Rwandan Health Research Articles

Scaling up a surgical residency program in Rwanda

Background: Beginning in 2012, the Government of Rwanda implemented the Human Resources for Health (HRH) program to enhance capacity building in the Rwandan health education sector. Through this program, surgical training at University of Rwanda (UR) has expanded. The aim of this presentation is to describe the scaling up of the UR surgical residency programMethods: We performed a descriptive analysis of the UR surgical residency program after initiation of the Rwanda HRH Program.Results: Through the HRH Program, faculty from US institutions supplements the existing Rwandan educational infrastructure to increase the teaching capacity in Rwanda. Intake of surgical trainees more than doubled within the first year of the program. Service-based surgical training has changed to competency-based training through curriculum development, dedicated academic days and surgical education within firms. Lectures remain a dominant feature of the educational program, but more focus is placed on bedside teaching and peer-education. Shortage of operative space and a tremendous number of emergency patients overwhelm public teaching hospitals posing a challenge towards providing residents with a broad spectrum of operative experiences, especially elective surgical cases.Conclusion: Through this program, the ursurgical residency program has greatly expanded. Over time, the quantity and quality of surgical residents is expected to increase.

"Every day I dream ..." An interview with the Rwandan Health Minister.

"Every day I dream ..." An interview with the Rwandan Health Minister.

Does provider-initiated HIV testing and counselling lead to higher HIV testing rate and HIV case finding in Rwandan clinics?

BackgroundProvider-initiated HIV testing and counselling (PITC) is promoted as a means to increase HIV case finding. We assessed the effectiveness of PITC to increase HIV testing rate and HIV case finding among outpatients in Rwandan health facilities (HF).MethodsPITC was introduced in six HFs in 2009-2010. HIV testing rate and case finding were compared between phase 1 (pre-PITC) and phase 3 (PITC period) for outpatient-department (OPD) attendees only, and for OPD and voluntary counseling & testing (VCT) departments combined.ResultsOut of 26,367 adult OPD attendees in phase 1, 4.7 % were tested and out of 29,864 attendees in phase 3, 17.0 % were tested (p < 0.001). The proportion of HIV cases diagnosed was 0.25 % (67/26,367) in phase 1 and 0.46 % (136/29864) in phase 3 (p < 0.001). In multivariable analysis, both testing rate and case finding were significantly higher in phase 3 for OPD attendees. In phase 1 most of the HIV testing was done in VCT departments rather than at the OPD (78.6 % vs 21.4 % respectively); in phase 3 this was reversed (40.0 % vs 60.0 %; p < 0.001). In a combined analysis of VCT and OPD attendees, testing rate increased from 18.7 % in phase 1 to 25.4 % in phase 3, but case finding did not increase. In multivariable analysis, testing rate was significantly higher in phase 3 (OR 1.67; 95 % CI 1.60-1.73), but case finding remained stable (OR 1.09; 95 % CI 0.93-1.27).ConclusionPITC led to a shift of HIV testing from VCT department to the OPD, a higher testing rate, but no additional HIV case finding.Electronic supplementary materialThe online version of this article (doi:10.1186/s12879-016-1355-z) contains supplementary material, which is available to authorized users.

The paradox of water accessibility: understanding the temporal and spatial dimensions of access to improved water sources in Rwanda

According to the United Nations, the world has met the Millennium Development Goal target of halving the proportion of people without access to safe drinking water. However, global figures mask massive disparities between regions and countries, and within countries. For instance, only 64% of the people in sub-Saharan Africa have access to improved water sources. Over 40% of all people globally who lack access to drinking water live in sub-Saharan Africa. Rwanda is used as a case in point in this study. Despite the abundance of water resources in the country, access to improved water sources is limited. Using the Rwandan Demographic and Health Surveys (2000–2010), we examined regional disparities in access to improved water sources. Results from logistic regression models show that overall, access to improved water has declined between 2000 and 2010; except in the western region, where access to water marginally improved. Educated individuals, wealthier and urban dwellers were more likely to have access to improved water sources over time compared to their uneducated, poor and rural counterparts. The persistence of regional disparities in access to improved water over time suggests the need for policy to address insufficient investments in water infrastructure in Rwanda.

