Introduction

Over the past two decades, Rwanda has made tremendous progress in implementing innovative, high impact, health programmes to improve the health of children, adolescents and women. Rwanda is one of the few countries in sub-Saharan Africa to have successfully achieved the Millennium Development Goals (MDGs) related to maternal health, with maternal mortality reducing from 1,071 in 2000 to 203 per 100,000 live births in 2020 and over 90% of births are attended by a skilled healthcare provider and occur in a health facility.

Now committed to implement the Sustainable Development Goals (SDGs), the country has introduced new tools to further strengthen and institutionalise accountability and governance mechanisms. One of these tools is the reproductive, maternal, newborn, child and adolescent health (RMNCAH) scorecard. This is a management tool introduced to enhance tracking of priority RMNCAH indicators promptly for better decision-making grounded in near real-time data. Recently cited in the National Strategic Plan as the main tool for monitoring and evaluation, the scorecard also counts on high-level engagement, with the Minister of Health accessing scorecards directly on DHIS2.

RMNCAH scorecard implementation is one of the flagship initiatives and a top priority initiative for the Government of Rwanda and partners in addressing maternal and child health in Rwanda.

Hon. Dr. Daniel Ngamije, Minister of Health, Republic of Rwanda

Background

In 2017, the government of Rwanda, with support from ALMA, introduced the RMNCAH scorecard to accelerate progress toward country and global RMNCAH targets. The RMNCAH scorecard is an integrated, action-oriented management and accountability tool that supports Rwanda’s health sector in general and particularly the Ministry of Health (MoH) in monitoring reproductive, maternal, newborn, child and adolescent health (RMNCAH) interventions.

In accordance with government of Rwanda and MoH policies, it was decided that the scorecard management tool would be integrated into DHIS2. The online dashboard on DHIS2 provides users access to routine analysed data on numerous health indicators including 60 RMNCAH indicators. The initial RMNCAH scorecard developed at the central level in 2017 included 24 priority indicators on maternal, neonatal, child and adolescent health (8 in the first wave) along with other indicators comprising financing and delivery of health commodities.

The scorecard was revised in September 2020 and currently comprises 14 indicators, most of them capturing the continuum of care and coverage indicators from the revised MCCH, family planning and ASRH strategic plans.

In 2020, the RMNCAH scorecard was decentralised down to district level in all 30 districts. Workshops were organized in November and December 2020 with the financial support of partners including the World Health Organization (WHO) and ALMA. Workshops gathered all the Director Generals of Districts, Provinces and Referral Hospitals, as well as officers in charge of monitoring and evaluation and data managers. Participants were oriented on the scorecards, including how to produce them, how to analyse and use them to generate actions. At the end of the workshop, each team for the participant hospital had produced a scorecard that showed the performance of RMNCAH indicators within their catchments area.

Indicators

The scorecard indicators are categorised with colour codes:

• Red – indicator not on track “lagging behind”
• Yellow – progress but more effort required
• Green – target achieved

The targets for the colour codes are set annually by reviewing trends and targets in national strategic plans and documents. Once established, the colour code ranges and targets are discussed and approved through the RMNCAH Technical Working Group (MCCH TWG).

How it works

The scorecard is produced directly in DHIS2 on a quarterly basis and discussed at several routine national level meetings. These include senior management meetings, sub-national level during district coordination meetings, health facility supervision meetings as well as in the RMNCAH Technical Working Group which brings together all the government and development partner institutions acting in the matter related to RMNCAH issues.

The Central level, which has been using the RMNCAH scorecard since 2017, uses the management tool to improve accountability, avail information to stakeholders on time, strengthen effective coordination of partners, advocate in mobilizing resources and allocate available resources efficiently where needed, and it is used to prompt political commitments at various levels toward the improvement of RMNCAH indicators.

At District level, health professionals, including district hospital managers, who have been trained in the use of scorecard in 2020, now use the scorecard to gather information about performance and drive accountability and action. At a decentralised level, the scorecard aims to improve the overall district performance, by highlighting which health centres require attention and support with addressing bottlenecks in a particular RMNCAH indicator.

