Information flow and_referral_system_project_-_wdi_internship_2012-1

William Davidson Institute
Ruli Hospital Summer Internship 2012
Daniel Bickley

Table of Contents
Introduction......................................................................................................................................................3
Rwanda...............................................................................................................................................................3
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The Rwandan Health Care System......................................................................................................................3
Background.......................................................................................................................................................5
Summary of 2012 MAP Project...........................................................................................................................6
Expansion of MAP Project Scope........................................................................................................................7
Information Flow Study....................................................................................................................................8
Description of Project.........................................................................................................................................8
Methods.............................................................................................................................................................8
Findings...............................................................................................................................................................8
Information Flow............................................................................................................................................9
Patient Flow..................................................................................................................................................31
Discussion.........................................................................................................................................................33
Recommendations for Improvements..............................................................................................................34
Implementation of Appointment System Improvements................................................................................35
Background.......................................................................................................................................................35
MAP Team Recommendations.........................................................................................................................35
Additions to MAP Recommendations...............................................................................................................36
Implementation Report....................................................................................................................................40
Problems and Solutions................................................................................................................................42
Recommendations for Future Improvements...................................................................................................47
Conclusion......................................................................................................................................................49
Summary of Information Flow Study................................................................................................................49
Summary of Implementation............................................................................................................................50
Summary of Recommendations and Next Steps...............................................................................................50

I. Introduction

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a. Rwanda

Rwanda is a landlocked country in Central-East Africa with a population of roughly 11.7 million. With
a land area of approximately 10,000 square miles, it is the 149th smallest country in the world,
comparable in size to Maryland. However, despite its small size, it boasts the highest population
density of any country on the continent. Interestingly, it is also predominantly a rural nation, with 90
percent of the population carving out an existence as subsistence farmers. The nation features a small
number of urbanized areas, most notably the capital of Kigali, which serves as an economic, cultural,
and political hub.

The primary drivers of the Rwandan economy include tourism, mineral extraction, and coffee and tea
production. The country has a tumultuous past, attaining independence only 50 years ago and suffering
a devastating genocide and period of lingering violence in 1994. Therefore, although there has been
relative stability and increased development in the last decade or two, the poverty rate remains elevated
at around 45 percent. Despite this state of relative poverty, the Rwandan government commits sizeable
funding to health care, spending 9% of GDP on health-related expenditures annually1.

b. The Rwandan Health Care System

The health care system in Rwanda operates on a tiered basis. There exist 4 separate levels of care
delivery: community health workers, health centers, district hospitals, and referral hospitals. Each tier
delivers care to patients with an appropriately complex disease state, and refers those patients who
cannot be treated effectively to the next level. A brief description of each level follows:

1) Community Health Workers: Broadly speaking, this tier of the health system is responsible for
disseminating health maintenance and public health information at the village level. Each
village elects four lay-people to function as community health workers. Of these four, two are
designated as responsible for nutrition outreach efforts. This outreach includes regular
monitoring of height and weight for each child living in the community, as well as counseling
and education for mothers on adequate nutrition and demonstrations of proper cooking
techniques and meal composition. Another community health worker is assigned to
maternal/child health within the village, and helps to keep track of pregnant and peri-partum
women in that community. This worker must report problems – or potential problems – to
health centers. The last of the four volunteers is assigned to coordinate large meetings and
events, and may assist the other community health workers in their roles if needed. Community
health workers may refer patients to health centers when they find a condition requiring
treatment, and patients may also self-refer whenever they have a complaint.
2) Health Centers: The health centers that exist in Rwanda function as primary care outpatient
clinics. A single health center will serve several villages and outlying areas, and may see
between 30 and 100 patients daily, depending on its location. The primary clinic of the health
center is labeled “Consultation”, but there are other auxiliary services housed in the health
center as well. These services include HIV/AIDS, Tuberculosis, Malnutrition, Vaccination, and
Maternity, among others. Neither the primary clinic nor the ancillary services employ
physicians at the health center level; all are staffed by nurses. A wide variety of common acute
complaints are addressed satisfactorily on this tier of the health care system, as well certain
1
. "CIA World Factbook." . CIA, 11 Sep 2012. Web. 15 Aug 2012. https://www.cia.gov/library/publications/the-world-
factbook/geos/rw.html
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chronic but uncomplicated conditions. Patients are referred to the next level, the district
hospital, when the health center either lacks the laboratory or radiographical tools to make a
firm diagnosis, finds a diagnosis which cannot be treated adequately at the Health Center, or
when patients present emergently (at which time they can be transferred by an ambulance
belonging to the health center or district hospital).
3) District Hospital: At this tier of the system, patients are referred from large areas of the district
that the hospital is located in, as well as nearby areas of adjacent districts. Each hospital
therefore receives patients from roughly six to ten health centers on a regular basis. District
hospitals treat patients both on an outpatient and inpatient basis. As is the case at health centers,
the primary outpatient clinic is “External Consultation”, which sees non-urgent cases referred
from health centers. In addition, there are emergency services, including ambulances and an
exam room dedicated to emergencies. Additional outpatient services include such ancillary
specialties as dentistry and ophthalmology. On the inpatient side, district hospitals typically
have general adult and pediatric wards, a maternity ward, some level of critical care, and the
ability to perform some surgeries. All of these services, both inpatient and outpatient, are
staffed by doctors who are aided by a complement of nurses. Doctors at the district hospital
level are all generalists. District hospitals rarely have specialists on hand, and when they do, it
is typically on a visiting basis. Patients are referred to the next level, referral hospitals, when
they have a very rare or complicated condition that is not easily treated with the resources
available at the district level. This is an uncommon step that is reserved for the sickest patients,
or those who require diagnostic capabilities that are too complicated or expensive to distribute
to district hospitals, such as CT and MRI scanners.
4) Referral Hospital: The highest level of the Rwandan health care system consists of hospitals
located in Kigali which have access to advanced diagnostic and treatment modalities. Few
patients are referred to this level, and only when other options are exhausted.

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Gakenke District Health Centers and Hospitals

II. Background

It is within this system that The Ihangane Project has been working for the last decade. In addition to
sponsoring work towards economic and infrastructure development in the wider community around
Ruli, Rwanda, The Ihangane Project has also made commitments to improving the efficiency of the
health care system, specifically at Ruli Hospital and its affiliated health centers. In the last few years,
this partnership between the community and The Ihangane Project has grown to include students and
faculty from the University of Michigan. Students have contributed to health care and public health
projects through William Davidson Institute fellowships as well as through Multidisciplinary Action
Projects. Since 2010, the focus of many of these projects has been on learning about the flow of
patients through the hospital system, and making recommendations to improve the existing system.
The latest MAP team to spend time in Ruli focused on ways to improve the utilization of data within
the hospital, specifically through evaluation of a new appointment system that had been implemented
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within the last year. They conducted an analysis of the situation and made recommendations for
improvements to the hospital’s referral and registration processes.
a. Summary of 2012 MAP Project

The spring 2012 MAP team conducted interviews with patients and staff, and observed and mapped out
different processes related to appointment-making and patient registration. They found that even
though an appointment system had been mandated by the Ministry of Health, a majority of patients
were still arriving to the hospital without appointments. Furthermore, they identified duplicative or
inefficient processes within the hospital registration system which prevent hospital administrators from
effectively using the collected data. They made a number of short and long-term recommendations to
improve the functionality of the registration system. The short term recommendations are as follows:

