Thursday, June 7, 2012

Rwanda's Pursuit of Shared Wealth through Health for All

My latest article in Commonwealth Health Partnerships journal is below. To visit the website where the article is printed, click here

Rwanda is determined to join the ranks of middle-income nations by the year 2020. This determination is largely driven by one thing: the demand for what Rwandans call ‘agaciro,’ or ‘dignity’ for our people. In pursuit of agaciro, the Rwandan people are continuously compelled to find better ways of doing things. Our economy must be vibrant and more independent; our politics must be inclusive and founded on consensus building; and our people must live a decent and dignified life, able to fulfill basic social needs. 

To achieve these ambitious goals, the Government of Rwanda has adopted a number of innovative approaches to policymaking and implementation, including both universally applicable and home-grown solutions that effectively account for context in addressing Rwanda’s most pressing challenges.

Indeed, seeds sown since the 1994 genocide against the Tutsi are beginning to bear fruit. The recent publication of the countrywide household survey indicated that Rwanda has reduced poverty levels by 12 percent over the past five years, from almost 56 percent of the population in 2005 to 44 percent in 2010. 

The understanding underlying this success is that for a nation to be successful, it must invest in and rely upon the human asset or capabilities of its own people. Rwanda’s philosophy for growth starts with a shared vision that a well educated and healthy population is the starting point for any economic development.   

This is why the health sector been a key priority for the country’s Government; 18 years down the road to recovery after 1994, the achievements in this sector speak volumes. 

Documenting Recent Progress

The recently released Demographic and Health Survey (DHS) of 2010 revealed several areas of dramatic progress in health outcomes since the last survey in 2005. Across the spectrum, the findings demonstrate significant progress in combating infectious diseases, improving child and maternal health, and addressing both financial and geographical barriers to accessing health care.

A Rwandan child born today has more hope than ever before of living to celebrate his/her first and then fifth birthdays. Between 2005 and 2010, the infant mortality rate dropped from 86 to 50 per 1,000 live births, while the under-five child mortality rate plummeted by fully 50% from 152 to 76 per 1,000 live births.

Rwanda remains dedicated to surpassing the Millennium Development Goal targets for infant and child mortality by 2015, but as a result of our deeply rooted conviction that our children must enjoy the right to life and hence a right to adulthood, we know that we can drive these figures down even further.

These declines have not come as a surprise; they are partially attributable to the fact that more and more of Rwanda’s mothers are enrolled in and retained by antenatal care programs throughout their pregnancy. This has led to an increase in the number of women giving birth at a health facility from just 30% in 2005 to 69% in 2010.

To adequately address issues concerning maternal and child health (MCH), Rwanda has employed many synergetic interventions along the continuum of care, but all of these are built upon the foundation of a strong community health system driven by Community Health Workers (CHWs) deployed in all villages across the country. These community health workers have bridged crucial access gaps in the health system and have brought prevention, treatment, and care services closer to the people. 

One clear result of CHW’s effectiveness can be seen through Rwanda’s active immunization campaign, which has achieved over 90% coverage of all children and ensured the provision of new vaccines targeting emerging diseases to the population. In 2009, Rwanda was the first country in Africa to roll out the pneumococcal vaccine, and in 2010 became the first low-income country in the world to roll out the human papillomavirus vaccine. Both initiatives have attained over 90% coverage by building on the country’s pre-existing robust vaccination program.

Investing In Our Population

It is well known that Rwanda does not have major natural resources like oil, gold, and diamonds; but our Government knows that our greatest asset is our people themselves. To ensure that we deliver appropriate services in an equitable way that allows each Rwandan to reach their full potential, we have continuously worked to educate our people on the need for smaller families.

Rwanda needs a population whose growth does not outpace that of our economy. Declines in birth rates over recent years are not as dramatic as those that will be needed in the future, but they do show that we are achieving concrete results. Between 2005 and 2010, total fertility rate (the number of children a woman is expected to have throughout her entire life) dropped from 6.1 to 4.6. Uptake of modern family planning methods jumped by 450% during the same period, from just 10% in 2005 to 45% in 2010. Taken in the context of other socioeconomic indicators discussed earlier, we can see a strong relationship between improving child survival and declining birth rates – as fewer children die premature deaths, families feel the need to have fewer children.

Combatting Infectious and Non-Communicable Diseases 

With the support of our global partners, Rwanda has made substantial gains in the fights against HIV/AIDS, tuberculosis, and malaria. HIV prevalence has fallen from 13.9% in 2000 to 3% today due to an integrated approach to tackling the pandemic with urgency and equity.

