Evaluation of Strengthening Human Resources for Health Capacity in the Republic of Rwanda under the President's Emergency Plan for AIDS Relief (PEPFAR)

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Since 2004, the U.S. government has supported the global response to HIV/AIDS through the President's Emergency Plan for AIDS Relief (PEPFAR). The Republic of Rwanda, a PEPFAR partner country since the initiative began, has made gains in its HIV response, including increased access to and coverage of antiretroviral therapy and decreased HIV prevalence. However, a persistent shortage in human resources for health (HRH) affects the health of people living with HIV and the entire Rwandan population.

Recognizing HRH capabilities as a foundational challenge for the health system and the response to HIV, the Government of Rwanda worked with PEPFAR and other partners to develop a program to strengthen institutional capacity in health professional education and thereby increase the production of high-quality health workers. The Program was fully managed by the Government of Rwanda and was designed to run from 2011 through 2019. PEPFAR initiated funding in 2012. In 2015, PEPFAR adopted a new strategy focused on high-burden geographic areas and key populations, resulting in a reconfiguration of its HIV portfolio in Rwanda and a decision to cease funding the Program, which was determined no longer core to its programming strategy. The last disbursement for the Program from PEPFAR was in 2017.

Evaluation of PEPFAR's Contribution (2012-2017) to Rwanda's Human Resources for Health Program describes PEPFAR-supported HRH activities in Rwanda in relation to programmatic priorities, outputs, and outcomes and examines, to the extent feasible, the impact on HRH and HIV-related outcomes. The HRH Program more than tripled the country's physician specialist workforce and produced major increases in the numbers and qualifications of nurses and midwives. Partnerships between U.S. institutions and the University of Rwanda introduced new programs, upgraded curricula, and improved the quality of teaching and training for health professionals. Growing the number, skills, and competencies of health workers contributed to direct and indirect improvements in the quality of HIV care. Based on the successes and challenges of the HRH program, the report recommends that future investments in health professional education be designed within a more comprehensive approach to human resources for health and institutional capacity building, which would strengthen the health system to meet both HIV-specific and more general health needs. The recommendations offer an aspirational framework to reimagine how partnerships are formed, how investments are made, and how the effects of those investments are documented.

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298 pages · 6 x 9 · paperback
ISBN Paperback: 0-309-67205-8
ISBN Ebook: 0-309-67206-6
DOI: https://doi.org/10.17226/25687

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National Academies of Sciences, Engineering, and Medicine. 2020. Evaluation of PEPFAR's Contribution (2012-2017) to Rwanda's Human Resources for Health Program. Washington, DC: The National Academies Press.

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Ann E. Kurth

Ann E. Kurth, Ph.D., C.N.M., M.P.H., F.A.A.N., (Chair), is dean and Linda Koch Lorimer Professor of the Yale University School of Nursing. Dr. Kurth is an elected member of the National Academy of Medicine and a member of the 2014–2018 U.S. Preventive Services Task Force, which sets screening and primary care prevention guidelines for the United States. She is a member of the New York Academy of Medicine and of the Connecticut Academy of Science and Engineering. Dr. Kurth is the 2018–2020 chair of the Consortium of Universities for Global Health, the more than 185 university member academic global health network. An epidemiologist and clinically trained nurse–midwife, Dr. Kurth’s research focuses on HIV/reproductive health and global health system strengthening, particularly in the context of climate change (see www.planetaryhealthnow.org). Her work has been funded by the U.S. National Institutes of Health (NIH)—National Institute of Allergy and Infectious Diseases, National Institute on Drug Abuse, National Institute of Mental Health, National Institute of Child Health and Development—as well as the Bill & Melinda Gates Foundation, Joint United Nations Programme on HIV/AIDS, U.S. Centers for Disease Control and Prevention (CDC), Human Resources Services Administration, and others, for studies conducted in the United States and internationally. Dr. Kurth has consulted for the NIH, Gates Foundation, World Health Organization, U.S. Agency for International Development, and CDC, among others. Dr. Kurth has published over 200 peer-reviewed articles, book chapters, and scholarly monographs and presented at hundreds of scientific conferences and invited talks. Dr. Kurth has received awards for her science and leadership including the Friends of the National Institute of Nursing Research Award and the International Nurse Researcher Hall of Fame award from Sigma Theta Tau International, the global nursing honor society. She chairs the National Academies of Sciences, Engineering, and Medicine’s Board on Global Health.

