title: Drivers of improved health sector performance in Rwanda: a qualitative view from within.
abstract: BACKGROUND
  Rwanda has achieved great improvements in several key health indicators, including maternal mortality and other health outcomes. This raises the question: what has made this possible, and what makes Rwanda so unique?
  
  
  METHODS
  We describe the results of a web-based survey among district health managers in Rwanda who gave their personal opinions on the factors that drive performance in the health sector, in particular those that determine maternal health service coverage and outcomes. The questionnaire covered the six health systems building blocks that make up the WHO framework for health systems analysis, and two additional clusters of factors that are not directly covered by the framework: community health and determinants beyond the health sector.
  
  
  RESULTS
  Community health workers and health insurance come out as factors that are considered to have contributed most to Rwanda's remarkable achievements in the past decade. The results also indicate the importance of other health system features, such as managerial skills and the culture of continuous monitoring of key indicators. In addition, there are factors beyond the health sector per se, such as the widespread determination of people to increase performance and achieve targets. This determination appears multi-levelled and influenced by both intrinsic and extrinsic motivation.
  
  
  CONCLUSIONS
  It is the comprehensiveness and combination of interventions that drive performance in Rwanda, rather than a single health systems strengthening intervention or a set of interventions that target a specific disease. There is need for policy makers and scholars to acknowledge the complexity of health systems, and the fact that they are dynamic and influenced by society's fabric, including the overall culture of performance management in the public sector. Rwanda's robust model is difficult to replicate and fast-tracking elsewhere in the world of some of the interventions that form part of its success will require a holistic approach.
authors.affiliation: Ministry of Health, Maternal & Child Health Department, PO Box 84, Kigali, Rwanda.
authors.forename: Felix
authors.initials: F
authors.lastname: Sayinzoga
authors.affiliation: Radboud University Medical Centre, Radboud Institute for Health Sciences, PO Box 9101, 6500, HB, Nijmegen, The Netherlands. leon.bijlmakers@radboudumc.nl.
authors.forename: Leon
authors.initials: L
authors.lastname: Bijlmakers
mesh_terms: D001291:Attitude of Health Personnel; D003150:Community Health Workers / Q000592:standards / Q000706:statistics & numerical data; D003267:Contraception / Q000706:statistics & numerical data; D005260:Female; D005380:Financing, Government; D018166:Health Care Reform; D019538:Health Care Surveys; D006297:Health Services Accessibility / Q000458:organization & administration*; D006801:Humans; D009042:Motivation; D011247:Pregnancy; D011635:Public Health Administration; D019984:Quality Indicators, Health Care / Q000706:statistics & numerical data; D011787:Quality of Health Care / Q000458:organization & administration* / Q000592:standards; D012432:Rwanda / Q000453:epidemiology; D011795:Surveys and Questionnaires
keywords: District health; Governance; Health system building blocks; Rwanda; Sector performance; Web-based qualitative study