Healthcare in Rwanda

Healthcare in Rwanda was historically of poor quality, but in recent decades has seen great improvement. Rwanda operates a universal health care system, and is considered to have one of the highest-quality health systems in Africa.^[1]

History

In the pre-genocide era before 1994, Rwanda's healthcare was supported by the Bamako Initiative which was sponsored by UNICEF and WHO and adopted by African ministers of health in 1987.^[2][3] Progress was started towards decentralising the health management system, first to the Province level and then to the district level. Unfortunately this was disrupted by the 1994 genocide, which crippled the healthcare system alongside the economy. In the post genocide period, Rwanda has had an uphill climb in the recovery of its health system as well as its economy. However, it has since built one of the best healthcare systems in the region. In 2008, the government spent 9.7% of national expenditure on healthcare, compared with 3.2% in 1996.^[4] Health insurance became mandatory for all individuals in 2008;^[5] in 2010 over 90% of the population was covered.^[6] In 2012, only about 4% were uninsured.^[1]

Health insurance system

Rwanda follows a universal health care model, which provides health insurance through a system called Mutuelles de Santé.^[7] The system is a community-based health insurance scheme, in which residents of a particular area pay premiums into a local health fund, and can draw from it when in need of medical care. Premiums are paid according to a sliding scale, with the poorest members of society entitled to use the service for free, while the wealthiest pay the highest premiums and are charged copays for treatment.^[1]

In 2012, about 45% of the system was funded by premium payments, with the rest coming from government funding and international donors.^[1]

Quality

Rwanda's healthcare system operates roughly 440 health centers, 34 health posts which are mainly involved with the outpatient programmes such as immunizations and family planning services, a number of dispensaries, and 48 district hospitals.^[7] The country's villages are served by a network of thousands of community health workers. There are four national referral hospitals.^[8] which are Centre Hospitalier Universitaire de Kigali (CHUK), Centre Hospitalier Universitaire de Butare (CHUB), King Faisal Hospital (KFH) and the Kanombe Military Hospital. The most advanced of them is King Faisal Hospital, which, although a private facility, participates in the national health insurance system, and therefore accepts patients referred to it by other hospitals and clinics. It is the most advanced hospital in Rwanda, equipped with a CT and MRI machine, two dialysis machines, and a wide range of surgical capabilities.

Rwanda's clinics are equipped with basic medical equipment and a cupboard of essential medications. The district hospitals offer basic surgical services, and all have a minimum of 15 doctors. Those in need of more advanced and specialized care are referred to one of the four national referral hospitals. There is one cancer treatment center in the country which offers an almost full spectrum of cancer treatment, providing services such as screening, diagnosis, surgery, chemotherapy, palliative care, and a pathology laboratory, with those in need of radiology services referred to Mulago Hospital in Uganda.^[1] A new university teaching hospital which will be equipped with the country's second cancer treatment center is scheduled to start construction in June 2016, and is expected to be completed by 2018, with a second campus ultimately planned. It will be run by Partners in Health.^[9]

Rwanda is also currently participating in a seven-year program begun in 2013 that sees hundreds of medical educators and clinicians from 25 American medical institutions, including Harvard Medical School, Yale Medical School, and Duke Medical School, training Rwandan medical personnel and establish training and residency programs, which, after seven years, will be run by the Rwandan government with its own budget, teachers, and clinicians.^[10]

Maternal and child health

Rwanda is one of the countries which is on track in fulfilling the 4th and 5th Millennium Development Goals. In terms of the maternal mortality ratio,it reduced from 1,400 deaths per 100,000 live births in 1990 to 320 deaths per 100,000 live births in 2013.^[11] This was with an average annual rate of reduction to 8.6 from 2000 to 2013.^[12] Due to a variety of reasons such as poverty, poor roads due to the hilly terrain in the rural areas, misleading traditional beliefs and inadequate knowledge on pregnancy related issues, 31 percent of the women end up delivering at home despite having a public health insurance scheme. Some of the solutions which have been sought to the challenges include the training of more community health workers (village health teams) to sensitize the community,on top of providing them with mobile phones to contact the health facilities in emergency situations such as heamorrhage. The number of ambulances to some of the rural health centres have also been increased.^[13] According to a recent report by WHO most of the pregnant women die from hemorrhage (25%), hypertension (16%), abortion and sepsis (10% each) and a small number die from embolism (2%).^[14]

The demand for family planning was satisfied by 71% by 2010,the number of women who went for ante natal visits that is 4 or more visits went up to 35% in 2010 which though is low could have probably led to an increase in the number of pregnant women seeking a skilled attendant at delivery from 26% in 1992 to 39% in 2005 and then to 69% in 2010.^[12] In terms of prevention of mother-to-child transmission of HIV,in 2010 the percentage of HIV and pregnant women receiving ante retrovirals drugs rose from 67% to 87% in 2012.^[15] 45 percent of women between the ages of 15 to 49, use family planning methods. This comes as no surprise as Rwanda women on average, give birth to 4.6 children throughout their lifetime (RDHS 2010).

