Impact on access to care.
intestinal parasitic infections, injuries
INTESTINAL PARASITIC INFECTION
The administrative data suggest that SGHPs complemented health centers’ provision of outpatient care for conditions such as ARIs, injuries, and oral health care. However, we did not find a significant change in the provision of ANC services. For outpatient visits, for all intervention areas combined, the SGHPs showed a remarkably high penetration rate during their first full year of operation (November 2019–October 2020). The use data showed that 88.1% of the 113,788 outpatient visits in all the intervention areas took place in SGHPs. From the household survey, we estimated some modest improvements, but they were not statistically significant. The delay in seeking the first ANC visit was reduced in the intervention areas by about a week. Women sought care 1.4 weeks earlier at health centers, but 0.6 week later in SGHPs in the intervention areas compared with trend-based expectations.The quality of health care in the intervention areas improved by 7.6 points for pregnant women (on a 0- to 100-point scale). Findings from the FGDs suggest that the small staff size of a SGHP compared with a health center, staff shortages, and staff turnover may have contributed to perceptions of declining quality of care from 2019 to 2021 at both health centers and SGHPs. On the other hand, quality of care for pregnant women improved in intervention areas compared with control areas, and the service index in the intervention areas improved by 2.3 points compared with the pre-SGHPs period. Travel time to a health post (averaging 17 minutes one way) was shorter than to a health center per administrative data compiled by the SFH.In household surveys, respondents reported much longer travel times than the administrative data suggested. The FGDs offered several explanations for this discrepancy. First, because the women were pregnant, some were not able to walk. They had to walk slowly or wait by the side of the road until an available bicycle taxi came by that could transport them. Second, respondents misinterpreted the question and incorporated time at the facility as part of their response. Third, respondents did not generally wear wristwatches or carry phones (which often remained with the household head), so they had trouble estimating time precisely, or performing the arithmetic to convert one-way time in minutes to a round trip in hours. Although the times differed among the three populations, likely because of one or more of the reasons just mentioned, patterns within a population were consistent and plausible, raising confidence that the SGHPs lowered travel time.Poor sanitation and limited access to water are known risk factors for intestinal parasitic infections across all ages. In Rwanda, rural areas experienced a greater burden than urban areas.As small private enterprises, the SGHPs were incentivized financially to generate a high volume of visits, with associated revenues to cover their costs and hopefully a margin for the operator. On this measure, they succeeded, averaging 1.83 visits per person per year. With no financial incentive for quality of care, preventive services, or coordination with other parts of the health system, the lack of impact was not surprising.Despite several successes, SGHPs have not yet met their targets for various preventive indicators, such as earlier ANC visits and greater use of preventive services. There were several reasons. Some women preferred receiving ANC at a health center so the location would be familiar when they gave birth. Some policies designed to facilitate continuity of care for pregnant and postpartum women acted as unintended barriers against the use of SGHPs. For example, health centers, but not SGHPs, could provide pregnant women with insecticide-treated bed nets and, if eligible, food supplements. In addition, Rwanda’s pay-for-performance mechanism incentivized CHWs to bring pregnant women to a health center, but not a SGHP, to start ANC within the first trimester. This design created an unintended conflict between the SGHPs and the health centers, leading CHWs to stop referring most pregnant women to SGHPs. The only exceptions were women more than 3 months into their pregnancy and late in initiating ANC. In this case, the CHWs referred the woman to the SGHPs for ANC so she could avoid paying a fine (reprimand) for the delay in seeking care.