Nursing and Midwifery Education in Rwanda: Telling our Story

This article reviewed the development of the education of nurses and midwives in Rwanda. Nursing and midwifery education started with missionaries providing general nursing education and later evolved into the integration of nursing education in public and private schools. The establishment of the Kigali Health Institute in1996 greatly advanced nursing and midwifery education with the awarding of an advanced diploma (A1) in nursing and midwifery, followed by the bachelor’s (A0) and master’s degrees in nursing. This increased level of education for nursing and midwifery was supported by the Ministry of Health (MoH) when in 2007, the five Schools of Nursing and Midwifery were tasked with the goal of upgrading the A2 (enrolled nurses) to A1. More recently in 2011, the innovative Human Resources for Health program (HRH) was initiated by the MoH. The HRH program highlights skill transfer from faculty of leading schools of nursing in the United States to the Rwandan faculty. In 2013 all public higher learning institutions, including the Schools of Nursing and Midwifery, merged to form one University of Rwanda, under the Ministry of Education. In collaboration, Rwandan and US faculty have developed eight tracks within the Master of Sciences in Nursing curriculum which will well prepare nurses and midwives for leadership and educator roles in the Rwandan health care system. This stunning progress in education of Rwandan nurses and midwives over the past two decades promises a brighter future for nursing and midwifery as a profession. Keywords: nursing, midwifery, education, collboration

Abstract: The Evolution of the Nursing Profession Post Genocide

Abstract Background Nurses and midwives play a pivotal role in ensuring that patients get quality care and form the largest portion of the Rwandan health workforce. Rwandan nursing has continued to suffer constraints that hinder the ability to offer quality of care. Educating midwives and allied professionals was limited before the Genocide. Reviewing the history of nursing post genocide in Rwanda is important as it provides direction and structure for the future of nursing education. Historical Review In 1995 the nursing division was created within the structure of the Ministry of Health (MoH) to strengthen nursing education and practices. In 1997, in collaboration with the MoH, Minister of Education, AMREF Health Africa, and the World Health Organization, health professionals who had returned to Rwanda joined efforts to start the Kigali Health Institute (KHI). Educating Registered Nurses, Registered Midwives, Psychiatric Nurses and Allied health professionals was initiated. After three years, KHI started showing results by graduating health professionals. In 2006, the first nurse and midwives educators were trained. In 2007 the number of Nursing and Midwifery Schools increased to five, with approximately 200 midwives and 500 nurses graduating each year. These graduates worked in hospitals, schools of nursing and midwifery, and the health centers. In 2012, the e-learning program was launched in five nursing and midwifery schools to upgrade the associate nurses to diploma level. The first cohort of 298 students completed their program in October 2014. Recently the National Council of Nurses and Midwives was established to regulate the professions. Rwanda nurses continue to be active in joining and collaborating with global nursing organizations to share experiences with other nurses and midwives worldwide to improve global health care delivery. Conclusion Better understanding of the history of nursing in Rwanda post-genocide can help guide the future direction of nursing education, leadership priorities, and policy development. Key words : nursing, leadership, history, nursing councils, education

Latent Tuberculosis Infection and Associated Factors among Health Care Workers in Kigali, Rwanda.