Till Barnighausen

Till Bärnighausen, M.D., Sc.D., M.Sc., M.Sc., is Alexander von Humboldt University Professor at Heidelberg University, Germany’s oldest university, and director of the Heidelberg Institute of Global Health in the Faculty of Medicine. He is also adjunct professor of global health at the Harvard T.H. Chan School of Public Health, faculty affiliate at the Harvard Center for Population and Development Studies, and senior faculty at the Wellcome Trust’s Africa Health Research Institute in KwaZulu-Natal, South Africa. Dr. Bärnighausen’s research focuses on developing and testing population health interventions that address large health care needs in poor countries, in particular for HIV and other chronic conditions such as diabetes and hypertension. He focuses on interventions that can be implemented in resource-poor settings, such as community health worker initiatives and novel interventions in nurse-led primary care clinics. In 2015, Dr. Bärnighausen won the Alexander von Humboldt Professor Award, Germany’s most highly endowed international price for science. Dr. Bärnighausen is principal investigator on several U.S. National Institutes of Health grants (including 5 R01s). His research is also funded by the Wellcome Trust; the Alexander von Humboldt Foundation; the European Commission; the German Federal Ministry of Science and Education; World Health Organization; World Bank; UNAIDS; UNITAID; U.S. Agency for International Development; ANRS; Clinton Health Access Initiative; Gavi, the Vaccine Alliance; Elton John AIDS Foundation; Rush Foundation; and the International Initiative for Impact Evaluation (3ie). Dr. Bärnighausen is a medical specialist in family medicine and holds doctoral degrees in population and international health (Harvard University) and history of medicine (University of Heidelberg), as well as master’s degrees in health systems management (London School of Hygiene and Tropical Medicine) and financial economics (SOAS University of London). He previously worked as physician in China, Germany, and South Africa; as a journalist in Berlin; and as management consultant for McKinsey & Co. in Europe. Dr. Bärnighausen has published more than 300 peer-reviewed articles, including in Science, Lancet, PNAS, and PLoS Medicine. His work has attracted more than 15,000 citations. His h-index is 58.

Eran Bendavid

Eran Bendavid, M.D., M.S., is an associate professor of medicine at Stanford University, and a faculty affiliate in the Division of Infectious Diseases, the Department of Health Research and Policy, and the Woods Institute for the Environment. His work, broadly, involves studying the drivers of population health improvements, mostly in lower-resource contexts. He explores how decisions about foreign assistance for health are made, and how those decisions affect the health of those whom assistance aims to serve. Dr. Bendavid is also a disease modeler, and uses that skill to explore issues of resource allocation in low- and middle-income countries with cost-effectiveness analyses. His recent research projects include an impact evaluation of the U.S. assistance program for HIV in Africa, and an exploration of the association between drug prices, aid, and health outcomes in countries heavily affected by HIV. He received a B.A. in chemistry and philosophy from Dartmouth College, and an M.D. from Harvard Medical School. His residency in internal medicine and fellowship in infectious diseases were completed at Stanford.

Carla Castillo-Laborde

Carla Castillo-Laborde, M.Sc., M.A., is an assistant professor at the Centro de Epidemiología y Políticas de Salud, Facultad de Medicina Clínica Alemana, at the Universidad del Desarrollo, Santiago. Previously, she was a researcher at the Department of Health Economics of the Ministry of Health, Chile, from 2005 to 2012, participating in various studies related to the establishment of health reform, among others associated with areas of health economics, such as financing of health systems and economic evaluations. From October 2012 to June 2014, she was analyst of methodologies at the Department of Methodologies in the Ministry of Social Development, participating in the development and update of methodologies for social evaluation of projects, particularly for projects associated with the health sector or health effects. From April 2014 to January 2016, Ms. Castillo-Laborde worked as technical advisor to the Ministry of Health, specifically on issues related to private health system financing reform, and from April 2016 to July 2018, she was technical advisor at the Social Policies Coordination of the Ministry of Finance, on economic issues related to health. She has also been a professor of introductory courses in economics and introduction to microeconomics at the Pontificia Universidad Católica de Chile from 2006 to 2008, and of economic evaluations in health at the Universidad de Chile (for the Magister Informática Médica) from 2012 and 2014, in addition to various courses related to health economics prepared by the Chilean Chapter of the International Society for Pharmacoeconomics and Outcomes Research since 2012.

