Integrated PHC performance management system

Background: PHC in Rwanda

Strong primary healthcare (PHC) programs are a critical foundation required for the achievement of universal health coverage (UHC) and the health-related Sustainable Development Goals . PHC programs equitably maximize health and well-being – from health promotion and disease prevention to diagnosis, treatment, rehabilitation, and palliative care –in an accessible setting for all people. 

Rwanda has made substantial strides in improving its health systems, prioritizing PHC as one of the health sector's core strategies,  and dedicating 71% of its overall health spending on PHC (Rwanda's Health Resource Tracking Tool, 2014-15 data). Among the investments executed by the Rwandan government is the construction of more than 450 health posts that has resulted in 47% improvement in geographic accessibility reducing the average time to reach the nearest health facility on foot from 95 minutes in 2005/2006 to 50 minutes in 2016/2017. Moreover,  access to PHC services such as vaccination coverage among children aged 12 to 23 months has risen from 90% in 2010 to 96% in 2020, while the use of any modern contraceptive method has been increased from 45% in 2010 to 58% in 2020.

Rwandan Digital Health Information System to strengthen PHC system:

Complementing these achievements, since 2009 the Rwandan Ministry of Health (MOH) has embarked on digitizing the Health Information Management System (HMIS) for access to real-time data from its service delivery points (health facilities)and community health workers to monitor the health system functions. The first five-year Digital Health strategic plan was endorsed in 2009 and continued to be updated every five years in line with the national health sector strategic plan. The country has been an exemplar in Africa in implementing Digital Health solutions at a national scale. As a result, Rwanda has transitioned most of its routine health information reporting systems to the Rwanda HMIS (RHMIS) on the web-enabled DHIS-2 platform: These systems include the RHMIS, TracNet, SISCom, eIDSR, Health Financing, eTB). In Rwanda
However, gaps remain in the data from service delivery points (health facilities and communities): 

• Data lacks quality assurance mechanisms resulting from weak culture of data use especially at sub-national level by PHC implementers.
• Data is being reported in a fragmented manner rather than in form of integrated information that translates the collective performance in the PHC system. While a central DHIS2-based HMIS exists for disease-specific and service delivery data, data on human resources, infrastructure and medical equipment, community-level PHC services, and health insurance are captured in disparate tools, typically on Excel-based or paper-based systems. 
• There is no institutionalized mechanism to review PHC performance comprehensively in an integrated fashion, prioritize gaps, re-organize resources and timely action by PHC managers and service providers.
• No evidence-driven accountability framework is in place to include community participation to address the PHC gaps.

These challenges hinder effective PHC performance measurement and improvement at all levels. Relevant PHC stakeholders (i.e., patients, frontline health workers, policymakers, community members, CSOs and private sector) are not able to adequately define bottlenecks in their PHC system, mobilize and allocate resources efficiently, and execute solutions to improve equitable access and utilization of quality health services. The service coverage index of Rwanda (based on tracer interventions that include reproductive, maternal, new born and child health, infectious diseases, noncommunicable diseases and service capacity and access) is 65 out of 100, illustrating that current access to PHC by citizens is far below universal coverage targets. With a regular and effective PHC performance measurement strategy at all levels using real-time integrated performance indicators, gaps in PHC can be prioritized and efficiently addressed to  move towards universal access to quality PHC programs. 

In order to strengthen PHC systems and achieve UHC, Rwanda needs to assess how policy strategic decisions, implementation and investments are addressing the broader determinants of health. PHC performance measurement indicators have been developed globally but it has been a challenge for countries, including Rwanda, to adapt those measurement standard indicators and tools as well as contextualize the approach to be part of the routine health program performance within their health system. 

