Rwandan Medical Intern Seeks Progress in Healthcare

Janvier Yubahwe, a medical intern at Ruhengeri District Hospital in northern Rwanda, starts his day around 6:30 a.m. with a 15 minute walk to the hospital from his house. Recently, photographer Greg Kendall-Ball and I spent the day at the hospital with Janvier and his colleagues, learning more about the life of a doctor in Rwanda.The sun rises early here, so it was already bright and clear when we left Janvier’s house and made our way to the hospital with the hundreds of other people also walking to the market or to their work places. The volcanoes of the Virunga Mountains rose up behind us, and the dirt roads were black with volcanic rock—a contrast to the dark orange-red soil that characterizes much of the rest of this region.Apr09_Ruhengeri4By 7 am on this Monday morning, the staff of Rugengeri District Hospital gathered for the weekly all-staff meeting. Doctors, interns, nurses, lab staff and pharmacists sat on benches in a small room in the hospital to review cases from the week just past. Any deaths that occurred over the weekend were reported and discussed. Each department presented at least one difficult case for review by the specialists and other staff. General announcements—about H1N1 flu precautions, the next quarterly evaluation of the staff and hospital, and the visit from Physicians for Human Rights—closed the meeting, and the staff dispersed to their departments.Ruhengeri District Hospital is a high-performing and busy hospital serving somewhere between 380,000 – 400,000 people. District Hospitals in Rwanda are usually staffed only by medical officers with bachelor’s degrees in medicine, with specialists (those who have gone on to do a Masters degree) working only in the National Referral Hospitals. But Ruhengeri is home to a number of foreign specialists who have been recruited through partnerships between the hospital and outside universities or development agencies, making them an informal referral site for other district hospitals in the region.Apr09_Ruhengeri17

Strong Political Will Brings Incredible Progress

Rwanda has made significant strides in strengthening and expanding the health workforce over the past few years. According to the Human Resources for Health Strategic Plan (2006-2010), in 2005 health centers and district hospitals met less than 30% of the required staffing norms. And, at the time of the drafting of the Health Sector Strategic Plan 2005-2009, the doctor to population ratio was 1 doctor to 50,000 people and the nurse to population ratio was 1 to 3900. Today, according to the Ministry of Health, Rwanda currently has one doctor for every 18,000 people and 1 nurse for every 1700 people. Although this is still not enough health workers to provide all the services needed to the population, it does demonstrate incredible progress and strong political will.Health outcomes also reflect this progress. The maternal mortality rate in Rwanda has dropped from 1,000 deaths per 100,000 live births, to 750 deaths per 100,000 over the past few years. Between 2005 and 2007, infant mortality decreased from 86 deaths per 1,000 live births to 62 deaths per 1,000. Although these rates are still far too high, the rapid decrease indicates that Rwanda is working hard to improve the health of its population.

Better Access to Health Services

The health workers and administrators I spoke with praised the social health insurance program—“Mutuelle de Sante”—for significantly increasing the number of people who are able to access health services. At a cost of about $2 a year for enrollment and then 10% of services and medicines costs when visiting a hospital or health centre, health care is more affordable for the poor. The percentage of insured in Rwanda jumped from 3% in 2002 to 75% in 2007, and current estimates of insurance coverage are now as high as 95%. Health facility utilization has also increased from 25% in 2001 to 72% in 2007, an increase that direct correlates with the initiation of the social health insurance program.

Lingering Concerns and Challenges

Despite this significant progress, the doctors and nurses we spoke to still articulated many of the same concerns and challenges that are present across Sub-Saharan Africa. The workload is still too much for the few health professionals available. The skill and training of the health professionals available at the district and community levels does not match the needs of the population. There are not enough trained midwives to assist in all the deliveries, contributing to the high rates of maternal and child deaths. Advocacy is still needed to encourage continued improvement within the health sector.As he finished seeing his last patient for the day, Janvier said:

Sometimes we see problems, and sometimes we see opportunities that we can use to solve people’s problems. But if everyone just keeps quiet, there will be no change. I think that we as health professionals have to advocate, because it’s the only way that will bring about a positive change.

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