Rwanda Pain Case Study

Many healthcare systems in low-income sub-Saharan African countries such as Rwanda face the challenges of communicable diseases, inadequate healthcare financing and a chronic shortage of healthcare workers. Despite these challenges, Partners in Health and the Rwandan government have been implementing value- based healthcare reform for more than a decade, specifically through decentralisation and community-based health insurance.

“The GK programme, which translates to “healthy Kinzig valley”, is available without additional cost to everyone insured by the sickness funds living in the Kinzigtal region.”

At the Millennium Summit in September 2000, 149 heads of state and government unanimously adopted the UN Millennium Declaration to reduce extreme poverty with a deadline of 2015.1 That commitment has become known as the Millennium Development Goals (MDGs). The MDGs quantified targets for addressing extreme poverty and promoting gender equality, education, environmental sustainability and basic human rights.2

While many countries in sub-Saharan Africa faced and still face the difficulties of building a strong healthcare system, Rwanda was faced with rebuilding a nation after the 1994 genocide. In little more than 30 years, Rwanda has become one of the few African countries to have successfully met the MDGs on reduction in maternal mortality, child mortality and combating communicable diseases such as HIV/AIDS and malaria.

A key lesson of Rwanda’s success begins with the introduction of the MDGs, which inserted into the national health dialogue a set of targeted outcomes that domestic and international non-governmental organisations stakeholders could agree upon. In 2005, Partners in Health (PIH) was invited by the government of Rwanda to provide technical expertise to help strengthen the healthcare system—with the aim of meeting the MDG targets.

PIH, founded in 1987, is a Boston, Massachusetts-based non-profit healthcare organisation focused on capacity-building and on strengthening healthcare systems. PIH and its sister organisation in Rwanda, Inshuti Mu Buzima, have been partnering with Rwanda’s Ministry of Health since 2005. “Value-based care has been integral to the Rwandan healthcare system

architecture,” Dr Neil Gupta, chief medical officer for the PIH programme in Rwanda, explains. “Decentralisation and community-based health insurance are two important illustrations of value-based care that synergistically improve access to healthcare.” Value-based care also included healthcare financing with the Ministry of Health’s 2001 introduction of performance- based financing that established direct linkages between finances, outputs and outcomes. This has been a key factor in supporting more efficient utilisation of scarce financial resources for health and rapid progress towards the health-related MDGs.3

In the past 15 years, Rwanda has adopted a healthcare development strategy based on decentralised management that began with the development of individual health offices for health system management. Within provinces, district health offices are responsible for the healthcare needs of the population in that zone and for health facilities and services. The healthcare system strategy also included community-based health insurance schemes (CHIs). In 1999, across three districts, 54 CHIs were piloted. In 2002, a strategy to scale up and to build technical capacity was implemented by the Ministry of Health, Ministry of Local Affairs and external partners—by 2005 CHIs were available across the country. The annual premium is approximately $5, with a 10% co-pay for services not covered. Many preventive interventions such as bed nets and vaccinations are fully covered along with treatment for HIV disease, tuberculosis and some cancers.4 Since the pilot programme, CHI enrolment has increased from 1% to nearly 85% of the population in 2014; by that year, Rwanda had spent 10% of its annual national budget on healthcare, compared with Mozambique’s and Botswana’s 8.8% and Angola’s 5% (South Africa was the highest with 14.2%5 in the sub-Sahara region).

Improving healthcare infrastructure

Rwanda’s healthcare system utilises task-shifting, community health workers, improving technology infrastructure and community health assurance to deliver quality healthcare at low cost. The focus on value-based health service delivery is a key reason that Rwanda successfully met key health-related MDGs.

PIH is providing technical support for the implementation of electronic medical records in health facilities across the country; these collect timely population health data and support decisions at the individual clinician level as well as at the district and country levels. PIH initiated electronic records for HIV/AIDS patients to track individual patient outcomes and aggregated population outcomes to help in programme design decisions. Over the past 15 years, successful treatment and prevention programmes have kept the HIV-prevalence level at a constant 3%. Efforts to maintain progress, for example, the collaboration between PIH and the Government of Rwanda to expand the use of electronic records for all health facilities to build a comprehensive health facility-based disease profile, are crucial.

PIH’s work fighting HIV/AIDS has shown that a community-based approach to antiretroviral therapy is possible in poor local contexts and impacts not only individuals but potentially stopping the HIV pandemic,” says Dr Gupta. PIH has also worked with the Ministry of Health, which sets the national health research agenda, on research that has influenced the

development of data-driven policies and protocols. One example is the development and implementation of national policies and protocols around neonatology services delivered at the district hospitals outside major cities. Task-shifting has allowed nurses and general practitioners to take on some of the work of specialist paediatricians, while technology-focused policies have increased the amount of specialised equipment available at these district facilities.

Capacity building

In September 2015 PIH’s University of Global Health Equity in Kigali, Rwanda, welcomed the inaugural student cohort. Dr Gupta, who also teaches at the university, explained, “The idea of [the university] and the Master of Science in Global Health Delivery is to support and build localised excellence and talent in national healthcare in developing countries—and to keep the talent at home. Elements of the curriculum and methodologies such as case-based learning come from a value-based perspective.”

Lecturers from Rwanda’s Ministry of Health, Harvard Medical School, Tufts University and elsewhere taught students, mostly from Rwanda, everything from epidemiology to budget management. The second class, starting in September 2016, had nearly 9 applications for each of the 27 placements. Future plans include the expansion of degree programmes, including nursing, as well as the completion of a 250-acre campus for the university. When complete in 2018, the campus will house thousands of students and medical professionals from around the world, offering lessons in not just how to treat patients but how to build healthcare systems.

