International University of Africa

Faculty of Medicine and Health Sciences

African Medical Students Association

Health Problems in Africa: Is there any hope left?
10 11 January 2013 AD/ 28 -29 Safar 1434 AH Khartoum - Sudan

Major Health Problems in East Africa

Rwanda

Prepared by:

Ngoga Saad, MBBS Level 4, Faculty of Medicine IUA

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Country background:
Rwanda is a land-locked Great Lakes Region country sharing boundaries with the Democratic Republic of Congo (DRC), Tanzania, Burundi and Uganda. Rwanda covers a surface area of 26,338 square kilometers and currently has a high population density of 360 persons per square kilometer. Administratively, the country is divided into five provinces and 30 districts. Of the five provinces, Kigali is predominantly urban and the rest are predominantly rural. Rwanda has a tropical climate and vegetation with four distinct seasons: two wet seasons and two dry seasons. The short wet season lasts from October-November, and the main rainy season lasts from mid-March to the end of May. During the dry seasons, which last from December to mid-March and from June to the end of August, frequent light cloud cover yields a pleasant, never stifling, temperature. According to the National Institute of Statistics (NISR, 2010) projections, Rwanda has a population of about 10.12 million. About 85% of the population live and work in the rural areas; while the remaining 15% live in the urban areas.

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Country Health Indicators

It has a population growth rate of approximately 2.7%. The interim Demographic and Health Survey (2007) results show that fertility rate in Rwanda is 5.8 births per woman. The ratio of females to males is 1:1, with one third of the households headed by females. Forty two percent of the total population is under 15 years of age. Infant mortality rate is 50/1000 (Interim DHS 2010), under 5 Mortality rate is 76/1000 (Interim DHS 2010), Maternal mortality rate is 383/ 100,000 (Estimation, 2009). Under 5 years severe malnutrition stood at 19.4% (IDHS, 2005), Per capita utilization of Health facilities is 70%, (HMIS 2007), with 83 Visit person/year, Life expectancy at birth 52.73 (UNDP 2007)

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GENERAL ORGANIZATION OF THE HEALTH SYSTEM

Introduction
The Rwandan health care sector has undergone substantial changes over the past 150 years. Prior to the arrival of colonial Germans, African traditional medicine constituted the basis of health care provision for the entire country. The pre-colonial Rwandan health care system was based on traditional healing using plants, powders, and herbs to treat disease. Traditional healers were also assisted by spirits whom they said helped resolve health problems in the population. This practice continued even after the introduction of modern medicine at the beginning of the colonial period and lasted until the 1970s. The transition to the use of modern medicine began when the Germans arrived and continued through the first half of the20th century. Religious institutions, such as the Catholic Church, also played an important role in this process. During the second half of the 20th century, before the war and genocide in 1994, Rwandan health care was characterized by a strong centralized system, and health services were theoretically free to all Rwandans. Religious institutions still played a major role in the system. During the genocidal period, a large part of the health infrastructure was destroyed and there was an enormous loss of human resources for healthcare. Immediately after these tragic events, Rwanda started urgently rebuilding its primary health care system and human resources for health. Since 2000, the health care system has entered a new stage of steady development.

OVERVIEW OF THE HEALTH SYSTEM IN RWANDA

Following the 35th session of the African Regional Committee of the World Health Organization held at Lusaka in 1985, Rwanda adopted a health development strategy based on decentralized management and care at the district level. The decentralization process began with the development of provincial-level health offices for health system management. Progress was made toward decentralizing the managerial responsibilities to the province and, ultimately, to the district level. The

