Strengthening public health care in Rwanda
Ilona Dekkers writes on her visit to Rwanda and the state of the health system there.
In April 2007 I had the great opportunity to visit Kigali, the capital of Rwanda together with 24 other young Europeans from all Member States of the European Union. We accompanied the European Commissioner for Development and Humanitarian Aid, Louis Michel, on an educational visit to Rwanda. The young people from the 25 Member States of the EU were the winners of the Development Youth Prize awarded at the first European Development Days held in Brussels.
Rwanda, one of the most beautiful countries in the world, has a dark history. During the 100 days of genocide from April to July 1994, almost one million Rwandans were killed. The genocide was triggered by the assassination of the Rwandan’s Hutu president Juvenal Habyarimana when his plane was shot down above Kigali airport on April 6 1994. Hutu extremists wanted revenge for the murder and began to systematically murder Tutsi and moderate Hutu. The genocide has left massive scars on this tiny central African country.
After the genocide Rwanda has been striving to rebuild the country and this is still going on today. For example, Rwanda has made substantial progress in stabilizing and rehabilitating its economy to pre-1994 levels. The post-genocide government has a policy of “unity and reconciliation” and key individuals suspected of taking part in the genocide appear before the UN International Criminal Tribunal for Rwanda. (1) The government has also embraced a fiscal policy to reduce poverty by improving education, infrastructure, and investment. Unfortunately, 56.9 % of the population still live below the poverty line. (2)
The government has adopted the Health sector strategic Plan for 2005-2009 with the aim of improving the health status of the population. (2) During our journey we visited the Kicukiro health centre, a public hospital centre in Kigali, where the population have access to basic health care. One of the greatest problems of the health sector in Rwanda is the lack of medical staff, particularly in rural areas. The number of inhabitants per doctor in Rwanda is 50,000, (3) far below the ratio of 1:10,000 recommended by the World Health Organization. Maternal mortality has also declined since the genocide but remains one of the highest in the world and infant mortality has not yet reached pre-genocide levels. (3) The prevalence of HIV-AIDS, TB and malaria is high and constitutes a major public health problem. (3) However, Rwanda is committed to reaching the Millennium Development Goals and has made sustainable improvement in health care and accessibility. (4) In particular, Rwanda has a community based health insurance scheme, which provides access to treatment to the poorest members of the population. (4)
Rwanda has one of the largest populations of orphans and vulnerable children and youths in the world. In 2002, Rwanda had 1,264,000 orphans and more than 100,000 children living in child-headed households. (5) Their parents were either killed in the genocide, died from AIDS or were imprisoned for genocide-related crimes. Many orphans have poor health and often suffer from depression. (6) One of the greatest challenges facing Rwanda today is how to care for this massive population of orphans.
Through a new National Policy on Orphans and Vulnerable Children, the Rwandan government has introduced a framework for protecting them. School fees have been eliminated and other initiatives include the catch-up program for children who previously were not able to attend school and the new ‘Child-Friendly School’ model. This new type of school focuses on the “whole child”, including health and well-being, and has helped to increase school enrolment and retention. (7)
In Rwanda orphans are overwhelmed with domestic responsibilities. During our trip we visited important social projects; one of them was the Nkundabana project, which is a mentoring programme run by CARE International. I was deeply impressed by the strong sense of social responsibility and solidarity in the Rwandan community. Nkundabana means “I love children” in Kinyarwanda and the Nkundabana community volunteers provide guidance and psychosocial support to orphans through weekly home visits, assess the situation in the home, and protect the children from abuse and exploitation. These adult mentors are chosen by the children themselves and have receive training on different topics, such as counselling skills, child rights, advocacy skills and hygiene and health, before becoming a Nkundabana. The Nkundabana model is a succesfull community-based project that provides not only for the material needs of child-headed households but also for their psychosocial and protection needs.
The highlight of our visit was a meeting with Rwanda’s President, Paul Kagame. President Kagame is a leader of great vision and hope who is leading his land into vigorous recovery through strategies like Vision 2020, an ambitious development plan which aims to transform Rwanda into a middle-income country by 2020. President Kagame expressed gratitude to the delegation and said that cooperation in development is essential for a sustainable future for his country. Rwanda has achieved impressive progress since 1994 but its government still faces big challenges.
There are many issues which threaten the improvement of developing countries such as inadequate health infrastructure, lack of access to education and high population growth, but poverty is still a major cause of poor health and vice versa. Health is thus a crucial determining factor of economic development. I believe that the biggest health care challenges in Rwanda are to strengthen the quality of medical services, to provide access to treatment to the most needy and to retain competent health professionals. Rwanda has limited natural resources and must invest in its human resources to be able to decrease poverty in the long term. It is essential to strengthen Rwanda’s public health care, especially in the area of mental health for children who have experienced extreme violence. I hope that we, the new generation of doctors, will recall that our effort is needed to help turn devastation into development, so that health conditions can be improved in communities that need it the most.
Ilona Dekkers, 2nd year medical student at the Erasmus Medical Centre, Rotterdam, the Netherlands.
References
(1) Official site of the International Criminal Tribunal for Rwanda. http://69.94.11.53/default.htm (accessed August 19, 2008)
(2) United Nations Development Programme and Government of Rwanda. Turning Vision 2020 into reality. National Human Development Report. United Nations Development Programme and Government of Rwanda, 2007.
(3) Government of Rwanda. Heath sector strategic plan 2005-2009. Ministry of Health, Kigali, Rwanda 4.Logie D. Innovations in Rwanda’s health system: looking to the future. Lancet 2008; 372:256-61.
(5) Rwanda General population census 2002.
(6) Boris NW et al. Infants and young children in youth-headed households in Rwanda: implication of emerging data. Infant Ment Health J. 2006: 27(6):584-602.
(7) UNICEF news line: UNICEF and local partners promote child-friendly schools in Rwanda.