Engage Africa Foundation works with future public health leaders to mentor them in public health as it relates to chronic disease prevention and control. Through their practicums, their grow in their understanding of and ability to contribute to emerging public health challenges. One of those students is Yllka Sejdiu and she will be reflecting on her growth through monthly blogposts.
My name is Yllka Sejdiu and this is my first blog posting for the Engage Africa Foundation which I am thrilled to be a part of. I am in my last semester of the Health Evaluation Masters program with the University of Waterloo. I have learned so much during the range of this program including quantitative and qualitative methods for analysis, applying theories in evaluation, and evaluation practice and management. Currently, I am completing my last course where we are learning about systems thinking and analysis in heath program planning and evaluation. In this course, there is a major project where we are expected to develop a proposal to address significant health problems and challenges through health system reform within a particular jurisdiction. I have chosen Rwanda as the jurisdiction for my project and have learned some amazing things about Rwanda thus far which I hoped to summarize with you in my first blog for Engage Africa Foundation.
Rwanda is located in East Africa, and has a current population of 12, 381, 336 people with an approximate area of 25 thousand square kilometers (1). After genocidal interethnic conflict which killed hundreds of thousands of peoples just two decades ago, Rwanda's economic development and healthcare system was expected to stagnate since the country was too poor to reduce the burden of disease. The 1994 civil war left the economy in a mess, and the post-genocide governments have since investigated for social and economic development reform (2).
Although Rwanda was and continues to be one of the poorest countries in the world, it has made significant changes to the health of its communities. Rwanda has constructed a universal healthcare system which is financed by tax revenue, foreign aid, and voluntary premiums scaled by income (3). This healthcare system covers more than 90% of its population and has improved substantially over the turn of the century, increasing life expectancy by 18 years (3). Rwanda's healthcare system is known by many as the most advanced in Africa. With many still living in poverty and much work to do in order to reach the goal of equitable health services for all individuals, Rwanda seems to understand what method to best use in order to provide access to health for all so to control diseases and to lift Rwandans out of poverty. In the recent years, Rwanda’s population has seen a growth socioeconomically as determined by gross domestic product (GDP) per capita from $317 in 2005 to $550 in 2010 resulting in an increase in the economic development indicators. With increased economic growth, an expected decrease in poverty of 59% in 2001 to 45% in 2010 has been reported (4). In addition, the health sector has seen a significant improvement providing preventative and timely curative care. These changes in the healthcare system have resulted in middle and low-class income earners to pay less for their health related services (4).
Rwanda’s health indicators have been improving in the last 10 years and there is an expectation for continued growth beyond the health related millennium development goal (4). Despite the country's total population increasing over the years, Rwanda has been successfully fighting against many endemic infectious communicable diseases such as HIV/AIDS, tuberculosis, malaria. For example, in 2008 malaria was the top cause of death affecting 15% of its population (5). In 2014, malaria prevalence had reduced by half.
The Rwanda health sector has made considerable achievements in the recent years. But there is also a new disease pattern which seems to have stemmed in Rwanda through the emergence of non-communicable diseases (NCD). This includes the development of high-risk behaviors and urbanization such as cancer, cardiovascular diseases, hypertension and diabetes, as well as other disease groups. There are many challenges that need to be addressed in order to develop prevention and control health services for NCDs. These challenges include (6):
- lack of trained health care provides,
- lack of integration and accessibility of NCDs services at all levels of the healthcare system,
- specialized NCDs services,
- high NCDs costs and lack of funds mobilization frameworks at global, regional and national levels,
- lack of basic equipment and specialized infrastructure for NCDs,
- essential drugs and advanced NCDs treatment, and
- lack of proper NCDs data management
A total of 36% of all deaths in 2012 included NCDs with 20 of the 36% portraying cardiovascular diseases (hypertension, heart failure, and strokes) and cancers (mainly cervical, liver, breast, prostate, and stomach) (5). In 2008, deaths that occurred due to NCDs comprised of cardiovascular disease at 48%, cancers at 21%, chronic respiratory diseases at 12%, diarrhea at 7.2%, premature birth at 6.3%, cerebrovascular disease at 5.9%, diabetes at 3.5%, and psychological trauma at 3.2% (5,6). An estimated 17% of NCD burden was accounted for in Rwanda in 2004, whereas in 2014 36% of all deaths were by NCDs (5). Literature shows that the burden of NCDs is anticipated to continue growing as the economy develops. Because of this, the Ministry of Health (MOH) has launched a program for prevention and control of NCDs (5). The MOH is also trying to gain more evidence-based research which can guide policy makers on how to respond to the populations health needs effectively.