1. Develop a subnational (province, district, and health facility) PHC performance measurement framework and set key performance indicators that ultimately give a cumulative PHC performance status of the country once implemented at a scale. .
2. Strengthen the existing DHIS2-based HMIS in Develop a simple, interactive digital health tool manner: a) data integration across different existing health data sources, based on the PHC performance measurement framework from #1; b) an interactive dashboard (adapting the Primary Health Care Initiative (PHCI) model) to visualize sub-national performance for decision makers at all levels, allowing for rapid identification of program gaps
3. Establish PHC performance management and improvement system (including an accountability framework) to address identified gaps at all levels of the Rwandan health system.

Our solution leverages the widely used existing HMIS to integrate the range of PHC-relevant data sources into a single system, visualize the data in simple actionable dashboards, and offers a low cost digital health tool for data integration and sustainable approach of information use towards improving PHC performance measurement in Rwanda. The highly flexible and configurable DHIS2 system, used across over 55 countries as a national health information system, allows for data to be imported, or integrated (through application program interfaces, APIs), and for effective and customized dashboards for each user level to be developed and updated. 

The Ministry of Health MOH is well versed in maintaining and managing the DHIS2-based system, and will utilize its own health workforce, infrastructure, and leadership to implement these PHC performance tools and approaches with capacity building benefits for local and national level staff. 

• Leverages existing Rwandan digital health information systems to streamline the collection and interpretation of data to support meaningful use of primary health care data collected from different sources through various digital platforms. Given that Rwanda has a national digitalization strategy, we do not plan to deploy a new data collection system for PHC; rather develop a tool to integrate information from existing sources and produce useful information to assess PHC performance at institutions at all levels. 
• Aligns PHC performance ratings with the existing Performance Based Financing (PBF) approaches within the health care system in Rwanda to broaden key performance indicators to include PHC performance rather than verticalized disease or program performance of institutions and hence improve PHC financing.
• Provides actionable, accountable, and accessible insights for health care providers, health management leaders, donors that can be used to optimize the performance as well as accountability within primary health care leadership and service providers. 
• Provides opportunities for frontline health workers, communities, local CSOs and private sector to participate in performance monitoring and improvement efforts through different coordination platforms (such as joint review meetings among District health management, health facilities, community stakeholders) using visual tools to prioritize key gaps and dedicate resources towards addressing them for better PHC service as close to the community as possible.

Our approach leverages the existing established working relationship and trust by the Rwandan health sector leadership at the Ministry of Health and other relevant sector ministries to our organization, Clinton Health Access Initiative (CHAI) for the past two decades supporting government priorities to respond to needs of Rwandan citizens. 

Our solution targets all Rwandan citizens. Our solution focuses on establishing a sustainable PHC performance monitoring and improving system through the existing government structure and health institutions that demands community, local CSO and private sector involvement targeting prioritization and adequate resource allocation as well as efficient utilization to address gaps in access to quality PHC services for all citizens. In addition, through this solution, health care providers and administrators will be directly involved in identifying challenges and prioritizing efficient use of resources as well as mobilizing additional resources to respond to the needs of the communities that they serve. 

CHAI is an internationally known organization in its reputation to bring innovative solutions through long term partnership with governments, investors, philanthropists and innovators by prioritizing needs of underserved communities throughout the world over the past two decades. So far the organization operates in more than 35 countries across Africa, Asia and Latin America and the Caribbean supporting governments and citizens to address various health and health related gaps affecting wellbeing of their citizens.

CHAI Rwanda has been a close partner with Rwandan government for the past two decades supporting strategic decisions, implementations and learning in the Rwandan health sector through various health projects using public health experts and leveraging resources from multiple donors. Our organizational approach is anchored on the needs of Rwandan citizens and priorities of the government focusing on lasting solutions and establishing strong and sustainable systems within the health sector. 

To design and implement this solution, CHAI will leverage existing relationships and trust within the Ministry of Health. CHAI will engage government leadership to identify priority gaps in the existing PHC performance monitoring system, understand current and previous trials to address the gaps and learn from local as well as global experiences to come up with best way of addressing the observed gaps. Once endorsed, the concept note will be discussing with sub-national health sector leadership, PHC service providers and communities specifically on the performance indicators, mechanisms and their roles and responsibilities in establishing this PHC performance system. 

