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UBC Theses and Dissertations

Health system performance and impact of quality improvement interventions for maternal, newborn and child health in Rwanda Hategeka, Celestin


Growing evidence suggests that achieving Sustainable Development Goal 3 will require high-quality health systems in low- and middle-income countries. I assessed whether routine health information systems in Rwanda capture relevant quality measures. Using data on available quality measures and time series methods, I tracked Rwandan health system performance focusing on quality of care across primary, secondary, and tertiary levels of care. Further, I performed a systematic review of the literature to investigate whether use of interrupted time series (ITS)—one of the strongest quasi-experimental designs—in the evaluation of health system quality improvement (QI) interventions has followed best practice standards and recommendations. Finally, using ITS with a concurrent control group, I evaluated the impact of three QI interventions on maternal, newborn, and child health in Rwanda. While health outcome measures were captured across all levels of care, there were gaps in the measurement of relevant quality impact measures such as confidence in health systems and economic benefit, and processes such as user experience. Information about competent care and systems was rarely available outside maternal and newborn health. Clearly, the current health information system would benefit from capturing additional healthcare quality metrics to allow the effective tracking of performance of the Rwandan health system and to identify new potential efficiencies. Available quality measures suggest that quality of care provided in Rwandan healthcare facilities has generally improved over the past decade; however, further improvements are still necessary to maximize the impact of the health system. Use of ITS in the evaluation of QI interventions has increased considerably over the past decade; however, variations in methodological considerations and reporting of ITS studies remain a concern. This warrants the development and / or reinforcement of formal reporting guidelines to improve its application in the evaluation of QI interventions. Lastly, the QI intervention that employed clinical mentorship was associated with improvements in maternal and newborn health outcomes such as a reduction in obstetrical complication case fatality, in-hospital neonatal mortality, incidence of postpartum hemorrhage and neonatal asphyxia. In contrast, those that used training approaches had a limited impact.

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