What Happens When District Health Teams Lead: Reflections from Rwanda on Primary Health Care Performance
What Happens When District Health Teams Lead: Reflections from Rwanda on Primary Health Care Performance
District health teams often already know where the gaps in primary health care are. They know which communities are hardest to reach, where staffing and supply shortages affect care, and which indicators are consistently lagging behind national targets. What they often lack are the tools, authority, and flexible financing to act quickly on what the data shows.
That was the challenge the Gates Foundation-funded Primary Health Care Performance Management (PHC-PM) Activity set out to address in Rwanda and Ghana. Implemented by Management Sciences for Health (MSH) and partners, the activity supported district health management teams (DHMTs) in using routine data, structured improvement cycles, and catalytic funding to strengthen primary health care performance in ways designed to be practical, locally led, and sustainable.
In Rwanda, the experience in Bugesera and Gicumbi districts offers a closer look at what can happen when district teams identify priorities, test solutions, and lead implementation themselves.
A model built for those closest to the challenges
The PHC-PM Activity was designed around a straightforward idea: the teams closest to communities are often best positioned to identify and solve PHC challenges when they have the right support. Through the PHC Leadership Development Program (PHC-LDP), adapted from MSH’s long-standing leadership development approach, DHMTs strengthened their capacity to use routine health data through the Rwanda Health Analytics Platform (RHAP) to identify performance gaps, conduct root cause analysis, and design targeted improvement action plans.
Each district selected a Desired Measurable Result (DMR ) and worked through iterative six-month improvement cycles, adjusting strategies between cycles based on what the data showed and what teams learned along the way.
What made the approach distinctive was the addition of catalytic grants: flexible funding provided directly to DHMTs to support activities that routine district budgets often cannot quickly cover, including training, supervision, outreach, and equipment. Each district received a base of $10,000 per six-month cycle, with additional funding based on population size. Importantly, the grants were intentionally designed at levels governments could realistically sustain over time. Gicumbi, which completed four cycles, received nearly $130,000 in total over the course of the project while Bugesera, which completed three cycles, received $85,000.
Both districts selected antenatal care (ANC) coverage as one of their priority indicators. The path each took to improve it reflects two different realities and two different kinds of system change.
Bugesera: from data review to community action
At the start of the project, ANC 1 coverage in Bugesera stood at 35% baseline, below both the national average and the district’s own target of 47%. Root cause analysis identified three primary barriers: under-resourced community health workers (CHWs), missing ANC equipment at health facilities, and staffing shortages.
Before the project, district data review processes were largely retrospective. “We would mainly review data at the end of the month, but it was not informing decision-making, “ said Didier Habimana, Data Manager at Nyamata Level II Hospital. ” Through this project, that changed completely. We started regularly reviewing the data we had, asking ourselves what the data was telling us, and then prioritizing actions based on those findings.”
Catalytic grants funded doppler ultrasound machines, delivery kits, and beds for health centers that lacked essential equipment or were relying on outdated supplies. Forty health workers received updated ANC protocol training, while district advocacy efforts led to the recruitment of 14 additional staff. Monthly CHW coordination meetings also became routine, strengthening early pregnancy identification and referral across communities.
“One of the indicators that improved quickly was ANC attendance, especially during Cycle 3,” Didier noted. “A major reason for this improvement was the involvement of local leaders in community mobilization efforts.”
The introduction of ultrasound services at health centers also helped build trust and demand for services. “Mothers who received the service shared their experiences with others in the community,” Didier explained. “That community word-of-mouth significantly contributed to the increase in ANC uptake.”
By the end of the project, ANC1 coverage had reached 51%, surpassing the district’s original target. The number of health centers with functional fetal heart rate monitors increased from zero to 15.
A culture of performance monitoring took hold that Didier believes will outlast the funding: “When a health center sees itself performing poorly, it pushes them to investigate the causes, engage staff, and identify solutions.”
“Good data collection leads to good planning….And district planning eventually contributes to national planning.“
Yvette Imanishimwe, Vice Mayor in charge of Social Affairs, Bugesera
Gicumbi: from national targets to field realities
In Gicumbi, ANC1 coverage began at 59%, already above the national average. But district leaders identified operational barriers that routine indicators alone did not fully capture, including long waiting times, weak patient flow, gaps in CHW supervision, and financial barriers limiting access to care.
One of the most significant shifts was structural. Leonard Hakizimana, Director of Education and Research at Byumba Level II Hospital, describes what changed when technical staff gained a seat at the DHMT table: “When we started, membership was mostly limited to upper management, and that created a lot of limitations. Many of the decisions being made were not fully informed because the technical staff, who understood the day-to-day realities, were often not involved.” Through the PHC-LDP, Leonard joined DHMT discussions alongside heads of health centers, finance officers, and midwives, bringing field-level data directly into planning decisions.
“Before, discussions were driven by national targets and high-level indicators. We started bringing data from the field directly into those conversations: community complaints, supervision findings, and local observations. That shift changed where we focused our efforts and what we decided to act on.”
— Leonard Hakizimana, Director of Education and Research, Byumba Level II Hospital
With a clearer understanding of local barriers, the DHMT reorganized patient flow and established dedicated ANC consultation rooms across all 23 health centers to reduce waiting times. Fifty staff received refresher training on ANC protocols, while 56 providers were trained in ultrasound use through catalytic grant funding.
Community mobilization campaigns also addressed financial barriers directly, helping increase health insurance coverage among pregnant women to 95%. ANC1 coverage rose from 59% to 68%.
The same data-driven approach extended to other district priorities. After identifying anemia testing during pregnancy as a major gap, they acted with the same method. As Dr. Issa Ngabonziza, Director General of Byumba Level II Hospital, explains: “When we identified anemia testing as a priority, we set up measures — calling women to come for consultation, testing for anemia, and providing supplements to prevent their babies from having neurological deficits. We managed to raise anemia testing significantly.” Anemia testing in coverage improved from 78% to 96%.
Catalytic grants also expanded services the routine budget could not cover: a dental chair installed at Mukono Health Center and additional community outreach helping to reach 2,167 patients, and an eye care outreach program reaching 287 patients who had no prior access to those services. These were not add-ons; they were district-identified priorities, surfaced through data and acted on because the funding was there to support them.
What this approach leaves behind
Both districts acknowledge the sustainability challenges that remain. Activities requiring ongoing financial support, including outreach, supervision, and community engagement, may become harder to maintain without continued focus and funding. But district leaders also point to changes they believe will endure: stronger use of routine data in planning, greater participation of technical staff in district decision-making, and a deeper culture of accountability across facilities and communities.
For the vice-mayors, the question is no longer whether the approach worked. It is how to keep it alive. For Bugesera’s DHMT, the shift in approach, from treating symptoms to addressing root causes, is what makes the gains achieved through this project more likely to hold.
“Our commitment is to sustain the progress we have made and build on it, so we can go even further.” — Jean Marie Vianney Mbonyintwari, Vice Mayor in charge of Social Affairs, Gicumbi
“Primary health care is part of our daily work. The goal is for these lessons to be integrated into ongoing primary health care work so that the progress made can continue beyond the life of the project, and that this creates opportunities for further advocacy, collaboration, and resource mobilization to sustain and expand these efforts.”
Dr. Anita Asiimwe
The PHC-PM Activity leaves behind practical evidence about what happens when districts are trusted, equipped, and held accountable. Structured improvement cycles work when teams have the authority to act on their own data. Catalytic grants, modest, predictable, and time-bound, can unlock decisions that routine budgets never could. And bringing technical voices into DHMT discussions changes not just what is decided, but the quality of thinking behind it.