Using all inputs, a detailed implementation plan in selected districts as a proof of concept will be designed and all lessons will be documented for a full-scale implementation design with the health sector leadership well aligned with annual and multi-year health sector strategic plan. All relevant stakeholders will be involved in designing the full scale up plan. 

We apply to this challenge to see a foreseeable change in effective PHC performance monitoring through integrating the various data sources and build sustainable capacity within the Rwandan government to use data for decision making to improve PHC services. Our solution for this challenge targets improving the data use culture within the health sector at all levels and introduce a shift in community stakeholders’ engagement in the PHC performance improvement through social accountability that follows performance visibility to citizens. In addition, we believe winning this challenge do help leverage the required domestic and external financial resources to establish a strong PHC performance management system and sustain it within Rwandan Ministry of Health by incorporating it in the existing Performance Based Financing (PBF) system.  

Our solution is innovative in that it:

• Uses digital tools to integrate data from various sources and analyze composite PHC performance indicators (that show performance beyond disease or program specific indicators) by institutions at national and sub-national level. 
• Deploys an interactive dashboard to visualize color coded performance ratings of health institutions by geographic location (province, district, and health facility) for decision makers at all levels to see and validate PHC performance at all levels.
• Focuses not only on PHC performance measurement, but also establishing a robust PHC performance management and improvement system within Rwandan health sector that involves PHC improvement plan, investment case development for domestic as well as external donor resource mobilization to address identified gaps hindering access to quality PHC.
• Provides a mechanism of converting the lessons learnt from routine PHC performance management to policy strategic shift within the health sector and beyond by involving all relevant stakeholders. 

Our impact goals:

Short term 1-2 years: 

1. Increase proportion of provincial and district leadership that apply the integrated PHC performance monitoring system to identify, prioritize and address gaps in their PHC system (Target = 100%)
2. Increase use of PHC performance status for resource mobilization from domestic and external sources.

Medium to Long term: 

1. Improved PHC performance levels of  health facilities and districts in respective provinces.
2. Improve citizens satisfaction on access and quality PHC services.
3. Increased PHC service access and utilization by citizens.  

Some of the key measurable indicators for monitoring implementation success of our solution include (but not limited to):

1. Proportion (in percentage) of provincial and district leadership that apply the integrated PHC performance monitoring system to identify, prioritize and address gaps in their PHC system (Target = 100%)
2. Proportion (in percentage) of districts and health facilities that use of PHC performance status for resource mobilization from domestic and external sources.
3. Proportion (in percentage) of districts and health facilities with improved PHC performance status measured using standard indicators.
4. Percentage of citizens satisfaction rate on access and quality PHC services in Rwanda.
5. Percentage of PHC service access and utilization by citizens in Rwanda

The Theory of change for our solution:

Impact: Improved health outcomes, Financial Protection and Increase trust on the health system by citizens

 Long-term outcomes:

• Improved PHC performance data use attitude and practice (culture) by PHC managers, service providers and community stakeholders.
• Increased involvement of community stakeholders in PHC performance management and improvement planning and execution.

 Short-term outcomes:

•  Robust PHC performance measurement/monitoring and management/improvement system established and executed within Rwandan Ministry of Health at levels (National, Provincial, District, Health facility and community levels)
• Integrated and costed PHC plan and specific District and health facility investment cases developed and used for domestic as well as external resource mobilization to the health sector.
• Policy strategy for PHC performance measurement and improvement system within Rwandan health sector.