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4. P E Farmer, et (2013) “Reduced premature mortality in Rwanda: lessons from success”, BMJ 364:f65

5. World Health Organisation database 2014 data

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Group counselling: the workshop that saved a Kigali family

Fredrick Uwanyigira, living in Gisozi, the poorest neighbourhood of Kigali, couldn't work for more than 10-12 days a month. Aids and daily drinking would leave the 47-year-old construction worker too frail to even get out of bed.

His wife of 14 years, Grace Nzikobankunda, who is also HIV positive, was growing desperate. The labourer would keep most of his meagre earnings for alcohol, leaving Nzikobankunda with just RWF 8,000-9,000 (£7.50) a month to buy food. Illiterate and unskilled, the mother-of-four was pawning household items to meet the shortfall.

Things came to a head when the younger two of their constantly hungry children, aged five and three, began to lose weight rapidly. "It terrified me. My brother had lost children to illness, his pain was unbearable," Uwanyigira says.

On Nzikobankunda's suggestion he agreed to seek help at RWAMREC's local men's workshop. "I was surprised to see I was not the only one with alcohol and violence problems. It helped me tremendously to listen to the problems of the other men and find solutions to my own," he says.

"But most importantly I learnt to include my wife in decision making, especially in money matters," Fredrick adds.

Inspired by other participants in the workshop, the construction worker also encouraged his wife to enrol in a vocational programme.

Today Fredrick's children are back to a healthy weight, thanks to the nutritious meal they get daily at Aspire Rwanda, where their mother is learning hairdressing skills. The labourer has quit drinking and is able to work more days.

"This is a better life," he smiles.

Career women: how a job earned a husband's respect

Twenty kilograms – that's how much beauty, human dignity and freedom from violence collectively weigh for 32-year-old Virginia Mukagsana. The number now also means receiving respect and a weekly supply of goat's milk and eggs from Jean Claude Ntawugashira, her husband of 11 years and the father of her two young boys.

"Look," Mukagsana points to her torso, "can you tell I was an ugly heap of 45kgs only 10 months ago? Last year he started locking me up for two to three days at a time with only water to drink," she wells up.

Mukagsana had hoped for a better life when she fled to Kigali to escape the 1994 genocide. The carnage had claimed more than half of her family. A few years later, violence and agony returned to her life after she married Ntawugashira, a mechanic living and working in Gisozi. With no skills and very little education Mukagsana was wholly dependent on her husband.

"We were always struggling financially and I wanted to know how he was spending the income. My questions used to make him furious," she says.

Determined to escape penury and violence, Mukagsana secretly enrolled in a vocational training programme at Aspire Rwanda. Initially angry at the discovery, Claude was surprised when he heard Virginia was offered a job as a training assistant after completing her course.

"The change in Claude was dramatic after that. I never thought he would ask for my opinion in important decisions. Today I am confident, independent and much happier," she says.

Back at her healthy weight of 65kg, Mukagsana feels beautiful again.

Male perspectives: Rwandan men begin to talk

"Have you noticed that newspapers, NGOs and governments mostly focus on women and how they feel? Their stories and case studies mostly feature their account and agony." Edouard Munyamaliza pulls his chair closer.

"But we go to the men. We ask them why they do it. We force them to think about their attitude and challenge their cultural beliefs. That's how we approach the problem," he adds emphatically.

Founded by Rwandan men in 2006, the NGO Rwanda Men's Resource Centre (RWAMREC) primarily works with and for men in order to sensitise them towards gender equality and the ills of violence against women.

This is achieved through a multi-pronged approach of community mobilisation, awareness campaigns and training programmes at grassroots level. According to Munyamaliza, RWAMREC's executive secretary, the NGO mainly focuses on creating male role models who are respected in their communities and can act as an example for other men to follow.

"We have found that men find it easier to talk to other men and learn from their experience. In that backdrop, our training programme 'Positive Masculinities' helps them understand that empowering women does not make men subordinate to them," he adds.

MenEngage is another such programme. It targets young males between the ages of 12 and 20. Young agents then reinforce the sensitisation process through songs, debates and cultural activities in their local communities.

Gender education: the abusive husband who became a role model

Hassan Shyaka , 45, can barely read or write. But the cassava farmer from Nyarugenge district in Kigali province never leaves home without his blue pen neatly clipped to his shirt pocket. Sometimes he also wears his solitary green embroidered tie. The father-of-six is proud to be his village's community leader and goes the extra mile to look the part. Remembering the past, Shyaka cannot believe how a simple decision catapulted him into the most respected position in the village.

"Not beating my wife changed my life," Shyaka laughs baring his stained yellow teeth. "I was the most notorious man in the village – so notorious for being foul-mouthed and violent to Hasina that women used to hate me," he admits. Beside him 42-year-old Hasina Nyiraminani, his wife of 22 years, nods.

Shyaka confesses he used to beat Nyiraminani whenever she confronted him about the rumours of his illegal "second marriage". In 2011, after his children witnessed him leave her seriously wounded, the community leader referred him to Rwanda Men's Resource Centre's RWAMREC gender workshop.

"The workshop forced me to rethink my relationship with my family, and whether I was a role model to my children. It shamed me," says Shyaka.

According to Nyiraminani, he returned a "reformed" man. No beating, no shouting – Shyaka left everyone shocked. Before long, he was being asked to counsel and share his experience to help save other marriages.

Last year, to his surprise, he was chosen to be a community leader. "Today I tell everyone to respect their wife if they want to change their life," Shyaka swells with pride.


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