Elvin H. Geng

Elvin H. Geng, M.D., M.P.H., is a professor of medicine in the Division of Infectious Diseases in the Department of Medicine and Director of the Center for Dissemination and Implementation at the Institute for Public Health, both at Washington University in St. Louis. He earned M.D. and M.P.H. degrees from Columbia University and subsequently completed postdoctoral training through the Aaron Diamond AIDS Institute at The Rockefeller University (posted to Kunming, China) as well as fellowship training in infectious diseases at the University of California in San Francisco. Using the lens of implementation science, Dr. Geng conducts research to optimize the use of evidence-based interventions in the public health response to HIV. His work is carried out through collaborations in Kenya, Zambia, Uganda, as well as in a safety net setting in the United States. His current activities make use of a range of observational, mixed methods, quasi-experimental, and experimental methods. His work is sponsored by the Bill & Melinda Gates Foundation and the National Institutes of Health. Dr. Geng serves in an advisory capacity for the World Health Organization, nongovernmental organizations, and professional organizations. He is an academic editor at PLOS Medicine, a member of the editorial board of JAIDS and Journal of the International AIDS Society, and editor for implementation science at Current HIV/AIDS Reports.

Fastone M. Goma

Fastone M. Goma, Ph.D., M.B.Ch.B., M.Sc., is an associate professor of physiology and cardiovascular Health at the University of Zambia school of Medicine. He is a medical doctor with a Ph.D. in cardiovascular science from the University of Leeds. He also studied international public health at the University of Alabama at Birmingham and tobacco dependency treatment at University of Toronto. Dr. Goma is also appointed senior scholar at the World Health Organization Collaborating Centre for Health Workforce Planning and Research at the University of Dalhousie, Canada. Currently he is director for the Centre for Primary Care Research (CPCR) which has taken on health systems and noncommunicable diseases (NCDs) as the main areas of focus for research and policy influence. Dr. Goma continues to actively participate in processes of formulating and implementing risk-reduction strategies for NCDs in Zambia and Africa. He is the founding president for the Zambia Heart and Stroke Foundation, and an active member of the African Heart Network and World Heart Federation. The CPCR is the secretariat for the Zambia Tobacco Control Campaign, a community advocacy group, and the International Tobacco Control Evaluation Project. Other research interests include palliative care, knowledge translation, and indigenous knowledge systems. He has been a keen advocate of competency/needs-based approaches to health workforce planning.

Laura Hoemeke

Laura Hoemeke, Dr.P.H., is a global health policy consultant, and has nearly 25 years of experience in global health, including field assignments in Benin, the Central African Republic, Senegal, and Rwanda, and short-term assignments throughout East, West, and Central Africa. Her areas of expertise include policy analysis and program design and management. She has worked in family planning, maternal and child health, malaria prevention and control, and HIV/AIDS prevention and control, as well as health systems strengthening and health governance. Dr. Hoemeke served as United States Agency for International Development (USAID) Benin’s family health technical advisor for 4 years. In early 2003, she joined IntraHealth International as regional director for West and Central Africa, based in Senegal. From 2005 through early 2010, Dr. Hoemeke was based in Rwanda as the director of IntraHealth’s successful USAID-funded Twubakane Decentralization and Health Program, which contributed to the country’s impressive results, particularly in the areas of health-sector decentralization, family planning, and child health. In 2010, she joined IntraHealth’s headquarters leadership team and served as director of communications and advocacy then director of health policy and systems through November 2018. Dr. Hoemeke has authored several publications and has spoken and presented at numerous global health conferences and other events. She earned her doctorate in public health from the University of North Carolina at Chapel Hill Gillings School of Global Public Health in health policy and management. She has an M.P.H. from Johns Hopkins University and a B.S. in journalism from Northwestern University.