1) Collect all data points via phone call: Health centers should give the hospital all the
information needed to make an appointment during a phone call at the time of the patient’s visit
to the health center. This recommendation would eliminate a duplicative task, wherein health
centers would transmit information on referred patients via a phone call and a follow-up email.
Moreover, as internet connectivity is slow and highly unreliable in most areas of Rwanda,
transmission of all necessary information via phone eliminates the possibility of the required
information arriving late or not at all.
2) Modify data points collected: The MAP team proposed collecting the following information
for each appointment: Patient Name, Hospital ID Number, Illness, Health Center, Village, and
Desired Appointment Date. Having the Hospital ID number would allow for pre-emptive
searches for patient charts (see recommendation 4, below). Foreknowledge of illnesses would
allow for allocation of staff (including, the MAP team suggested, specialist doctors, though they
are not normally available at district hospitals). Finally, a record of the patients’ health center
and village would allow for closer follow-up (see recommendation 7, below).
3) Shift appointment setting to registration: The benefit of this recommendation is twofold.
Firstly, by relieving the hospital data manager, who currently receives appointment phone calls,
that position is given greater latitude to cover other responsibilities including monthly Ministry
of Health report generation. Furthermore, the data manager can assume a more supervisory role
over the referral system (see recommendation 7, below). The second benefit is that the
registration desk is naturally more central to the flow of patients and doctors in the hospital, and
will be able to easily verify that patients have arrived – or not – at the point of entry into the
consultation process.
4) Gather patient files ahead of time: The MAP team found that registration workers currently
spend considerable lengths of time searching for patient files upon arrival at the registration
office. With patients’ hospital ID numbers available in real time as the registration workers
schedule appointments throughout the day (see recommendations 2 and 3, above), it will be
possible to collect files for the next day’s patients during periods when the registration desk is
less busy, typically towards the end of the day. This will reduce patient waiting time at the
registration desk.
5) Add doctor-scheduled follow-ups to appointment log: Referrals from health centers are not
the only source of patients at the hospital. Doctors can also request that patients return for a
follow-up visit after an initial evaluation. If this follow-up visit occurs within 30 days of the
initial referral, no second referral from the Health Center is required. However, doctors at Ruli
Hospital have not scheduled these appointments through the normal channel via the data
manager. Therefore, a second stream of patients has been avoiding the appointment log
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altogether, and limiting the ability of the system to truly forecast patient arrivals. This failure to
schedule appointments undermines the effectiveness of the system, and therefore should be
corrected. Adding doctor-scheduled follow-up appointments to the general appointment log
will contribute to a well-functioning referral and registration process.
6) Shift to electronic log only: The registration desk currently uses paper logbooks to record data
when patients arrive at the hospital. The MAP team suggested replacing these logs with
electronic versions in order to derive the benefits of an electronic system. These benefits would
include faster data entry, the ability to perform data analytics, ease of generating monthly
Ministry of Health reports, and a decrease in the number of logs required to be maintained
(three logs for different patient types are currently kept by registration employees to satisfy
MOH reporting requirements). To this end, the MAP team created a Microsoft Excel
spreadsheet that could function as a database and automatically generate monthly Ministry of
Health reports. With this system in place, the hospital could discard the paper registration
system.
7) Modify feedback loop with health centers: This recommendation is intended to combat the
low proportion of patients (38% by the MAP team’s count) who currently arrive at the hospital
with appointments. As the registration desk will be responsible for taking appointments (see
recommendation 3, above) as well as verifying that patients have arrived for scheduled
appointments, it will be an easy next step for registration workers to tabulate the number and
names of patients who arrive without appointments. The data manager can then take this
compiled list and contact the health centers which are sending patients without setting
appointments, and troubleshoot the issues affecting low appointment rates. After some time,
this step should increase adherence to appointments by health centers and patients alike, and
will allow the appointment system to function as intended.
b. Expansion of MAP Project Scope

The MAP team spent 4 weeks on the ground in Ruli during March and April of 2012, and spent a good
deal of time weighing options and considering recommendations during the next three weeks after their
return to the United States. With the efforts of 4 talented students and guidance from their faculty
advisors, it appeared likely that the recommendations that they settled on would be good ones.

However, some concern remained that the scope of the project and analysis was too narrow to simply
begin implementing the recommendations. While the Rwandan health care system is a complicated
machine, composed of hundreds of interlocking pieces, the MAP team had focused specifically on only
one process among them. Moreover, it was possible that the MAP project recommendations
overlooked an important part of this specific process, as the referral system overlaps the jurisdiction of
both the Health Centers and the District Hospital. The MAP team had spent most of their time at Ruli
Hospital, seldom visiting the Health Centers. Therefore, The Ihangane Project leadership felt it prudent
to investigate the process of patient referral and registration from the point of view of the Health
Centers.

Rather than simply complete this task in isolation, it was thought that it would be of benefit to future
projects of this nature to attempt to understand the total flow of information and patients between the
community health worker level, health center level, and district hospital level. With this type of “big
picture” approach, information could be discovered that could be used to inform future projects as well
as critically analyze the referral system as a specific process within the larger whole. This project
could therefore lead to potential modifications to the MAP team’s recommendations, ensuring that the
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changes to the appointment and registration processes would be beneficial for all stakeholders –
patients, health centers, and Ruli Hospital.
III. Information Flow Study

a. Description of Project

The Information Flow Study consisted of investigations at the community health worker level, health
center level, and district hospital level. The aim of the study was to characterize and map out the entire
flow of information, as well as patients, through the bottom three levels of the Rwandan health care
system. In the context of this analysis, the flow of information is inclusive not only of the transmission
of clinical information and reports, but also the administrative information that is exchanged to keep
the health care system running, and even the higher-level information exchange that helps employees to
know how to do their jobs. Tracking the flow of patients includes defining their exact trajectory in an
episode of care, and sometimes the time required to complete various stages in the process.
b. Methods

The primary method of gathering information in the Information Flow Study was through interviews
with representative members of health center and district hospital staff. Interviews were attempted to
be held with both clinicians and administrators in the main service lines of each facility. A standard
line of questioning was developed and applied to each interview, attempting to detail the job functions
and a portrait of a typical day for each employee, as well as the type and manner of information
exchanged with patients and other health care employees.

Although the general line of questioning was held relatively constant for most interviews, the
framework of questions was kept flexible to allow each conversation to unfold in a way that would
reveal each employee’s unique insights. In addition to this interview process, direct observation of
many processes was carried out. Specifically, these processes included hospital supervision of Health
Centers, appointment setting and receiving, health center registration and cashier workflow, Ruli
Hospital registration and cashier workflow, and Ruli Hospital patient reception. After data was
gathered through interviews and direct observation, it was condensed and analyzed to produce a picture
of the flow of information and patients through three levels of the health care system.
c. Findings

The investigation uncovered networks of communication relying primarily on four methods: phone
calls, electronic communications including email, hard copies of written communications, and in-
person meetings. There is also a trend towards more complicated networks of communication from the
Community Health Worker level to the District Hospital employee level. The networks tend to grow in
complexity both in types of communication utilized and number of other workers with whom
information is exchanged. Below are descriptions of the networks of several employees at hospital,
health center, and community levels, along with flowchart-style maps to illustrate many of them.

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1. Information Flow

Hospital Nutrition Service Chief
Job Description: The Chief of the hospital Nutrition Service has five basic activities
which comprise his or her job. The first is to make reports about nutrition data analysis.
The second is to follow up with nutrition services at all health centers which report to the
district hospital, depending on the results of the data analysis report. The third is to make
home visits to difficult cases as reported by Community Based Nutrition association.
Fourth is to attend meetings of health center chiefs and the monthly Coordination Meeting
with the community and social affairs workers of different sectors. The fifth and last
major responsibility is to transmit counter-referral forms and quarterly supervision reports
to the health centers and district hospital, respectively. These five responsibilities
represent the main activities necessary to control the Nutrition Service at the district
hospital level.

The counter-referrals that the Nutrition Chief is responsible for consist of 1 of 3 copies of
the referral forms that patients bring to the district hospital from the health center. One of
these forms is intended for hospital staff, another is for insurance records, and the third is
meant to record the treating doctor’s remarks and be sent back to the health center.

The Nutrition Service at the district hospital level provides nutritional rehabilitation to
inpatients. This can mean milk and other diet supplementation, as well as medication and
education for patients and families. The Chief of the service administers this treatment at
times, but it is primarily carried out by a number of other nurses. The Chief receives
Ministry of Health training twice, and district-level training once per year, for a total of at
least 3 weeks of instructional time. This training must then be passed on to the other
hospital nurses who cover malnourished patients, as well as to nutrition workers at the
health center level and community health workers.

The Chief of Hospital Nutrition is also tasked with supervision of nutrition workers at
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health centers, but at least in the case of the Ruli Hospital Nutrition Service Chief, this
responsibility is too time-consuming. Instead, at Ruli, one of the employees who is
dedicated to health center supervision carries out this supervision function. While the
health centers send monthly nutrition reports to the Nutrition Service Chief who briefly
looks them over, the reports are forwarded to one of the full-time supervisors for the
actual task of supervision.

Once quarterly, the hospital Nutrition Service Chief attends the Coordination Meeting
with hospital supervisors, health center representatives, social affairs workers (sector-
level government representatives), the head of the district hospital, and others as
necessary to explain the status of certain programs including nutrition.

