not observed in the data. Across all cohorts, 58 students graduated from the Master of Hospital and Healthcare Administration (MHA) program; another 3 received postgraduate certificates, and 5 were expected to graduate in 2019.

Interview respondents across all stakeholder types agreed that more physician specialists were trained and more nurses with advanced skills were produced under the HRH Program. One MOH representative who received her medical training before the program began expressed appreciation for the improved skills HRH trainees gained under the program:

The HRH Program was amazing—helped cover the gaps in-country, including specializations such as pediatrics and internal medicine. There is a difference in the quality of training and doctors from before the HRH Program…. We had high level, skilled teachers from top tier U.S. institutions. When I was training, we didn't learn how to treat HIV or co-infections, so that is a big difference the HRH Program has made. We don't have to retrain the graduates coming out now; they are integrated into the system, and their education is providing them the required skills. They are very well equipped. (87, Government of Rwanda HRH Program Administrator)

Respondents also credited the establishment of postgraduate specialty training programs in medicine and nursing under the HRH Program with producing more health workers with specialized skills. However, there were conflicting opinions on the distribution of these new specialists in medicine and nursing. One respondent from an international nongovernmental organization (NGO) commented that during a recent visit to a district hospital, he had observed that there were now 15 doctors, including physician specialists in obstetrics and gynecology and pediatrics, which was an increase from when his organization started working with the hospital (04, Other Donor Representative). Such increases were seen as strengthening the district hospital level and reducing the burden on referral hospitals (05, International NGO Representative). However, one international NGO respondent observed that despite the increase in the number of doctors, there was variation by specialty and uneven geographic distribution:

This last graduation round, I think for the first time I saw internal medicine graduates pumping up more rural district hospitals. Pediatricians have spread out a little bit more. I think the bigger residency programs have spread around a little bit further. I haven't seen any of the other specialties. So, most district hospitals don't have a pediatrician and … it's a part-time job and not a full-time placement. I don't think I have seen any advanced practice nurses spread out to the district level yet. (12, International NGO Representative)

TABLE 6-3Number of Practitioners Receiving Their License

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	2009	2010	2011	2012	2013	2014	2015	2016	2017	2018
Internal Medicine	61	70	83	102	106	120	117	103	93	95
Obstetrics and Gynecology	50	64	59	77	92	94	95	94	86	85
Neurology	4	3	3	4	5	5	4	5	4	3
Cardiology	6	7	6	7	6	6	8	8	9	8
Dentistry	—	—	—	21	28	50	48	48	38	47
Pediatrics	50	62	61	85	87	85	88	84	78	80
Surgery	27	38	44	60	60	65	59	57	57	47
Anesthesiology	23	27	28	33	32	33	28	29	26	26
Psychiatry	11	12	14	13	11	15	10	9	10	12
Emergency Medicine	1	2	3	3	11	11	11	8	9	6
General Practitioners	413	448	487	606	612	726	822	864	893	850
Nurses					2,988	5,027	2,298	2,954	1,369	1,116
Midwives					504	686	293	245	51	117

NOTES: 850 general practitioners received their licenses in 2018, while only 783 were in public practice, according to the Master Facility List. Physicians in private practice and those renewing their licenses but not practicing account for the difference. Per the Master Facility List, only 51 percent of all facilities in Rwanda are in the public sector, meaning a large portion of providers work in private, nongovernmental, and faith-based facilities.

SOURCE: Licensure data provided by the Rwanda Medical and Dental Council and National Council of Nurses and Midwives.

Data from the Master Facility List showed that in 2018, 447 of the 567 physician specialists worked in four districts—Gasabo, Huye, Kicukiro, and Nyarugenge—while six districts had no specialists and another five districts had only one each.

Evidence from qualitative data collection supports the claim that the HRH Program produced more health care workers and academics with specialized skills who are feeding back into the health system. For example, of 25 HRH trainees interviewed for this evaluation, 9 went on to work in district hospitals, 9 went to work in teaching hospitals, 4 became University of Rwanda faculty, 1 continued studies in Rwanda, and only 1 left to pursue other studies in the United States (see Figure 6-4).

