Why Rwanda? The 1994 genocide resulted in the destruction of the existing medical system of hospitals, and trained medical support personnel. Seventy-five percent of the medical community was either murdered or left the country. There are currently 625 physicians for a country of 11 million. High rates of maternal and childhood illnesses, rheumatic heart disease, and malaria limit the life expectancy to 62 years of age.
While a new generation of Rwandan physicians is actively involved in rebuilding their country’s medical infrastructure, the need for foreign resources is overwhelming. Our connection with King Faisal Hospital and Dr. Joseph Mucumbitsi has made it possible for HHNW to develop a plan of teaching, training, and supporting local physicians, medical students, and health care providers. This can be done both in the hospital and at rural clinics and villages. Focusing on Rwanda’s health care providers will promote our common vision of a more independent and sustainable healthcare system for Rwanda.
Health care in Rwanda:
The 1994 genocide in Rwanda devastated much of the socio-economic fabric of country as well as its health infrastructure. The healthcare system is still suffering in its aftermath. Although the health status of the Rwandan population has improved significantly in recent years, it remains insufficient. Training health workers to advanced levels has taken time and has not been rapid enough to meet the needs of the Rwandan population.
The health system in Rwanda is a decentralized, multi-tiered system. It is composed of the following tiers and associated packages of health services:
- 18 dispensaries (primary health care, outpatient, referral),
- 16 prison dispensaries,
- 34 health posts (outreach activities – immunizations, antenatal care, family planning)
- 442+ health centers (prevention, primary health care, inpatient, maternity),
- 48 district hospitals (inpatient and outpatient) and4 national referral hospitals (specialized inpatient and outpatient).
The 4 referral hospitals are: Centre Hospitalier Universitaire de Kigali (CHUK), Centre Hospitalier Universitaire de Butare (CHUB), King Faisal Hospital (KFH) and the Kanombe Military Hospital.
Rwanda’s health system is financed both by state funds and by individuals’ contributions through health insurance and direct fees for services. Health insurance is provided through a variety of programs. The largest is the Community-Based Health Insurance Scheme, which is primarily comprised of a social health insurance program called Mutuelles de Sante. Members pay annual premiums of approximately USD $6 per family member (increased in 2011 from USD $2 per person) with a 10% service fee paid for each visit to a health center or hospital. Membership is voluntary and payment of premiums is based on economic status. The program was first introduced in 2004. By 2010, 91% of the Rwanda population was insured through Mutuelles de Sante. Rwandans can access health care at all public and non-profit health centers in Rwanda, but the Mutuelles de Sante member’s package does not include coverage at private health centers.
Rwanda Health Indicators
DOCTORS PER 1000 POPULATION: .06 (SSA=.19)
NURSES PER 1000 POPULATION: .66 (SSA=1.02)
UNDER 5 MORTALITY: 91 per 1,000 live births (SSA = 70; USA = 6.8)
540 per 100,000 live births (SSA = 640 per 100,000 live births; USA = 24 per 100,000 live births)
BIRTHS ATTENDED BY SKILLED HEALTH PROFESSIONALS:
69% (SSA = 44%). Of all assisted deliveries, 69% took place in a health facility (2010).
HIV PREVALENCE: 2.9% (urban = 7.3% vs. rural = 2.2%)
HEALTH EXPENDITURE PER CAPITA:
9% of GDP, USD $48 per capita (SSA = $76; USA = $7410).
Source: CIA World Factbook (2012), WHO (2006), World Bank World Development Indicators (2011), Government of Rwanda, Ministry of Health (2011)
- The Ministry of Health’s information about health indicators.
- The World Health Organization’s health profile for Rwanda.
The Rwandan Cardiac Program
The Rwandan Cardiac Program, as named at the Geneva conference in June 2013 for Global Humanitarian Medicine in Cardiology, is an uplifting story of international teams operating in Rwanda and developing the infrastructure for an independent, sustainable Rwandan Cardiac Surgery Program. Children and young patients, who lives are threatened, are operated on by 4 teams from 3 continents and cared for by each team in concert with Rwandan medical staff.
There are children yearning to attend school but unable to do so, mothers who give up care of newborns to grandmothers shortly after delivery of the baby, and workers who leave their villages embarrassed that neighbors believe their shortness of breath is due to HIV, rather than heart failure from Rheumatic Heart Disease. There are teachers, whose skills are wasted, as they are too ill to teach, and aspiring college students too short of breath to attend classes. Every story is unique, but the theme is the same. Rheumatic Heart Disease, a disease of poverty throughout Africa and affecting an estimated million people, extracts a toll on the patients, the families, the village and the country. In a country with limited natural resources, Rwanda’s main resource is it people, gaining skills and robust with energy as it moves beyond the Genocide of 1994. Restoring these patients to health reclaims these individuals from health clinics and returns them as contributing individuals to their society.
A unique collaboration of medical personnel work to not only provide life saving surgery, but to help create the infrastructure for an independent Rwandan Heart Surgery Program. Australia, Belgium, Boston and Spokane send physicians, nurses, and other medical personnel for periods of 2 weeks to help those most in need, while teaching and working side by side with Rwandan counterparts. The challenges are never ending including finding the money for airfare, leaving family with ongoing issues, or dealing with one’s personal health issues in a foreign land. Equipment and drugs must find their way half way across the world, but may be waylaid in a distant African Airport or held up in Customs under bureaucratic scrutiny. But the most challenging issues revolve around the patients including the decision to not operate on a patient. A patient who is too sick and could benefit from surgery may remain in ICU for extended time compromising the need for beds of other patients. The heart aches for the patients now too sick, whose hearts may not recover despite a new valve, and would have been good surgical candidate a year ago. And then issue of pregnancy – tell a 16-year-old girl and her family that the best valve is a mechanical one with the need for Coumadin and they should never have a baby, redefining her as a woman in African society.
The Visiting Cardiac Surgical Team concept is not a sustainable remedy to the problem of rheumatic heart disease. The answer lies in prevention of rheumatic heart disease by treating strep throat with penicillin. A program already exists ‘Awareness and Prevention of RHD’ which is presently ongoing through the Ministry of Health, Rwandan Heart Foundation and Team Heart of Boston . The answer lies in enhancing the knowledge of internal medicine physicians in cardiology, training more cardiologists and cardiac surgeons and ultimately, in the creation of an independent Rwandan Cardiac Surgery Program. A general surgeon is presently training in cardiac surgery in South Africa and a curriculum for cardiology diploma has been adopted. There are other pieces of the personnel infrastructure that are being developed to the credit of Minister of Health and administration of King Faisal Hospital. To this end, there is a Rwandan anesthesiologist with cardiac expertise who is assuming a greater role along with a Rwandan cardiac pump technician. Rwandan nurses have assumed a greater primary role in care of patients both in the ICU and cardiac Telemetry units.
Without substantial funding support, a full-fledged cardiac program will not emerge. This is a great challenge to a country such as Rwanda, emerging from the Genocide of 1994 and dealing with many social issues and poverty. Watching children die as Dr. Emmanuel said in Open Heart is extraordinarily difficult. Making the decision that one child will be saved while another cannot, due to the limitation of days that we can operate as a Visiting Team, is a decision and burden that no one should bear. Demand that sustainable cardiac surgery be possible for those in need, while forging forcibly ahead with education, prevention and early intervention. The support of major companies and benefactors can go a long way toward advancing this cause.