Patient Flow: There are two types of patients who flow through the Nutrition Service:
those who are treated at the health centers and those who are referred to the hospital.
Patients who come to the hospital are referred in the same way as other patients and are
received by a doctor in charge of malnourished patients with complications, typically a
pediatrician.

They are admitted to a separate ward from other pediatric patients as a precaution due to
the low-immunity state that accompanies severe malnutrition. By Ministry of Health
protocol, there should be two rooms in this separate ward for the two stages of treatment:
the first treating complications and the second treating malnutrition alone. However, due
to space constraints at Ruli Hospital, these two rooms are combined.

The doctor on the malnutrition service evaluates the complications which brought the
patient to the hospital, and then calls the Chief of Nutrition to make diet recommendations
to treat the malnutrition component. Occasionally doctors will write a diet order without
consulting the Nutrition Service, but most patients receive a consultation.

From there, the theoretical length of stay for these patients is between 21 and 30 days,
though in practice it ranges from 2 to 6 weeks depending on the severity of malnutrition
and complications. After discharge, patients follow up at their Health Center for a period
of 1 to 3 months. If improvement is verified, then patients return to surveillance at the
village level by community health workers.

It is rare for patients not to improve with sustained treatment, but if it happens, the Chief
of Hospital Nutrition is informed and writes a letter to the village and sector-level
governments asking for investigation into the family’s food security and ability to care for
the patient in question. These patients who have not improved are then treated in the
same pathway as before.

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Types of Communication:
Electronic: Meeting minutes, new policies and supervisor findings from the hospital are
sent to the Nutrition Service Chief via email, and the Chief may email the Nutrition
Chiefs of other district hospitals. The nutrition workers at health centers also send
monthly reports by email, and the Nutrition Service Chief emails the health center
Titulaire after training events to disseminate updates.
Phone: The Ministry of Health sometimes calls the Chief to verify receipt of emails, pass
on information about new malnutrition treatment products, or to ask for short reports.
The district may call for many of the same reasons. Within the district hospital, the Chief
speaks on the phone with the Director of the hospital regarding messages and reports, and
with doctors regarding diet choices and other clinical questions. At the health center
level, the Chief has phone calls with the health center Nutrition Chief about home visits,
treatment product stock levels, new policies, and email receipt verification. Also, when
the health center calls the ambulance phone at the district hospital, the nurse answering
that phone calls the Nutrition Chief afterwards when the patient is being received for
malnutrition treatment. Very occasionally a community health worker will make or
receive a call from the Chief, typically for messages that are normally supposed to be
passed on through health centers.
In-Person: At the hospital level, the Chief meets with the head of the hospital in person to
talk about reports, MOH messages, and new policies. The Chief also meets with
supervisors to share certain job tasks, administrators to get approval for expenses and site
visits, and the hospital accountant/cashier to get money after being approved for travel or
expenses. At health centers, the Chief speaks with the Titulaire and health center
Nutrition Chief to review supervision results and recommendations. Finally, the Chief
meets with community health workers to deliver hospital directives and follow up with
home visits for patients who have been discharged from the hospital.
Paper: Used to confirm electronic communication; in other words, an email may be sent
first and then later a hard copy with signatures. Meeting minutes and summaries are sent
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via hard copy to meeting participants. Official letters and requests and new policy
changes are also sent via hard copy, as are monthly reports from health centers.

Hospital Data Manager
Job Description: The district hospital Data Manager is responsible for the collection and
quality assurance of demographic and epidemiological data at the district hospital and all
of its referring health centers. He or she must travel to the health centers to do data
quality auditing roughly 1 week total per month.

Another task that the hospital Data Manager must do is to set appointments for patients
referred from health centers to the district hospital. This task falls to the Data Manager
whether working at the hospital or on the road. To set an appointment, the Data Manager
receives a phone call from the health center, typically from the health center Data
Manager. During this phone call, the hospital Data Manager writes down on a paper pad
the name, sex, and age of the patient, and the desired appointment date.

Later, an email is sent from the health center which has an excel spreadsheet attached
which includes further information including: date of appointment phone call, name, sex,
age, sector, cell, zone, referring health center, presumptive diagnosis, and appointment
date. Information is sometimes not received in a timely manner due to the internet
connection being down on either the hospital or health center end.

After receiving this information, the hospital Data Manager writes the number of
appointments for each day on a piece of paper, along with the patients’ names. This paper
is given to the hospital Registration Desk. Registration is supposed to keep records of
which patients came to their appointments and which did not, but it disrupts their work
and is inconsistently done.

The Ruli Hospital Data Manager also reports problems with patients coming from health
centers outside the Ruli Hospital Zone, which send patients to the hospital but are not
directly controllable.

Other parts of the hospital Data Manager’s job include data auditing within the hospital
and at the health centers, and generation of a substantial number of reports. There are two
weekly reports – neonatal and epidemiological – which are sent to the Ministry of Health,
along with monthly reports of disease incidence stratified by age. The neonatal report
necessitates phone calls to each health center once per week to retrieve the data. The
epidemiological report is filled out electronically in a Ministry of Health program and
sent automatically to report the prevailing diseases in the district.

The monthly report entails gathering data from health centers and hospital services,
drafting the report in Microsoft Word, and entering the data in a Ministry of Health
program to send electronically, as well as printing a hard copy for transfer at a later
meeting or during MOH supervision of the district hospital. Each monthly report must
also have a graphical analysis generated, which is also supervised by MOH to determine
the most common pathologies seen in the hospital.

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There are also quarterly reports on maternal and child health in the catchment area.
Furthermore, an annual hospital report must be made each year summarizing the monthly
reports with some added data points and indicators. It is a high level report with few
details, including human resources and training information to produce a total picture of
the district hospital.

Data quality auditing is divided into quantitative and qualitative indicators determined by
MOH. The hospital Data Manager at Ruli Hospital is in charge of overseeing qualitative
indicators, while another supervisor is in charge of quantitative ones.

The hospital Data Manager must also attend the monthly Coordination Meetings which
take place at the health centers and at the district hospital. At the health centers, this
meeting includes the hospital and health center Data Managers, the Titulaire, and the
Chief of Supervisors of the Hospital. At the hospital level, this meeting includes the
Chiefs of all hospital services, the Data Manager, and the hospital supervisors. Each
meeting is centered around analysis of the data collected during the preceding month.

Electronic: The MOH emails the hospital Data Manager about meetings and changes in
policy, and reports are sent to MOH and also to district governments electronically. The
health centers send reports electronically as well, and send emails regarding
appointments. The hospital Data Manager also uses email to inform health centers of
MOH policy changes that have been handed down.
Phone: The hospital Data Manager sets hospital appointments by phone calls with the
health center Data Managers or other employees, calls the health center Data Managers
for weekly reports and monthly reports if they are not done by the 5th of the month.
Furthermore, the hospital Data Manager makes phone calls to the health centers to report
feedback or mistakes on reports, as well as to inform of MOH visits or new policies. The
MOH calls the hospital Data Manager from time to time to coordinate supervisor visits
and communicate about data quality auditing.
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In-Person: The hospital Data Manager attends meetings and trainings at the district
hospital and health centers, supervises services at the hospital and the Data Manager at
the health center, and asks questions and exchanges information informally with
employees of the district and MOH when delivering hard copies of reports by hand or
reporting for MOH training exercises.
Paper: The hospital Data Manager sends written copies of MOH policy changes and
written requests to appear for training exercises to health centers and receives written
monthly reports. All reports are transmitted to MOH, the district government, and district
hospital administrators and service chiefs by hard copy.

Hospital Environmental Officer
Job Description: The Environmental Officer of the district hospital works with affiliated
health centers and surrounding communities to supervise hygiene and nosocomial
infections, as well as water quality and insect control. This employee is responsible for
visiting commercial establishments within the hospital’s catchment area to evaluate
hygiene, and subordinate employees at each health center do the same for households in
the outlying villages. He or she also supervises construction at the district hospital to
ensure that no harm comes to the surrounding environment. Environmental quality
officers at the health center level and community health workers send monthly or
quarterly reports to the district hospital Environmental Officer. From these, monthly
hospital hygiene reports and quarterly summaries of health center hygiene reports are
generated, both of which are sent to the hospital, and the latter of which is also sent to the
Ministry of Health. This officer also functions as the secretary of the hospital’s hygiene
committee.

