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Reduced premature mortality in Rwanda

Rwanda's approach to delivering healthcare in a setting of post conflict poverty offers lessons for other poor countries, say Paul Farmer and colleaguesIn the immediate aftermath of the 1994 genocide, which claimed up to a million lives and left two million homeless, Rwanda was among the poorest countries in the world.1 Health and education systems, already weak and limited in reach before the conflict, lay in ruins; less than 5% of the population had access to clean water; the banking system had collapsed; almost no taxes were collected. Epidemics of infectious disease including AIDS, malaria, tuberculosis, and waterborne infections further thinned the population.2Today Rwanda has been transformed. Mass violence has not recurred within the country's borders, and its gross domestic product (GDP) has more than tripled over the past decade (box 1). Growth has been less uneven than in other countries in the region, partly because both local and national governments have made equity and human development guiding principles of recovery.3 Recent studies suggest that more than one million Rwandans were lifted out of poverty between 2005 and 2010, as the proportion of the population living below the poverty line dropped from 77.8% in 1994 to 58.9% in 2000 and 44.9% in 2010.3 Life expectancy climbed from 28 years in 1994 to 56 years in 2012.4 It is the only country in sub Saharan Africa on track to meet most of the millennium development goals by 2015. Although metrics for equity are disputed, it is an increasingly well known fact that Rwanda today has the highest proportion of female civil servants in the world.5Box 1: Rwanda's social and economic contextPopulation (2011): 10942950Population living in rural areas (2011): 81.2%Population below age 15 (2011): 42.8%Parliamentary seats held by women (2011): 56.3%Net enrolment in primary education (2010): 98.7%Gross domestic product (GDP) per capita (2011): $582.79 (361; 435)Average annual GDP growth over past decade (2002 11): 7.6%Agriculture as percentage of GDP (2010): 32.2%External assistance for health (2010): $277mExternal assistance as proportion of total health spending (2010): 47%Public spending on health as proportion of public spending (2010): 20.1%Total health spending per capita (2010): $55.51Some have characterised Rwanda's rebirth as good fortune or as a "black box" case with few lessons for others. However, as doctors and researchers who have worked for a decade with Rwanda's Ministry of Health and its development partners, we contend that the country's approach to strengthening its health system offers insights for other countries faced with persistent poverty and lagging health indicators.Reining in AIDS: a blueprint for strengthening health systems The Rwandan government laid ambitious plans to scale up access to health services in the years immediately after the genocide. Its Vision 2020 strategy for equitable social and economic development, produced in 2000, emphasised health as a pillar of the national cross sector approach to reducing poverty. Funds for implementation were scarce, however, and van earrings replica AIDS and tuberculosis epidemics, compounded by a heavy burden of malaria and food insecurity, caused substantial premature death and disability.2In December 2002, only 870 of the tens of thousands of Rwandans with advanced HIV disease were receiving antiretroviral therapy most in private clinics in Kigali, and many erratically.6 In the early 2000s, new funding mechanisms, most notably from the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) and the US President's Emergency Plan for AIDS Relief (PEPFAR), substantially increased development assistance for health, but these funds were often restricted to specific programmes, especially for HIV.It soon became apparent that advocacy and funding alone do not guarantee that quality health services will reach those who need them most.Rwanda sought to control AIDS, tuberculosis, and malaria, building a stronger health system as it did so. Integration of disease control programmes was recognised as a worthy goal. From the start, Rwanda's AIDS programme was characterised not only by efforts to integrate prevention and control but also by attention to concomitant problems such as tuberculosis and malnutrition, and to strengthening the healthcare system. As Rwanda's minister of health, Dr Agnes Binagwaho, says: "If you give Rwanda money to save the life of the oldest person in Rwanda today, we will make sure that the infant born tonight benefits too." Disease specific or "vertical" funding from the Global Fund and PEPFAR was used to rebuild the country's health infrastructure and develop robust platforms for primary care.7 Similar approaches had been successful in rural Haiti.8Scale up of AIDS services began in cities and towns and then expanded into the rural regions in which most Rwandans live. In June 2012, 108113 people with advanced HIV disease in Rwanda were receiving antiretroviral therapy, making Rwanda (along with much richer Botswana) one of only two countries in sub Saharan Africa to achieve the United Nations goal of universal access to antiretroviral therapy.9 Rwanda's HIV epidemic has remained at a prevalence of about 3% for the past seven years.10Rebuilding the health systemTackling conditions ranging from obstructed labour to chronic infectious diseases requires modern health infrastructure and well trained staff. Rwanda's health facilities five referral hospitals, 42 district hospitals, 469 health centres, and many private clinics are currently staffed by 625 physicians, 8273 nurses, and 240 nurse midwives, heavily concentrated in urban areas.11 Decades of instability contributed to an exodus of many health workers in the years leading up to the 1994 genocide, when many more were killed. Rwanda faces one of the greatest shortages of human resources for health in the world.Addressing this shortage by training physicians and nurses will take many years; this effort is now under way. A cadre of 45000 community health workers has performed many tasks over the past decade. After being elected by their communities, health workers are trained to diagnose and provide empirical treatment for malaria, pneumonia, and diarrhoeal disease. They also play a key replica van cleef vintage alhambra earrings role in health promotion efforts for family planning, antenatal care, and childhood immunisations and can refer patients to health centres and hospitals.12 This approach has extended the reach of the health system, helped prevent the most vulnerable from falling through the cracks, and improved the coordination of care. Rwanda achieved a 91% success rate for community based tuberculosis treatment in 201011 and even higher rates of long term adherence for community based HIV care.13Another pillar of Rwanda's health strategy is universal health coverage. A national community based health insurance scheme known as mutuelles de sant was piloted in 1999 and extended nationwide by the mid 2000s, facilitated by the country's improved financial situation. As of June 2012, 90.6% of the population was enrolled, while another 7% are covered by civil service, military, or private insurance plans. In addition to annual premiums, subscribers pay 10% copayments at the point of care for services not fully covered. The country's online health management information system22 and national AIDS informatics system, TRACnet,23 aggregate data and improve information flow between procurement and distribution divisions of the ministry, in addition to facilitating management of the performance based financing system. A mobile phone based alert and audit service for maternal and child health, RapidSMS, links community health workers to nearby health facilities.12 An van cleef turquoise earrings replica open source, customisable electronic medical record system, OpenMRS, has been piloted at 24 health facilities and is currently being rolled out across the country.24

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