IntroductionData are limited regarding tuberculosis (TB) and latent TB infection prevalence in Rwandan health facilities.MethodsWe conducted a cross-sectional survey among healthcare workers (HCWs) in Kigali during 2010. We purposively selected the public referral hospital, both district hospitals, and randomly selected 7 of 17 health centers. School workers (SWs) from the nearest willing public schools served as a local reference group. We tested for latent TB infection (LTBI) using tuberculin skin testing (TST) and asked about past TB disease. We assessed risk of LTBI and past history of TB disease associated with hospital employment. Among HCWs, we assessed risk associated with facility type (district hospital, referral hospital, health center), work setting (inpatient, outpatient), and occupation.ResultsAge, gender, and HIV status was similar between the enrolled 1,131 HCWs and 381 SWs. LTBI was more prevalent among HCWs (62%) than SWs (39%). Adjusted odds of a positive TST result were 2.71 (95% CI 2.01–3.67) times greater among HCWs than SWs. Among HCWs, there was no detectable difference between prevalence of LTBI according to facility type, work setting, or occupation.ConclusionHCWs are at greater risk of LTBI, regardless of facility type, work setting, or occupation. The current status of TB infection control practices should be evaluated in the entire workforce in all Rwandan healthcare facilities.

Epidemiology of untreated non-obstetric surgical disease in Burera District, Rwanda: a cross-sectional survey

BackgroundIn low-income and middle-income countries, surgical epidemiology is largely undefined at the population level, with operative logs and hospital records serving as a proxy. This study assesses the distribution of surgical conditions that contribute the largest burden of surgical disease in Burera District, in northern Rwanda. We hypothesise that our results would yield higher rates of surgical disease than current estimates (from 2006) for similar low-income countries, which are 295 per 100 000 people. MethodsIn March and May, 2012, we performed a cross-sectional study in Burera District, randomly sampling 30 villages with probability proportionate to size and randomly sampling 23 households within the selected villages. Six Rwandan surgical postgraduates and physicians conducted physical examinations on all eligible participants in sampled households. Participants were assessed for injuries or wounds, hernias, hydroceles, breast mass, neck mass, obstetric fistula, undescended testes, hypospadias, hydrocephalus, cleft lip or palate, and club foot. Ethical approval was obtained from Boston Children's Hospital (Boston, MA, USA) and the Rwandan National Ethics Committee (Kigali, Rwanda). Informed consent was obtained from all participants. FindingsOf the 2165 examined individuals, the overall prevalence of any surgical condition was 12% (95% CI 9·2–14·9) or 12 009 per 100 000 people. Injuries or wounds accounted for 55% of the prevalence and hernias or hydroceles accounted for 40%, followed by neck mass (4·2%), undescended testes (1·9%), breast mass (1·2%), club foot (1%), hypospadias (0·6%), hydrocephalus (0·6%), cleft lip or palate (0%), and obstetric fistula (0%). When comparing study participant characteristics, no statistical difference in overall prevalence was noted when examining sex, wealth, education, and travel time to the nearest hospital. Total rates of surgically treatable disease yielded a statistically significant difference compared with current estimates (p<0·001). InterpretationRates of surgically treatable disease are significantly higher than previous estimates in comparable low-income countries. The prevalence of surgically treatable disease is evenly distributed across demographic parameters. From these results, we conclude that strengthening the Rwandan health system's surgical capacity, particularly in rural areas, could have meaningful affect on the entire population. Further community-based surgical epidemiological studies are needed in low-income and middle-income countries to provide the best data available for health system planning. FundingThe Harvard Sheldon Traveling Fellowship.

Contribution analysis as an evaluation strategy in the context of a sector-wide approach: Performance-based health financing in Rwanda

Sector-wide approaches (SWAps) emerged as a response to donor fragmentation and non-adjusted and parallel programming. In the health sector, SWAps have received considerable support by the international donor community due to their potential to reduce inefficiencies through alignment to common procedures and hence to increase development effectiveness. Evaluating development cooperation in the context of a SWAp, however, translates into methodological challenges for evaluators who have to disentangle the cumulative effects in strongly donor-aligned, complex sector environments. In this article the authors discussed the application of a methodological strategy for evaluating development interventions in complex settings – for example in the context of a SWAp –and reflected the suitability of the approach. The authors conducted a contribution analysis, a theory-based approach to evaluation, and exemplified the approach for an intervention of performance-based financing for Rwandan health workers supported by the Rwanda-German cooperation. The findings suggested that the Rwandan system of performance based financing increased service orientation and outputs of health professionals, but also indicated that negative motivational side effects and resource constraints are real. With regard to the methodological approach, the authors conclude that contribution analysis has a high potential to evaluate development cooperation in the context of a SWAp dueto its high flexibility to use different data collection tools and its capability to assess risks and rival explanations. Challenges can be identified with regard to the efficiency of the evaluation strategy and a remaining trade-off between scope and causal strength ofevidence.

