Feb. 13, 2020

PEPFAR’s Investments in Rwanda Helped Boost Health Workforce, But Future Programs Should More Comprehensively Support Long-Term Capacity

WASHINGTON – Rwanda’s Human Resources for Health (HRH) Program – funded in part by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) from 2012 to 2017 – more than tripled the country’s physician specialist workforce and produced major increases in the numbers and qualifications of nurses and midwives, says a new report from the National Academies of Sciences, Engineering, and Medicine. The report recommends that future  investments in health professional education be designed within a more comprehensive approach to human resources for health and institutional capacity building, which would strengthen the health system to meet both HIV-specific and more general health needs.

“People with HIV are living longer, which means they have long-term HIV care needs while also needing care to manage other diseases and to enhance their quality of life. Supporting the entirety of their needs depends on the same strong health system that is needed to address all people’s health needs,” said Ann Kurth, Linda Koch Lorimer Professor and dean of the Yale School of Nursing, and chair of the committee that wrote the report. “The committee’s report is an opportunity to highlight how future investments in Rwanda’s health workforce can be better designed, operationalized, and evaluated.”

Implemented by Rwanda’s Ministry of Health, the HRH Program was created to help the country build its health workforce. Following the 1994 genocide against the Tutsi, 80 percent of the country’s health professionals were displaced. In 2011, before the HRH Program started, Rwanda had fewer than nine skilled health professionals (physicians, nurses, and midwives) per 10,000 people, posing a major barrier to HIV treatment and care. This is far below the World Health Organization’s recommended minimum of 44.5 health workers per 10,000 people.

The HRH Program surpassed its workforce growth target, increasing the number of physician specialists from 150 in 2011 to more than 500 in 2018, and the number of nurses with advanced degrees from less than 800 to more than 5,000. Partnerships, or “twinning” between U.S. faculty and University of Rwanda faculty introduced new programs, upgraded curricula, and improved the quality of teaching and training for health professionals, the report says. Growing the number, skills, and competencies of health workers contributed to direct and indirect improvements in the quality of HIV care, including greater availability of providers, improved skills for basic and HIV-specific care, and improved skills to address HIV-related complications.

Examining how the HRH program affected rates of HIV-related morbidity and mortality in Rwanda’s population was challenging for several reasons, the report says. Observing such impact as a result of training and deploying new specialist physicians and nurses could take decades, which is beyond the time frame of the evaluation. Furthermore, the National Academies’ evaluation was requested after PEPFAR funding had ended, so there was no opportunity to design a methodology from the start of funding to measure this impact at the end. Rwanda made notable HIV-related achievements during the program, including decreased HIV prevalence and increased access to antiretroviral therapy. However, it is not feasible to directly attribute these outcomes to the program, since existing health care delivery, other HIV programs and funders, and other factors that affect health also played a role.

Based on the successes and challenges of the HRH program in Rwanda, the report provides six recommendations to inform future efforts to strengthen the health workforce in Rwanda as well as in other countries. The recommendations offer an aspirational framework to reimagine how partnerships are formed, how investments are made, and how the effects of those investments are documented.

Intended for governments, funders, institutions of health professional training and education, regulatory bodies, health professional societies, and civil society organizations, the report’s recommendations include:

Collaborate across sectors to design a comprehensive and coordinated approach. Health workforce development policies and investments should be coordinated not only between government and nongovernmental stakeholders in health and education, but also in labor and the private sector. Policies should take into account health worker supply, demand, and need; country goals for health care access and coverage; and how to absorb and retain graduates in systems of health care delivery and health professional education.

Support adaptable strategies in design and funding. The health workforce and population health needs, including the HIV epidemic, are complex and evolving. Donors should allow for greater flexibility to coordinate their investments with related efforts and periodically revisit program objectives and activities.

Choose models for improving health professional education that best fit the needs and the context. During the HRH Program, faculty from U.S. teaching institutions “twinned” with Rwandan faculty to transfer skills, mentor each other, or share clinical or teaching responsibilities. However, “twinning” at the institutional level may be more effective in building faculty and institutional capacity for health professional education. All partnership models should be designed based on a country’s health workforce development priorities.

Invest in monitoring, evaluation, and learning. HRH programs should invest in a robust plan at the outset to inform program design, measure results, and learn and adapt in real-time. This was a missed opportunity for the program in Rwanda, the report says.

The study — undertaken by the Committee on the Evaluation of Strengthening Human Resources for Health Capacity in the Republic of Rwanda under the President’s Emergency Plan for AIDS Relief (PEPFAR) — was sponsored by the Centers for Disease Control and Prevention. The National Academies are private, nonprofit institutions that provide independent, objective analysis and advice to the nation to solve complex problems and inform public policy decisions related to science, technology, and medicine. They operate under an 1863 congressional charter to the National Academy of Sciences, signed by President Lincoln.

Report Highlights

Stephanie Miceli, Media Relations Officer

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