Angelina Kakooza-Mwesige

Angelina Kakooza-Mwesige, M.B.Ch.B., M.Med., Ph.D., is a senior lecturer and a pediatric neurologist in the Department of Pediatrics and Child Health, School of Medicine, Makerere University College of Health Sciences in Kampala, Uganda. Her major research interests are in the fields of neurology and infectious diseases, with considerable experience in the field of HIV/AIDS and neurodevelopmental disorders, particularly cerebral palsy, autism, and epilepsy. Her doctoral study was on cerebral palsy, which she defended in May 2016 as a joint degree from the Karolinska Institute, Sweden, and Makerere University, Uganda. For her postdoctoral fellowship, she will continue to pursue her research interests which will be key to addressing how acquired infections of mothers during pregnancy may have impacts on their pregnancy, as well as the development of neurodevelopmental disorders in their children with a focus on the Zika virus. Her postdoctoral fellowship is funded by the DELTAS Africa Initiative grant #DEL-15-011 to THRiVE-2 (an independent funding scheme of the African Academy of Sciences’ Alliance for Accelerating Excellence in Science in Africa that is supported by the New Partnership for Africa’s Development Planning and Coordinating Agency, with funding from the Wellcome Trust grant 107742/Z/15/Z and the UK government). Dr. Kakooza-Mwesige is also closely involved in training post- and undergraduate medical and paramedical students on neurological disorders in children and has more than 20 years of experience in medical practice in low-resource settings. She was elected as the 2017–2021 chair of the Commission for African Affairs of the International League Against Epilepsy. She is a board member on the African Child Neurology Association; African Regional Committee of the International Brain Research Organization (IBRO-ARC); and the Women in World Neuroscience, a branch of IBRO. She has been instrumental in the founding of the East African Academy on Childhood Disability, where she is the current treasurer. Dr. Kakooza-Mwesige has served on a previous committee for the outcome and impact evaluation of global HIV/AIDS programs implemented under the Lantos-Hyde Act of 2008 at the National Academies of Sciences, Engineering, and Medicine.

Emmanuel B. Luyirika

Emmanuel B. K. Luyirika, M.B.Ch.B., B.P.A.(Hons), M.P.A., M.Fam.Med., is the executive director of the African Palliative Care Association (APCA). Dr. Luyirika joined APCA as the executive director in 2012. He holds a bachelor of medicine degree from Makerere University in Uganda, a master’s degree in family medicine from the Medical University of Southern Africa, and a postgraduate honors degree and a master of public administration from University of Stellenbosch. As part of the master in family medicine, he conducted research focusing on issues around HIV among school-going teenagers. As part of the master’s degree in public administration from the University of Stellenbosch's School of Public Management and Planning, his research focused on the national HIV/AIDS policy of South Africa. He also holds an HIV certificate from the University of Witwatersrand in South Africa. Dr. Luyirika started his career as a medical officer in rural Uganda at Kagando Hospital, near the Rwenzori Mountains on the border with the Democratic Republic of Congo. He later moved to South Africa, where he worked at the Donald Fraser Hospital in Limpopo Province, after which he trained in family medicine at the Medical University of Southern Africa, where he was also appointed lecturer in the Department of Family Medicine. Apart from practicing medicine in a hospital setting in South Africa, Dr. Luyirika worked as a facilitator in the Rural Health Initiative of the South African Academy of Family Practice, where he trained multidisciplinary teams to care for HIV patients and to develop home care strategies and kits as well as community HIV prevention strategies. Returning to Uganda in 2002, Dr. Luyirika accepted the role of overseeing the health care program run by Mildmay International as clinical director, and after 3 years he became the overall center director; after another 3 years he became Mildmay International's country director. In these roles, he was actively involved in HIV prevention, care, treatment, education, and research and oversaw more than 20,000 patients in care. In his current role at APCA, he is involved in overseeing palliative care development both in Uganda and across Africa. Dr. Luyirika's vision for APCA’s work in Africa is to strengthen health systems by integrating palliative care using evidence-based models and for advocating for policy development and change for palliative care across the continent. He also values knowledge and best practice sharing in the region to influence stakeholders to ensure the integration of palliative care into national health-sector plans using available resources. Dr. Luyirika has also authored and coauthored a number of publications related to palliative care and HIV.

