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User:Tommygoodwin/Healthcare in Rwanda

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Location of Rwanda within Africa

Healthcare in Rwanda has transformed from a system marked by poor quality in comparison to its regional neighbors,[1] to one that is considered "remarkable."[2] Like the majority of the world's countries, Rwanda operates a universal health care system that was enacted following the Rwandan genocide in 1994.[3] The public health consequences following the genocide, which included increased rates of HIV/AIDS,[4] have led to widespread government efforts to improve public health.[5]

Healthcare before the Rwandan Genocide

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Bamako Initiative

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Prior to the outbreak of the genocide in April 1994, Rwanda's healthcare system was supported by the Bamako Initiative. The Bamako Initiative, instituted in 1987 in Bamako, Mali, was the product of UNICEF efforts to improve access and quality of healthcare in Sub-Saharan Africa.[6] One of the main goals of the system was to decentralize healthcare and to give the people decision making power at the local level.[6] While the system saw some marginal improvements in African countries, it failed to enact consistent benefits because many poor people still could not afford healthcare.[1] The majority of the people the system aimed to target were from rural areas. However, the initiative's goals to allow for local decision making led to adverse effects, including:

  1. Administration of funds and community management was disorganized due to lack of managerial skills in rural areas.[7]
  2. Selling drugs/medicines for profit made healthcare more inaccessible than it did before for the poorest populations.[1] These groups often avoided healthcare centers due to fear they might be charged to be admitted.[7]

Ultimately, the Rwandan genocide resulted in the destruction of Rwanda's health sector. During the genocide period, Rwandan healthcare workers either fled the country[8] or were killed. To date, one of greatest challenges facing the Rwandan health sector is the amount of healthcare professionals in the country. However, much progress has been made in rehabilitating Rwanda's health sector post genocide.

Healthcare Needs post Rwandan Genocide

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Rwandan industries, including healthcare, were left in shambles when the Rwandan Patriotic Front (RPF), led by current president Paul Kagame, declared a ceasefire after establishing control over the country in late July 1994.[9] There were numerous health and logistical problems faced by the war torn population.

A Country in Crisis

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Systematic Sexual Violence and HIV/AIDS

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The brutality of the genocide in 1994 resulted in a massive increase in HIV/AIDS cases due to widespread sexual violence against mostly Tutsi women.[10] In fact, the perpetrators of the genocide used HIV positive militia men as weapons to rapidly spread the disease to civilians in order to destroy the Tusti population. The AIDS crisis was so severe post genocide that 70% of surviving women were living with HIV/AIDS.[11]

It is estimated that anywhere between 250 and 500 thousand women were victims of rape during the genocide. As a result, Rwandan women sought medical care for unwanted pregnancies and abortions. Until 2012, Rwandan law made it impossible for women to obtain abortions for any reason. Subsequently, HIV/AIDS continued to spread.[12]

Other Diseases

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In addition to the widespread dispersion of HIV/AIDS through Rwanda during and following the genocide, Rwandans faced numerous other health crises that the healthcare system in place could not address. These included malaria and tuberculosis.[13]

Labor Shortage

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The dangers of the genocide was a catalyst for the exodus of many Rwandans to neighboring countries, namely Zaire (now the DRC), Uganda and Burundi. Consequently, the killings and the mass exodus left Rwanda without a proper health workforce to address the dire medical situation in the country. International medical assistance groups such as MSF (Doctors Without Borders) were unable to address health needs due to the extreme violence.[14] Moreover, there were incidents of Hutu healthcare workers, including doctors and nurses, refusing to see patients and then reporting them to the Interhamwe militia, where they were murdered.[15] The lack of consistent medical help during and immediately following the genocide was a crucial factor in the rapid spread of HIV/AIDS and other diseases.[16]

Government Response

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The Rwandan Patriotic Front (RPF) took control of Rwanda following their victory over the government in mid-July 1994.[17] Immediately, the new government began organizing massive reconstruction efforts across the country. To address healthcare needs, RPF leader and current Rwandan president, Paul Kagame, took quick action to put a new system into effect. 1996 saw the new government make formal, legal changes to its health system.