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declaration of Lusaka promoted the following three strategies to improve the quality of and access to the health care system: 1. Decentralization of the health care system using health districts as the operational base of the system; 2. Development of the primary healthcare system through its eight elementary components;1 and 3. Strengthening community participation in service management and financing. The 1987 international conference on primary health care in Alma Ata called upon national and international communities to take urgent and effective action, to conceive and implement worldwide health care, in a spirit of technical cooperation, particularly in developing countries. Rwanda adopted a primary health care policy immediately after the declaration of Alma Ata and was committed to developing a basic health system that offers primary health care responding to the needs of the population. The tragic events of 1994 negatively impacted the health care system in a profound manner, because a large portion of the health care infrastructure was destroyed by the enormous loss of human life. After the war and genocide, Rwanda immediately started to rebuild and reform its health care system and to train health care professionals. In February 1995, the Ministry of Health launched its health sector reform initiative according to the declaration of Lusaka, which was adopted in 1996 by the Government of National Unity. The objective of this initiative was to improve the well-being of the population by ensuring that the health care system provides quality services throughout the country, and that these services are accepted by and accessible to a majority of the population. In March 2005, the Government of Rwanda adopted the Health Sector Policy (2005) and Health Sector Strategic Plan (2005-2009) for achieving its global vision to guarantee the health and well-being to the entire population, increase production, and reduce poverty. The health care sector aims to ensure and promote the health status of the population by offering quality preventive services and rehabilitating curative services within an effective health care system. To fulfill this mission the Minister of Health focuses on the following main objectives/programs: Ensuring the availability of human resources for health

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 Ensuring the availability of quality medicine, vaccines, and others medical supplies Providing care and services at an affordable cost The eight elementary components include: 1) Education about common health problems and what can be done to prevent and control them; 2) Maternal and child health care, including family planning; 3) Promotion of proper nutrition; 4) Immunization against major infectious diseases; 5) An adequate supply of safe water; 6) Basic sanitation; 7) Prevention and control of locally endemic diseases; and 8) Appropriate treatment for common diseases and injuries.

Health Financing
Performance-based Financing (PBF) is an approach to health financing that shifts attention from inputs to outputs, and eventually outcomes in health services. PBF consists of a group of methods and approaches that aim, through differing levels of intervention, at linking incentives to performance. PBF can be defined as a voluntary agreement between independent or autonomous partners who commit to a set of reciprocal obligations that will be of mutual benefit to all. Performance-based financing in Rwanda is defined as: A method of health care services management which seeks to increase the volume and quality of health care services provided to the population. Performance-based financing increases funds available at the operational level to increase health worker motivation through a system of complementary remuneration based on performance. Performance-based financing operates through contracts between those providing the financing and the various local actors in the health system. Performance-based financing facilitates efficiency and cost-effectiveness in the utilization of health resources. It is more effective in achieving results than input-based financing because it motivates workers to achieve better performance and it ensures that funds arrive at the health facility levels instead of trickling down from higher levels in the system.

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Health Services in Rwanda

Geographic Distribution and Populations Served by Health Facilities To ensure the most efficient health care coverage possible, given limited availability of resources, norms were established in 1997. These norms include an average coverage of 200,000 people per district, with one district hospital per district and 20,000 people per health center. The geographic area covered by an administrative unit or health care facility is the catchment area, or zone de rayonnement. Originally, under the restructuring of the health system, administrative units for the health system were formed primarily based on geographic accessibility, regardless of the availability of infrastructure or existing civil administrative boundaries. Over time, the boundaries of administrative units for the health system have been adapted, taking into account the size and boundaries of civil administrative units, while still considering geographic accessibility. At present, a population is defined as having access to health care if the service can be reached by foot in one and a half hours. Considering the current distribution of facilities, about 85 percent of the population live within one and a half hours distance from of a primary health care unit. Geographic distance and mountainous terrain, however, continue to constrain access to health care. To improve geographic accessibility, a referral system combining access to ambulance services and telephone network fordistrict-level facilities is gradually being developed. This system will solve the problem of geographic accessibility between primary care health centers and hospitals but not the problem of transporting patients to health centers, which still depends largely on traditional means of transportation. Health districts in Rwanda vary greatly by the size of their catchment population. The population covered by a district facility varies from 70,000 to 480,000 people. The national average is around 200,000, which approximates the national norm.

Package of Health Services

Most common disease morbidities in Rwanda are infectious diseases, which are preventable through the improvement of hygiene and sanitation, and health-related behavior. Infectious diseases are the top ten leading causes of morbidity and mortality in Rwanda. Nine in ten health consultations at primary health care facilities in Rwanda are for diseases such as malaria, respiratory infections, diarrhea, intestinal parasites, skin diseases, HIV/AIDS, STI,

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tuberculosis, typhus, cholera, and meningitis. A package of activities directed toward these diseases and other common preventive interventions have been delineated for each level of the health system. A different package of activities was defined for each level of the health care system to ensure equitable access to care throughout the country, the availability of procedures, and standards for operation and management. It allows for better resource planning and management, as well as furnishing, establishing, and evaluating the basic quality of health services