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Electronic: The Environmental Officer sends email to health centers with any relevant
documents, and sends and receives emails for any of the reasons that a phone call might
also be made (see above).
Phone: The Environmental Officer calls the heads of health centers and chiefs of services
to arrange meetings, verify email receipts, and ask questions regarding submitted reports.
He or she calls the Ministry of Health or vice versa to exchange protocol information and
instructions for work.
In-Person: The Environmental Officer does in-person education to patients and families
in the hospital about environmental hygiene, and performs supervisory functions in
person at the hospital each morning. In addition, the Environmental Officer provides
educational presentations to the doctors and nurses at the hospital, and interfaces directly
with administrators whenever there is a request for materials or funds. The officer also
travels to health centers for direct supervision of environmental quality officers and
custodians, and goes to outlying communities for education sessions with the local
population.
Paper: All reports, both received and sent, are done in hard copies. Formal requests for
materials and funding from the district hospital or MOH are also made on paper. Finally,
the Environmental Officer prints out any invitations to meetings that are received through
email to bring to the meeting.

Hospital Reception Area
Job Description: The hospital Receptionist is the first employee to receive patients when
they arrive at the hospital. Typically, many patients are waiting at the beginning of the
day and the Receptionist processes them in batches.

First, the patients’ insurance information is gathered and photocopied (note: this only
applies to patients with MUSA insurance, though they make up the large majority of
visits). Patients pay the receptionist a small fee at this time for the photocopies. The
receptionist then collects each patient’s referral form and gives that form along with the
photocopy of insurance paperwork to the outpatient cashiers.

The cashiers call 1 or 2 people at once, depending how many are working simultaneously,
to pay for their appointment. They check the services which the patients have been
referred for and calculate a charge according to each patient’s insurance plan. MUSA
members pay 10% to the MUSA officer who is located nearby, while patients with other
insurances pay 100% of the charge up front and seek their own reimbursement later. For
insurance purposes, each patient receives a receipt and a form from the MUSA officer
noting the services to be received, which is stapled to the insurance information
photocopy. This process has been observed taking anywhere from 3 to 11 minutes per
patient.

After paying and receiving all their paperwork, patients are oriented to the registration
desk and shown where to wait for one of the doctors. Once a patient has been seen, the
doctor marks the prescribed medication on the patient’s forms and the patient goes to the
cashier again to pay for the prescription. The patient gives the cashier a form listing the
services rendered by the doctor and hospital, takes a receipt, and picks up medications
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from the pharmacy.

Most patients arrive between 7:30am and 10:00am, and then the rate of arrival slows to
only a few per hour. Registration workers cover the receptionist when he or she is gone,
in addition to having to fulfill their usual responsibilities.

Hospital Registration Desk
Job Description: The hospital Registration Desk functions to check patients in to see
doctors in the consultation service. Patients arrive from the reception area and cashier
and hand their documents to the registrars who enter demographic information in a
registration log book. A valid receipt from the cashier must be presented to verify
payment. For patients with chronic diseases who do not require health center referrals to
be seen at the hospital, the registrars fill out an in-house referral form.

The registrars then hunt for the patient’s chart or make a new one if the patient has not
been to the hospital before (if two registrars are working simultaneously, this can be done
while the registration log book is being filled out). To make a new chart, three forms are
completed and stapled together: a full-page blue cover sheet, a half-page white cardstock
demographic form, and a small yellow rendez-vous card on which are written the dates of
future appointments.

The patients are sent off to wait for a doctor, while the charts sit in a pile on the registrar’s
desk until a circulating emergency room/consultation service nurse arrives to pick them
up. The nurse then takes each patient’s vital signs and directs them to an available doctor,
transferring the patient’s chart as well.

On the weekends, the registrars come to work to fill in the second half of the registration
log. Aside from the previously entered demographic information, they must record each
patient’s presenting complaints, diagnostic tests, eventual diagnosis, and treatment
information, among other data points. As finished charts are not returned until the
following morning, at which time there is a rush of new patients at the registration desk,
this task typically is left until the weekend when the registrars have enough time to
complete it.

Health Center Registration Desk
Job Description: The registration desk at the health centers serves a similar function to
that of the District Hospital, though it assumes some of the functions associated with the
reception area at the hospital. Patients arrive at the health center and either go to the
MUSA office or the registration desk first. If they arrive at registration prior to the
MUSA office, they are redirected there to pick up insurance paperwork before they return
to registration.

The patients bring from home a small half-sheet of blue paper which serves as a medical
record. The registrar at the health center asks about the problem bringing the patient to
the health center and then measures weight and temperature, recording all on the half-
sheet. After recording this information, the patient waits until a consultation nurse is
available. Unlike registration at the district hospital, the registration log book is not
16

located at the registration desk at the health center. Instead, each consultation nurse fills
out the necessary information in the log book during the visit with the patient.

After the visit, the registrar takes the MUSA form from each patient and uses it to
calculate the amount to be reimbursed to the health center by MUSA. These forms are
taken to the MUSA office to be added to the monthly reimbursement cycle for the health
center. The blue half-sheet which comprises the health center’s medical record is kept by
the patient and taken home. If patients require medication from the pharmacy, they pay at
the cashier prior to going there. The cashier stamps their clinical forms to verify
payment.

This flow of patients is not exactly the same at all health centers. At Ruli Health Center,
for example, returning patients do not pass through the registration process, but are seen
directly by consultation nurses instead after going to the MUSA office. Only new patients
go through registration to receive their clinical forms. The registration worker may take
temperatures among the waiting patients, but not weights, and will defer temperature and
other vital signs to the consultation nurses if the clinic is busy.

There is not necessarily a dedicated employee at the registration desk. The health center
cashier and several nurses were observed performing this task at the Nyange Health
Center, in addition to their normally scheduled activities. However, at Ruli Health Center,
there is a dedicated cashier who is assisted in the large volume of patients by a part-time
assistant cashier and the health center accountant when she is not otherwise occupied.

The cashier has a number of other duties in addition to covering registration. He or she
must receive and calculate revenues and expenses at the health center. Other
responsibilities include issuing stipends to health center employees who are traveling for
work, traveling to a bank (which may be several villages away) to withdraw and deposit
money from the health center’s account, calculating and exacting payment from non-
MUSA insurance holders, and collecting money for other patient expenses such as the
paper forms used as medical records.

The cashier has no communication with the hospital. The cashier does have in-person
communication with Community Health Workers when attempting to track down patients
who have not paid their Health Center bills.

17

Health Center Organization
The health center is partly governed at the village level, in the COSA (Community
Health) committee where each health center holds one representative position. The health
center is run internally by the COGE (Steering Committee), which is composed of
representatives from health center clinical workers, service lines, and administrative staff.
The president of the COGE is the Titulaire, or head, of the health center. Under the
Titulaire is a vice-Titulaire who handles the operations of the health center in the
Titulaire’s absence. Underneath the layer of top administrators, each service line has one
person responsible for it, who reports to the Titulaire. In addition to the medical service
lines and administrative functions of the health center, there are also a number of support
staff such as security guards and building custodians.

18

Health Center Data Manager
Job Description: The health center Data Manager is responsible for managing all patient
data from all services at the Health Center. He or she verifies that the data is collected
and enters it into computer systems (DHS and HMIS) which transfer it electronically to
the relevant district hospital and the Ministry of Health. This patient data is used to help
the MOH and hospitals to monitor trends and epidemiology for various diseases.

In addition to this primary responsibility of data collection and transmission, the health
center Data Manager must also set appointments for patients who are referred to the
district hospital. For patients with non-emergent conditions, the Data Manager first asks
the patient which dates they would be available to travel to the hospital. Then, the health
center Data Manager makes a phone call to the hospital Data Manager to inform them
which day the patient will arrive. The hospital Data Manager typically accepts the
appointment, and very rarely, if ever, responds negatively to a proposed appointment date.

In this phone call, the health center Data Manager tells the hospital only the patient’s
name, age, and the date of the appointment. Later, the health center Data Manager sends
an email containing an excel spreadsheet with further demographic and medical details
about the referred patients. Although the health center Data Manager has all of this
information prior to the phone call, it is not currently transmitted via phone.

For patients with emergent conditions, the transfer process omits the step of calling for an
appointment. In these situations, the health Center Data Manager only calls the hospital if
the health center ambulance is busy or malfunctioning, and the phone call is then a
request for a district hospital ambulance rather than a request for an appointment.

