COUNTRY FOCUS: RWANDA

From Ashes to setting the trends In Africa’s Healthcare system

It is otherwise known as the land of a thousand hills. Stretching over an area covering 26,333 square kilometers, Rwanda is one of the smallest nations in Africa. With an economy estimated to grow at 10.9% in 2021, the East African nation punches above its weight on many fronts. One of the areas that has recorded tremendous growth is the Healthcare sector.

Dusting itself from the 1994 internal conflict, Rwanda, with a population of 12.9 million people, is a shining example of the potential that the continent’s healthcare system holds.  Today, the country enjoys improved healthcare services under the Universal Health Coverage (UHC) program and boasts of strengthened and well-structured Primary Healthcare Systems funded by the Government in collaboration with development partners. USAID, a key partner, has been particularly resourceful in the country’s fight against malaria and HIV/AIDS. The role of the private players in the country’s health sector can also not be understated. Its network of hospitals and clinics helps release pressure from publicly funded institutions, further driving universal access to healthcare in the country.

What does the health landscape in Rwanda look like in 2022? What prospects, if any, does the country’s health sector hold in the near future? This article seeks answers to these and many more questions about Rwanda’s budding health sector.

A robust network of healthcare facilities

The Rwandan system is a referral system. The burden of the disease is treated at the bottom of the pyramid by the Community Health Worker. From the CHWs, the case can be scaled up to a Health Post. Over 850 Health Posts exist in the country. Then, the beneficiary will be sent to a Health Center (600), from Health Centers the patient can be referred to a District Hospital (37 in the country). At the top of the pyramid are four Provincial Hospitals and seven Referral Hospitals. This is how Rwanda implemented its vision of geographical accessibility. Private Health care facilities such as the Baho International Hospital, Kigali are also scattered across the country to support the public-run hospitals in offering care.

Manning these network hospitals is a contingent of healthcare workers who are estimated to number about 60,000 in 2022. Nurses and Midwives account for the second highest number of HCWs at 10,758. General physicians (786), specialist physicians (567), Dentists (228), Pharmacists and technicians (167), laboratory personnel (1,990), community health workers: 45,000, and other health workers (506) complete the list of the country’s healthcare team.

Although impressive, the country’s workforce of 11 health workers per 10,000 population density in 2018 is still far below the World Health Organization (WHO) recommended critical minimum of 44.5 per 10,000 people. Several initiatives by President Paul Kagame-led government have however tried to boost these numbers up to enhance access to healthcare for Rwandans. In 2011, the country introduced the Rwanda Human Resources for Health (HRH) to increase the quantity and quality of health care workers needed to ensure the sustainability of the health system.

The initiative has greatly raised the number of qualified HCWs in the country. Data from the ministry of health (MOH) indicates specialist physicians in Rwanda increased from 197 in 2015 to 567 in 2018. Between 2011 and 2017, the country was also able to add about 111 specialist nurses to its workforce thanks to the HRH program.

The government also shifted many clinical decisions and activities to nurses and community health workers (CHWs) in 2009, including in the delivery of HIV care, under a strategy called Task Shifting. With a deficit of physicians, task shifting leveraged the relatively large pool of Nurses and CHWs to increase the ability to care for patients. Through further task shifting and a reformation of the national community health system, care for 80 percent of the disease burden was offloaded to CHWs at the village level through health promotion activities as well as preventive, diagnostic, and curative care. A 2015 study revealed that the program coupled with upskilling of nurses has achieved high levels of retention and improved patient health outcomes.

In a move to enhance the capacity to train new healthcare workers, the Ministry of Health has upgraded nine hospitals to the level of university teaching hospitals to increase the workforce in the health sector. The hospitals include Ruhengeri, Kibungo, Rwamagana, Kabgayi, Butaro, Kibogora, Kibagabaga, Nyamata, and Byumba. The new university teaching hospitals will support five existing ones including the University Teaching Hospital of Kigali (CHUK), Rwanda Military Hospital, University Teaching Hospital of Butare (CHUB), King Faisal Hospital, and Neuro-Psychiatric Hospital Caraes Ndera.

To ensure a smooth running of the Healthcare sector, the Rwanda Government has established several agencies to oversee the sector. The Rwanda Allied Health Professionals Council was established in 2013 to promote, support, and regulate allied health professionals in the Country. Established by law in 2013, The Rwanda National Pharmacy Council serves as an interlocutor with the public and the private organs in matters relating to the pharmacy profession. The Rwanda Nursing Council of Nurses and Midwives of Rwanda protects the public from harmful or unprofessional practices. The council ensures that the public receives medical care from competent and ethically behaved nurses and midwives.

Disease Burden

As in many other countries in the region, malaria, tuberculosis (TB), and HIV AIDS are endemic in Rwanda. Malaria has remained a life-threatening disease with millions of children and pregnant women falling prey to the disease, particularly during April and May. Remarkable improvements have been realized in recent times following a government contingency plan to call on all stakeholders, including external financiers, to join efforts in combating the killer disease. With efforts such as Indoor Residual Spraying (IRS) and encouraging the use of Treated mosquito nets, the country has seen a decline in malaria cases from 4.8 million in 2017 to 1.8 million in 2020.

