Catching up to a fast-moving target: Evaluation of a health system strengthening intervention in rural Rwanda 2005-2010 using data from repeated cross-sectional surveys

Introduction Although Rwanda’s health system underwent major reforms and improvements after the 1994 Genocide, the health system and population health in the southeast lagged behind other areas. In 2005 Partners In Health and the Rwandan Ministry of Health began a health system strengthening intervention in this region. Methods Combining results from the 2005 and 2010 Demographic and Health Surveys with those from a supplemental 2010 survey, we compared changes in health system output indicators and population health outcomes between 2005 and 2010 as reported by 21,338 women living in the intervention area and similar rural areas, controlling for potential confounding by economic and demographic variables. Results Overall health system coverage improved similarly in both regions between 2005 and 2010, with an indicator of composite coverage of child health interventions increasing from 57.9% to 75.0% in the intervention area and from 58.7% to 73.8% in other rural areas. Despite experiencing poorer health outcomes in 2005, the intervention area caught up to or exceeded other rural areas on 23 of 25 indicators. Most notably, under-five mortality declined by an annual rate of 12.8% in the intervention area, from 229.8 to 83.2 deaths per 1000 live births, and by 8.9% in other rural areas, from 157.7 to 75.8 deaths per 1000 live births. Improvements were most dramatic among the poorest households. Conclusion We observed dramatic improvements in population health outcomes including under-five mortality between 2005 and 2010 in rural Rwanda generally, and in the intervention area specifically. SUMMARY BOX What is already known about this topic? Much of the evidence that health system strengthening in rural Africa has improved health outcomes comes from studies of targeted regional interventions such as performance based financing or community health worker programs, rather than integrated interventions that encompass multiple components including infrastructure and supply chain investments, health management information system, workforce training and incentives at all levels, community health workers, and free services for poor patients. In addition to these experimental or quasi-experimental studies, a series of case studies have documented individual nations, pathways to achieving millennium development goal 4 target, the reduction of under-five mortality by two thirds between 1990 and 2015. These reports suggest that improvements in coverage of reproductive, maternal and child health indicators explain some, but not all, of the decline in child mortality and that these successes occurred in the context of national gains in health, nutrition and food security, sanitation, poverty reduction, and access to clean water. What are the new findings? Coverage of most maternal and child health care interventions improved at a similar pace in our rural intervention area and other rural areas. Despite experiencing poorer health outcomes in 2005, our rural intervention area caught up to or exceeded other rural areas on 23 of 25 population health indicators by 2010. Infant and under-5 mortality declined in our rural intervention area even more precipitously than in other rural areas of Rwanda between 2005 and 2010. How might this influence practice? The process of strengthening national health systems often involves trade-offs between a focus on first testing individual programs that distributed widely, as is often practiced by pilot programs with multilateral institutions, or implementing multiple simultaneous programs locally. Our results show that integrated health system strengthening interventions can be locally adapted to enable the rapid expansion of health care coverage as well as dramatic improvements in population health outcomes. Integrated multi-level interventions can also help narrow the health care coverage and outcome gap between richer and poorer members of a society. National governments can leverage nongovernmental partners to achieve the health related sustainable development goals through joint implementation of national health policy.