The Challenges and Outcomes of Dual Clinical Practice in Rwandan Public Health Facilities

As twilight descends on the bustling city of Kigali, healthcare providers transition from their demanding daytime roles into a shadowy realm of private practice. With the sun setting, hospitals like CHUK and CHUB come alive again, offering specialized care beyond regular hours, thanks to the implementation of Dual Clinical Practice (DCP) policy. This approach aims to alleviate the strain on public health resources while presenting unique challenges and opportunities for both healthcare providers and patients.

Understanding Participant Profiles

Provider Demographics

The study surveyed healthcare providers and patients across six hospitals in five Rwandan provinces, revealing a diverse landscape of experiences. Providers included specialists largely focused on internal medicine, pediatrics, surgery, and diagnostics, with 75% reporting government employment. Interestingly, only 15% of the surveyed providers were female, a statistic that echoes socio-economic barriers facing women in the healthcare sector.

• Average age of providers: 39.15 years
• Gender disparity: 15% female representation
• Work environments: 45% in teaching hospitals
• Government employment: 95% of providers

Client Experience

Client exit interviews revealed that 94% of patients possessed health insurance, which greatly influenced their ability to access DCP services. The demographic profile was notably diverse, with patients aged between 24 and 69 years, and 59% being female. Educational attainment also skewed high, a potential factor in easing the reception of healthcare reforms.

The DCP Policy Implementation Landscape

Variability in Adoption

Survey responses from healthcare facilities demonstrated significant variability in how DCP policies were implemented. While some hospitals reported successful training and record-keeping, others struggled with adequate resources. Dr. Alice Umutoni, a healthcare policy analyst, noted, “The inconsistency in implementation across facilities reflects broader systemic challenges such as funding and administrative oversight.” Almost all providers voiced concerns about remuneration, with one stating, “Longevity in DCP participation hinges not only on financial incentives but also on the pressures of increased workload.”

Operational Challenges

Many respondents highlighted operational challenges, including insufficient spaces for after-hours care and a lack of cohesive tracking at the national level. Some hospitals, despite their efforts to communicate DCP services, faced confusion regarding service availability among patients. “For DCP to be effective, we need both willing providers and well-defined spaces for care,” remarked a hospital manager from CHUB.

Health Service Provision: Shifting Paradigms

Access to Specialized Care

One of the most significant benefits of DCP is the provision of specialized care after hours. Data indicate that outpatient visits soared by up to 15.5% from 2020 to 2021 across various facilities. Notably, CHUK saw an increase in its DCP outpatient visits to 8.53% of its total patient visits. This trend suggests that DCP has catalyzed a necessary shift in access, particularly for urgent and specialized treatments. “We’ve noticed reduced waiting times and increased patient satisfaction,” affirmed Dr. Jean Pierre, a pediatric specialist.

Patient Perspectives

While patients appreciated the accessibility of after-hours services, many voiced concerns over the costs associated with DCP, particularly those under Community-Based Health Insurance (CBHI). “Being able to see a specialist after hours was crucial for my child’s health, but the cost caught me off guard,” one parent explained. This dichotomy illustrates the fine line DCP walks in serving underserved populations while attempting to maintain financial viability.

Revenue Generation: The Economic Undercurrents

Financial Implications of DCP

The revenue generated from DCP services constituted a meager 0.1% to 3.6% of total hospital revenues, primarily attributed to inefficiencies in billing and administrative practices. “The DCP is still in its infancy, and we are finding our footing,” acknowledged a financial officer at Gihundwe Hospital. In a financial environment largely dependent on the CBHI scheme, which accounted for up to 82% of income, the growth potential for DCP remains limited.

Remuneration and Patient Satisfaction: A Balancing Act

Challenges in Compensation

Interviews revealed a discontent with remuneration levels among healthcare providers, a sentiment echoed across all facilities. The prevailing atmosphere of dissatisfaction stemmed from the taxing nature of DCP roles coupled with a lack of corresponding financial rewards. “The burden of extra hours without proportional pay is a heavy weight for many providers,” articulated one healthcare worker, highlighting an urgent need for systemic review.

Satisfaction Metrics

Surveys indicated that 81% of patients were either ‘Satisfied’ or ‘Very Satisfied’ with DCP services, primarily due to the timely access to specialists and reduced waiting times. Dr. Honoré Kagame, an expert in health systems, articulated, “Patient satisfaction reflects the core intent of DCP, but unless we address provider concerns, the model may falter.”

Strategic Approaches to Enhance DCP Outcomes

Proposed Changes to Improve Provider Retention

In light of growing concerns about provider retention, several targeted strategies were proposed:

• Lowering tax rates on DCP earnings from 30% to 15%.
• Allocating 60% of DCP-generated revenue to provider remuneration in accredited facilities.
• Matching DCP tariffs for CBHI members with those of other insurance schemes to boost utilization.

Early analysis of these proposals indicates they could substantially increase both provider satisfaction and utilization rates, thereby potentially enriching the healthcare landscape in Rwanda.

As Rwanda continues to wrestle with the intricacies of DCP, the interplay between patient access, health provider satisfaction, and financial sustainability remains a nuanced challenge. The DCP policy could herald a new era of healthcare accessibility in Rwanda, but only if it navigates the multifaceted demands of healthcare providers and patients alike. With the right systems in place, the legacy of these reforms might resonate far beyond the corridors of urban hospitals, fostering a healthier population and a more robust health infrastructure.

Source: bmchealthservres.biomedcentral.com