19

Electronic: appointment-setting, communications to and from MOH (usually sent and
received via District Hospital), to and from district hospital regarding data, meetings,
changes in health policy and protocols, monthly reports, and official requests, to and from
the District regarding development, meetings, and reports.
Phone: appointment-setting, guidance and explanation for reporting, new MOH rules and
regulations
In-person: supervisor visits, meetings at the district hospital, training events
Paper: filling out information in paper appointment log kept at health center (if not Data
Manager, the Data Entry worker will do this task), summary and tally of number of
patients with each designated tracked illness in each service line’s written registration
logs, monthly reports, and letters for official requests

Email communications are the most important to the job of the health center Data
Manager because they allow for larger and more detailed messages than phone calls,
despite connectivity issues in rural areas. However, sending messages via email is also
problematic because of issues in electrical infrastructure as well, which provide a second
layer of communication insecurity. Although dissimilar to the rest of the job
responsibilities, the task of appointment setting does not necessarily present itself as a
problem to health center Data Managers, as vice-Data Managers or other employees can
perform this task if the primary Data Manager is busy or otherwise unable.
20

The health center Data Manager at Nyange currently has 3 desktop computers to work
with – one for data entry, one for the Data Manager’s use, and one for the IT Manager of
the Health Center. One laptop also exists as a portable workstation for the Data Manager.
They will have to new system soon to transfer information directly from each service
line’s registration log books to electronic files. This system will begin in the VCT/HIV
service.

Health Center Reception Desk Employee
Job Description: The health center Receptionists typically start work around 7am, have
a break in the middle of the day for lunch, and wrap up operations around 5pm. They are
the first point of contact for patients within the health center and receive patients at
reception, making some attempt to triage patients who are already waiting according to
severity of illness. Reception sends patients to the health center Nurses, who then
evaluate and treat them, deciding whether treatment at the health center is appropriate or
hospital transfer is needed.

Patients requiring hospital transfer fall into two categories: emergent and non-emergent.
Patients who are very ill require ambulance transfer, while those who are not so sick
typically walk to the hospital.

Some patients are sick enough to be treated as inpatients, but not sick enough to require
transfer to the district hospital. These patients can take advantage of a limited number of
beds at the health center (~25 at Nyange, for example, including maternity beds).

The Receptionist separates patients by age (greater or less than 5 years old), thereby
determining which of two consultation rooms they will go to. In principle, Receptionists
should also separate patients according to whether or not they present with a cough, in
order to reduce transmission of respiratory illnesses. In practice, this is not done (at least
at Nyange) because of limited space; there are simply not enough consultation rooms for
coughing patients to occupy one of their own.

When patients arrive, the Receptionist fills out a sheet with their demographic and
insurance information. Then vital signs are taken (except in emergencies) and patients are
sent to see nurses based on the above criteria.

In addition to responsibilities with patients, the Receptionist may orient new health center
workers to the layout and operations of the facility. The Receptionist’s responsibilities are
covered by the cashier or a nurse while at lunch or after 5pm. Likewise, the Receptionist
covers the cashier’s job during breaks in the day.

Types of communication: The only communication the Receptionist has with the district
hospital is through the health center Nurses and Data Manager. Every nurse can call the
hospital when necessary for patient care, and the Titulaire of the health center
communicates changes to policy from higher up in the hierarchy directly to the
Receptionist.

21

Health Center Head of Community Health Workers
Job Description: The Head of the community health workers at the health center is
responsible for overseeing the work of those volunteers in all the villages within the
health center’s catchment area. At the beginning of each month, the Head of CHWs
makes a quarterly plan and a monthly calendar, submits them to the health center and
Sector for approval, and then makes a summary of operations and collected information at
the end of each quarter. The Head visits villages, makes monthly reports, and performs
training of CHWs. He or she is also in charge of environmental hygiene for the
catchment area. This duty entails visiting commercial centers and households to evaluate
hygienic status. It is a relatively minor duty, accounting for 2 days per month of work.
However, at least at Ruli Health Center, it is not always a duty that is fulfilled; as it is
difficult to fit in with the somewhat unpredictable course of other work, the Head of
CHWs there spends only 1 day per month on environmental hygiene. Findings are
reported to the sector government and to the Chief of Environmental Hygiene at the
district hospital.

Electronic: No email is sent or received at the village level. However, electronic versions
of forms are sent from the Ministry of Health via the district hospital to the health center
for delivery to the Head of CHWs. In addition, monthly hospital meeting reminders and
minutes may be delivered via email. Finally, the Head of CHWs sends electronic copies
of monthly and quarterly reports to the district hospital by email in addition to hard
copies.
Phone: Community health workers all have telephones and call the Head of CHWs to
notify of events happening at the village level such as complicated patients or pregnant
women about to give birth. The community health worker can also call an ambulance
from the health center or district hospital. This kind of communication helps emergent
patients bypass the health center and proceed directly to the district hospital. At the
hospital level, the Head of CHWs receives phone calls communicating about monthly
meetings, and may also make direct phone calls for a hospital ambulance in emergencies.
In-Person: The Head of CHWs travels to villages at least twice per week, averaged over
an entire month, to meet with CHWs and villagers and exchange information and reports,
as well as speak about preventive health issues. There is also a monthly meeting at the
22

health center which CHWs all attend to meet with the Head and analyze the monthly
reports to find gaps in data, errors, and determine prevailing illnesses and trends. It is
also possible for the Head of CHWs to meet CHWs in person if they escort patients to the
health center. There is another monthly meeting which takes place at the district hospital
and is attended by Heads of CHWs from many health centers, wherein similar report
analysis is done. Occasional other meetings at the hospital level may require the Head of
CHWs to attend, typically regarding reports, new Ministry of Health programs, or
training. In addition, at Ruli Health Center at least, there are informal conversations
which transmit information regarding epidemiology in the villages, reasons for levels of
referrals to the hospital, and so forth. While health centers in close physical proximity to
their district hospitals may have these types of communications between employees, they
appear to be uncommon in more remote health centers.
Paper: The Head of CHWs receives 5 hard copy reports from each village each month,
and an additional 2 reports from each village on a quarterly basis. The information in
these reports covers childhood illnesses, family planning, maternal health, deaths, and
nutritional status reports. The Head of CHWs then summarizes these reports and submits
a hard copy to the district hospital. In addition, Ministry of Health letters are sometimes
sent to the district hospital which forwards them to the health center for delivery to the
Head of CHWs.

Health Center Hospitalization Service Chief
Job Description: This employee is responsible for the limited number of beds that health
centers offer for moderately-ill patients and expectant mothers. Patients are hospitalized
at health centers for lengths of 1-2 days, for illnesses such as uncomplicated pneumonias,
diarrhea, or simple traumas, which are not quite severe enough to be referred to the
district hospital, yet require some form of extended observed treatment. The process is as
follows:

1. The chief verifies that the patient has a hospitalization form from the consultation
service
2. The chief checks to see if the patient is registered in the hospitalization registration
log book. If the patient has not been registered, the chief enters the patient’s name, the
date, the illness, length of stay, time of first dose of medication, and the time of the
second dose
3. The chief verifies that the patient has taken all necessary medication
4. Patients are followed to document progress. If they do not demonstrate improvement,
they will be sent to the hospital. Patients not responding to the first dose of
medication are given a different medication for their second dose. If improvement
cannot be seen after two doses, or if the patient’s condition worsens after a single
dose, the patient is referred to the district hospital.
5. An official transfer form is filled out including name, date, illness, age, sex, insurance
information, and treatment already rendered. A health center representative, typically
a nurse, travels with the patient by ambulance to the district hospital and signs a form,
along with the head of the health center and a hospital representative, to verify the
transfer. The hospital representative is a nurse, unless the patient is arriving for a
cesarean section, in which case a doctor receives the patient at the hospital directly.
6. The same information contained on the transfer form is copied to an ambulance
transfer log book.
23

The decision to hospitalize a patient is made by the nurse who evaluates them in
consultation. Once a patient is hospitalized at the health center, the decision to transfer to
the hospital is made during the daily staff meeting after the patient has spent one night at
the health center but shown no improvement. The staff exchange ideas for alternative
treatments, then may consider a transfer if appropriate. Although the normal process is
collective, on weekends a single individual may make the decision to transfer.

The Nyange health center has 25 beds – 6 for me, 6 for women, 6 for children, and 7 for
maternity patients. Roughly 12 patients are admitted there each month for illnesses,
though this figure jumps to 20-25 per month when maternity admissions are included.
Women delivering children stay for 3 days unless complications occur, in which event
they are transferred to the hospital.