FIGURE 6-4

Career trajectory of interviewed HRH Program graduates following graduation. NOTE: HRH = human resources for health; MHA = Master of Health Administration; MSN = Master of Science in Nursing; UR = University of Rwanda.

There is also clear evidence of upgrading of nurses in the interview respondent sample. Before the HRH Program, 4 were working as faculty in district nursing schools, 5 were working as A1 nurses, and 4 were working as A2 nurses. All 13 nurses improved their skills by one level through their courses under the HRH Program and have returned to or continued working in the health system, with 4 working in district hospitals, 5 working in teaching hospitals, 3 serving as faculty at the University of Rwanda, and 1 working as an MSN tutorial assistant while she finishes her degree (see Figure 6-5).

FIGURE 6-5

Career trajectory of interviewed HRH Program trained nursing respondents. NOTE: HRH = human resources for health; MHA = Master of Health Administration; MSN = Master of Science in Nursing; UR = University of Rwanda.

Of 567 physician specialists in Rwanda in 2018, 222 (39 percent) worked at the national referral and teaching hospitals, 221 (39 percent) at private facilities, 46 (8 percent) at the intermediate level, and 78 (14 percent) at the peripheral level (MOH, 2018b). The distribution of general practitioners is different, with the majority (53 percent) stationed at the peripheral level and only 11 percent at the national referral and teaching hospitals (see Table 6-4).

RECRUITMENT AND RETENTION OF HEALTH WORKERS

Retention of adequately trained graduates is among the ubiquitous challenges facing the region and is key to addressing an imbalanced health workforce (WHO, 2013). While sub-Saharan African medical schools have expanded student enrollment, “faculty-related issues were most commonly identified as key to improving the quality of graduates” (Mullan et al., 2011). In a survey of 146 medical schools, 26 percent of domestic graduates were reported to have migrated from their respective home countries within 5 years after graduation, with “80 percent of that emigration being to countries outside of Africa” (Chen et al., 2012). Even so, the “assessment of retention strategies has been challenging because of the poor ability by most health systems to track medical school graduates” (Mullan et al., 2011).

The 2011 HRH Strategic Plan set a goal to increase the number of skilled, motivated, and equitably distributed health care workers in Rwanda (MOH, 2011a). However, challenges persist in meeting this goal, including high health worker turnover rates that result in insufficient staff to provide training for new health care providers (MOH, 2013a); low salaries; and a lack of career growth and opportunity for further training that leads to attrition and a move from public to private service (MOH, 2011a). Other difficulties encountered with the health workforce include poor social and economic incentives to work in health care, lack of management tools, and a weak human resources information system (MOH, 2009a). High turnover of trained service providers is a major hurdle in maintaining sufficient levels of qualified staff (MOH, 2012b). As seen in other countries, an exodus of health care workers from Rwanda after receiving training also needs to be addressed (Alleyne, 2015), though given the timing of this evaluation, it was not possible to assess whether the newly trained nurses, midwives, and medical specialists were retained in Rwanda. Several of these factors are discussed in more detail in the sections that follow.

UPGRADING AND PROCURING EQUIPMENT

Across the region, issues of infrastructure permeate health professional education. A literature review of medical education in sub-Saharan Africa cited infrastructure as a common challenge due to the “inadequacy of overall funding to maintain or update facilities as well as the insufficiency of staff resources for teaching and administration” (Greysen et al., 2011). Additionally, “the quantity and quality of a number of resources—student and teaching resources, technology, and clinical teaching sites—were perceived by respondents on average to be below adequate” (Chen et al., 2012). Chen and colleagues (2012) also write:

Medical schools report inadequacies in a number of key physical resource areas, including skills and research labs, journals, student residences, and computers.… The most significant reported barriers to improving quality and increasing graduate numbers are insufficient physical infrastructure (labs, computers, teaching resources, and libraries) and faculty shortages.

