Understanding variation in health service coverage and maternal health outcomes among districts in Rwanda - A qualitative study of local health workers' perceptions.

ObjectiveTo obtain the perspectives of health professionals and community health workers on factors that determine health service coverage and maternal health outcomes so as to understand variations between districts.Methods16 Focus group discussions involving four different groups of participants were conducted in May 2015 in four purposively selected districts, complemented by three key informant interviews in one of the districts.ResultsThe solidarity support for poor people and the interconnectedness between local leaders and heads of health facilities were identified as enablers of health service utilization. Geographical factors, in particular location close to borders with mobile populations and migrants, and large populations with sparsely distributed health infrastructure, exacerbated by hilly topography and muddy roads were identified as barriers. Shortages of skilled health providers at the level of district hospitals were cited as contributing to poor maternal health outcomes.ConclusionThere is a need to take into account disparities between districts when allocating staff and financial resources in order to achieve universal coverage for high-quality maternal health services and better outcomes. Local innovations such as the use of SMS and WhatsApp text messages by health workers and financial protection schemes for poor patients improve solidarity and are worth to be scaled up