Mosa Moshabela

Mosa Moshabela, Ph.D., M.Sc., M.B.Ch.B., M.Fam.Med., Dip.HIV (SA), is currently an associate professor and the dean in the School of Nursing and Public Health, University of KwaZulu-Natal, South Africa. A qualified physician in family medicine and primary health care, he works as a chief medical specialist in rural health medicine, and a public health scientist in health services, systems, and policy in KwaZulu-Natal, South Africa, with the aim of improving access, quality, and equity in health care. Dr. Moshabela is also adjunct faculty and a Wellcome Trust research fellow at the Africa Health Research Institute, South Africa, where he collaborates with the London School of Hygiene and Tropical Medicine, and conducts research in several countries in sub-Saharan Africa. He was previously the regional health advisor for the Millennium Villages Project in West and Central Africa, based at the Millennium Development Goals Centre in Mali/Senegal, working with the Earth Institute at Columbia University. Prior to the Earth Institute, he worked for 5 years as a senior lecturer in the School of Public Health at the University of Witwatersrand, Johannesburg, where he was also the director of the Rural AIDS and Development Action Research Programme. Currently, Dr. Moshabela’s research portfolio seeks to design, implement, and evaluate complex interventions in public health care services and programs, in ways appropriate for resource-poor settings in sub-Saharan Africa.

Denis Nash

Denis Nash, Ph.D., M.P.H., is a distinguished professor of epidemiology at the City University of New York’s (CUNY’s) School of Public Health and the founding executive director of CUNY’s Institute for Implementation Science in Population Health. He has more than 20 years of expertise in implementation science. His experience includes extensive domestic and international work in implementation science, comparative effectiveness research, and large-scale epidemiologic studies examining key outcomes among persons with HIV. Dr. Nash brings seasoned expertise in study design and methodological approaches to large-scale, “real-world” research projects. Prior to joining CUNY, Dr. Nash was an Epidemic Intelligence Service Officer and subsequently the director of HIV/AIDS surveillance, where he played a key role in the implementation of named reporting for HIV. He also worked at ICAP at Columbia University as the director of monitoring, evaluation, and research—spearheading a multicountry initiative collecting routine medical records electronically. Dr. Nash has vast global health implementation and research experience. He has worked extensively on large-scale initiatives and research projects in sub-Saharan Africa, including on the Guinea Worm Eradication Program in Nigeria, sentinel HIV surveillance in Botswana and Nigeria, and rapid expansion/scale-up of HIV/AIDS care and treatment under the President’s Emergency Plan for AIDS Relief in Burundi, Cote d’Ivoire, Ethiopia, Kenya, Lesotho, Mozambique, Nigeria, Rwanda, South Africa, Swaziland, Tanzania, Uganda, and Zambia. Dr. Nash currently leads the U.S. National Institutes of Health (NIH) funded IeDEA Central Africa regional collaboration (as one of the multiple principal investigators with Kathryn Anastos), which is an implementation science study that follows more than 50,000 persons enrolled in HIV care in five Central African countries (Burundi, Cameroon, the Democratic Republic of Congo, Republic of Congo, and Rwanda). He has recently begun research collaborations on noncommunicable diseases, which includes household population health survey of four urban slums in Port au Prince, Haiti. Dr. Nash has published more than 150 scientific articles, and his research is primarily funded by the NIH and the U.S. Centers for Disease Control and Prevention. Dr. Nash also serves as a standing member on NIH study section review panels, and holds secondary faculty appointments in the Department of Epidemiology at Columbia University’s Mailman School of Public Health and in the Department of Epidemiology and Population Health at the Albert Einstein College of Medicine.

Charles O. Pannenborg

Charles Ok Pannenborg, Ph.D., is a national of the Netherlands and recently retired from the World Bank, where he served as its chief health advisor/director and chief health scientist. Previously he lived and worked in Bangladesh, Congo, Ethiopia, Pakistan, and Tanzania. Dr. Pannenborg served on the boards of the Tropical Disease Research program, the Global Forum for Health Research, the Council on Health Research for Development, and more recently on the board of IntraHealth International and as an interim director at the Pan American Health Organization. He also served as an advisor to the World Bank’s higher education programs, and as chairman of the Netherlands Commission on Global Health Research, as well as the Royal Tropical Institute’s Board on Health. In the past 40 years, he has been a global leader in several highly successful infectious disease programs, in the introduction of joint sectorwide health reform programs in Asia and Africa, and in reform of health and medical education worldwide. He holds degrees from the law and medical schools of the Universities of Groningen, of Amsterdam, and of Toronto. Dr. Pannenborg remains active as an advisor for health reform efforts in lower-, middle- and higher-income countries, as well as global multilateral health organizations.