Outputs:

• Standardized definition and list of PHC performance measurement indicators and methodology/approach for PHC performance management system within the Rwandan health sector.
• Digital health tools to integrate information from multiple sources, analyze that information in to an integrated PHC performance rating and visualize using dashboard to visualize PHC performance rating by level of PHC management and service provision.
• Improved capacity of MoH leadership, PHC managers, service providers and community stakeholders to determine and monitor PHC performance.
• Implementation guidelines and standard operating procedures for implementation of integrated PHC performance measurement and improvement.

 Activities:

• Defining PHC performance using standardized and customized PHC performance indicators.
• Define PHC performance rates using color coding approach for respective performance levels.
• Mapping data sources for an integrated comprehensive PHC performance management system.
• Designing a digital tool for integrating, analyzing and visualization of PHC performance.
• Develop an engagement and accountability framework for all stakeholders in PHC performance measurement and improvement plan
• Design and execute a prototype project implementation plan as a proof of concept.

The core technology of our solution is based on DHIS2, an open source, web-based platform commonly used as a health management information system (HMIS), in use by 73 low and middle-income countries. The software platform is highly configurable and can collect, analyze, visualize, and share data. It supports both aggregate and individual-level data — including features for monitoring and following up with individual people or entities over time — and online and offline data entry via the DHIS2 web portal, mobile Android app, SMS, or direct import. This flexibility and range of features, and the fact that it is already in use in all health facilities across Rwanda make it a strong fit to serve as a central repository and decision making tool for the range of PHC health data in the country. 

The relevant features of DHIS2 are described below: 

Integration and Interoperability: DHIS2 supports its own format for meta-data and data exchange called DXF2 as well as the ADX standard. Most parts of the system can be accessed through the extensive REST-based Web API, which makes interoperability with third-party clients like Android apps, Web portals and other information systems easy. DHIS2 also allows setting up scheduled integration jobs in order to periodically synchronize with or import data from other sources.

Analytics and Data management features: DHIS2 allows managing and analyzing aggregate and individual-level data. It can be configured as a data warehouse for data from a variety of sources, and includes advanced features for dynamic data visualization, like maps, charts, pivot tables and dashboards, as well as social analytics features.

Sustainability: DHIS2 is free and open source software released under the liberal BSD 3-Clause license. It is developed in Java and runs on any platform with a JRE 8 installed. DHIS2 is web-based and follows HTML 5 standards. You can download the WAR file and drop it into a Web container like Tomcat. Or download the Live package and simply click the executable file.

Scalability: DHIS2 implementations have had thousands of concurrent users and 100s millions of data records on a single, standard web server. It has a quick response time for analytics (tenths of a second) and is being used as a national health information system in 20+ countries.

Our solution will be using the existing health information system within the Rwandan Ministry of Health and data will be collected using the district health office experts, health professionals at facility level, community health workers at community level. 

However, depending on the need to incorporate new PHC performance indicators and data to be collected from new data source, a separate  trained data collectors can be used in the short term of implementation until the new data set are incorporated into the routine health information system as a medium to long term plan. 

Our organization, CHAI, are an inclusive organization and promote and integrate fairness, respect, equality, and dignity into CHAI’s culture. We take a firm stance against discrimination and harassment and foster an environment where people with a multiplicity of personal characteristics, including race, color, religion, sex or gender (including gender identity and gender expression), sexual orientation, ethnicity, national origin, age, disability, HIV status, political or interest group affiliation, genetic information, veteran status, marital status, parental or pregnancy status or any other characteristic, are embraced and valued. 

Our health systems program leadership, under which this solution-team will be placed, is a diversified team from different countries with different cultures mingled with local Rwandan experts. Our team lead, senior program manager is a medical doctor with public health specialty from Ethiopia. Our program manager, Nigerian citizen, is an urban planner with public health experience in Nigeria and Rwanda. Our technical experts are from Rwanda with economics and IT back grounds working in the Rwandan public health sector for more than five years. Our future talent recruitment for this solution will abide to CHAI’s over all diversity and inclusivity culture. 

