Mist had settled over the morning. I was visiting with staff at the Remera-Rukoma District Hospital in the hills of the Southern Province of Rwanda. Founded in 1927, the hospital serves a population of more than 376,000 people, providing 177 beds and receiving patients referred by 11 surrounding health centers.
I was there with the team from the Rwanda Health Systems Strengthening (RHSS) Project, supported by USAID and led by Management Sciences for Health (MSH), which works to reinforce the Rwandan government's capacity to plan, lead, and implement strategic interventions to strengthen key health system structures and processes, all while building sustainability and country ownership.
The first stop on our tour was the neonatal ward. Every day, staff at Remera-Rukoma deliver an average of nine babies, two of whom require birth by Caesarian section. Those born too early or struggling to survive are moved to the neonatal ward.
Seven beds, four incubators, equipment, and posters of neonatal practice and data lined the walls, taking up almost every square inch of the room. Four women, in their beds, were now long-term residents in the neonatal ward, as their babies relied on medical interventions to help keep them alive. A mother, with her twins sleeping on her chest, told me she had been there for over a month. Along one wall, an infant’s cry emanated from an ultraviolet incubator covered by a white sheet. In another incubator, a premature baby, connected to several tubes and swaddled in fleece blankets, slept quietly. Another, wearing a diaper more than half the size of his frail body, lay on his back, steadily breathing, showing his will to survive.
When a woman gives birth in a health facility, she trusts that she and her baby will be safe, and will emerge from the hospital alive and healthy. But if a health system fails to provide the high-quality care they need—which means mobilizing all of the necessary personnel, financing, and infrastructure—then neither mother nor child may survive.
Watching these babies breathe, attached to all kinds of machinery, and attended by a dedicated neonatal nurse, I thought about what it takes for a health system to keep just one premature baby alive. Here are just a few of the components that, together, help ensure that Remera-Rukoma District Hospital is able to provide care to its tiniest patients.
Policy and planning
Planning is the first step to achieving a functioning health system. Rwanda’s Ministry of Health (MoH) affirmed its commitment to maternal and newborn health in its fourth Health Sector Strategic Plan (HSSP) (2018-2024) where it states that by 2024, all persons in Rwanda will equitably receive quality Maternal, Neonatal, Child & Community Health (MCCH) services corresponding with the economic development standards of the country.
The RHSS Project works with district health management teams—comprising the district health director and leaders from hospitals, community health insurance, pharmacies, and health centers—to facilitate successful integration of the MoH’s priority areas and strategies for maternal and newborn health into planning and budgeting. Through collaboration with peers from other districts, and supported by workshops and coaching from the RHSS Project, district management teams define their objectives for the year, develop and implement action plans, create budgets, mobilize funds, and monitor finances.
While I was at the hospital, the RHSS Project was leading a three-day workshop to foster peer-to-peer learning sessions on strategic planning and financial management. Representatives from Remera-Rukoma and other hospitals in the Southern Province shared their experiences on addressing financial management challenges and strategies for steadily increasing hospital revenues. The neonatal ward has barely changed since colonial times, and it requires substantial infrastructural updates if it is going to provide modern high-quality services. Remera-Rukoma aims to increase its revenue, so that it may realize its vision of constructing a larger, updated neonatal ward.
Quality of care
Doctors and nurses must have the appropriate training and skills to provide high-quality health care to women and their premature babies, who are particularly vulnerable to potentially life-threatening infections and complications that affect their brain, heart, and lungs. The RHSS Project works with hospitals like Remera-Rukoma to develop and implement standards of quality care for maternal and newborn health, in line with Rwanda’s national accreditation program. The accreditation program addresses leadership, workforce competence, environmental safety, and patient-centered care to mitigate risk and improve health outcomes. Accreditation was scaled up to all district hospitals with the support of the RHSS Project. For instance, Remera-Rukoma staff adhere to hygiene standards by using personal protective equipment and regularly washing their hands at the station located outside the neonatal room.
Access to health services
Under the supervision of the local health center, three to four trained community health workers (CHWs) bring health services to every village. CHWs link women to Rwanda’s health system by providing health information and referring them to health facilities for antenatal care and safe delivery services. As a result of Rwanda’s efforts to increase coverage of these essential maternal health interventions, coverage of antenatal care (at least four visits) increased from 13% to 44%, and skilled birth attendance increased from 39% to 91% between 2005 and 2015.
All over Rwanda, CHWs have formed cooperatives, supervised by the health centers in their catchment areas, to manage funds received for meeting performance targets established by district health management teams. The MoH and the RHSS Project provide technical support to these CHW cooperatives on strategies to earn income in sectors such as agriculture and food, livestock, property rentals, and transportation. As these CHWs are volunteers, income-generating strategies help CHWs earn a living while providing health information and health facility referrals to the community.
All of the mothers in the neonatal ward at Remera-Rukoma were members of Rwanda’s community-based health insurance (CBHI) program. Introduced in 2004, CBHI, locally known as Mutuelle de Santé, is a government-led health insurance program improves people’s access to services and promotes a culture of prevention by removing the financial hardship of medical costs for individuals and families. According to RSSB/CBHI data, 71 percent of all Rwandans adhere to the CBHI scheme. Members pay their premiums based on their income, while the government subsidizes the full cost for families earning the lowest income. The RHSS Project works with the Rwanda Social Security Board, which manages the CBHI program, to analyze risk pools, establish and update claims management systems, investigate public and private sector costs of health services, and monitor and evaluate the CBHI program. As the majority of the Rwandan population is insured, the country’s gap in coverage between the poorest and richest quintiles for all of the pregnancy, birth, and newborn-related services is low, compared to other countries in the Central and East African region.
The premature babies surviving in the Remera-Rukoma neonatal ward are small miracles of what a working health system makes possible. When a health system works efficiently and effectively, it reaches—and saves the lives of—its most vulnerable people fighting to survive against all odds.
By: Alanna Savage