Enhancing Formal Educational and In-Service Training Programs in Rural Rwanda

Global disparities in the distribution, specialization, diversity, and competency of the health workforce are striking. Countries with fewer health professionals have poorer health outcomes compared with countries that have more. Despite major gains in health indicators, Rwanda still suffers from a severe shortage of health professionals.This article describes a partnership launched in 2005 by Rwanda's Ministry of Health with the U.S. nongovernmental organization Partners In Health and with Harvard Medical School and Brigham and Women's Hospital. The partnership has expanded to include the Faculty of Medicine and the School of Public Health at the National University of Rwanda and other Harvard-affiliated academic medical centers. The partnership prioritizes local ownership and-with the ultimate goals of strengthening health service delivery and achieving health equity for poor and underserved populations-it has helped establish new or strengthen existing formal educational programs (conferring advanced degrees) and in-service training programs (fostering continuing professional development) targeting the local health workforce. Harvard Medical School and Brigham and Women's Hospital have also benefited from the partnership, expanding the opportunities for training and research in global health available to their faculty and trainees.The partnership has enabled Rwandan health professionals at partnership-supported district hospitals to acquire new competencies and deliver better health services to rural and underserved populations by leveraging resources, expertise, and growing interest in global health within the participating U.S. academic institutions. Best practices implemented during the partnership's first nine years can inform similar formal educational and in-service training programs in other low-income countries.

Increasing maternal healthcare use in Rwanda: Implications for child nutrition and survival

Rwanda has made great progress in improving maternal utilization of health care through coordination of external aid and more efficient health policy. Using data from the 2005 and 2010 Rwandan Demographic and Health Surveys, we examine three related questions regarding the impact of expansion of health care in Rwanda. First, did the increased use of health center deliveries apply to women across varying levels of education, economic status, and area of residency? Second, did the benefits associated with being delivered at a health center diminish as utilization became more widespread? Finally, did inequality in child outcomes decline as a result of increased health care utilization? Propensity score matching was used to address the selectivity that arises when choosing to deliver at a hospital. In addition, the regression models include a linear model to predict child nutritional status and Cox regression to predict child survival. The analysis shows that the largest increases in delivery at a health center occur among less educated, less wealthy, and rural Rwandan women. In addition, delivery at a health center is associated with better nutritional status and survival and the benefit is not diminished following the dramatic increase in use of health centers. Finally, educational, economic and residential inequality in child survival and nutrition did not decline.

Development of a simulation and skills centre in East Africa: a Rwandan-Canadian partnership.

Simulation replicates clinical experiences without patient risk; it remains uncommon in lower-income countries. We outline the creation of Rwanda's first centre for simulation and skills training. We secured funding for renovations, equipment and staff; curricula were developed, tested, and refined; local clinicians were trained to teach. In 13 months the centre provided 2,377 learning-encounters and 822 hours of training to Rwandan health care professionals. Our strategy represents an adaptable model for simulation and skills centre development in low-resources settings

Barriers and solutions for timely initiation of antenatal care in Kigali, Rwanda: Health facility professionals' perspective