In fact, physical infrastructure was included as one of the “greatest needs for medical schools” (Chen et al., 2012).

Enhancing education-related infrastructure and equipment in health facilities and educational sites was a critical challenge to address within the HRH Program to facilitate improved health professional education and its sustainability (MOH, 2014b). With a total budget of $151.8 million for the 8-year project period, $29.8 million was projected for infrastructure and equipment upgrades under the line item “Rwandan Schools” (MOH, 2011b). Of that projected budget, $1.5 million was allocated for equipment maintenance. The 2014 monitoring and evaluation (M&E) plan cited two key output indicators for semiannual monitoring: (1) number of newly procured equipment and installed at site level, and (2) number of staff trained on equipment maintenance (MOH, 2014b).

According to MOH records, President's Emergency Plan for AIDS Relief (PEPFAR)-supported HRH Program expenditures totaled $59.1 million, including $17.9 million on health professional education-related equipment procurement, almost $2 million more than the $16.1 million budgeted for equipment. Equipment procured with PEPFAR funds included a range of items: teaching and reference books, thermometers and stethoscopes, teaching simulators, and larger equipment for clinical services, such as echocardiograph machines and portable blood testing machines. Equipment primarily went to facilities in 24 of Rwanda's 30 districts (see Figure 6-6), with the largest portion going to Nyarugenge District (see Table 6-5), specifically to CHUK, the country's largest teaching hospital (see Table 6-6). Huye District and CHUB, another large teaching hospital and the previous site of Rwanda's medical school, received the second largest amounts of equipment.

FIGURE 6-6

Distribution of sites receiving health professional education equipment through PEPFAR support under the HRH Program by district.

One HRH Program administrator from the Government of Rwanda described equipment as a component in the M&E plan; however, no such details were actually included. The financial sustainability of the HRH Program assumed 5 percent growth in the Government of Rwanda's budget and commitment to increased health-sector spending to meet Abuja Declaration targets estimated at $54.5 million, which would presumably include equipment maintenance costs (MOH, 2011b). Donor restrictions in what the HRH Program could fund were highlighted in the 2016 midterm review. Necessary infrastructure and medical equipment investments outlined in the funding proposal could not be funded, affecting planned hospital upgrades and development of new training programs such as dentistry⁴ (MOH, 2016). Challenges with procurement processes were also cited by respondents. The midterm review recommended improvements in infrastructure and equipment deficiencies as well as procurement delays moving forward. Non-Rwandan respondents noted similar challenges within the context of this evaluation.

Rwandan respondents reported that equipment was procured under the HRH Program, while non-Rwandan respondents were largely skeptical about whether teaching sites actually received such equipment. Government of Rwanda HRH Program administrators reported positive achievements in the increased procurement of equipment to fill gaps at the health facilities (e.g., ultrasound machines, autoclaves, anesthesia machines, pediatric monitors, radiotherapy and other heavy equipment, equipment to facilitate training at the simulation center, wireless Internet connections, computers, and other similar devices). One respondent from this stakeholder group stated:

The Program equipped the teaching site from the schools to the hospitals with innovative equipment. To equip them with wireless [equipment] … to upgrade their online library, buying some mannequins for simulation, constructing for simulation labs, and some heavy equipment. Even radiotherapy, they helped to buy a radiotherapy [device]. Even a cancer center, which is under building now. Not only that, for the nursing school which was upgraded, there was a simulation lab, a library with books, Internet connection, videoconference, even tablets for them to really access online courses. All these really have been achieved from the support of the HRH Program. (03, Government of Rwanda HRH Program Administrator)

Procurement data provided by the MOH demonstrate that the equipment with the greatest value was for radiology, while the greatest number of pieces of equipment purchased went to internal medicine as well as critical care and surgery. More sites received equipment for obstetrics and gynecology than other specialties (see Table 6-7).

