title: Improving district facility readiness: a 12-month evaluation of a data-driven health systems strengthening intervention in rural Rwanda.
abstract: BACKGROUND
  While health systems strengthening (HSS) interventions are recommended by global health policy experts to improve population health in resource-limited settings, few examples exist of evaluations of HSS interventions conducted at the district level. In 2009, a partnership between Partners In Health (PIH), a non-governmental organization, and the Rwandan Ministry of Health (RMOH) was provided funds to implement and evaluate a district-level HSS intervention in two rural districts of Rwanda.
  
  
  METHODS
  The partnership provided limited funds to 14 health centers for targeted systems support in 2010; six others received support prior to the intervention (reference). RMOH health systems norms were mapped across the WHO HSS framework, scored from 0 to 10 and incorporated into a rapid survey assessing 11 domains of facility readiness. Stakeholder meetings allowed partnership leaders to review results, set priorities, and allocate resources. Investments included salary support, infrastructure improvements, medical equipment, and social support for patients. We compared facility domain scores from the start of the intervention to 12 months and tested for correlation between change in score and change in funding allocation to assess equity in our approach.
  
  
  RESULTS
  We found significant improvements among intervention facilities from baseline to 12 months across several domains [infrastructure (+4, p=0.0001), clinical services (+1.2, p=0.03), infection and sanitation control (+0.6, p=0.03), medical equipment (+1.0, p=0.02), information use (+2, p=0.002)]. Composite score across domains improved from 6.2 at baseline to 7.4 at 12 months (p=0.002). Across facilities, 50% had composite scores greater than the average score among reference facilities (7.4) at 12 months compared to none at baseline.
  
  
  CONCLUSIONS
  Rapid facility surveys, stakeholder engagement, and information feedback can be used for gap analysis and resource allocation. This approach can achieve effective use of limited resources, improve facility readiness, and ensure consistency of facility capacity to provide quality care at the district level.
authors.affiliation: Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda.|Division of Global Health Equity, Brigham and Women's Hospital, Boston, USA; hari.s.iyer09@gmail.com.
authors.forename: Hari S
authors.initials: HS
authors.lastname: Iyer
authors.affiliation: Partners In Health, Boston, USA.
authors.forename: Emmanuel
authors.initials: E
authors.lastname: Kamanzi
authors.affiliation: Partners In Health, Boston, USA.
authors.forename: Jean Claude
authors.initials: JC
authors.lastname: Mugunga
authors.affiliation: Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA.
authors.forename: Karen
authors.initials: K
authors.lastname: Finnegan
authors.affiliation: Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda.
authors.forename: Alice
authors.initials: A
authors.lastname: Uwingabiye
authors.affiliation: Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda.
authors.forename: Edward
authors.initials: E
authors.lastname: Shyaka
authors.affiliation: Ministry of Health, Kigali, Rwanda.
authors.forename: Saleh
authors.initials: S
authors.lastname: Niyonzima
authors.affiliation: Division of Global Health Equity, Brigham and Women's Hospital, Boston, USA.|Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA.|Ariadne Labs, Boston, USA.
authors.forename: Lisa R
authors.initials: LR
authors.lastname: Hirschhorn
authors.affiliation: Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda.|Division of Global Health Equity, Brigham and Women's Hospital, Boston, USA.
authors.forename: Peter C
authors.initials: PC
authors.lastname: Drobac
mesh_terms: D003695:Delivery of Health Care / Q000191:economics / Q000458:organization & administration*; D004864:Equipment and Supplies; D006295:Health Resources / Q000458:organization & administration; D006801:Humans; D017053:Infection Control / Q000458:organization & administration; D058996:Quality Improvement / Q000191:economics / Q000458:organization & administration*; D019035:Rural Health Services / Q000191:economics / Q000458:organization & administration*; D012432:Rwanda; D012944:Social Support
keywords: Rwanda; global health; health systems strengthening; impact evaluation; resource allocation; rural; sub-Saharan Africa