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Impact of a health system strengthening intervention on maternal and child health outputs and outcomes in rural Rwanda 2005–2010
  1. Dana R Thomson1,2,
  2. Cheryl Amoroso3,
  3. Sidney Atwood4,
  4. Matthew H Bonds1,5,
  5. Felix Cyamatare Rwabukwisi3,
  6. Peter Drobac3,4,6,
  7. Karen E Finnegan7,
  8. Didi Bertrand Farmer3,
  9. Paul E Farmer1,3,4,
  10. Antoinette Habinshuti3,
  11. Lisa R Hirschhorn8,
  12. Anatole Manzi3,
  13. Peter Niyigena3,
  14. Michael L Rich3,4,
  15. Sara Stulac1,3,4,
  16. Megan B Murray1,4,9,
  17. Agnes Binagwaho1,10
  1. 1 Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
  2. 2 College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
  3. 3 Partners In Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda
  4. 4 Division of Global Health Equity, Brigham and Women’s Hospital, Boston, Massachusetts, USA
  5. 5 Woods Institute, Stanford University, Stanford, California, USA
  6. 6 Global Health Delivery, University of Global Health Equity, Kigali, Rwanda
  7. 7 Department of International Health, Johns Hopkins University, Baltimore, Maryland, USA
  8. 8 Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
  9. 9 Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts, USA
  10. 10 Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire, USA
  1. Correspondence to Dana R Thomson; dana.r.thomson{at}


Introduction Although Rwanda’s health system underwent major reforms and improvements after the 1994 Genocide, the health system and population health in the southeast lagged behind other areas. In 2005, Partners In Health and the Rwandan Ministry of Health began a health system strengthening intervention in this region. We evaluate potential impacts of the intervention on maternal and child health indicators.

Methods Combining results from the 2005 and 2010 Demographic and Health Surveys with those from a supplemental 2010 survey, we compared changes in health system output indicators and population health outcomes between 2005 and 2010 as reported by women living in the intervention area with those reported by the pooled population of women from all other rural areas of the country, controlling for potential confounding by economic and demographic variables.

Results Overall health system coverage improved similarly in the comparison groups between 2005 and 2010, with an indicator of composite coverage of child health interventions increasing from 57.9% to 75.0% in the intervention area and from 58.7% to 73.8% in the other rural areas. Under-five mortality declined by an annual rate of 12.8% in the intervention area, from 229.8 to 83.2 deaths per 1000 live births, and by 8.9% in other rural areas, from 157.7 to 75.8 deaths per 1000 live births. Improvements were most marked among the poorest households.

Conclusion We observed dramatic improvements in population health outcomes including under-five mortality between 2005 and 2010 in rural Rwanda generally and in the intervention area specifically.

  • child health
  • health systems evaluation

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  • Handling editor Seye Abimbola

  • Contributors The following people were involved with the design and/or implementation of the health system intervention in K/SK: CA, FCR, PD, KEF, DBF, PEF, AH, AM, PN, MLR, SS and AB. MHB, LRH and MBM helped to conceive of the evaluation design. DRT and SA conducted the analysis. DRT, MHB and MBM drafted the paper. All coauthors closely reviewed the paper, contributed additional interpretations and approved the final version to be published.

  • Funding This study was funded by Doris Duke Charitable Foundation (Population Health Implementation & Training (PHIT)).

  • Disclaimer The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of the institutions to which the authors are affiliated.

  • Competing interests Past and current employees of PIH and RMOH contributed to the study design and writing of this manuscript because they had knowledge of the programme under evaluation and of Rwanda’s health system and context. No PIH or RMOH affiliated coauthors were involved with statistical analysis and interpretation.

  • Patient consent Detail has been removed from this case description/these case descriptions to ensure anonymity. The editors and reviewers have seen the detailed information available and are satisfied that the information backs up the case the authors are making.

  • Ethics approval Protocols for the 2010 supplemental survey were reviewed and approved by the Partners HealthCare Internal Review Board (protocol #: 2009 P-001941/8) and the Rwanda National Ethics Committee.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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