Given that many of the resources went to purchasing equipment for tertiary care, it is understandable that the geographic distribution was weighted more toward urban locations, where tertiary care hospitals are located.

HRH trainees generally agreed that equipment had been procured, and reported improvements in infrastructure, such as access to research websites and educational materials; ultrasound machines; ear, nose, and throat materials; high-fidelity mannequins; new centers of excellence; and simulation labs. University of Rwanda administrators reported new e-learning programs, fiber-optic Internet, books, and subscriptions to journals. Nonetheless, HRH trainees reported that needs remained, and that some of the infrastructure the HRH Program had provided did not match their skill sets. An HRH Program administrator in the Government of Rwanda and a former HRH trainee further noted that training in equipment use and maintenance was lacking or a challenge. Almost all respondents reported that it was unclear which procurements were supported through the HRH Program or were unable to specifically link discrete procurements to the Program.

Non-Rwandan respondents reported skepticism on equipment procurement, citing that requests were changed or not delivered and that projected funds for procurement did not fund what they were intended to, or reported defensiveness from the MOH. One respondent supplemented procurement from Partners In Health funds. Specifically, for HIV, a donor agency respondent commented that her organization had procured equipment and other commodities for HIV service delivery. However, equipment was still viewed as missing or insufficient.

CONCLUSIONS

The HRH Program succeeded in expanding Rwanda's health workforce, with particular success in increasing the qualifications of nurses (both general and specialty) and increasing the number of physician specialists. The number of specialist physicians grew from 150 in 2011 to 567 in 2018, surpassing the HRH Program target of 551 (MOH, 2011b). It is important to note that the considerable gains in the number of specialists in Rwanda have not come at the expense of the number of general practitioners, which also increased. Although the targeted numbers of general practitioners and the targeted number of nurses and midwives were not reached, both have increased by 10 percent on a per-population basis since 2011. Also, while the absolute number of nurses fell short of the HRH Program target, the qualifications of nurses increased considerably, with 111 nurses graduating with specialty qualifications in the first cohort. According to the Master Facility List, there were 5,676 practicing A1 and A0 nurses in Rwanda in 2018 (MOH, 2018b). In 2011, there were 104 practicing nurses and midwives with bachelor's credentials and 797 with advanced diploma credentials according to the HRH Program midterm review (MOH, 2016).

More health workers, physician specialists, nurses, and midwives were produced but there is still an unmet need. Rwanda continues to lag well behind the WHO recommended 44.5 physicians, nurses, and midwives per 10,000 population with only 10.5 per 10,000 population. The country's HSSP IV targets call for increasing the health workforce to 15 doctors, nurses, and midwives per 10,000 population by 2024 (MOH, 2018a). This continued shortage poses a major bottleneck for the population of 10 million Rwandans seeking health services, with implications on their health outcomes.

Furthermore, distribution of health workers throughout the country remains inequitable. The geographic imbalances in the distribution of qualified health workers is exacerbated by those who favor urban areas, preference of workers for the private sector, and low levels of motivation and performance in the public sector (Lievens et al., 2010). Although some physician specialists have begun working at the district hospital level, the vast majority are concentrated in 4 of Rwanda's 30 districts (Gasabo, Huye, Kicukiro, and Nyarugenge). Likewise, the numbers of general practitioners, nurses, and midwives vary considerably. Five districts exceed the HSSP IV target of 1 doctor per 7,000 population, while 18 districts have fewer than 1 doctor per 15,000 population (MOH, 2018a). Four districts exceed the HSSP IV target of 1 nurse per 800 population, while 10 districts have fewer than 1 nurse per 2,000 population.