HIV/AIDS is also a major health concern in Rwanda, with the country ranking among the top ten African nations most affected by HIV/AIDS, according to the WHO. Rwanda is however doing the most to manage the disease and limit the number of new infections. Efforts by the authorities include accelerated scale-up of HIV testing and immediate linkage to Antiretroviral Treatment (ART) for those testing positive. Rwanda also actively pursues evidence-based prevention interventions such as condom availability, voluntary medical male circumcision (VMMC), and mass community education.

Combined, these strategies have managed to give Rwanda a stable prevalence of 3% and a relatively low incidence of between 0.08% to 0.27% among the ages of 15-64 years, translating to between 5,400 new to 14,000 new infections per year. Rwanda has also made progress toward the Joint United Nations Programme on HIV/AIDS (UNAIDS) 90–90–90 targets. A study by the US Centers for Disease Control in Rwanda revealed that 83.8 percent of adults living with HIV were aware of their status, of adults who knew their status, 97.5 percent were on ART, and of adults who had detectable ARVs or reported current use of ARVs, 90.1 percent had Viral Load Suppression.

When it comes to TB, Rwanda has made significant progress in diagnosis, treatment, and prevention. Based on WHO Global Tuberculosis reports, the incidence of tuberculosis in Rwanda has decreased from 96 patients per 100,000 population in 2000 to 57 patients per 100,000 population in 2020. This decline in TB incidence in Rwanda represents a decrease of 41% in the last 20 years.

Almost 59 percent of cases of
death we are getting in our health
facilities are as a result of NCDs
and injuries

Dr. Daniel Ngamije – Minister of Health, Rwanda

Tweet

Non-communicable diseases present new challenges

As Rwanda makes significant strides in improving the health outcomes of her people, non-communicable diseases threaten this progress. According to the Ministry of Health, 15.9 percent of adults in Rwanda are living with hypertension while 40 percent of adults present for the first time with heart failure class III to IV. The number of Cardiovascular patients treated in the country’s health facilities has more than tripled between 2018 and 2020, from 25,353 to 88,486 cases. Similarly, the number of men and women diagnosed with cancer increased from 3,000 in 2018 to 10,400 new cases, according to current WHO estimates, indicating a high prevalence of the killer disease.

While addressing a virtual World Health Summit, the Rwanda Minister of Health, Dr. Daniel Ngamije, noted that NCD had become a huge burden for the country. “Almost 59 percent of cases of death we are getting in our health facilities are as a result of NCDs and injuries,” Ngamije revealed. To address this problem, the country rolled out a 5-year National Strategy and Costed Action Plan for the Prevention and Control of NCDs in 2020. Rwanda is planning to spend some US$638 million during the 5 years when the plan is active and targets to reduce NCD-related premature mortality by 25 percent by the time the plan matures in 2025.

New Hospitals crop up to meet rising demand

With an annual growth of 2.5%, Rwanda’s population is projected to increase by more than 50% to 17.6 million by 2035 and double to about 22.1 million people by 2050. This influx of people coupled with an increased health burden requires investment in new health infrastructure. The government, with the support of development partners, has recently been investing in new hospitals or upgrading existing ones. In 2021, the country inaugurated the US$8 million, 120-bed capacity Nyarugenge District Hospital in Kigali. Less than a year after commissioning, plans are already underway to expand the hospital, built with funds from the Kingdom of Belgium, to add another 180 beds and more medical facilities like pharmacies, laboratories, and operating theatres for US$11 million.   

King Faisal, Rwanda’s top teaching and referral hospital, secured US$14 million funding from the Eastern and Southern African Trade and Development Bank (TDB) undertake towards the expansion of the hospitals outpatient facilities in a bid to boost Rwandan health system. The Butaro Hospital, which was launched less than a decade ago is also being expanded under a multi-year construction project which will increase its bed capacity from 150 to 240 beds and further establish it as a leading medical institution and teaching hospital in the region. Nyanza Hospital in the southern province of Rwanda has also benefited from an increased focus on hospital expansions. In 2019, the facility took reception of a new maternity ward, equipped with new essential medical equipment with support from UNICEF. Gisenyi Hospital is also expected to become even bigger as authorities decided to move it to a safer location after it was affected by tremors, which followed the eruption of the Nyiragongo volcano in May last year. Construction of the new hospital will cost €32 million and is expected to accommodate 400-500 patients or more, according to Ildephonse Kambogo, the Mayor of Rubavu District.

With the incidence of non-communicable diseases rising by the day, Rwanda is set to take reception of a new cardiac teaching hospital that will reportedly be the first of its kind in the Sub-Saharan region. Built by the Heart Care and Research Foundation (HCRFR), the 12,000 sq teaching hospital will provide cutting-edge, free-of-charge medical care to local communities. It is also expected to spur the creation of a biomedical and innovation knowledge base, training a generation of young Rwandan doctors, nurses, scientists, and technicians to ensure sustainability in the region.