CHAI uses a business-minded approach to shape healthcare markets to reduce the costs of lifesaving medications, diagnostics, and other health products in low- and middle-income countries. We work with governments to reform their health systems, targeting areas where current approaches are failing, moving too slowly, or at a scale that leaves too many dying or suffering needlessly. As a 501(c)(3) non-profit organization, we wholly operate through donor funds to implement our lifesaving work.

We employ a Value for Money (VFM) framework to quantify the outputs of our interventions in terms of 1) reduced commodity prices and 2) increased numbers of patients accessing product at these lower prices. We  quantify  benefits  relative  to  counterfactual  scenarios  that  reflect  how  product markets and program uptake would evolve without CHAI-facilitated interventions.

Many of CHAI's grant  goals  are  set  to  achieve  specific  value  for  money  targets.  CHAI quantifies commodity savings based on market interventions to increase volumes to meet specific targets while at the  same  time  negotiating  reduced  price  targets.  CHAI measures  the  savings  delivered  by  comparing progress  to  reduce  prices  and  increase  patient  volumes  against 'counterfactual' scenarios  which demonstrate the prices and volumes that would have likely occurred without CHAI's interventions.  Some projects can more easily be evaluated against some or all of these metrics than others, but overall, CHAI projects significant value for money savings as a result of our grant work; the achievement of these savings guide our work under the grant.

We are guided overall by CHAI's mission of saving lives, values and guiding principles: Economy, Efficiency and Cost-Effectiveness. 

Economy: We have a sound procurement policy, implement agreed audit recommendations in a timely manner and adhere to one of our CHAI values to be frugal as we undertake our work. We maintain low overheads  and  the  direct  donor  funds  we  fundraise  as  much  as  possible  to  saving  lives  directly  rather than to compensating ourselves excessively or incurring elaborate expenses. During  proposal  development  we  aim  to  identify  key  and  strategic  costs,  their  sequence  and  how  they feed into output targets, and thereafter review our assumptions regularly during implementation.

Efficiency:  We  aim  to  maximize  the  output  of  any  given  level  of  inputs.  We  closely  monitor  our  cost drivers  and  risks  that  affect  the  delivery  of  our  program  and  grant-specific  goals.  To  do  this,  program managers   proactively   review   and   manage   their   workplans   and   budgets.   Past   program/grant implementation experience also provides information and trends that they can use for comparison. We  work  with  urgency.  We  work  with  utmost  speed  and  it  is  important  that  our  programs  are implemented  on  a  timely  manner.  The  faster  we  act  the  more  lives  we  can  save.  We  also    closely  monitor our budget utilization rates over the required reporting period. Program  managers  are  encouraged  to  constantly  review  costs  and  targets  in  an  integrated  way  to respond to the evolution of particular indicators, contexts and to justify the value of activities in view of long-term results.

Effectiveness  and  cost-effectiveness: CHAI is confident the links in the program's theory of change are robust  and  evidence-based.  Additionally, working  in  cooperation  with  and  at  the  service  of  partner governments ensures our programs are sustainable and scalable. This means that we align our program strategies with our partner governments to work in service of their priorities and goals. Partnering with governments  ensures  transformational  impact,  as  they  are  the  strongest  institutions  in  developing countries with long-term and expansive health policies and programs.

CHAI is a 501(c)(3) non-profit organization and wholly operates through donor funds to implement our lifesaving work. In addition, CHAI can leverage more resources from the government of Rwanda as part of the eHealth strategy implementation as well as from other donors who are currently supporting the government the mentioned strategy including World Bank, CDC/PEPFAR and Global Fund on different components of the system. 

Since its inception as a legal entity in 2010, CHAI has received USD 2 Billion in funding for 1,088 grants from 240 donors to support the 35 countries we are currently supporting. 

Using this grant, we shall pilot our novel solution and help the Rwandan Ministry of Health use it as an investment case to raise funds from domestic and external sources as part of its eHealth Strategy implementation.