Retention strategies for trainees once they were placed into practice were outside the scope of the HRH Program; these strategies relied mainly on the government-established bonding mechanism, with limited approaches to bolster retention beyond this. Although graduates did work in the public health system, in large part due to the bonding scheme, the long-term impact on retention remains unclear, due to the timing of this evaluation. Retention in both Rwanda and in underserved areas is important to address. The availability of supplies and equipment, especially in remote and rural areas, is key to retaining health workers and promoting productivity and performance. In Ghana, for example, midwives cite several motivating factors for working in a rural area: having time off for training after 2 years of rural service; an acceptable work environment that includes a reliable supply of medications, electricity, and appropriate technology; and adequate housing. In Nigeria, inadequate facilities and medication supplies, poor management of the public health sector, and primitive living conditions affect retention of rural health workers (Awofeso, 2010), with midwives citing poor job satisfaction, low salaries, and lack of career opportunities (Adegoke et al., 2015).

Multiple studies have found decreased risk of emigration of health workers from low- and middle-income countries with expanded in-country specialty training, opportunities for research, and partnerships with universities that can offer research and leadership training. In-country training of physician specialists has been shown to improve retention, with 87 percent to 97 percent of surgeons trained at the Ghana College of Physicians and Surgeons from 2003 to 2016 remaining in Ghana (Gyedu et al., 2019). In the 25 institutions that train surgeons in the 10 countries that are covered by the College of Surgeons of East, Central and Southern Africa (COSECSA), 85.1 percent of 1,038 graduates from 1974 to 2013 stayed in the country of training, 88.3 percent stayed in the COSECSA region, and 93.4 percent stayed in Africa (Hutch et al., 2017).

Despite the increase in health workers and the upgrading of skills, there was a tension between the perceived need for specialized care and advanced practice skills and the perceived need for more general practice and primary care. The Alma Ata Declaration of 1978, reiterated in 2018, identified primary health care as pivotal to attaining the goal of health for all. Although significant advances have been made in primary health care, including health benefits across the social gradient, many have drifted away in preference for specific vertical health care programs (WHO, 1978, 2008). The tension between primary and specialist care can be further compounded by systems of financing. The payment policies in some insurance-based financing favor specialized services, while in some cases efforts to achieve universal health coverage (UHC) can increase the demand for primary care by reducing the financial burden for those seeking such care (Rao and Pilot, 2014).⁵

Rwanda's movement toward UHC is often cited as an example of success. Rwanda is continuing to make progress toward improved access to and use of health care through community-based health insurance and performance-based financing. Both options emphasize primary and preventive care, contributing to the envisioned Alma Ata Declaration with positive effects on the use of health care services such as curative care visits, institutional deliveries, antenatal care, or child health care (Collins et al., 2016; Rusa et al., 2009). The annual per capita use rate for community-based health insurance members surpassed the WHO recommended average of 1.0 visit, with 1.23 visits at the health center level and 0.18 at the district hospital level in 2012 and 2013. This was a marked increase from the 0.25 visits recorded in 1999 (Kalisa et al., 2016).

A specialty care model, when implemented successfully, can also expand access to care and care delivery through the implementation of management systems that emphasize standardization and continuous improvement, attracting and training of a specialized health workforce, access to equipment and low-cost technologies, and generation of patient volume (Bhandari et al., 2008). The growth of specialization in graduate medical education and physician practice has had an effect on physician workforce composition, contributing to a shortage in general practitioners. However, there is also a shortage of and critical need for specialized physicians, and the distribution of specialists is often imbalanced (Hoyler et al., 2014). Allowing nurses and midwives to practice to full scope can save lives and improve health outcomes, as has been noted for HIV and improved mother and baby outcomes (Colvin et al., 2010; Dohrn et al., 2009; Fairall et al., 2012; Iwu and Holzemer, 2014; Lancet Series on Midwifery Executive Group, 2014; Sanne et al., 2010).

Rwanda's pursuit of specialized physician care and upgraded nursing practice in some ways combined elements of both schools of thought (vertical/specialty versus horizontal/primary). Whether the balance was right, and can be maintained, remains to be seen. The concurrent role of CHWs and their support by health professionals was unaddressed in the HRH Program.

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