Progress in the Implementation of a Decentralized Health System

Rwanda implemented the second phase of its political and administrative decentralization in 2006, and by the end of 2007 the country will have been divided into 30 administrative districts. In 2007, there were 38 operational district hospitals, and four national referral hospitals. From 2006 to the end of 2007 the total number of health facilities increased from 382 to 401, of which 38 are adjacent to each district hospital. In 2006, the Minister of Health reconstructed four new district hospitals and rehabilitated two other district hospitals. Additionally, it constructed seven new health centers and equipped 14 other health centers. A total of 75 distillers and 25 centrifuges were distributed to laboratory units of health centers. To improve accessibility to health services, the government purchased 51 ambulances for hospitals and health centers and 370 motorcycles for health centers. In addition, each health district received a vehicle for supervision activities.

Human Resources for Health

Almost all health personnel in Rwanda that work in public health facilities are staff of the Ministry of Health. The MOH recruits approximately 62 percent of the health workforce and pays their salaries directly through the administrative district. The remaining 38 percent of health personnel working in public health facilities are paid through various means, including direct contracts with government assisted health centers (24 percent), NGOs, volunteer organizations, or the districts (14 percent). Health personnel working in public health facilities also include

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some expatriates whose salaries are paid by NGOs, bilateral, or volunteer organizations. Irrespective of their source of payment, all personnel working in public health sites are considered MOH personnel. A very small number of health personnel work in the private sector of the health care delivery system.

Basic Qualifications for Health Personnel

At the end of December 1999 the Ministry of Health assessed its workforce capacity and counted a total of 4,141 staff registered with the Ministry of Public Function (MOPF). They included 2,262 medical and clinical personnel and 1,879 nonmedical personnel. There were 148 physicians and 1,143 nurses, accounting for 3.6 percent and 27.6 percent, respectively, of all personnel. In December 2000, the MOH registered 3,363 staff with MOPF, including 2,320 medical and clinical personnel and 1,043 nonmedical personnel. The proportion of physicians and nurses had increased to 4.4percent and 34.7 percent of the total health workforce, respectively. In 2003, the health personnel situation had improved slightly. The MOH had a total of 4,222 registered staff that included 220 physicians, 19 midwives, 1,997 nurses, and 79 senior health technicians. In 2005, the public sector had a total of 6,961 registered staff (5,850 medical/clinical and 1,246 nonmedical), with 221 physicians (3.2 percent) and 4,063 nurses (62.5 percent) (Table 2.2). According to the 2006 Minister of Health Annual Report, the physician population ratio improved from 1/50,000 in 2005 to 1/42,000 in 2006. During the same period, the nurse population ratio improved from 1/3,900 to 1/3,138.

Health Sector Financing

Traditionally, the level of health sector financing has been weak. The main sources of health sector financing are 1) the government budget, which is allocated for the Ministry of the Health through the Ministry of Finances and Economic Planning, 2) assistance from bilateral/multilateral international partners or nongovernmental partners of the Ministry of Health, and 3) contributions from the population through prepayment programs or out-of-pocket.

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The percentage of the national budget designated for the public health budget is very small (4.7 percent in both 2005 and 2006). This figure is much lower than the minimum recommended (8 percent) by the World Health Organization. If there were a consistent increase in the governments budget allocation for the health sector, the proportion could reach 6.5 percent in 2010. In 2005, the expenditure per capita for health care remained low, the equivalent of only US$13 per capita per year. In 2007, 48 percent of the health sector budget came from the national budget; the remaining 52 percent came from international partners. It is estimated that to provide public health care of minimally acceptable quality in a developing country, a minimum budget of US$45 per capita per year must be allocated, which is more than three times the current Rwandan expenditure per capita for health. This provides a general idea of the amount of work that remains to be done in this area. The nation of Rwanda is the most densely populated country in Africa, with a population of more than 10 million. Beginning in April 1994, a tragic genocide took the lives of close to a million Tutsis and moderate Hutus in just 100 days. The genocide destroyed Rwanda's already fragile economy, further impoverishing the population, and resulted in a massive loss of health professionals and the collapse of health infrastructure. The AIDS epidemic in Rwanda today is, in large part, a consequence of the violence, instability, and displacement that occurred as a result of the genocide. An estimated 3 percent of the population is infected with HIV. Many of those infected during the 1994 genocideespecially women who were the victims of rapeare now suffering from full-blown AIDS. Since the 1994 genocide, many international institutions and aid organizations have worked to improve health outcomes in Rwanda and conditions have improved remarkably since the late 1990s. Despite its progress, the country has a long way to go before it will see the complete elimination of HIV/AIDS, tuberculosis and malaria within its borders.

