Quality and resilience of clinical laboratories in Rwanda: a need for sustainable strategies.

BACKGROUND: Quality healthcare is a global priority, reliant on robust health systems for evidence-based medicine. Clinical laboratories are the backbone of quality healthcare facilitating diagnostics, treatment, patient monitoring, and disease surveillance. Their effectiveness depends on sustainable delivery of accurate test results. Although the Strengthening Laboratory Management Towards Accreditation (SLMTA) programme has enhanced laboratory quality in low-income countries, the long-term sustainability of this improvement remains uncertain. OBJECTIVE: To explore the sustainability of quality performance in clinical laboratories in Rwanda following the conclusion of SLMTA. METHODS: A quasi-experimental design was adopted, involving 47 laboratories divided into three groups with distinct interventions. While one group received continuous mentorship and annual assessments (group two), interventions for the other groups (groups one and three) ceased following the conclusion of SLMTA. SLMTA experts collected data for 10 years through assessments using WHO's StepwiseLaboratory Quality Improvement Process Towards Accreditation (SLIPTA) checklist. Descriptive and t-test analyses were conducted for statistical evaluation. RESULTS: Improvements in quality were noted between baseline and exit assessments across all laboratory groups (mean baseline: 35.3%, exit: 65.8%, p < 0.001). However, groups one and three experienced performance declines following SLMTA phase-out (mean group one: 64.6% in reference to 85.8%, p = 0.01; mean group three: 57.3% in reference to 64.7%, p < 0.001). In contrast, group two continued to enhance performance even years later (mean: 86.6%compared to 70.6%, p = 0.03). CONCLUSION: A coordinated implementation of quality improvement plan that enables regular laboratory assessments to pinpoint and address the quality gaps is essential for sustaining quality services in clinical laboratories.

Main findings: We found that continuous laboratory quality improvement was achieved by laboratories that kept up with regular follow-ups, as opposed to those which phased out these followups prematurely.Added knowledge: This study has affirmed the necessity of maintaining mentorship and conducting regular quality assessments until requisite quality routines are established to sustain laboratory quality services.Global health impact for policy and action: These findings emphasise the significance of instituting a laboratory quality plan, with regular assessments, as policy directives to uphold and enhance quality standards, which benefits both local and global communities, given the pivotal role of laboratories in patient treatment, disease prevention, and surveillance.

Predictors of physical violence against children in Rwanda: findings from a National Cross-Sectional Survey.

BACKGROUND: To address the challenges of limited national data on the prevalence and nature of violence experienced by children, Rwanda conducted, in 2015-2016, the first National Survey on Violence among female and male children and youth aged 13-24 years. To further contribute to these efforts to fill existing data gaps, we used the Rwanda survey data to assess the prevalence and predictors of physical violence (PV) in children aged 13-17. METHODS: A nationally representative sample of 618 male and 492 female children were analysed. Nationally representative weighted descriptive statistics were used to analyse the prevalence of PV self-reported by children, and logistic regression models were applied to investigate its predictors. RESULTS: Sixty percent of all children, including 36.53% of male and 23.38% of female children, reported having experienced any form of PV in their lifetime. Additionally, 21.81% of male children and 12.73% of female children reported experiences of PV within twelve months before the survey date. Older children (OR: 0.53 [0.40-0.72]), female children (OR: 0.43 [0.31-0.58]), and children not attending school (OR: 0.48 [0.31-0.73]) were less likely to be physically abused. However, sexually active children (OR: 1.66 [1.05-2.63]), children in households from the middle wealth quintile (OR: 1.63 [1.08-2.47]), children living in a larger family (OR: 1.55 [1.07-2.26]), and children who reported not feel close to both biological parents (OR: 2.14 [1.31-3.49]) had increased odds of reporting physical violence. CONCLUSION: Higher rates of PV in children attending school were the key finding. There is an urgent need to design and implement particular national interventions to prevent and reduce the incidence of PV in schools in Rwanda. PV was also associated with poor parent-child relations. Parents and other adult caregivers should be sensitised to the consequences of PV on children and be urged to adopt positive parenting practices.

Physicians' satisfaction with clinical referral laboratories in Rwanda.

BACKGROUND: The quality of laboratory services is crucial for quality of patient care. Clinical services and physicians' decisions depend largely on laboratory test results for appropriate patients' management. Therefore, physicians' satisfaction with laboratory services is a key measurement of the quality service that stresses impactful laboratory service improvement to benefit patients. OBJECTIVE: To assess physicians' satisfaction and perspectives on the quality of services in clinical referral laboratories in Rwanda. METHODS: A cross-sectional survey among physicians from four referral hospitals with closed-ended questionnaire and one general open-ended question. A five-point Likert scale rating was used to measure satisfaction. Descriptive, ordered logistic regression, and thematic analysis were used. RESULTS: In total, 462 of 507 physicians (91% response rate) participated in the study. Overall mean satisfaction was 3.2 out of 5, and 36.2% of physicians were satisfied (satisfied and strongly satisfied) with laboratory services. In four service categories out of 17, the physicians' satisfaction was over 50%. The categories were: reliability of results (69.9%), adequacy of test reports (61.9%), laboratory staff availability (58.4%), and laboratory leadership responsiveness (51.3%). Lowest satisfaction was seen for routine test turnaround time (TAT) (19.3%), in-patient stat (urgent) test TAT (27%), communication of changes such as reagent stock out, new test (29%), and missing outpatient results (31%). Eighty-four percent answered that test TAT was not communicated, and 73.4% lacked virology diagnostics. Pediatricians, internists, and more experienced physicians were less satisfied. While ineffective communication, result delays, and service interruption were perceived as dissatisfying patterns, external audits were appreciated for improving laboratory services. CONCLUSION: Availing continuously laboratory tests, timely result reporting, and effective communication between laboratories and clinicians would increase physicians' satisfaction and likely improve the quality of health care. Laboratory staff participation in clinical meetings and ward rounds with physicians may address most of the physicians' concerns.