The chief of the hospitalization service may also have another job function. At Nyange,
this employee is also the vice chief of hygiene for the health center, working closely with
the district hospital Environmental Officer to control hygiene in all health center areas
and ensure adequate performance by custodians.

This service chief must generate a monthly hospitalization report for the health center
Data Manager and health center chief (Titulaire). Once this report is signed and verified,
it is delivered to the district hospital Data Manager. There is no specific monthly report
that must be given to the district hospital Environmental Officer, but the Education
Communication Information that is given to patients is kept track of, and simple reports
are transmitted regarding the cleaning supplies needed for the health center. Periodically,
this health center Environmental Officer must make reports to the sector government
about the state of the health center grounds and gardens.

24

Electronic: The Hospitalization Chief receives emails through the health center Chief
regarding changes in policy, medication utilization, meeting requests, and other general
information. This information is then transferred in person during meetings or via hard-
copy printouts of the emails. The monthly report is sent electronically as well, via the
HMIS system.
Phone: District hospital nurses sometimes call for more information on referred patients;
these calls typically go to the health center Chief or to the Data Manager, but the
Hospitalization Chief will receive them after normal clinic hours. The Hospitalization
Chief calls ahead to the hospital for maternity patients after normal clinic hours, typically
speaking with a nurse.
In-Person: The Hospitalization chief has face-to-face interactions with supervisors
regarding reports sent to the district hospital and recommendations for improvements.
Occasionally the chief will also travel with transferred patients and interact with the
receiving nurse at the hospital.
Paper: The monthly report to the hospital is sent via hard copy, and referrals for children
under 5 years old to the health center, as well as feedback to community health workers,
are all done on paper.

Health Center Consultation Service Nurses
Job Description: The consultation service at the health centers is the general outpatient
clinic. It is staffed entirely by nurses and has responsibility for seeing all new and
returning patients. When patients arrive at the clinic, they are registered in the
consultation log book by a consultation nurse after verification that the patient came from
25

the reception area with properly collected basic information and vital signs. The nurses
interview and examine each patient, including measuring blood pressure, respiratory rate,
and pulse (the vital signs taken by the reception desk include weight and temperature).

The patient’s history and an assessment of the illness is written on the proper forms and
labs and studies are ordered if necessary. The required studies are written on a piece of
paper that the patient takes to the health center laboratory. Within 10-20 minutes, the
patient receives the results and returns them to the nurse in consultation, informing the
diagnosis. With a diagnosis in mind, the nurse writes a prescription (if necessary) which
the patient picks up at the health center pharmacy after paying the cashier. The
pharmacist (also often a nurse) explains how to take the medication and the patient takes
the first dose while at the pharmacy to verify tolerance before going home.

It is also possible for the consultation nurse to decide to hospitalize a patient at the health
center or refer to the district hospital. This decision to refer to the district hospital hinges
on the type or severity of the disease, whether the patient has had multiple health center
visits without improvement, or if a diagnosis can only be made with the resources of the
hospital. Hospitalization within the health center is done when the nurse is sure of the
diagnosis and the patient cannot go home safely (i.e. the patient requires intravenous
treatment). When the decision is made to hospitalize a patient, the nurse must fill out a
hospitalization form, enter the patient in the hospitalization registration log book, escort
the patient to the designated bed, and deliver treatment and follow up at specified
intervals.

One nurse from the health center is supposed to be assigned to hospitalized patients
during the day, but this nurse is usually assigned to other services and there is no
consistent staffing. Consultation nurses end up checking on hospitalized patients in
between their other, normally scheduled duties. 2 consultation nurses work per day and at
Nyange, each sees about 20 patients daily. At busier health centers, both figures are
increased. Though the consultation nurses try, it is difficult for them to make time to see
hospitalized patients in addition to outpatients.

When hospitalized patients are discharged, the date is noted in the hospitalization register
log book. The patient then takes a form with information about their hospitalization to the
cashier to pay, then heads to the pharmacy to pick up outpatient medication, and leaves
for home.

When patients are referred to the hospital, the consultation nurse must fill out a referral
form with the patient’s name, vital signs, and the reason for referral. Then, the process is
somewhat different for urgent and non-urgent referrals.

For non-urgent referrals, the patient is sent to the health center Data Manager who calls
the district hospital Data Manager to make an appointment. The patient is given three
copies of the referral form filled out by the consultation nurse. The patient is logged in
the health center’s transferred patient registration log and the Data Manager’s
appointment date log. Then the patient arranges for travel to the district hospital by
themselves, often walking. At the hospital, one copy of the referral form is given to the
patient’s health insurance provider, one copy is kept by the hospital, and the last copy is
26

used by the doctors and sent back to the health center later for performance-based
financing requirements. The patient keeps the original form filled out by the consultation
nurse.

For urgent referrals, the patient is given the same three copies of the referral form, but this
time an ambulance is called. The patient pays an ambulance fee and receives a receipt.
Then, the patient is logged in an ambulance registration log book, and a nurse
accompanies the patient on the ambulance ride to the hospital. At the district hospital, the
receiving nurse signs the ambulance registration log book to verify the patient’s arrival.
The nurse returns to the health center with the ambulance.

Electronic: Electronic communications are done at the health center level, and not sent to
nurses directly. The chief of the health center relays any relevant messages, and reports
that nurses make to the health center Data Manager are sent to the district hospital
electronically.
Phone: Nurses call community health workers when patients fail to arrive at the health
center for follow-up appointments, attempting to discover the reason for the absence and
to direct the patient to the health center. Nurses also receive calls from the district
hospital when the referral forms were not completed with enough detail and further
information is needed about referred patients. Consultation nurses may also call the
27

hospital when pregnant women are being transported there emergently in order to prepare
the doctors and time their arrival correctly.
In-Person: Nurses have direct contact with community health workers when maternity
patients arrive at the health center to give birth. Community health workers accompany
all delivering patients and give the nurse information regarding the woman’s clinical
course. Hospital supervisors also see the nurses in person to collect information on
clinical operations and give guidance. Furthermore, nurses often attend training events at
the district hospital or even in other districts where they interact with hospital supervisors
and representatives from the Ministry of Health for educational sessions.
Paper: Consultation nurses receive paper notes about patients from community health
workers when they refer patients to the health center. Nurses write their findings on those
paper notes along with their recommendations and patients return them to the community
health workers. Nurses also fill out referral forms for patients who they send to the
district hospital, receiving the copy with doctor’s comments as a “counter-referral” later.

Health Center Nutrition Service
Job Description: The employees of the health center Nutrition Service work primarily
out of their health center, but also have many activities they are responsible for in the
field. They primarily serve women and their children to evaluate nutritional status,
provide education regarding proper nutrition, teach practice cooking classes and sample
food from the community to ensure nutritional appropriateness, and give nutrition
counseling to pregnant and postpartum women for 6 months after birth, as well as to
women with HIV.

After evaluation, patients are treated according to their nutritional status, being divided
into green, yellow, and red zones. Patients in the green zone are normal and continue to
be monitored at the village level but not seen at Health Centers. Those in the yellow zone
are moderately malnourished, while those in the red zone exhibit severe malnutrition.
Patients in these latter two zones are referred to the health center Nutrition Service by
community health workers. Community health workers assist in all villages to follow
children, especially newborns, to determine nutritional status. These community health
workers are elected by Community Based Nutrition Programs in each village to perform
these tasks. The employees of the health center Nutrition Service are responsible for
educating the 4 lay people elected as community health workers.

For children under 6 months old who are found to have malnutrition, the mothers are sent
to the local health center for education. Children and women in the red zone are given
Ready to Use Therapeutic Food (RUTF) which is distributed to health centers centrally by
the Ministry of Health. Patients in the yellow zone are treated with SoSoMa
supplementation in their diet.

At the time of treatment, women and children are sent to the health center from their
villages. Women are only treated if the child is less than 6 months of age, as Ministry of
Health policy states that infants that young should be fed exclusively with breast milk
unless requiring oral medication or their mothers are unable to breastfeed. Mothers of
these children receive RUTF and nutritional counseling.