PIH's (partners in health) work in Rwanda

Since being invited in 2005 by the Rwandan government to work in underserved areas of the country, PIH has brought quality health care to 800,000 people in three rural and impoverished districts. Together with

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our Rwandan sister organization, Inshuti Mu Buzima (Kinyarwanda for Partners in Health), PIH now works at three district hospitals and 37 health centers. Facilities supported by PIH and Inshuti Mu Buzima (IMB): Building off PIHs approach in Haiti, the Rwanda project was designed as a comprehensive primary health care model within the public sector. The approach uses HIV/AIDS prevention and care as the entry point to build capacity to address the major health problems faced by the local population. Haitian physicians, nurses, and managers traveled to Rwanda extensively in the early years of the program to provide training and program design assistance. In 2009, PIH/IMB received funding from the Doris Duke Charitable Foundation to strengthen health systems in two eastern districts, Southern Kayonza and Kirehe, which serve a population of 460,000 people. Partnering with Rwanda's ministry of health and Brigham and Women's Hospital, this project includes interventions aimed at making significant improvements to the World Health Organization's six health systems building blocks. The partnership will also support research and monitoring and evaluation of PIH's approach to rural health, and help inform the government of Rwanda's ambitious plan to replicate the approach nationally. In the northern Burera District, the state-of-the-art Butaro Hospital was inaugurated in January 2011. This facility brings highquality medical care to a district that did not have a functional hospital and serves as a flagship center for medical education and innovation for the entire east Africa region.

THE BURDEN OF DISEASES

The most common communicable diseases are malaria, HIV and AIDS, acute respiratory infections, diarrheal diseases and tuberculosis. Other diseases occur in the form of epidemics: typhus, cholera, measles and meningitis. These diseases are the subject of specific control strategies and permanent surveillance in Rwanda

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The Challenges of AIDS, Tuberculosis and Malaria HIV/AIDS: 190,000 people infected Tuberculosis: 60,000 people sick Malaria: 856,233 cases of malaria

HIV/AIDS
The impact of the 1994 genocide continues to be felt through the increased prevalence of HIV/AIDS. Estimates suggest that of the approximately 250,000 women raped by militia members during the violence, over 70% of them are now HIV-positive. Their children, known as the children of bad memories, make up a large portion of the 27,000 children under the age of fifteen living with HIV/AIDS. In addition to being HIV-positive themselves, many of these children are orphans. According to UNAIDS there are more than 210,000 AIDS orphans in the country. In 2003, 9 years after the conflict ended, Rwanda had an HIV prevalence of 5.2%. However, by 2005 as a result of significant donor investments and a well-coordinated national response led by the National AIDS Control Commission, Rwanda was able to lower its HIV prevalence to 3.1% a two percent decrease in just two years.

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Although this progress is significant, there are still 190,000 people living with HIV/AIDS and over 21,000 people had died from AIDS by 2005. Rwanda has vastly increased the number of health facilities adding 182 since 2004. Yet only 42 of these facilities are capable of providing ARV treatment. Currently, Rwanda is focusing its efforts on obtaining and administering treatment as well as incorporating HIV/AIDS information and education into reproductive health programs. The country seeks to increase the availability and use of ARV treatment for pregnant women and new mothers as well as reduce the number of new HIV infections.