 
President Paul Kagame, leader of Rwanda since 2000

Similar to the previously implemented Bamako Initiative, the government supported the decentralization of its healthcare system into several "healthcare districts" and an emphasis on community participation at the local level.[18] The government's subsequent investment into its own healthcare policy also aimed to bolster the Rwandan economy and work strategically with outside investors such as the United States, which according to the US Department of State, "is the largest contributor to Rwanda’s health sector with annual investment of about $116 million in the last three years [2019-2022], benefitting an estimated 13 million Rwandans." In many areas, there was clear evidence of improvement.

Private Insurance

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Rwandans have the option to enroll in private health insurance as well and a small piece of the population enrolls in a growing private health sector. Private health in Rwanda operate their own facilities such as hospitals and clinics across the country.[19] However, the government has voiced that private healthcare providers have started to become inefficient by 2015.[20]

Organization and Financing

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The new government, through its Ministry of Health, approached healthcare starting with the local level upwards. According to the Rwandan government's Vision 2020, "The initiative of communities is recognized as a crucial component in successful delivery of health services."[18] The integration of local communities allowed the government to address the lack of connectivity between Rwandans in rural communities and those in urban places. Moreover, the Rwandan government prioritized community financing to make health services accessible to all in a fair and equal manner. The community financing program, also known as a 'community-based health insurance scheme,'[21] was introduced in 1999 and after the first locales were successful, the program was launched on a nationwide scale. To date, the government insurance program premium is 8 USD per year.

Nonetheless, the government has faced certain challenges in terms of financing its healthcare system. By 2015, the government released its healthcare strategy. The policy stated that despite major improvements in areas such as vaccinations, disease prevention, and promoting healthy lifestyles, the healthcare the Rwandan government sought to provide was threatened by financial difficulties, including low international funding.[20] The same policy also highlighted a continued weakness of weak community involvement in the management of the healthcare system. By 2022, the government invested over 33.6% more into its healthcare budget compared to the year before according to UNICEF.[22] To date, Rwanda continues to overcome stagnation challenges and continues to accept funds in the form of external donations and loans.

A study published in 2020 to the Pan African Medical Journal found that in order for the community based health schemes to thrive in Rwanda, increased involvement politically is necessary as well as continued funding.[23] To this effect, the government agreed.

 
A psychiatric hospital in Ndera, Rwanda

Three Tiered System

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The present system in Rwanda follows a triangular system with three tiers. The top of the system represents the referral hospitals designed to administer complex care and specialized treatment to patients who need it.[24] These referral hospitals include King Faisal Hospital and The University Teaching Hospital of Kigali among others. As of 2023, the King Faisal Hospital, Rwanda's largest referral hospital, employs nearly 350 doctors and nurses. At the second level, there are district hospitals and health centers across the country. More importantly, at the third level, are over a thousand health posts designed to address the needs of communities not well connected to the rest of the country.[25]

Accessibility

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A health post in Rwanda.

The accessibility to healthcare remains a major problem for the entire system.[20] By 2015, over 20 years after the Rwandan genocide, the government still faced challenges reaching the most remote communities and assisting them in paying healthcare premiums.[20] The Rwandan government has made efforts to increase accessibility to healthcare for its citizens. This includes the construction of more than one thousand health posts to reduce time spent walking to receive care. In 2013, there were only 60 of these health posts. By promoting efforts to make remote Rwandans aware of their role and power in governing their own healthcare needs at the local level, the government has shown massive improvements in connecting Rwandans since the era of the Bamako Initiative. Up until 2020, the time it took rural Rwandans to get to a health post was 95 minutes.[25] By 2024, that time is expected to decrease to 25 minutes.