Leveraging massive open online courses to expand quality of healthcare education to health practitioners in Rwanda.

Improving the quality of healthcare delivery is increasingly a global health priority. However, quality improvement training opportunities that provide theoretical foundations and basic skills for patient safety and other quality initiatives have been limited or historically out of reach, especially in low-and-middle income countries (LMICs). To address this gap, the Harvard Initiative on Global Health Quality (HIGHQ) created and launched a massive open online course (MOOC) in 2014 focused on patient safety and quality of care using the edX platform. More than 30 000 students from across 195 countries registered for the online course. This paper summarises an innovative educational partnership between the course team and one of these countries, Rwanda, to develop a blended-learning model to bolster participation in this new course among Rwandan healthcare professionals. Although a small country, Rwanda was among the top performing countries for attracting course registrants and was the leading country for the proportion of enrollees who ultimately completed the course. Further, half (21 of 42) of Rwanda's district hospitals opted to appoint a PH555x course facilitator at their site to help lead regular meetings and discussions about the course content at their facility. The majority of Rwandan enrollees were health professionals (63%) and 81% reported that PH555x was their first experience taking an online course. Among those participating in the 'flipped' component at hospital sites, 94% reported that the course helped them to think of specific ways to improve healthcare quality at their facility. In this paper, we describe this innovative public-private educational model, challenges to implementation and lessons learned that may be helpful for future MOOC developers who wish to augment learning opportunities among healthcare professionals in LMICs.

Clinical Referral Laboratory Personnel's Perception of Challenges and Strategies for Sustaining the Laboratory Quality Management System.

OBJECTIVES: To explore challenges explaining the decrease in quality performance and suggest strategies to improve and sustain laboratory quality services. METHODS: Twenty key informants' interviews from laboratory personnel were conducted in five laboratories. Four had previously shown a decrease in quality performance. Interviews were transcribed verbatim and analyzed using inductive thematic analysis. RESULTS: Two themes emerged: (1) insufficient coordination and follow-up system towards accreditation, where lack of coordination, follow-up, and audits explained the decrease in performance; (2) inadequate resource optimization, where insufficient knowledge in Laboratory Quality Management System (LQMS), ownership by laboratory workforce, and insufficient stakeholders' communication contributed to low-quality performance. CONCLUSIONS: The coordination, follow-up, and assessments of LQMS, in conjunction with training of laboratory workforce, would establish an institutional culture of continuous quality improvement (CQI) towards accreditation and sustainment of quality health care. To achieve CQI culture, routine gap checking and planning for improvement using a system approach is required.

Clinical Referral Laboratories in Rwanda.

OBJECTIVES: We investigated the quality system performance in Rwandan referral laboratories to determine their progress toward accreditation. METHODS: We conducted audits across five laboratories in 2017, using the Stepwise Laboratory Quality Improvement Process Towards Accreditation checklist. Laboratories were scored based on the World Health Organization grading scale (0-5 stars scale) and compared with earlier audits. RESULTS: Between 2012 and 2017, only one laboratory progressed (from four to five stars). Four of the five laboratories decreased to one (three laboratories) and zero (one laboratory) stars from four and three stars. Management reviews, evaluation, audits, documents, records, and identification of nonconformities showed a low performance. CONCLUSIONS: Four of five laboratories are not moving toward accreditation. However, this target is still achievable by energizing responsibilities of stakeholders and monitoring and evaluation. This would be possible because of the ability that laboratories showed in earlier audits, coupled with existing health policy that enables sustainable quality health care in Rwanda.

Health worker attrition at a rural district hospital in Rwanda: a need for improved placement and retention strategies.