Prevalence of some diseases is declining, including the elimination of maternal and neonatal tetanus^[19] In 1990 there were 163 under five deaths for every 1000 live births.^[20] In 2010, 91 children died before their fifth birthday for every 1000 live births,^[20] often from diarrhoea, malaria or pneumonia.^[21] However, this figure is improving steadily.

In 1990,the percentage of children immunized against measles was roughly estimated to be 82% and by 2012 it had increased dramatically to 98% coverage of measles,3 doses of hepatitis B, 3 doses if pnuemoccal conjugatevaccine and 3 doses of DTP.^[22] Exclusive breast feeding rate increased to 85%. This can be explained by a number of factors such as increased awareness among the populations both rural and urban through education programmes as well as improved coverage of effective interventions. This has been significant in the prevention and treatment of the major causes of child mortality.

The number of malnourished children in Rwanda still poses a challenge. The percentage of children under 5 years who were moderately or severely underweight decreased from 24 percent in 1992 to 18% in 2005 to 12% in 2012. Stunting reduced slightly from 57% in 1990 to 44% in 2010.^[23]

Millennium Development Goal 6

Initially in the post genocide era, there was a heavy burden of diseases such as malaria, tuberculosis and HIV/AIDS, this was coupled with insufficient funds and food insecurity.^[24] The Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) and the US President’s Emergency Plan for AIDS Relief (PEPFAR) were then began though they were mainly used for HIV programmes in Rwanda.^[25] In 2005, to fight against malaria in his country, President Kagame launched the President's Malaria Initiative and initiative who's goal was to bring the most necessary materials such as mosquito nets to the most rural parts of Rwanda.^[26] In June 2012, 113 people with advanced HIV disease in Rwanda were receiving anti-retroviral therapy, making Rwanda (along with much richer Botswana) one of only two countries in sub-Saharan Africa to achieve the United Nations goal of universal access to antiretroviral therapy.^[27] Rwanda’s HIV epidemic has remained at a prevalence of about 3% for the past seven years.^[28] In reference to the gapminder graph,a comparison between the life expectancy versus the number of people living with HIV (number, all ages). It illustrates that between 1989 and 1990, the number of people living with HIV was 181,838 with a life expectancy of 48 years. During the 1994 genocide, the number increased to 200,000 with a life expectancy of 6 years. In the post genocide era, 1995 the numbers were still the same but the life expectancy had increased to 40 years as now HIV programmes had gradually begun. In 2011, the figures were still the same but life expectancy shot up to 63 years which showed that the number of people receiving the anti-retrovirals and had increased leading to more people living longer. Expansion and enhancement of Directly Observed Treatment Short-course (DOTS) in the six point Stop Tuberculosis (TB) strategy described by Laserson and Wells has been implemented in Rwanda by the health ministry's integrated program to combat leprosy and TB since 1990. This has led to treatment success rates rising from 58% (2003) to 81% by late 2006. In 2005, the case detection percentage for TB was 24%, which was below the target for case detection.^[29] In 2005, 477,000 people died because of malaria. This number reduced to 11,450 people dying of malaria in 2012.^[30] This can be attributed to the various malaria prevention strategies which have been put in place such as:

• Education campaigns.
• Community mobilisation.
• Training of trainers.
• Bed net distribution.

Sustainable Development Goal 3

The sustainable development goal 3 : Good Health and Well-Being replaced the Millennium Development Goal 3. The Rwandan government continued on the same track as it had for MDG 9, making good progress in the field, especially for HIV/AIDS and Malaria ^[31]

Water and sanitation

From 1990 to 2012, an improvement in the drinking water coverage was registered from 59% to 67% and the use of surface water reduced from 25% to 11%.^[32] There was also an improvement in the sanitation coverage from 1990 to 2012. This was from 30% to 64%. The unimproved sanitary facilities reduced further from 59% to 23%, while open defecation reduced from 7% to 3%.^[32]

Notes

References