Case Study on Mentorship and Enhanced Supervision for Health Care and Quality Improvement (MESH-QI)

The approach was initially piloted to support primary health care nurses and improve the quality of integrated management of childhood illness (IMCI) and antenatal care (ANC). MESH-QI enables mentors to visit health centers to provide one-on-one clinical mentorship for nurse mentees, on-site education sessions for facility staff, quality improvement (QI) coaching, and data collection, all to improve programs and the quality of patient care. The MESH-QI approach was rooted in the principle of complying with existing national and global health sector policies and guidelines and addressing MOH priorities to implement the IMCI protocols effectively. Globally, Rwanda is remarked as a country context in which political will has shown to be a strong enabling factor to facilitate effective change and policy implementation, including in the health sector. At the health system level, the MOH has sought to strengthen the health care delivery system in selected remote and underserved districts in the country. A proxy for health systems effectiveness is the infant and under-five mortality rates, which were both high. In 2006, IMCI emerged as a national priority to address infant and child health. The MOH worked with partners, including PIH, to develop an IMCI protocol, which was among the first service areas for implementing MESH-QI. At the workplace or health facility level, Rwandan primary care health centers (HCs) faced challenges including high costs of centralized didactic training, limited clinical supervision, and supply-chain issues. These factors contributed to the limited implementation of MOH evidence-based clinical protocols, such as IMCI, in care delivery in many HCs. MESH-QI implementation has expanded in Rwanda from being implemented in two district hospitals and 21 nurse-led HCs in two rural districts to all 30 districts in Rwanda. The approach has been used to enhance the existing primary health care supervision system as well as emerging, more specialized health needs. In 2010, health areas included maternal and child health, HIV, and integrated management of adolescent illness (IMAI). In 2012, MESH-QI expanded to non-communicable diseases (NCDs) and mental health. Building on successful implementation of the MESH-QI program, a neonatal mortality reduction initiative known as “all babies count (ABC)” was designed and implemented in Kirehe and Kayonza district hospital catchment areas. MESH-QI implementation and results have been documented in five peer-reviewed journal articles, including a case study, qualitative study, and three pre-post intervention studies. In addition, PIH published the detailed MESH-QI Implementation Guide in 2017. Inputs for the MESH-QI approach were classified by type: human resources, financial, informational, equipment, supplies, and technical inputs. Human resources included clinical mentors, supervisees, and supervisor trainers. Financial resources were provided by the Doris Duke Charitable Foundation’s African Health Initiative and PIH. Informational resources included clinical records, national health management information system (HIMS) reports, and district health sector strengthening plan. Material resources required for mentor training and implementation included mentor transport, overnight accommodation, printed clinical observation forms, and other standardized tools.