The review of the scorecard at the coordination meetings brings together stakeholders from health centres and we can also invite the health posts managers and representatives of community health workers. So, if one health centre is red and performing poorly in one area we are to involve all those stakeholders to know what is going on in their locality. It will help us to analyse if the failure is at the level of community health workers, or at the level of health posts, and try to engage them in improving performance.

Dr William, Director General of Bugesera District Hospital

Importantly, the scorecard has led to enhanced leadership commitments, increased accountability and enhanced mutual trust and participation of all stakeholders including development partners, civil society organizations, as well as government officials. Also, the scorecard has proven to be a valuable management tool that drives improvements in data quality and availability through its quarterly production. The scorecard has further altered and boosted managerial functions with consequences to make managers further accountable and responsive to actions taken to enhance the performance of RMNCAH. At district level, the scorecard provides important data to enhance district leaders political buy-in and to advocate for increased resource allocation to maternal and child health for underperforming districts.

The way the scorecard is designed you can see where you are performing well, it is in green; where you are in progress but you need additional efforts, it is in yellow; where you are behind it is red, then it became more easy to know where you can put emphasis, coming with additional resources being human resources, financial resources, mobilization of partners, engagement of community. We know that we need improve or we need to work hard to improve the coverage rate for women, especially those attending antenatal care services. The scorecard helps us monitor our progress. By looking at the scorecard, we can see that for the last five years there is no significant difference between performance last year compared to what we did five years ago. It means we need to act on key determinants to reduce infant mortality and neonatal mortality.

Hon. Dr. Daniel Ngamije, Minister of Health, Republic of Rwanda

Impact examples

Family planning

Following the identified underperformance of family planning in the scorecard, the Ministry of Health has prioritised resource mobilisation for sexual and reproductive health. Rwanda has declared family planning and adolescent sexual reproductive health (ASRH) a national priority for poverty reduction and socioeconomic development of the country and the government has committed to ensuring “every reproductive age Rwandan citizen have full access to sexual and reproductive health services of their choice, enabling an overall increase in contraceptive prevalence by 2024”. After the scorecard review and bottleneck analysis, it was shown that family planning was delivered only through health facilities, and the Ministry of Health decided to implement a different approach in districts with low coverage, with community health workers going door to door to mobilise the population, provide services and refer clients to health facilities for long lasting methods.

We work with the community health workers in mobilizing mothers who live in their neighbourhood to come here to follow the family planning program. There are those who wish to continue to take family planning methods within their community and this works because the community health workers have received good training.

Odette Muhorakeye, Deputy Director of Gihundwe Health Centre

Antenatal care

A review of the quarter 3, 2020 scorecard showed ANC1 and ANC4 were red in many districts, especially in the Southern Province (Districts of Huye, Ruhango, Nyamagabe, Gisagara, Muhanga, Kamonyi, Nyanza, and Nyaruguru) achieving an average score of 36.6% for pregnant women that attended at least four antenatal care visits. The national target was to achieve over 40%. 3 out of 8 districts in the Southern Province had very poor performance (in red) ranging between 26.4% and 28% for this indicator. During the next quarterly meeting, the scorecard was presented by the MCCH division and discussed at the MCCH TWG with stakeholders including partners supporting the decentralised level. This led the Ministry of Health to engage with local and religious leaders and partners to mobilise resources leading to put in place interventions to increase ANC uptake.

Postpartum family planning

Scorecard review showed that there was a low uptake of postpartum family planning services, especially for women who had delivered their baby in hospitals (40% of all deliveries). As a result, the Ministry of Health worked with district hospitals to appoint one focal point of family planning in each hospital who would be in charge of providing education sessions and family planning methods to women who had just given birth. This led to an increase of postpartum family planning coverage, from 32% to 54% of women delivering in hospital and going back home with a family planning method. In addition, community health workers are now going door to door to sensitize people on family planning and encouraging male engagement around family planning.

We do door to door mobilization where we sensitize pregnant women to make the first antenatal visit during the first three months of pregnancy and we tell them to think about family planning already. After giving them the starting method, the health centre sends them back to us in the villages where we continue to monitor them.