Derek J. Sloan

Derek J. Sloan, Ph.D., M.B.Ch.B., is a senior clinical lecturer and consultant infectious diseases physician with a joint appointment at the University of St. Andrews and NHS Fife. He has previously worked extensively in southern Africa. In 2004, he was worked as a clinician at PCEA Chogoria Hospital in Kenya and supported setup of an HIV clinic which provided comprehensive rollout of antiretroviral therapy for the first time in the district. From 2005 to 2006 he was senior medical officer and tuberculosis (TB) lead for Hlabisa subdistrict in KwaZulu-Natal, South Africa, where the dual burden of HIV and drug-resistant TB had become a public health crisis. Subsequently, he completed a Wellcome Trust-funded Ph.D. fellowship at the University of Liverpool Institute of Global Health and Liverpool School of Tropical Medicine. His work there was on the clinical pharmacology of TB treatment, and included 2.5 years of combined clinical and academic work in Blantyre, Malawi. During that time Dr. Sloan was also an honorary lecturer at the University of Malawi College of Medicine, and edited The Clinical Book, a practical pocket textbook of local management protocols for common adult medical conditions that still acts as a standard guide for medical students, clinical officers, and doctors across the country. In 2015, he spent 3 months in Sierra Leone working as clinical lead on the U.K.-Med Quality Monitoring Team, supporting the NHS contribution to the Ebola virus disease outbreak in West Africa. His ongoing research interests are targeted towards clinical therapeutics questions of global public health significance, particularly in the treatment of TB, HIV, and other infections.

Sheila D. Tlou

Sheila D. Tlou, Ph.D., R.N., F.A.A.N. (until May 2019), is the chair of the Global HIV Prevention Coalition. From 2010 to June 2017, she was UNAIDS regional director for Eastern and Southern Africa. She was a minister of health of Botswana, former professor of nursing at the University of Botswana, and director of the World Health Organization Collaborating Centre for Nursing and Midwifery Development in Primary Health Care for Anglophone Africa. She has conducted research and taught courses to nursing, premedical, and social science students on gender issues relating to HIV/AIDS, sexual and reproductive health and rights, and aging and older persons. She has played a key role in the development of national nursing and medical education curricula, working to broaden the scope of health sciences education in her home country of Botswana. Dr. Tlou has been involved in the AIDS response since 1985 and has worked to increase community awareness of HIV/AIDS in Botswana using youth groups, nongovernmental organizations, and grassroots women’s organizations. She was HIV/AIDS coordinator at the University of Botswana from 2002 to 2004 and facilitated the formation of the Students Against AIDS Society. During her term as minister of health, Dr. Tlou contributed to the improvement of global health care, especially for women and girls. She led a comprehensive HIV/AIDS prevention, treatment, care, and support program in Botswana with achievements including: a rollout of antiretroviral drugs and prevention of mother-to-child transmission to near universal uptake; decreased transmission of HIV from mother-to-child from about 30 percent in 2003 to about 8 percent in 2008; and decreased maternal mortality due to AIDS from 34 percent to 9 percent. As chairperson of Southern African Development Community (SADC) and of the African Union Ministers of Health in 2005 to 2006, Dr. Tlou provided leadership in the adoption of the SADC Malaria Eradication Program, the SADC HIV/AIDS Plan of Action, and the Maputo Plan of Action on Sexual and Reproductive Health and Rights. Dr. Tlou also represented Eastern and Southern Africa in the board of the Global Fund to Fight AIDS, Tuberculosis and Malaria.

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Evaluation of Strengthening Human Resources for Health Capacity in the Republic of Rwanda under the President's Emergency Plan for AIDS Relief (PEPFAR)

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Evaluation of Strengthening Human Resources for Health Capacity in the Republic of Rwanda under the President's Emergency Plan for AIDS Relief (PEPFAR)

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Evaluation of PEPFAR's Contribution (2012-2017) to Rwanda's Human Resources for Health Program

Description

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Major units and sub-units

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Provide feedback

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Review of the draft United by Nature assessment

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