Tuberculosis
Tuberculosis is a preventable and curable disease, yet it kills an estimated 4,400 people every day and nearly two million people each year. In immune-compromised patients, such as those with HIV/AIDS, opportunistic infections like tuberculosis can be deadly. In 2005, there were more than 60,000 people living with tuberculosis in Rwanda and 16% of those cases were HIV- positive adults. In recent years, Rwanda has substantially stepped up efforts to control tuberculosis and 100% of the population has access to DOTS therapy. Over the past few years, multi-drug resistant tuberculosis (MDRTB) has emerged as a new threat worldwide. In 2004, it was estimated that 3.9% of new tuberculosis cases in Rwanda were MDR-TB. Additionally, 9.4% of tuberculosis cases requiring re-treatment were MDR-TB. In November 2004, Rwandas National Integrated Program for Tuberculosis Control in conjunction with the Institute of Tropical Medicine of Belgium launched a national drug sensitivity survey to improve detection of drugresistant strains of tuberculosis. As a result of the survey between November 2004 and February 2005 Rwanda detected 200 new MDR-TB cases, up from 70 in previous years. Moreover, because detection rates improved, the number of MDRTB cases successfully treated also increased, from 70 in 2003 to 138 in 2004. Insufficient laboratory capacity and lack of effective second line treatments, however, still present major obstacles to Rwandas national tuberculosis control program.

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Malaria
The entire population of Rwanda nearly 10 million people is at risk for contracting malaria. In 2003, 856,233 cases of malaria were reported. Approximately 2,500 of those cases were fatal, making malaria the leading cause of death in Rwanda in 2003. Among those at greatest risk of death from malaria are children under five. In 2000, more than 50% of both reported malaria cases and malaria-related deaths in Rwanda occurred in children under age five. With such widespread risk, the country has undertaken a number of measures in order to control transmission and reduce the number of malaria-related deaths. The government has been promoting the use of insecticide-treated bed nets, timely treatment, and mosquito reduction as a part of its national malaria control efforts. However, rapid and widespread resistance to older first line treatment anti-malarial drugs hampered the countrys ability to effectively combat the disease. As a result, in 2005 the Rwandan government changed its national treatment policy to make artemisinin-based combination therapy (ACT) the official first line antimalarial drug.

Eradication and elimination

For diseases retained for eradication and elimination, Rwanda has subscribed to all the WHO recommendations aimed at eradicating poliomyelitis, eliminating maternal and neonatal tetanus and controlling measles. Highly-encouraging results have been achieved in the fight against these endemics. Rwanda documented the certification of the eradication of poliomyelitis in 2004, and since then, the indicators of surveillance of acute flask paralysis are maintained at the certification criteria.

Immunizations
Rwanda officially eliminated maternal and neonatal tetanus in 2004. The Expanded Program on Immunization has already initiated the process of integrating other interventions in favor of child survival into its regular immunization programme, such as the distribution of an insecticidetreated bed net to a 9-month old baby who has just received his antimeasles vaccine and the integration of vitamin A supplement during regular vaccination activities. Since 2002, the year Rwanda introduced the new vaccines (HepB and Hib), the vaccination coverage increased from

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82% in 2002 to 97% in 2007, according to administrative data from the EPI. The report of the Intermediate Survey on Demographic and Health Indicators (2007-2008) shows an improvement in the vaccination coverage of children since 2000, with the rate increasing from 76% to 80%. In April 2009, Rwanda became the first developing country to introduce vaccination against pneumococcal infections in its national programme. In the framework of vaccine independence, the Government fully finances traditional vaccines and injection materials, and has been doing so since 2000. Hence, co- financing for new vaccines started in 2006. Concerning child health, although morbidity and mortality attributable to vaccination preventable diseases have significantly declined during these past five years in Rwanda, infant mortality is still the highest in the world (107 for 1000 LB in 2000, and 86 for 1000 LB in 2005, according to the DHSR-III and 62 for 1000 LB in 2007, according to the Mini DHS). The challenges to be met would be the consolidation of the achievements of the vaccination programme and mobilization of financial resources to deal with the high cost of new vaccines largely financed by GAVI. The country is confronted with periodic epidemics of cholera, meningitis, measles and bacillary dysentery. Over the period 2006-2007, Rwanda experienced two epidemics of cholera and two epidemics of measles. In 2007, a cholera epidemic affected 3 regions and 918 cases were notified, including 17 deaths (lethality: 1.85%).

Natural disasters
The country is also exposed to natural disasters like volcanic eruption, floods and especially man-made disasters such as conflicts and wars, leading to massive population displacements. Indeed, in 2006, there was a repatriation of 19,000 Rwandans who had taken refuge in Burundi and 65,000 Rwandans from Tanzania. An earthquake occurred in Rwanda in February 2008, causing the death of 37 people and injuring 600 others in the South-Western part of the country. These emergency problems are quite important in the sub-region, hence the need to put in place mechanisms for their prevention and management at the national and subregional levels.