Joseph, Community Health Worker

Improved stakeholder coordination and collaboration on priority RMNCAH interventions

Following the introduction of the scorecard, stakeholders involved in RMNCAH services have reported that the scorecard review process has improved coordination and collaboration. Every quarter, the MCCH technical working group (TWG) – a coordination forum for government and key stakeholders including development partners supporting RMNCAH activities, review the RMNCAH scorecard and collaborate on actions. Similar coordination meetings every quarter with the national and decentralized level involve the MoH and partners, health facility managers and district administrative authorities. Through these meetings the scorecard is reviewed, bottlenecks analysed, and action taken for indicators that are lagging behind such as ANC1 and ANC4, as described above.

Resource mobilisation

The RMNCAH scorecard has become a powerful advocacy tool for concerted support and resource mobilization efforts. The quarterly review process provides a forum for engagement of political and social accountability levels and a robust approach to strengthening stakeholder action and resource mobilization for priority RMNCAH indicators. As an example, the MoH used the scorecard to highlight gaps in family planning uptake and mobilised partners to prioritise the allocation of resources in the support of CHW’s door-to-door family planning strategy in the Western province, where family planning uptake had persistently been below the national average. For instance, in the FY 2020 to 2021, ENABEL (the Belgian Cooperation for Development) reallocated USD$600,000 to support the community family planning as an incentive for CHWs to scale up the door-to-door activities.

Every quarter, the scorecard is evaluated to show progress on various issues including, facilitating the analysis to see how better we allocate resource and where we need more focus to improve results.

Dr Felix Sayizoga, MCCH Division manager at RBC

Success story: How the scorecard led to increased coverage in the Rusizi district

Following the review of the scorecard, the Ministry of Health found that the indicator for Modern Contraceptive Rate coverage was consistently underperforming in Rusizi district. The Health Sector Strategic Plan IV has a target of 60% for modern contraceptive rate coverage while the unmet need for the planning target is 15% by 2024. While much of the country has met the target of these family planning indicators before the HSSP IV life span (DHS 2015 to 2020), the RMNCAH scorecard has shown that the family planning achievements are not equally distributed across all the districts of the country, with the Rusizi district averaging 23% in 2017 to 2018 against a national average of 35%. One of the reasons identified for the underperformance was the high number of religious-affiliated health facilities that were not providing family planning in the district.

The Ministry of Health identified the door-to-door family planning approach as a national priority action and a means to increase coverage of family planning services in the Rusizi district. The door-to-door strategy to sensitize parents and adolescent girls and boys to modern contraceptive methods for family planning is done by community health workers. Community health workers in Rwanda are volunteers who deliver promotional, preventive, curative healthcare-related services to their members. Although volunteers, the community health workers are integrated into the health care delivery system pyramids, and they are well respected. Community health workers are able to advise households, mainly women and adolescent girls, to adhere to the family planning program and advise them to take a modern contraceptive method for spacing or limiting their birth.

Through different coordination meetings and forums, partners and other stakeholders were mobilised to support community health workers and through different forums for policy dialogue, partners were engaged to provide resources (human, infrastructure or financial).

As such, the national average for contraceptives prevalence for all methods has increased from 37% in 2016/2017 to 53% in 2019/2020. Regular civil society meetings are now held in the county through the Health NGO Network (HENNET) to ensure all non-government stakeholders in the health sector speak with ‘one voice’. Partners have further agreed that they will make their workplans public and ensure they are incorporated into the county’s annual work plan. The partners have produced a number of joint advocacy products which have relied heavily on scorecard data and gap analysis. These are credited with making a major contribution to increases in the county health budget.

These family planning strategies have led to some successes in the Rusizi district:

• Increasing knowledge of Family Planning in the Community and especially in the village
• Easy accessibility and reducing geographic barriers while needing family planning product
• Uptake of the postpartum contraceptive methods coverage stands between 50 and 70% of all assisted delivery
• The total district family planning coverage has increased from 31% to 42% from 2016 to 2017 to 2019 to 2020