For children over 6 months old who are found to be malnourished, the World Health
28

Organization recommendations are followed. These include beginning treatment with
SoSoMa as a supplement to breastfeeding if the child is in the yellow zone, or with RUTF
if the child is in the red zone. In addition to supplementation, the health center Nutrition
Service provides weekly education sessions for the mothers, as well as practice in
cooking, hygiene, family planning, and other useful skills. Typically in this case, the
child is the only one who is treated. If the mother is found to be malnourished as well,
then the case is typically referred to the hospital for a more comprehensive medical
workup. This type of case is quite rare.

Community health workers, who work very closely with the health center Nutrition
Service, receive training at the health center, district hospital, and Ministry of Health
levels. The health center Nutrition Service workers and the health center Chief of
Community Service are responsible for part of this training, and must also observe
community health workers to ensure that their work is being done correctly. They also
collect reports from all the villages in the health center’s catchment area for forwarding to
the district hospital Nutrition Service Chief. These reports detail the number and location
of children in the yellow and red zones of malnutrition so they can be followed up. The
community health workers and health center Nutrition Service make the diagnosis of
malnutrition by evaluating weight, height, weight gain over time, and upper arm
circumference.

From the health center level, patients with malnutrition are referred to the district hospital
if they are discovered to have malnutrition with complications which cannot be treated at
the health center. Diarrhea and pneumonia, for instance, can be treated locally, while
more serious complications such as cognitive deficits must be referred to the hospital.
Once at the hospital, the malnutrition is treated in a similar fashion as at the health center,
in accordance with Ministry of Health policies. At the same time, the complications are
addressed by whatever medical means necessary. The district hospital Nutrition Service
makes recommendations for much of the malnutrition treatment while the inpatient
medical service determines the correct course for the complications to be treated. Upon
discharge, the patients return to their communities and continue to be followed by
community health workers there.

29

Types of communication:
Electronic: Monthly reports are sent by email and contain a summary of malnutrition
cases from all villages in the health center catchment area
Phone: Call to chief of hospital Nutrition Service to apprise of patients being transferred
to hospital – this call contains no other information aside from arrival notification, unless
the patient is not one who has been logged in prior monthly reports. Phone calls are also
made to and from the hospital Nutrition Service to relay information about new MOH
policies.
In-person: Giving training to CHWs, receiving training at hospital/district/MOH level at
district hospital or other location from hospital Nutrition Service representative, district
hospital doctor, or another outside expert.
Paper: Paper forms are filled out with a nurse’s assessment, malnutrition status, and
measurements whenever a patient is referred to the hospital in order to help the Chief of
the hospital Nutrition Service. A paper copy of the aforementioned monthly report is also
filed with the Chief.

Community Health Workers
Job Description: Community health workers form the base of the health care system in
Rwanda, operating at the village level to provide preventive care, public health education,
and appropriate referral to the next level of care. There are four community health
workers in each village, typically lay-people who are elected to the position. Two of the
four focus on nutrition in the community, primarily in children and pregnant women. One
is tasked with maternal/infant health monitoring. The last functions as a coordinator for
events involving community health workers and representatives from health centers.

30

The community health workers who monitor the nutritional status of children in the
village give each mother a card to record her children’s health status. It includes a height-
for-weight chart to track malnutrition, a table to mark vaccination status, and areas to note
doses of vitamin A and albendazole/mebendazole treatment. The community health
workers organize periodic (typically monthly) meetings for all the mothers in the village
with young children. These meetings include weighing of children, educations sessions
taught by community health workers and visiting employees from the local health center,
and a didactic session focused on proper cooking techniques and healthy meal
composition.

Electronic: CHWs do not use email or other electronic communications.
Phone: CHWs can call the head of the health center or the head of CHWs for ambulances
when they are responding to medical emergencies in their village. Furthermore, health
center nurses who live in the vicinity may be called by CHWs for clinical guidance in
emergencies or ambiguous situations. Nurses call CHWs to arrange appointments for
field work in the villages, and the head of CHWs at the health center calls them to relay
information about patients in their care or to discuss problems with their monthly reports.
In-Person: There is a monthly meeting at the health center that all CHWs attend, where
they submit the hard copies of their reports and discuss community health issues with the
head of CHWs. They also receive several days of medical and public health training in
person at the health center when they are elected as CHWs. The head of CHWs also
comes to supervise them in person, usually once per month at the malnutrition screening
meeting.
Paper: The CHWs deliver paper copies of monthly reports to the head of CHWs at their
local health center. They receive blank copies of these reports from the head of CHWs at
the time that they turn in the completed reports.

2. Patient Flow

The Information Flow Analysis also focused on the way that patients physically move
through the health care system. From the data gathered, these charts were generated to
show the path that patients take from the Community Health Worker level through the
District Hospital.

The first diagram shows the pathway which patients follow to be seen at health centers,
and then referred onwards to the district hospital if needed.

31

The second diagram below shows an example of the flow of patients for a specific
illness. The treatment of malnutrition was selected as a specific example to highlight the
way that a particular disease state is handled within the general framework in first
diagram above.

32

e. Discussion

Through this extensive investigation, a number of interesting points and overarching patterns
emerged. Although the study did not include all employees at the health center or hospital
levels, it provides what appears to be a largely representative sample of the type of
communication used by health care workers in the course of their jobs. Therefore, the
information gathered here can be used to draw a number of conclusions and make some
recommendations for future improvements in communication.

One of the first clear trends that is present in the data is the increasing complexity of
information flow networks at the higher levels of the health care system. Health center workers
communicate with more people than community health workers, and they use more types of
communication. The same is true at the district hospital level compared to the health centers.

Another pattern that can be seen in the flow diagrams above is that a surprising amount of the
information being exchanged is internal to the health care system and non-clinical in nature.
This includes training, supervision, and transmission of reports. These broad categories
encompass a wide variety of activities and account for a significant portion of many employees’
time and effort. Comparatively little effort is spent communicating clinical information needed
to care for patients.

In the same vein, many of the employees who were interviewed had chiefly administrative lines
of communication, while a few performed primarily clinical duties. Another subset, including
the nutrition service employees, for example, treat and educate patients and therefore may
exchange some clinical information, but have many other duties to attend to as well.

It is possible that this apparent preponderance of non-clinical communication is due to a
selection bias in the interview process. Many of the people who were interviewed were the
chiefs of their particular service, and not ordinary workers within that service. Therefore, it is
possible that the focus of these employees is tilted more heavily to administrative
communication than the full-time clinicians. In addition, it is also conceivable that some of the
portrait being painted here is the ideal flow of information as the system is currently designed,
rather than the day-to-day actuality of communication.

A third theme that appears is the consistent reduplication of communication efforts. Often, the
same information or message is sent twice, in two different formats. Although in many cases
this may cause only a small inconvenience or extra burden on employees’ time for each
instance, it may add up to a significant extra effort in the long run. However, it is thought to be
necessary to repeat communications because of the significant insecurity in electricity and
internet access that exists in large portions of the country. If a better way can be found to deal
with this insecurity, this duplication may represent an opportunity for consolidation and
information flow improvement.

It is also notable that some responsibilities have been shifted, or MOH directives ignored.
Sometimes this is due to overwork, as in the case of the district hospital Nutrition Service Chief
outsourcing supervision duties to one of the other supervision employees. Other times it is due
to physical resource restriction, as in the case of Nyange Health Center not being able to
segregate patients by the presence of a cough on presentation, due to a lack of consultation
33

exam rooms. Breakdowns in the prescribed methods of communication might indicate potential
areas of improvement for the future.

One fine point relating to the recommendations of the 2012 MAP team (see section IV(b)
below) is that the health center Data Manager has several tasks, but the only one involving
patients is the setting of appointments. The other duties involve collection and validation of
aggregated clinical data points and the generation of reports, but no patient contact. Therefore,
the job of setting appointments is incongruous with the rest of the Data Manager’s
responsibilities.

Finally, it should be noted that this study of information flow comes with a few limitations. It is
somewhat incomplete for two reasons. It proved difficult to find time to meet all the employees
who could have been included. Due to job responsibilities and vacations, many people spent
significant time away from work over the course of the summer. It was also inherently difficult
to schedule appointments and make firms plans to travel at particular times, and some
employees were missed. Furthermore, some employees, particularly clinicians at the hospital
level, were present at work daily but simply could not make time to explore their
communication networks. For these two reasons, this study can best be thought of as a detailed
approximation that may have gaps in important areas. Nevertheless, it can be used to make
certain recommendations, as seen below.
f. Recommendations for Improvements

Based on the information flow study, a number of broad recommendations can be made for
future Ihangane Project workers to pursue.

