Comprehensive and integrated district health systems strengthening: the Rwanda Population Health Implementation and Training (PHIT) Partnership.

BACKGROUND: Nationally, health in Rwanda has been improving since 2000, with considerable improvement since 2005. Despite improvements, rural areas continue to lag behind urban sectors with regard to key health outcomes. Partners In Health (PIH) has been supporting the Rwanda Ministry of Health (MOH) in two rural districts in Rwanda since 2005. Since 2009, the MOH and PIH have spearheaded a health systems strengthening (HSS) intervention in these districts as part of the Rwanda Population Health Implementation and Training (PHIT) Partnership. The partnership is guided by the belief that HSS interventions should be comprehensive, integrated, responsive to local conditions, and address health care access, cost, and quality. The PHIT Partnership represents a collaboration between the MOH and PIH, with support from the National University of Rwanda School of Public Health, the National Institute of Statistics, Harvard Medical School, and Brigham and Women's Hospital. DESCRIPTION OF INTERVENTION: The PHIT Partnership's health systems support aligns with the World Health Organization's six health systems building blocks. HSS activities focus across all levels of the health system - community, health center, hospital, and district leadership - to improve health care access, quality, delivery, and health outcomes. Interventions are concentrated on three main areas: targeted support for health facilities, quality improvement initiatives, and a strengthened network of community health workers. EVALUATION DESIGN: The impact of activities will be assessed using population-level outcomes data collected through oversampling of the demographic and health survey (DHS) in the intervention districts. The overall impact evaluation is complemented by an analysis of trends in facility health care utilization. A comprehensive costing project captures the total expenditures and financial inputs of the health care system to determine the cost of systems improvement. Targeted evaluations and operational research pieces focus on specific programmatic components, supported by partnership-supported work to build in-country research capacity. DISCUSSION: Building on early successes, the work of the Rwanda PHIT Partnership approach to HSS has already seen noticeable increases in facility capacity and quality of care. The rigorous planned evaluation of the Partnership's HSS activities will contribute to global knowledge about intervention methodology, cost, and population health impact.

Prevalence of teenage pregnancy and the associated contextual correlates in Rwanda.

The rate of teenage pregnancy remains unacceptably high in most developing countries. In Rwanda, studies show a rapid increase over the past two decades despite the political achievements of women's empowerment, and efforts to curtail child sexual abuse. Unfortunately, the current knowledge of the household determinants of teenage pregnancies in Rwanda is limited, as recent studies have focused on providing numbers with little analysis of proximate causal factors or focused on the individual determinants. The study uses secondary data from the recent Rwanda Demographic and Health Survey (RDHS: 2014-2015) to analyse household factors associated with teenage pregnancies in Rwanda. In addition to descriptive analysis, we ran logistic regression models to determine the level of association between teenage pregnancy and household socioeconomic characteristics. Results indicate that marital status and age of household head, household size, number of bedrooms given the size of the household, and the educational level of the household-head are significantly associated with teenage pregnancy (p < 0.01). Teen girls from small households are more likely to get pregnant than those from large families, while financial, social and educational empowerment of parents, and harmonious household contexts contribute to lessening the cases of teenage pregnancy. It indicates that social and economic support to teen girls which include parental supervision, guidance, and financial care are essential aspects to consider in order to reduce teenage pregnancy rates. The study suggests that in addition to efforts directed to teens themselves, strategies for reducing teen pregnancies should focus on a range of household-level contexts that form two broad categories: empowering parents and maintaining parents' harmonious decisions on teen girls.