Leveraging DigiHealth to deliver quality care

As new health challenges crop up, the need for healthcare rises even further. Although Rwanda’s healthcare system is robust as discussed above, the rise of non-communicable diseases is putting new pressure on an already stretched workforce. To leverage the limited number of doctors and nurses to serve populations in the most impoverished and rural parts of the country, Rwanda has embraced digital health.

The government has been at the forefront of this transition, teaming up with UK-headquartered remote consultations provider Babylon Health to create the world’s first digital-focused universal primary health care service. When rolled out, the system will give everyone in Rwanda above the age of 12 access to consultations with doctors or nurses through their mobile phones within minutes. The project would be a scale-up of an existing digital health service which was launched by Babylon in 2016 and has so far gained two million registered users and delivered more than one million consultations.

The government has also rolled out the “SMART Health Card” to facilitate health information exchange. Health Minister Dr. Daniel Ngamije recently said that the country planned to leverage the card to its fullest in line with the country’s universal health coverage (UHC) objectives. He further revealed that there are plans underway to ensure the SMART Health Card standard will be extended to provide individuals with additional health data, such as routine immunization records, lab results, health insurance information, and prescriptions.

The transition to digihealth has been relatively easy for Rwanda as the country has a broadband infrastructure that now covers 90% of the country and mobile phone penetration that exceeds 75% of the population. Additionally, the Protection of Personal Data and Privacy law that was enacted in 2021 has further created an enabling environment for health information to be electronically shared among interested parties.

Babylon is not the only company to exploit Rwanda’s digital health potential. Silicon Valley-based Zipline has also established a partnership with the Rwandan Government to deliver blood, vaccines, and other essential medical products to hospitals, no matter how remote. With drones, the time it takes to supply products for emergencies has reduced from hours or days to just minutes. It also means refrigerated blood or other rarer products, such as frozen plasma, which often require expensive machinery can be easily delivered to local hospitals that lack the necessary infrastructure.

Eden Care Medical, another digihealth company, is also dipping its fork to get a share of the budding sector. The Rwanda-based digital health startup is focusing on insurance and recently became the first company in East and Central Africa to gain regulatory approval to offer digital health insurance following the Letter of No-Objection granted by the National Bank of Rwanda in June 2022.

Healthcare financing

With healthcare being naturally expensive globally, Rwanda has invested in health insurance to make it easier for its citizens to access quality care. Today, the country is one of the few developing countries in the world to have universal health coverage (UHC); its community-based health insurance program–known as Mutuelle de Santé–reaches more than 90% of the population.

The annual health budget has also been rising over the years as Rwanda ramps up its efforts to fight disease and improve healthcare delivery to its citizens. Domestic resources have increased in nominal terms from US$140 million in 2020/21 to US$150 million in 2021/22. Support from development partners such as the Global fund, the World Bank, COVAX, The US Government through PEPFAR, The Belgian Development Agency (Enabel), The GAVI Alliance, and The Rwanda Health Financing has also grown over the years. Data from the ministry shows that external funding grew from US$130 million in 2020/21 to US$200 million in the 2021/22 financial year.

Increased funding has been particularly resourceful in helping Rwanda implement its UHC program that targets all the citizens, including the nation’s poorest citizens. Higher-income earners also assist the government in realizing this program through annual premiums of up to US$8 per adult per year.

An emerging health hub in Africa

28 years after the country’s worst internal conflict, Rwanda is once again standing high in Africa’s health industry. The country recently outbid 8 other countries, including Algeria, Egypt, Morocco, Tanzania, Tunisia, Uganda, and Zimbabwe, to secure hosting rights to the African Medicine Agency Headquarters. AMA was the crown jewel of several big health moves that the country has been making recently. In May, the African Development Bank announced that the new African Pharmaceutical Technology Foundation will be hosted by Rwanda. At the end of June, BioNTech broke ground on the construction of a messenger RNA vaccine manufacturing facility in the country. The country had earlier, alongside Senegal, been selected by the International Finance Corporation (IFC) along Senegal and South Africa as potential regional vaccine manufacturing hubs in Africa.

By securing a chance recently to host the African Medicine Agency Headquarters (AMA), the tiny but progressive East African nation made a statement to the effect that it is an emerging economic powerhouse not only in the region but on the entire continent. It has also proved that with the right policies and proper investment in healthcare, a country can make great leaps in delivering quality healthcare to its people. Challenges still exist, particularly in the human resource department and hospital infrastructure, but if the recent moves to train more people and invest in hospitals are anything to go by, Rwanda is well positioned to achieve its 2050 vision of prosperity and high-quality life for all citizens.

This feature appeared in the June 2022 issue of Healthcare Middle East & Africa. You can read this and the entire magazine HERE