Denying diseases a chance, breeding a productive population BY THOMAS KAGERA

The Ministry of Health has registered tremendous milestones in the attainment of Economic Development and Poverty Reduction Strategy ideals as spelt out in the 2007 paper, ensuring a healthy breed of Rwandans. A healthy population is more creative, innovative, productive and has a higher propensity to save and therefore grow. The changes have been dramatic.

The medical footprint

The Ministry of Health over the years has been steadily improving the performance, bringing in the fold every Rwandan to consume the medical services provided in the country.

"Positive changes have been realised in the health sector with 97% of Rwandans having financial and geographical access to health services. This has been made possible through the strengthening of the working mechanics of Mutuelle de Sante and ensuring an eloquent geographical dispersal of health infrastructure, as well as creating demand for the health services through sensitization of the masses,” says the Minister of Health, Dr Agnes Binagwaho.

There are 42 district hospitals in the country, 436 health centers, 35 dispensaries, 18 prison dispensaries, 45 health posts and a military hospital. There are also 4 Referral Hospitals and 1 Police Hospital. That translates into an average of 19 health facilities per district.

Two of the four referral hospitals also serve as teaching institutions for doctors and pharmacists. Ndera hospital is the referral hospital for mental health. Two other facilities, Kanombe Military hospital and Kacyiru Police hospital, cover the surrounding civilian population in addition to the Rwanda Defence Forces and the National Police.

Public health facilities represent 64% of the total number of non-private health facilities in Rwanda, with 28% run by Faith-Based Organizations, 1% parastatal, 5% private and 2% by Communities.

National Referral Hospitals provide advanced inpatient/outpatient services , surgery, laboratory, gynaecology, obstetrics; radiology, specialized services: ophthalmology, dermatology, ENT, stomatology, physiotherapy among others, while district hospitals offer inpatient/outpatient services, surgery, laboratory, gynaecology obstetrics and radiology.

Health centres mainly provide prevention services, Primary health care, inpatient, referral and maternity. Dispensaries provide; primary health care, outpatient and referral with health posts giving services related to outreach activities (immunization, family planning, growth monitoring and antenatal care).

There are 45,000 Community Health Workers (CHWs) in the country, 3 per village, with one responsible for antenatal care and post-delivery follow-up for one year, while the two are charged with general care on; malaria, Family planning, pneumonia, diarrhea, and other ailments. These are not medical professionals, but they have been trained to handle some uncomplicated cases.  Statistics indicate in 2010/2011 over 743,589 children were treated by CHWs comparing to 462, 104 in 2009.

Indicators speak

There has been a dramatic change in the health indicators in the past six years. Modern family planning methods have gone up from 10% to 45% among married couples, whereas, on average, family planning use in urban areas stands at 47% and 45% among the rural folk. At the end of 2010/2011, a total number of 708,265 women of reproductive age were reported as continuing users of contraceptive methods in health centers and district hospitals (up 31% from 541,483 in 2009). Couple Years of Protection, (family planning indicator based on the distribution of contraceptive commodities) also increased by 36%, from 770,784 to 1,045,218 during the same period. This therefore has seen women fertility drop from 6.1% to 4.6%, coming  close to the Vision 2020 target of 4.5%.

The rate of vaccination, against the five killer diseases, of children between 12-23 months stands at 100%. This in itself has seen a drop in infant mortality rate (IMR) from 86/1000 live births in 2005 to 50/1000 live births in 2010/11 meeting the Vision 2020 target of 50/1000.

Acute malnutrition among children has decreased by 50% in the five years. Consultation, hospitalization, and deaths due to malaria have dropped by 60%.

Antenatal services have too been improving over time and space. The percentage of assisted births in an accredited health facility increased from 28.2% in 2006 to 69% in 2010/11 exceeding the 45% target as well as the final 60% EDPRS target.

Maternal deaths occurring in health facilities in 2010 were 220 out of 242,672 deliveries. This corresponds to a health facility Maternal Death Ratio of 91 deaths per 100,000 in health centers and district hospitals. This is well below the 2007-2008 Demographic Household Survey figure of 690/100,000.