1) Eliminate duplicative processes: Communications which are repeated in different ways may
represent a substantial usage of time and resources which could be redirected. Future studies
could spend time analyzing whether these should continue or if they could be simplified.

2) Minimize modes of communication: When considering future changes to these
communication networks, it may be beneficial to avoid assigning new communications that
employees aren’t used to. For instance, since most health center workers do not directly
utilize electronic communications, adding these to their repertoire of tasks should be
carefully considered, as it will add to training costs. Unless the benefit is truly worth the up-
front investment, such changes should be avoided.

3) Consider existing responsibilities: Examples can be seen of employees being overburdened
with responsibilities by top-down directives and failing to fulfill those requirements. When
thinking about which communication an employee should be responsible for, future
Ihangane Project workers should take into account whether recommendations are realistic
given the existing demands placed upon the health care workers.

4) Utilize existing channels: Certain employees already have close relationships with other
employees. For instance, the supervisors at the hospital level are very familiar with the
service chiefs at the health centers. If one employee is already in close contact with another,
particularly if those employees connect two different levels of the health care system, then it
could be advantageous to align multiple communications through those employees to make
34

use of the existing relationship.

5) Eliminate extra steps: In the charts describing the flow of patients through health centers
and hospitals, there are extra steps that could possibly be eliminated or consolidated (see
Appointment System recommendations, section IV(c) for one example). Consolidation of
these steps in the process has the potential to improve the patient experience.

6) Approximate sequential steps: Steps in patient flow which occur sequentially should be
placed in close proximity to whatever extent possible. This has the potential to speed patient
flow and improve the patient experience.

7) Assign communications according to skill: Certain types of communication require a skilled
worker to transfer specialized information, while other types of communication can be
carried out by any employee. Where possible, non-specialized communications should be
carried out by the lowest-skilled employee, especially if it will even out the relative share of
responsibilities.

8) Break bottlenecks: Future Ihangane Project workers could spend time measuring the time
spent on each step of patient flow to identify bottlenecks. The communication burden of the
employees at those bottlenecks could be shifted to increase total throughput of patients.

IV. Implementation of Appointment System Improvements

a. Background

The system for referrals and appointment-setting between the health centers and the district
hospital is a small piece of the larger picture of information flow within the health care
system. Within this process lies an opportunity to improve not only the way that district
hospitals collect data, but also the ability to utilize that information to plan for the future and
allocate resources more effectively. Changes to the way that this system functions have the
potential to be very high-yield in their positive impact to the patient experience and to the
work flow of the hospital employees. Once the place of the referral system among the other
vital processes of the health system was understood, the MAP team’s recommendations
could be fine-tuned and implemented.
b. MAP Team Recommendations

As detailed in section II(a) above, the MAP team came up with a series of 7
recommendations to enhance the referral and appointment systems. These
recommendations were:

1) Collect all information needed to make appointments during a single phone call
2) Modify the information collected for appointments to include name, ID number, illness,
health center, village, and appointment date
3) Shift appointment-setting responsibility at the hospital to the registration desk
4) Gather patient files ahead of time
35

5) Add doctor-scheduled follow-ups to the appointment log
6) Shift to electronic copies of the appointment and registration logs
7) Modify the feedback loop with Health Centers to encourage them to make appointments
and follow up on patients who do not appear for scheduled appointments
c. Additions to MAP Recommendations

During the Information Flow Study, the recommendations made by the MAP team were
critically evaluated in the context of the larger information flow between health centers and
district hospitals. Special attention was given to whether the proposed changes would have
an adverse impact on health centers or on other intra-hospital processes. Furthermore,
opportunities were sought to make parallel recommendations for health centers, as the MAP
team’s thoughts were centered mainly on alterations to be made within the district hospital.
After thorough exploration, it was determined that the MAP recommendations were sound
even when considering the larger context. A few slight alterations were thought to be
beneficial:

1) Include patient phone numbers in appointment-setting phone calls: Doctors at
Ruli Hospital made the suggestion that patient phone numbers should be collected in
order to facilitate communication between clinicians and their patients. Doctors’
phone numbers are already publicly available to patients, and collecting a list of
patient phone numbers will enhance the two-way flow of information even more.
This is especially important in an environment like the Rwandan health care system,
where it is not easy for all patients to physically travel to the district hospital each
time a doctor needs to communicate medical results or advice, or even just wants to
check in.

2) Use a Microsoft Access database as the format for the electronic registration and
appointment logs: Microsoft Access is superior to Excel in a number of technical
aspects relevant to the redesigned appointment and registration systems. Access
allows multiple users, can store data securely on an on-site server, and is a powerful
tool for querying databases to generate automated reports. The drawbacks of using
an Access database include a need for more advanced information technology
management systems and personnel. However, per conversations with the Ruli
Hospital IT manager, all hospitals in the Rwandan system have IT managers and the
computing resources necessary to host a secure database on an internal server.
Therefore, the benefits appear to outweigh the drawbacks, and an Access database
should replace the Excel database template generated by the 2012 MAP team.

In addition to these small changes, it was thought that the MAP recommendations could be
augmented by a few more modifications to the system. Those new recommendations
include the following changes at both the district hospital and the health center levels:

District Hospital Level

1) Sort new charts as they are created to reduce search time: Currently, the charts of
new patients are put in a large pile until the end of the month, at which time they are
sorted. However, new patients are more likely than other patients to have a follow-up
36

appointment within a month of their first visit. This leads to a significant delay in
finding the charts for these patients, as the registrars must sift through several large
piles of charts that have no organization. There is no barrier to sorting these charts on
a rolling basis, rather than at the end of the month, and it will save hours in search
time.

2) Return charts to registration as doctors finish with them: Currently, a nurse
periodically picks up charts from registration, takes patient vital signs, and delivers
the chart and patient to a doctor. Doctors keep charts in their consultation room after
they are finished until they are collected by registration workers the next morning. If
doctors traded any finished charts for new ones when interacting with the nurse, the
nurse could bring those finished charts back to registration during her next trip for
new charts. This would allow a near real-time return of finished charts with no extra
trips and minimal extra effort.

With finished charts in hand, the registrars can quickly add doctor-scheduled follow-
up visits to the appointment log, and if time permits, they can begin entering the
second half of the information in the registration log (diagnosis, treatment, etc.)
during the day. Right now, the two employees in registration are working long hours
on the weekends to catch up with this half of the data entry. If they have any time
freed up by the electronic system, it can be used to do this during the week, hopefully
saving them time on the weekend. If they cannot find time to enter this data during
the week, they can still make doctor-scheduled follow-up appointments in a timely
manner.

3) Triage patients with appointments: With foreknowledge of patient’s presenting
symptoms/presumptive diagnoses, the clinicians can attempt to see the sickest
patients first. Furthermore, if there are patients with conditions thought to be
complicated but non-urgent, clinicians can see those patients at the end of the
day. Deferring complexity in this way will result in smoother flow for patients earlier
in the day. This may not always work, as patients are not all waiting in the early
morning (although a large percentage of them are), but it should be relatively easy to
quickly scan the day’s appointments for these types of patients and make the attempt.

Health Center Level

At the health center level, the referral system is less complex. Health centers generally refer
less than 10 patients daily, and in some cases much less. There appear to be fewer changes
necessary at this level for a well-functioning referral system. One short-term opportunity for
change was found which would make a smoother process for patients who are referred to the
district hospital. Potential longer-term changes in the way that health centers do their work
were also identified.

1) Shift appointment-setting responsibility from the data manager to the
cashier: As seen in the following diagrams depicting proposed changes, shifting this
responsibility eliminates an extra step for patients. The cashier’s job also aligns
more with this type of task, as the data manager otherwise has no patient
contact. We have observed the cashier’s work flow in a low-volume (Nyange) and
37

high-volume (Ruli) health center to evaluate the potential impact of this
change. Although there are differences in the activity level of each health center, the
cashiers appear to have enough capacity to make several appointments per day
without becoming a bottleneck in the overall process (though the wait of a few
patients behind the patient receiving a referral may be lengthened by a few minutes).

The short-term recommendations above are represented in the diagrams below. The first
diagram shows the referral system as it existed prior to any intervention. The second diagram
shows the impact of the original MAP project proposals. Finally, the third diagram depicts the
flow of patients through the referral system with the current recommendations, including the
ideas from the MAP project and those generated above.

The Existing Referral System

38

Referral System with MAP Recommendations

Referral System with Current Recommendations
39

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