Objectivetimely initiation of antenatal care (i.e. within the first trimester) is associated with attendance of the full recommended regimen of antenatal visits. This study assessed social and behavioural factors that affect timely initiation of antenatal care in Kigali, Rwanda from the perspective of health facility professionals. Designhealth facility professionals involved in antenatal care provision were interviewed on their perceptions about untimely initiation of antenatal care based on open-ended questions. These one-on-one interviews were tape recorded and transcribed for analysis. Settinginterviews were performed in June and July 2011 at Muhima Health Center in Kigali, Rwanda. Participants17 health facility professionals with a wide range of skills and experience levels were selected from the 36 total staff members of Muhima Health Center based on their participation in and knowledge of antenatal care. Measurements and findingsinductive content analysis was used to group responses from these qualitative interviews with the goal of creating a conceptual map around barriers and solutions for untimely antenatal care. Qualitative responses were coded to identify the most common themes and sub-themes following a consensus methodology. The health-care professional interviews identified five themes as barriers to timely initiation of antenatal care: (1) lack of knowledge; (2) experience with previous births; (3) issues with male partners not willing/able to attend the clinic; (4) poverty or problems with health insurance; and (5) antenatal care culture. As potential solutions to these hurdles, the following themes were identified: (1) maternal/community education and sensitisation; (2) incentives to attend antenatal care visits; and (3) tracking the content and recommended number of antenatal visits. Key conclusionsqualitative results indicate that behavioural contextual interventions may help overcome antenatal care barriers. The Rwandan Government and health facilities should work together with target communities to improve antenatal care compliance, taking into account the solutions suggested by the health facility professional interviews. Implications for practicestudy findings suggest that there are specific solutions to increase adherence with timely initiation of antenatal care in Rwanda, including education and sensitisation, modifying couples' HIV testing policies, addressing costs of antenatal care, and tracking the number of recommended antenatal visits.

Local use of geographic information systems to improve data utilisation and health services: mapping caesarean section coverage in rural Rwanda

To show the utility of combining routinely collected data with geographic location using a Geographic Information System (GIS) in order to facilitate a data-driven approach to identifying potential gaps in access to emergency obstetric care within a rural Rwandan health district. Total expected births in 2009 at sub-district levels were estimated using community health worker collected population data. Clinical data were extracted from birth registries at eight health centres (HCs) and the district hospital (DH). C-section rates as a proportion of total expected births were mapped by cell. Peri-partum foetal mortality rates per facility-based births, as well as the rate of uterine rupture as an indication for C-section, were compared between areas of low and high C-section rates. The lowest C-section rates were found in the more remote part of the hospital catchment area. The sector with significantly lower C-section rates had significantly higher facility-based peri-partum foetal mortality and incidence of uterine rupture than the sector with the highest C-section rates (P < 0.034). This simple approach for geographic monitoring and evaluation leveraging existing health service and GIS data facilitated evidence-based decision making and represents a feasible approach to further strengthen local data-driven decisions for resource allocation and quality improvement.

Patient Enrolment into HIV Care and Treatment within 90 Days of HIV Diagnosis in Eight Rwandan Health Facilities: A Review of Facility-Based Registers

IntroductionAccess to antiretroviral therapy (ART) has increased greatly in sub-Saharan Africa. However many patients do not enrol timely into HIV care and treatment after HIV diagnosis. We studied enrolment into care and treatment and determinants of non-enrolment in Rwanda.MethodsData were obtained from routine clinic registers from eight health facilities in Rwanda on patients who were diagnosed with HIV at the antenatal care, voluntary counselling-and-testing, outpatient or tuberculosis departments between March and May 2009. The proportion of patients enrolled into HIV care and treatment was calculated as the number of HIV infected patients registered in ART clinics for follow-up care and treatment within 90 days of HIV diagnosis divided by the total number of persons diagnosed with HIV in the study period.ResultsOut of 482 patients diagnosed with HIV in the study period, 339 (70%) were females, and the median age was 29 years (interquartile range [IQR] 24–37). 201 (42%) enrolled into care and treatment within 90 days of HIV diagnosis. The median time between testing and enrolment was six days (IQR 2–14). Enrolment in care and treatment was not significantly associated with age, sex, or department of testing, but was associated with study site. None of those enrolled were in WHO stage 4. The median CD4 cell count among adult patients was 387 cells/mm3 (IQR: 242–533 cells/mm3); 81 of 170 adult patients (48%) were eligible to start ART (CD4 count<350 cells/mm3 or WHO stage 4). Among those eligible, 45 (56%) started treatment within 90 days of HIV diagnosis.ConclusionLess than 50% of diagnosed HIV patients from eight Rwandan health facilities had enrolled into care and treatment within 90 days of diagnosis. Improving linkage to care and treatment after HIV diagnosis is needed to harness the full potential of ART.