INTRODUCTION: The shortage and maldistribution of health care workers in sub-Saharan Africa is a major concern for rural health facilities. Rural areas have 63% of sub-Saharan Africa population but only 37% of its doctors. Although attrition of health care workers is implicated in the human resources for health crisis in the rural settings, few studies report attrition rates and risk factors for attrition in rural district hospitals in sub-Saharan Africa. METHODS: We assessed attrition of health care workers at a Kirehe District Hospital in rural Rwanda. We included all hospital staff employed as of January 1, 2013 in this retrospective cohort study. We report the proportion of staff that left employment during 2013, and used a logistic regression to assess individual characteristics associated with attrition. RESULTS: Of the 142 staff employed at Kirehe District Hospital at the start of 2013, 31.7% (n=45) of all staff and 81.8% (n=9) of doctors left employment in 2013. Being a doctor (OR=10.0, 95% CI: 1.9-52.1, p=0.006) and having up to two years of experience at the hospital (OR=5.3, 95% CI: 1.3-21.7, p=0.022) were associated with attrition. CONCLUSION: Kirehe District Hospital experienced high attrition rates in 2013, particularly among doctors. Opportunities for further training through Rwanda's Human Resources for Health program in 2013 and a two-year compulsory service program for doctors that is not linked to interventions for rural retention may have driven these patterns. Efforts to link these programs with rural placement and retention strategies are recommended.

Impact of a district-wide health center strengthening intervention on healthcare utilization in rural Rwanda: Use of interrupted time series analysis.

BACKGROUND: Evaluations of health systems strengthening (HSS) interventions using observational data are rarely used for causal inference due to limited data availability. Routinely collected national data allow use of quasi-experimental designs such as interrupted time series (ITS). Rwanda has invested in a robust electronic health management information system (HMIS) that captures monthly healthcare utilization data. We used ITS to evaluate impact of an HSS intervention to improve primary health care facility readiness on health service utilization in two rural districts of Rwanda. METHODS: We used controlled ITS analysis to compare changes in healthcare utilization at health centers (HC) that received the intervention (n = 13) to propensity score matched non-intervention health centers in Rwanda (n = 86) from January 2008 to December 2012. HC support included infrastructure renovation, salary support, medical equipment, referral network strengthening, and clinical training. Baseline quarterly mean outpatient visit rates and population density were used to model propensity scores. The intervention began in May 2010 and was implemented over a twelve-month period. We used monthly healthcare utilization data from the national Rwandan HMIS to study changes in the (1) number of facility deliveries per 10,000 women, (2) number of referrals for high risk pregnancy per 100,000 women, and (3) the number of outpatient visits performed per 1,000 catchment population. RESULTS: PHIT HC experienced significantly higher monthly delivery rates post-HSS during the April-June season than comparison (3.19/10,000, 95% CI: [0.27, 6.10]). In 2010, this represented a 13% relative increase, and in 2011, this represented a 23% relative increase. The post-HSS change in monthly rate of high-risk pregnancies referred increased slightly in intervention compared to control HC (0.03/10,000, 95% CI: [-0.007, 0.06]). There was a small immediate post-HSS increase in outpatient visit rates in intervention compared to control HC (6.64/1,000, 95% CI: [-13.52, 26.81]). CONCLUSION: We failed to find strong evidence of post-HSS increases in outpatient visit rates or referral rates at health centers, which could be explained by small sample size and high baseline nation-wide health service coverage. However, our findings demonstrate that high quality routinely collected health facility data combined with ITS can be used for rigorous policy evaluation in resource-limited settings.

Intensive point-of-care ultrasound training with long-term follow-up in a cohort of Rwandan physicians.

OBJECTIVE: We delivered a point-of-care ultrasound training programme in a resource-limited setting in Rwanda, and sought to determine participants' knowledge and skill retention. We also measured trainees' assessment of the usefulness of ultrasound in clinical practice. METHODS: This was a prospective cohort study of 17 Rwandan physicians participating in a point-of-care ultrasound training programme. The follow-up period was 1 year. Participants completed a 10-day ultrasound course, with follow-up training delivered over the subsequent 12 months. Trainee knowledge acquisition and skill retention were assessed via observed structured clinical examinations (OSCEs) administered at six points during the study, and an image-based assessment completed at three points. RESULTS: Trainees reported minimal structured ultrasound education and little confidence using point-of-care ultrasound before the training. Mean scores on the image-based assessment increased from 36.9% (95% CI 32-41.8%) before the initial 10-day training to 74.3% afterwards (95% CI 69.4-79.2; P < 0.001). The mean score on the initial OSCE after the introductory course was 81.7% (95% CI 78-85.4%). The mean OSCE performance at each subsequent evaluation was at least 75%, and the mean OSCE score at the 58-week follow up was 84.9% (95% CI 80.9-88.9%). CONCLUSIONS: Physicians providing acute care in a resource-limited setting demonstrated sustained improvement in their ultrasound knowledge and skill 1 year after completing a clinical ultrasound training programme. They also reported improvements in their ability to provide patient care and in job satisfaction.

Rwanda 20 years on: investing in life.

Two decades ago, the genocide against the Tutsis in Rwanda led to the deaths of 1 million people, and the displacement of millions more. Injury and trauma were followed by the effects of a devastated health system and economy. In the years that followed, a new course set by a new government set into motion equity-oriented national policies focusing on social cohesion and people-centred development. Premature mortality rates have fallen precipitously in recent years, and life expectancy has doubled since the mid-1990s. Here we reflect on the lessons learned in rebuilding Rwanda's health sector during the past two decades, as the country now prepares itself to take on new challenges in health-care delivery.