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Malnutrition
According to the DHSR-III, 45% of children under 5 suffer from chronic malnutrition, 19% of whom in the severe form. At the national level, 33% of women suffer from anaemia. Micronutrient deficiency in children under 5 and pregnant women concern mainly iodine, iron and vitamin A. The basic reasons for this situation are insufficiency of food ration, high prevalence of infectious and parasite diseases, high level of poverty, affecting particularly women and children family heads, poor dietary habits and very low level of education.

Mental health
Mental health remains a public priority in Rwanda. The national policy and mechanism of care should target and ensure not only basic mental healthcare but should also deal with the consequences of the genocide, which remain a key factor in the major causes of morbidity and invalidity, in the area of mental health. Moreover, it is important to note the share of epilepsy in the general morbidity in Rwanda, as well as inadequate knowledge of the share of neurological disorders in the general morbidity. The most frequent pathologies are, by order of importance, epilepsy (46.9%), psychiatric disorders (21%), psychosomatic disorders (15%), neurological disorders (7.4%), and psychotraumatic disorders (3.6%). To deal with this situation, several strategies have been adopted and put in place: Decentralization of mental health care: establishment of six mental health operational poles in 6 district hospitals and integration of mental health care into the package of care of district hospitals. Hence, 30 district hospitals have a mental health activity ensured mainly by specialized mental health nurses, supported by general practitioners; Establishment of a regular continuing training of health staff in the area of mental health and sending regularly abroad, general practitioners for specialization in psychiatry and neurology; Establishment of a regular supervision programme at the central level and in district hospitals; Supply and distribution of psychotropic drugs; Community management of mental health problems;

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 Consumption of tobacco and other drugs by young people, particularly teenagers, is becoming increasingly worrisome. A survey conducted in 2004 showed that 24% of secondary school children were smoking. The Global Youth Tobacco Survey, conducted in 2008, in secondary schools in the country among the 13-15 years age group, showed that 12.3% of students were smoking or using tobacco products. During these past years, observations in psychiatric clinic circles show an increase in hospital admissions and requests for consultation for drugs and tobacco abuse problems.

Non-communicable diseases
Hypertension, diabetes, breast cancer and cervical cancer constitute increasing public health problems, but their scope is not known. Oral health, pathologies associated with blindness, disabilities caused by wars and road accidents constitute a major socio-economic weight. The country is facing a rise in Non communicable diseases, the prevalence of which must be evaluated so as to develop efficient intervention strategies.

Maternal health
Maternal mortality rate increased from 1071/100,000 live births, in 2002, to 750/100,000 live births, in 2005, according to the DHSR-III. The most frequent causes of maternal death are infections, haemorrhages and eclampsia. The use of voluntary abortions, close pregnancies and early pregnancies increase the risk of mortality. The 2006 report of the Ministry of Health showed an increase in the number of deliveries in health facilities, which went from 39% in 2005 to 52% in 2007. The rate of modern contraceptive use increased from 4% in 2004 to 10.3% in 2006 and 27% according to the results of the EIDHS (2007-2008).

Sanitation and Health Environment

The rate of potable water supply was 69% at the national level in 2007. The rate of coverage in latrines was 85% at the national level in 2007, 38% of which meet the required standards. Poor management of wastes and dangerous and toxic chemical products constitute threats to the environment and public health. The main challenge is, therefore, improving the quality of potable water supply

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systems and their accessibility for the population and promoting a safe, sustainable and enabling environment for health. Healthy nutrition is marked by the lack of an efficient regulation, legislation and coordination system. The main challenge is to ensure food safety and nutrition at all levels.

Conclusion
Rwanda is still facing preventable and curable diseases that have been burdening the countrys development. Lack of man power, some degree of illiteracy and scanty facilities and health resources are of agree at concern as far as health in Rwanda is concerned

Recommendations
1. Strengthen AMSA to cherish its vision and objectives for the bright future of our societies; 2. Since Rwanda is a low income country needs financial support in its healthy sector for more facilities to encounter the underlying health problems; 3. Philanthropic provision of scholarships in different medical specialties to raise our health worker population ratio. 4. Investments in health.

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BIBLIOGRAPHY
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