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Open Access Research article

Baseline assessment of adult and adolescent primary care delivery in Rwanda: an opportunity for quality improvement

Ashwin Vasan123*, Manzi Anatole14*, Catherine Mezzacappa15, Bethany L Hedt-Gauthier145, Lisa R Hirschhorn156, Fulgence Nkikabahizi7, Marc Hagenimana7, Aphrodis Ndayisaba1, Felix R Cyamatare1, Bonaventure Nzeyimana7, Peter Drobac156 and Neil Gupta15

Author Affiliations

1 Partners In Health-Inshuti Mu Buzima, Kigali, Rwanda and Boston, USA

2 Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK

3 Department of Medicine, Weill Cornell Medical College/New York-Presbyterian Hospital, New York, USA

4 University of Rwanda, College of Medicine and Health Sciences, School of Public Health, Kigali, Rwanda

5 Division of Global Health Equity, Brigham and Women’s Hospital, Boston, USA

6 Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA

7 Ministry of Health, Government of Rwanda, Kigali, Rwanda

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BMC Health Services Research 2013, 13:518  doi:10.1186/1472-6963-13-518

Published: 17 December 2013



As resource-limited health systems evolve to address complex diseases, attention must be returned to basic primary care delivery. Limited data exists detailing the quality of general adult and adolescent primary care delivered at front-line facilities in these regions. Here we describe the baseline quality of care for adults and adolescents in rural Rwanda.


Patients aged 13 and older presenting to eight rural health center outpatient departments in one district in southeastern Rwanda between February and March 2011 were included. Routine nurse-delivered care was observed by clinical mentors trained in the WHO Integrated Management of Adolescent & Adult Illness (IMAI) protocol using standardized checklists, and compared to decisions made by the clinical mentor as the gold standard.


Four hundred and seventy consultations were observed. Of these, only 1.5% were screened and triaged for emergency conditions. Fewer than 10% of patients were routinely screened for chronic conditions including HIV, tuberculosis, anemia or malnutrition. Nurses correctly diagnosed 50.1% of patient complaints (95% CI: 45.7%-54.5%) and determined the correct treatment 44.9% of the time (95% CI: 40.6%-49.3%). Correct diagnosis and treatment varied significantly across health centers (p = 0.03 and p = 0.04, respectively).


Fundamental gaps exist in adult and adolescent primary care delivery in Rwanda, including triage, screening, diagnosis, and treatment, with significant variability across conditions and facilities. Research and innovation toward improving and standardizing primary care delivery in sub-Saharan Africa is required. IMAI, supported by routine mentorship, is one potentially important approach to establishing the standards necessary for high-quality care.

Primary care; Africa; Resource-limited settings; Quality improvement; Training; Integration; IMAI; Outpatient department; Nurses