In 2014, about 45% of Rwanda’s population was living in poverty, a state which resulted in health challenges such as malnutrition and high fertility rates especially among poor and rural women (5). Maintaining a clean and safe physical environment is important for the social, economic, and physical well-being of individuals, but in urban areas of Rwanda this is a issue due to environmental problems such as land degradation and pollution (5). Evidence shows that 80% of disease burden originates from poor sanitation and contaminated water, while the dry season increases risk of airborne diseases (5). In 2007, evidence shows that 19% of urban households used spring water while 12% used water from uncovered public wells (5). These living conditions put the population at risk of contracting infections and various diseases. The countries limited sources, mainly agricultural, are insufficient and therefore do not meet the needs of dietary requirements for Rwandans (5). Because of this, child malnutrition is severe and can eventually cause risk of developmental problems. Protein-energy malnutrition also is found to affect mainly children since they are the most vulnerable group being effected (5).
In conclusion, although there have been positive changes in Rwanda's health sector and population health, the epidemiological profile for Rwanda is dominated by communicable diseases, although there has been a rise in non-communicable diseases (5). The prevalence of poverty, low levels of education, lack of adequate sanitation systems and water, poor hygiene, and high population density all combine and cause mortality or morbidity for Rwandans. Although Rwanda still has a lot to do in order to implement health practices which will reach and help 100% of their population, considering their history and the genocide from two decades ago they are implementing some very beneficial ways to restoring its populations health. The following video will give you a better idea of how this is occurring: https://www.youtube.com/watch?v=VQ3sHfYzcv8&feature=youtu.be
I've also included a picture here that I found to be very interesting. This picture represents a member of the Community-Based Environmental Health Promotion Programme (CBEHPP) who is speaking to Rwandans about health promotion, hygiene, and best practices. World Vision has been in Rwanda since the 1994 genocide and holds these type of community health clubs within 10 districts of Rwanda. Changes have been seen throughout the years with 298,965 people having access to safe water as of 2017 (7).
- Worldometers. (2018). Rwanda Population. Worldometers.info. Retrieved from http://www.worldometers.info/world-population/rwanda-population/
- Williams, T. P. (2017). The political economy of primary education: Lessons from Rwanda. World Development, 96(Complete), 550-561. doi:10.1016/j.worlddev.2017.03.037
- Porter, E. (2017, July 18). In Health Care, Republicans Could Learn From Rwanda. The New York Times. Retrieved from https://www.nytimes.com/2017/07/18/business/economy/senate-obamacare-rwanda.html
- Ministry of Health (2014) National Health Research Agenda 2014-2018. Retrieved from http://www.moh.gov.rw/fileadmin/templates/cdc/NATIONAL_HEALTH_RESEARCH_AGENDA_2014-2018.pdf
- Leuchowius, K. (2014). Report on Health Care Sector and Business Opportunities in Rwanda. Swecare Foundation. Retrieved from https://www.swecare.se/Portals/swecare/Documents/Report-on-the-Health-Care-Sector-and-Business-Opportunities-in-Rwanda-Sep2014-vers2.pdf
- Binagwaho, A. (2014). Republic Of Rwanda: Health Sector Policy. Ministry of Health. Retreived from http://www.moh.gov.rw/fileadmin/templates/policies/Health_Sector_Policy_2014.pdf
- AfricaAhead. (2017). World Vision: Report on CBEHPP in 10 Districts. Africa Ahead. Retrieved from https://www.africaahead.org/2017/05/world-vision-report-on-cbehpp-in-10-districts/