Health Builders: Systems Strengthening Through Performance Management

At the end of my visit to Gashora Health Center in Bugesera District, built in partnership by Health Builders and the local Government, Executive Director Tyler Nelson turns to me and says with emphasis, “Rwanda will be the first country in Sub-Saharan Africa to have a complete primary health care system.” While this claim sounds bold, Rwanda has the statistics from the past two decades to back this up. Furthermore, the Health Builders’ staff has the experience working within the Rwandan health system to state it with confidence.

Rwanda’s Health System: A Rapid Recovery

Much has already been written on the exponential success of Rwanda’s health system, insurance scheme, and the Rwandan populations’ improved access to care. In the past twenty years, Rwanda went from measuring at the bottom of most health indicators to rising far beyond many countries in Sub-Saharan Africa. While still a low-income country, Rwanda has the pride of being at the same health level of many middle-income countries.

When Health Builders started in 2004, partnering with The Access Project, Rwanda had fewer than 1,000 doctors for more than 9 million people, and the average Rwandan life expectancy was 44 years.

In the past ten years, deaths in Rwanda from HIV, TB, and malaria have dropped by 80%. Life expectancy has risen from 44 to 62 years. The country’s rise in development has been attributed to a number of factors, with good governance and a focus on health in Rwanda’s Vision 2020 development roadmap being the most pivotal. Health insurance rates are now between 90% and 96% coverage for the entire country – a bold claim to fame that many countries in the global West cannot yet make.

Systems Strengthening from the Ground Up

Health Builders has contributed to the growth in Rwanda through an innovative health systems strengthening approach. Through their ten years of work in the country, the organization has shown just how powerful an effect building management capacity can have. Health Builders has proven that with proper fiscal management and technical assistance, even the lowest performing health centers can improve their staffing mechanisms and physical infrastructure management.

The program works by maximizing performance at the district level. According to their own performance evaluations, ratings have improved from 19% to 72% in 89 health centers. These evaluations cover eight domains deemed necessary to effective systems management, including: Human Resources; Infrastructure Management; Financial Management; Pharmacy Supply Chain; IT Systems, and more.

“The common understanding of health systems strengthening revolves around policy and governance, but there is a lot of field work that can be done” Tyler says. Health Builders works to train all levels of management, ensuring durability and adaptability among staff even when there are changes from the top. The organization knows the health systems strengthening argument is a complicated one, “but in Rwanda we’ve seen that the smallest interventions are the ones that work best. By ensuring best practices in management, Health Builders seen drastic improvements in health outcomes of the 89 centers we support.”

Health Builders’ Core: HMSs & the AMET

All facilities where Health Builders works are owned and staffed by the government, and are part of the national health care system. In situations of urgent need, Health Builders has constructed five full-service health centers and two maternity wards, but these are built through a cost-sharing model and are owned and staffed by the government before they are even completed. Their sixth full-service health center is currently under construction, expected to open its doors to more than 15,000 Rwandans in one of the most remote sectors of the country before the end of the year. Health Builders is now working in nearly 100 clinics in six districts, where Health Management Specialists (HMSs) serve as management consultants and go-to resources for technical assistance. The HMSs are Health Builders’ key trained staff, and come from a diverse array of backgrounds: doctors, MBA’s and mayors who meet often and directly assist local staff.

At the heart of Health Builders’ success is the AMET – the performance evaluation tool used to rank health centers and strengthen systems. The AMET is used to ensure that health centers are well-staffed, pharmacies are stocked, budgets are well-managed, and money is spent wisely. “Management is the key to everything – It’s better to improve the people who are actually in charge of the project, rather than focus on the project itself,” Bugesera district’s HMS Bertin Gakombe tells me, as he explains how the evaluation tool is put into practice. The AMET uses a yes/no scoring system to prioritize essential improvements for centers according to the eight domains. The HMSs work with district and sector-level health authorities to improve performance according to this rigorous scoring system. When Tyler tells me “We haven’t had stock-outs in the facilities where we work in years,” I am past the point of disbelief. Better financial and staff management in the centers where the AMET is used has cut down on financial losses in pharmacies and transportation costs, allowing for increased staffing expenses and reliable availability of essential medicines.

Health Builders regularly introduces improvements in the centers where they work, from IT and enhanced infrastructure to kitchen gardens and clean water projects. These kitchen gardens are used for nutrition training, while the water purification plants sell clean water back to the community, providing additional revenue for health centers. Infrastructure and architecture has also been a strong focus for Health Builders, allowing HMSs to suggest physical improvements that lead to financial savings. The layout of health centers, for example, can be rearranged to better process patient footfall, while administrative functions are also enhanced through better use of space.