As of December 2011, fully 100,656 patients at 390 health facilities across Rwanda were receiving antiretroviral therapy for free, accounting for 84% of all patients clinically in need of treatment. When compared to the 870 patients at just 4 facilities who had access to these lifesaving drugs in 2002, it is clear that we have come very far.

A combination of effective policies for malaria prevention and control have likewise contributed to a reduction in prevalence and mortality associated with malaria by almost 50%. This is largely due to an increase in the usage of mosquito nets from 56% of households in 2005 to 82% in 2010, but also tied to the provision of effective diagnosis and treatment at the community level by CHWs.

However, Rwanda and its leaders will not be complacent following progress against the major infectious killers: we recognize well the need to turn our attention to the growing burden of non-communicable diseases such as heart disease, cancer, diabetes, and respiratory diseases. As more Rwandans live longer, we must focus on the long-term needs of the population by anticipating health problems that are likely to arise and preparing solutions now. 

There are many areas where we can begin to act immediately on non-communicable diseases, such as the prevention and treatment of pediatric and female cancers where the market and partnerships have made new opportunities available today. The Ministry of Health is currently in the process of planning for comprehensive national early detection and treatment programs for breast and cervical cancer for women, who will also benefit from access to the human papillomavirus vaccine to prevent cervical cancer in the first place. 

We are currently in the final stages of assembling protocols, guidelines, and policies for pediatric cancers, beginning with those that are most prevalent and most amenable to immediate action. Non-Hodgkin’s Lymphoma, for example, affects many children in Rwanda, and there is something that can be done about it now even as we work to build the capacity to address more complicated cancers. 

While we understand the urgency of obtaining sufficient infrastructure, Rwanda will not wait for the last brick to be laid or the last road to be paved before we act – we will handle whatever illnesses we can within our present means while striving for a stronger system at the same time. For those who it is too late to offer successful treatment for cancer or other non-communicable diseases, we shall ensure the provision of palliative care. 

Persistent Challenges 

As we take pride in Rwanda’s achievements, we are also mindful of the challenges ahead. Much as the DHS 2010 results provide a roadmap for further improvement of infectious disease control programs, we need to adopt innovative new approaches that will provide quick solutions for transforming our sector across all initiatives. 

Through our Community-Based Health Insurance scheme, known as Mutuelle de Santé, we have addressed the issue of financial accessibility in the health system. More than 80% of Rwandans today are enrolled, guaranteeing them access to quality services. However, gaps persist in geographic accessibility that can be addressed by constructing more health facilities across the country. The Government’s aim is to have one health center serving each local government sector population of 20,000 to 25,000 people, meaning that significant further investment in infrastructure will be needed.   

The Ministry of Health and health providers around the country understand that access alone is not enough – we must also strive to provide the highest possible quality of care to our population. Rwanda aspires to become a hub of exemplary services for the entire East African region, and we will need to continue improving quality if this vision is to be achieved. Such efforts will include not only the acquisition of newer and better equipment, but also bridging the ratio of providers to population. 

Today, the ratio of physicians to population remains unacceptably high at 1 per 17,000. Our target is to reduce this figure to 1 per 10,000 in the near future. The Ministry of Health seeks to have at minimum a surgeon, a pediatrician, an anesthetist, an internist, and an oncologist at each district hospital. 

To this end, we have reached an innovative $34 million agreement with the United States Government that will bring more than 100 senior medical faculty from American universities to Rwanda over the next seven years to train and work with our physicians to build specialty capacity and create new residency programs. This program will begin in July 2012; with sustained commitment and sufficient vision from all involved, it has the potential to affect a massive paradigm shift in global health partnerships and medical education around the world.

Looking to the Future

As a core element to Rwanda’s Vision 2020 national strategic plan, the Government of Rwanda has established ambitious targets for the health sector that must be realized by the end of the decade. The under-five mortality rate, for instance, should be reduced to 30 per 1,000 live births from the current 76 and current prevalence of severe malnutrition must be reduced six-fold. These and many other goals will require concerted efforts from every stakeholder, including our development partners.

In assessing our current situation and where we want to go, we can see that the good news is that Rwanda has built the basics of a dynamic and equitable health system. In order to take the health sector to the next level, we must build upon our solid foundation and continue to seek out ways to improve the value, quality, and compassion of services we deliver. 

It is written in Rwanda’s Constitution that “the human person is sacred and inviolable.” The Ministry of Health could not possibly take this declaration more seriously; the quest for improvement is a civil, moral, and human duty that we accept with great humility and determination.