Delivering health care to the littlest patients: How a working health system saves newborn lives
By Alanna Savage
Mist had settled over the morning. I was visiting with staff at Remera-Rukoma District Hospital in the Southern Province of Rwanda. Founded in 1927, the 177-bed hospital serves a population of more than 376,000 and receives patients referred by 11 surrounding health centers.
I was there with the team from the USAID-funded Rwanda Health Systems Strengthening (RHSS) Project, led by Management Sciences for Health, which works to reinforce the Rwandan government’s capacity to plan, lead, and implement strategic interventions to strengthen key health system structures and processes while building sustainability and country ownership.
The first stop on our tour was the neonatal ward. Staff at Remera-Rukoma deliver an average of nine babies each day, with two of those by Caesarian section. Babies born too early or who struggle to survive are moved to the neonatal ward.
Seven beds, four incubators, equipment, and posters of neonatal practice and data lined the walls. Four women were long-term residents of the neonatal ward, staying with their babies who relied on medical interventions to survive.
One mother, with twins sleeping on her chest, told me she had been there for over a month. An infant’s cry emanated from an ultraviolet incubator covered by a white sheet. In another incubator, a premature baby, connected to several tubes and swaddled in fleece blankets, slept quietly. Another, wearing a diaper more than half the size of his frail body, lay on his back, steadily breathing, showing his will to live.
When a woman gives birth in a health facility, she trusts that she and her baby will be safe and will leave the hospital healthy. But if a health system fails to provide high-quality care—which means mobilizing all of the necessary personnel, financing, and infrastructure—then neither mother nor child may survive.
Watching these babies breathe, attached to all kinds of machinery, and attended by a dedicated neonatal nurse, I thought about what it takes for a health system to keep just one premature baby alive. Here are just a few of the components that, together, help ensure that Remera-Rukoma District Hospital is able to provide care to its tiniest patients.
Policy and Planning
Planning is the first step to achieving a functioning health system. Rwanda’s Ministry of Health (MoH) affirmed its commitment to maternal and newborn health in its fourth Health Sector Strategic Plan (2018–2024), which states that by 2024, all people in Rwanda will receive quality maternal, neonatal, child, and community health services corresponding to the economic development standards of the country.
The RHSS Project works with district health management teams—comprising the district health director and leaders from hospitals, community health insurance, pharmacies, and health centers—to facilitate successful integration of the MoH’s priority areas and strategies for maternal and newborn health into planning and budgeting.
Through collaboration with peers from other districts and supported by workshops and coaching from the RHSS Project, district management teams define their objectives for the year, develop and implement action plans, create budgets, mobilize funds, and monitor finances.
While I was at the hospital, the RHSS Project was leading a three-day workshop to foster peer-to-peer learning sessions on strategic planning and financial management. Representatives from Remera-Rukoma and other hospitals in the Southern Province shared their experiences addressing financial management challenges and strategies for steadily increasing hospital revenue.
The neonatal ward will require substantial infrastructural updates if it is to provide modern, high-quality services. Remera-Rukoma aims to increase its revenue so that it can realize its vision of constructing a larger, updated neonatal ward.
Quality of care
Doctors and nurses must have the appropriate training and skills to provide high-quality healthcare to women and their premature babies, who are particularly vulnerable to potentially life-threatening infections and complications that affect their brain, heart, and lungs.
The RHSS Project works with hospitals like Remera-Rukoma to develop and implement standards of quality care for maternal and newborn health that are in line with Rwanda’s national accreditation program. The program addresses leadership, workforce competence, environmental safety, and patient-centered care to mitigate risk and improve health outcomes.
Accreditation was scaled up to all district hospitals with support from the RHSS Project. For example, Remera-Rukoma staff adhere to hygiene standards by using personal protective equipment and regularly washing their hands at the station outside the neonatal room.
Access to health services
Under the supervision of the local health center, trained community health workers (CHWs) bring health services to every village. CHWs link women to Rwanda’s health system by providing health information and referring them to health facilities for antenatal care and safe delivery services.
As a result of Rwanda’s efforts to increase coverage of these essential maternal health interventions, coverage of antenatal care (at least four visits) increased from 13% to 44% and skilled birth attendance increased from 39% to 91% between 2005 and 2015.
Across Rwanda, CHWs have formed cooperatives, supervised by the health centers in their catchment areas, to manage funds received for meeting performance targets established by district health management teams.
The MoH and the RHSS Project provide technical support to these CHW cooperatives on strategies to earn income in sectors such as agriculture and food, livestock, property rentals, and transportation. As these CHWs are volunteers, income-generating strategies help them earn a living while providing health information and health facility referrals to the community.
All of the mothers in the neonatal ward at Remera-Rukoma were members of Rwanda’s community-based health insurance (CBHI) program. Introduced in 2004, CBHI is a government-led health insurance program that provides access to services and promotes a culture of prevention by removing the financial hardship of medical costs for individuals and families.
According to Rwanda Social Security Board (RSSB)/CBHI data, 71% of Rwandans adhere to the CBHI scheme. Member premiums are based on income, and the government subsidizes the full cost for families in the lowest income bracket. The RHSS Project works with the RSSB, which manages the CBHI program, to analyze risk pools, establish and update claims management systems, investigate public- and private-sector costs of health services, and monitor and evaluate the CBHI program.
As the majority of the Rwandan population is insured, the country’s gap in coverage between the poorest and richest quintiles for all pregnancy, birth, and newborn-related services is low compared to other countries in the Central and East African region.
The premature babies in the Remera-Rukoma neonatal ward are small miracles of what a working health system makes possible. When a health system works efficiently and effectively, it reaches—and saves the lives of—its most vulnerable people fighting to survive against all odds.