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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. Conclusion: 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.
In August-September 2014, we administered a web-based survey among district directors of health and district hospital directors to solicit their opinions and experiences. We invited all 30 district directors of health and all 42 district hospital directors in Rwanda, through a personal email, to participate in a web-based survey. The invitation contained a brief description of the purpose of the study and a unique hyperlink, which gave the invited persons direct internet access to the survey questionnaire. We used LimeSurvey, which is an open source survey application [https://www.limesurvey.com/], that allows respondents to save their responses at any given moment and, if desired, to resume completion of the questionnaire at a later point of time. The software allows researchers to monitor progress in the number of completed surveys and send customised email reminders to those who have not yet responded. No incentives were offered to participate, other than that we promised participants they would receive a summary of the findings as a token of our appreciation. In designing part I of the questionnaire we distinguished between nine clusters of health system factors: they comprise the six building blocks, as defined by WHO [14], complemented with community health and intersectoral collaboration. The latter two have been cited in critiques of the WHO framework, which is on the one hand considered incomplete and too static, and on the other hand does not sufficiently take into account the interaction between a health system and the wider environment in which it operates [15–17]. We further divided the WHO building block infrastructure & supplies into two: physical infrastructure and medical technologies & supplies. The survey was in English and consisted of five parts, as shown in Table 1 (the full questionnaire is available at the link provided in Additional file 1). The five parts of the questionnaire with corresponding number of questions asked The first three parts contained questions and statements with Likert-type scales, ranging from 1 (not important at all) to 5 (very important) for questions; and for statements from 1 (strongly disagree) to 5 (strongly agree). All questions in parts I to IV had a provision to add free text and respondents were encouraged to explain their answers – in either English or in French – particularly for factors and statements about which they held strong opinions (scores 1 and 5). No sampling was required: the directors of health of all 30 districts in Rwanda were invited as well as the directors of 42 district-level hospitals.23 We obtained their email addresses through the Ministry of Health. The email invitation to take part in the survey provided details about the purpose of the study and emphasised that all answers would be anonymised and treated confidentially. It was explicitly stated that by starting to complete the questionnaire participants consented to participate in the study. Approval for the study was granted by the National Health Research Committee (NHRC; reference number NHRC/2015/PROT/006), and the Rwanda National Ethics Committee (RNEC; reference number 105/RNEC/2015).