Access to prevention of HIV transmission from mother to child has seen tremendous  improvements. Today, 78% of all women who require to get PMTCT (Prevention of Mother to Child Transmission ) full package and so paediatric HIV has been greatly curbed. However, with the campaign launched by the first lady, Madamme Jeannette Kagame, elimination of paediatric HIV in Rwanda is likely to be attained in the very near future.

During 2010/2011, a total of 1,862,642 people were tested through voluntary counseling and testing services (up from 1,393,018 in 2009) and 1,641,752 (88%) knew their test results. Each year, the average number of people tested voluntary in all health facilities increased by 25%. The number of VCT sites increased from 403 to 434.

The Provider Initiated Testing (PIT) was rolled out in all health facilities in December 2010. Health facilities have already started to provide PIT services and 187,258 patients have been counseled and 5,339 (2.8%) tested HIV positive.

With regard to Prevention of Mother to Child Transmission of HIV/AIDS (PMTCT), the number of women who were receiving Ante-Natal-Care (ANC) services in PMTCT settings is 307, 904 in 2010/2011. Among them 297,145 (96.5 %) accepted to be tested for HIV and 99% of the women tested returned for information about their HIV serological status.

Among 297,145 women tested for HIV in ANC services during the year 2010, those found to be HIV positive were 8,343 (2.8%).The doctor-patient ratio currently stands at 1:5000, but with efforts and investments in training, those figures will go down.

Non-communicable diseases next

Now that the infectious diseases have been stablised, the government has proactively searched for the means and ways of strengthening the capacity of personnel to fight non-communicable diseases.

There is training of people on how to vaccinate against cancer. So far girls around the country have been vaccinated against cervical cancer.The capacity to treat non-communicable diseases; cancer, pulmonary, injury, heart and metabolic diseases is being strengthened.

The government has mobilized 16 United States of America Universities to bring in lecturers and mentors to create a consortium. Hopefully within a year, the government might have mobilized money, to bring them on board to train the trainers of medical personnel. In seven years, this will have boosted the medical personnel capacity to significant levels.

The Butaro Cancer Centre of Excellence, the first of its kind in the East African region to open in a rural area is a result of such efforts. The facility was funded by the Clinton Foundation, Partners in Health, the Jeff Gordon Children’s Foundation, the Dana-Farber/Brigham and Women’s Cancer Center, as well as the Government of Rwanda.

Mutuelle de Sante reforms

Membership has continued to expand in the community-based health insurance program. Average adhesion rate for the country stood at 91% in 2010. Adhesion rates are not evenly distributed across the country, but range from a low of 78% in Ruhango district up to 99% in Karongi, Nyamasheke and Gatsibo districts.

The Mutuelle de Sante reforms have been put in place to ensure equity. Since the programme operates on the principal of solidarity, it was revised that three categories be created instead of having one blanket insurance cover.

The poorest people were given cards to access medical services free of charge, people in the second category pay RwF3,000 and those in the third category pay RwF7,000. Currently, a dialogue is taking place with several consultations to establish the categories.

Infrastructure and ICT

The infrastructure in the health sector has continued to improve and expand. Every district has a hospital, and as mentioned earlier, health centers and dispensaries are also numerous. The soft infrastructure has also kept on improving, that today telemedicine/e-medicine can be efficiently practiced in the country.

The usage of ICT in the health sector is very vital. About 8% of the health centers are networked with modern ICT facilities. The Community Health Workers (CHWs) have been trained to relay data to the ministry using their mobile phones under a programme that has been dubbed Localised MDGs reporting.

"These CHWs, among other duties, do report on issues to do with disease outbreak (through the Rapid SMS) to the headquarters. They also report cases of malaria, child mortality, maternal health, and other health and social related activities. This is the first mechanism, in the whole world, of collecting data on a daily basis, on financial and epidemiological issues from the village to the national level. It is a homegrown initiative that is serving to enhance planning and transform lives. The data so collected is accurate and timely. The accurateness has been proven as it compares well with that collected by the DHS” the Minister of Health Dr Agnes Binagwaho notes. The CHWs are volunteers, whose workman’s compensation is performance-based.