Picturing the Climate: Radiologic Assessment of Rwandan Imaging Capacity

INTRODUCTION The influence of radiology in resource-limited settings has been variably addressed in international public health initiatives to date. Yet as the face of global public health changes, marked by an increasing percentage of worldwide disability-adjusted lifeyears attributable to chronic diseases, cancers, and injuries, the development of imaging into centralized health infrastructure has been and will be integral for medical progress. Rwanda is a small sub-Saharan, East African nation with the landmass of Maryland and the population of Virginia, approximately 11 million people. The country is bordered by the Democratic Republic of Congo, Uganda, Tanzania, and Burundi. The population is largely agricultural workers, with more varied occupations within the capital, Kigali. According to the World Bank, the gross national income per capita was reported as US $440 in 2008 [1]. The genocide of 1994 leveled the Rwandan health care infrastructure, including all radiographic services. Beginning in August 1994, the Australian Medical Support Force provided the first basic imaging as part of rebuilding the nation [2]. In the subsequent five years of the reconstruction period, more complex programs and provision of supplies were primarily the domain of foreign aid organizations. Since that time, Rwanda has experienced significant progress in rebuilding its health care infrastructure, evidenced by its membership in a select group of nations that are

Making the snip hip: mass circumcision in Rwanda

The goal was ambitious: halve HIV transmissions within a country in which male circumcision was virtually unheard of by convincing some two million men to volunteer for the procedure. But a successful six-month mass circumcision pilot in two districts has Rwandan officials and health experts

Orphanhood and vulnerability: a conduit to poor child health outcomes in Rwanda

The HIV epidemic in sub-Saharan Africa has caused many children to become orphaned and vulnerable. Recent studies show that orphaned and vulnerable children (OVC) lack the basic necessities for survival and development. These children are particularly at high risk of poor health and poverty. Although the poor health outcomes of these children are well documented, the complexities of the factors that mediate their health outcomes have not been systematically studied. The aim of this paper is to examine how the complex relationships between and within the proximate and socio-economic determinants mediate the poor health outcomes of children through their OVC status. The analyses considered graphical chain modelling of morbidity data from a sample of 3745 children aged below five years from the 2005 Rwandan Demographic and Health Survey. The results show that OVC status influences the risk of childhood morbidity both directly and indirectly and also as a conduit through which other significant proximate factors and socio-economic factors operate.

‘Paying for performance’ in Rwanda: does it pay off?

The study analyses strengths and weaknesses of the 'Paying For Performance' (P4P) approach rolled out in the Rwandan health sector since 2002. It uses three research methods: a cross-sectoral literature review on P4P, its history and its context; 69 mostly semi-structured interviews conducted in Rwanda; and an analysis of factors eventually confounding the impact evaluation of the Rwandan P4P approach. It is argued that P4P approaches can be traced backed in written form over four millennia and that considerable negative effects are reported throughout history. All side effects were found again in various forms in the Rwandan health sector. One particular side effect -'gaming'- seriously threatens to affect the quality of health services. It is argued that P4P implicitly (and unintentionally) promotes a questionable concept of human 'labour' and that its focus on improving indicators rather than systemic changes can be regarded as vertical and counter-productive. Two alternatives to the current P4P system are briefly depicted, and further research on the described challenges is recommended.

PBF in Rwanda: what happened after the BTC-experience?

PBF in Rwanda: what happened after the BTC-experience?