title: Baseline assessment of adult and adolescent primary care delivery in Rwanda: an opportunity for quality improvement.
abstract: BACKGROUND
  As resource-limited health systems evolve to address complex diseases, attention must be returned to basic primary care delivery. Limited data exists detailing the quality of general adult and adolescent primary care delivered at front-line facilities in these regions. Here we describe the baseline quality of care for adults and adolescents in rural Rwanda.
  
  
  METHODS
  Patients aged 13 and older presenting to eight rural health center outpatient departments in one district in southeastern Rwanda between February and March 2011 were included. Routine nurse-delivered care was observed by clinical mentors trained in the WHO Integrated Management of Adolescent & Adult Illness (IMAI) protocol using standardized checklists, and compared to decisions made by the clinical mentor as the gold standard.
  
  
  RESULTS
  Four hundred and seventy consultations were observed. Of these, only 1.5% were screened and triaged for emergency conditions. Fewer than 10% of patients were routinely screened for chronic conditions including HIV, tuberculosis, anemia or malnutrition. Nurses correctly diagnosed 50.1% of patient complaints (95% CI: 45.7%-54.5%) and determined the correct treatment 44.9% of the time (95% CI: 40.6%-49.3%). Correct diagnosis and treatment varied significantly across health centers (p = 0.03 and p = 0.04, respectively).
  
  
  CONCLUSIONS
  Fundamental gaps exist in adult and adolescent primary care delivery in Rwanda, including triage, screening, diagnosis, and treatment, with significant variability across conditions and facilities. Research and innovation toward improving and standardizing primary care delivery in sub-Saharan Africa is required. IMAI, supported by routine mentorship, is one potentially important approach to establishing the standards necessary for high-quality care.
authors.affiliation: Partners In Health-Inshuti Mu Buzima, Kigali, Rwanda and Boston, USA. ashwin@post.harvard.edu.
authors.forename: Ashwin
authors.initials: A
authors.lastname: Vasan
authors.forename: Manzi
authors.initials: M
authors.lastname: Anatole
authors.forename: Catherine
authors.initials: C
authors.lastname: Mezzacappa
authors.forename: Bethany L
authors.initials: BL
authors.lastname: Hedt-Gauthier
authors.forename: Lisa R
authors.initials: LR
authors.lastname: Hirschhorn
authors.forename: Fulgence
authors.initials: F
authors.lastname: Nkikabahizi
authors.forename: Marc
authors.initials: M
authors.lastname: Hagenimana
authors.forename: Aphrodis
authors.initials: A
authors.lastname: Ndayisaba
authors.forename: Felix R
authors.initials: FR
authors.lastname: Cyamatare
authors.forename: Bonaventure
authors.initials: B
authors.lastname: Nzeyimana
authors.forename: Peter
authors.initials: P
authors.lastname: Drobac
authors.forename: Neil
authors.initials: N
authors.lastname: Gupta
mesh_terms: D000293:Adolescent; D000328:Adult; D006801:Humans; D017060:Patient Satisfaction / Q000706:statistics & numerical data; D011320:Primary Health Care / Q000592:standards*; D011785:Quality Assurance, Health Care; D058996:Quality Improvement; D011787:Quality of Health Care / Q000706:statistics & numerical data; D019035:Rural Health Services / Q000592:standards / Q000706:statistics & numerical data; D012432:Rwanda; D055815:Young Adult