References

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  1. ^ a b c "Growth from Genocide: The Story of Rwanda's Healthcare System". Harvard International Review. 2022-03-07. Retrieved 2023-04-10.
  2. ^ "Rwanda". Partners In Health. Retrieved 2023-04-10.
  3. ^ "Countries With Free or Universal Healthcare". International Citizens Insurance. Retrieved 2023-04-10.
  4. ^ "Rwanda". www.hrw.org. Retrieved 2023-04-10.
  5. ^ Binagwaho, Agnes; Farmer, Paul E; Nsanzimana, Sabin; Karema, Corine; Gasana, Michel; de Dieu Ngirabega, Jean; Ngabo, Fidele; Wagner, Claire M; Nutt, Cameron T; Nyatanyi, Thierry; Gatera, Maurice; Kayiteshonga, Yvonne; Mugeni, Cathy; Mugwaneza, Placidie; Shema, Joseph (2014-07-26). "Rwanda 20 years on: investing in life". The Lancet. 384 (9940): 371–375. doi:10.1016/S0140-6736(14)60574-2. ISSN 0140-6736.
  6. ^ a b Asila Pangu, Kasa (September–October 1997). "The Bamako Initiative" (PDF). who.int.
  7. ^ a b Garner, P. (1989-07-29). "The Bamako initiative". BMJ. 299 (6694): 277–278. doi:10.1136/bmj.299.6694.277. ISSN 0959-8138.
  8. ^ African Health Business (April 14, 2023). "Rwanda's Health Sector" (PDF). {{cite web}}: |last= has generic name (help)
  9. ^ "Interactive: Rwanda genocide". www.aljazeera.com. Retrieved 2023-04-28.
  10. ^ Savchuk, Katia (April 8, 2014). [How Rwanda went from genocide to global health model "How Rwanda went from genocide to global health model"]. Retrieved April 28, 2023. {{cite web}}: Check |url= value (help)
  11. ^ Project, Sentinel (2013-12-01). "AIDS Intersects with Genocide". Retrieved 2023-04-30.
  12. ^ "When abortion is a crime: Rwanda". Ipas. Retrieved 2023-04-30.
  13. ^ Uwishema, Olivier (April 1, 2023). "Rwanda's health-care transformation: a case study for war-torn countries". Retrieved April 30, 2023.
  14. ^ "Rwanda- Doctors Can't Stop Genocide". Doctors Without Borders - USA. Retrieved 2023-04-30.
  15. ^ Yanditswe (May 14, 2020). "CNLG lists doctors and nurses who perpetrated the Genocide against the Tusti". Rwanda Broadcasting Agency. Retrieved April 30, 2023.
  16. ^ National Academies of Sciences, Engineering; Division, Health and Medicine; Health, Board on Global; Relief (PEPFAR), Committee on the Evaluation of Strengthening Human Resources for Health Capacity in the Republic of Rwanda Under the President's Emergency Plan for AIDS (2020-02-13). Health Worker Production. National Academies Press (US).
  17. ^ "Rwanda: Justice After Genocide—20 Years On". Human Rights Watch. 2014-03-28. Retrieved 2023-04-30.
  18. ^ a b "Healthcare Sector Policy" (PDF). Government of Rwanda. February 2005. Retrieved April 30, 2023.
  19. ^ "Health Services". Official Rwanda Development Board (RDB) Website. Retrieved 2023-05-01.
  20. ^ a b c d https://www.moh.gov.rw/index.php?eID=dumpFile&t=f&f=6008&token=13b8e7fdbacffe4356c60868b07047e62027f158
  21. ^ Africa, SPARC (2021-09-24). "Towards Sustainability Of The Community-Based Health Insurance In Rwanda: Successes, Challenges, And Opportunities". Strategic Purchasing Africa Resource Centre (SPARC). Retrieved 2023-05-01.
  22. ^ "Health Budget Brief: Investing in Children's Health in Rwanda" (PDF). UNICEF. November 2021. Retrieved May 8, 2023.
  23. ^ Nyandekwe, Médard et al. “Universal health insurance in Rwanda: major challenges and solutions for financial sustainability case study of Rwanda community-based health insurance part I.” The Pan African medical journal vol. 37 55. 14 Sep. 2020, doi:10.11604/pamj.2020.37.55.20376
  24. ^ Hensher, Martin; Price, Max; Adomakoh, Sarah (2006), Jamison, Dean T.; Breman, Joel G.; Measham, Anthony R.; Alleyne, George (eds.), "Referral Hospitals", Disease Control Priorities in Developing Countries (2nd ed.), Washington (DC): The International Bank for Reconstruction and Development / The World Bank, ISBN 978-0-8213-6179-5, PMID 21250317, retrieved 2023-04-30
  25. ^ a b "Rwanda's primary health care strategy improves access to essential and life-saving health services". www.who.int. Retrieved 2023-05-08.


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