Archive | September, 2012

Rwandan Health Care Structure

24 Sep

Wayyyyy back during PST I remember being impressed with Rwanda’s Health Care Structure. I don’t know anything about other African health care structures so I can’t compare the strengths and weaknesses, or if it is even all that unique. It’s a tiered system which seems to me like a pretty good idea considering the ratio of people to health facilities is pretty disproportional. For example, my health centers catchment area serves 20,000+ people and some serve upwards of 30,000. The only downside is that if you’re in need of serious medical treatment you may have to visit several different facilities for referrals before finally receiving treatment.

At the grass roots level, in the imidugudu (neighborhoods) there are Community Health Workers (CHWs). For each umudugu there are supposed to be four CHWs, a man/woman pair called a binome, a social affairs CHW, and one in charge of maternal and child health. However the actual number and their competency depends on the leadership at the health center. Luckily, in my sector we have dedicated and competent leadership meaning we also have 60+ dedicated and competent CHWs.

The maternal/child CHW weighs all children under 5 in the umudugu on a monthly basis and can make referrals to the health center for malnutrition interventions. CHWs are trained to make simple diagnoses and determine if a referral to the health center is necessary. They can also do rapid diagnostic tests for malaria (since malaria here is like the common cold/flu), they remind people of appointments at the health center etc.

CHWs are average people, there are no educational or language requirements, rather they have good standing in the community. This means that training CHWs to carry out some duties can be a complicated process. For example, a couple of months ago the Ministry of Health started a cell phone based reporting system for CHWs that contained auditory and text elements. There’s no Kinyarwanda language option on the phones here, only French or English neither of which at least half of the CHWs speak. You can imagine the difficulty in teaching people to send a text message on a phone in a language that they have a very basic knowledge of. Despite and difficulties, our CHWs are a tremendous asset to the health center and greater community.

In addition to the cell phone reporting, each month the CHWs compile a detailed report of their work and submit it to the supervisors at the health center. Per government requirements they are also organized into a cooperative so that a portion of the Performance Based Financing they receive is invested into income generating activities.

At the next level is the health center. There are no doctors on staff at a health center, and at mine there are a surprisingly few number of nurses (eight), the other staff providing medical care are known as ‘travailler’ (eight of them also) French for worker (I think). The health center is run by the ‘head nurse’ or most commonly referred to in French as ‘Titulaire’ who is commonly university educated. Most of the nurses at my health center have an enhanced secondary school education, though many of them study on the weekends to earn a nursing degree. There are three levels of nurses: A0 have studied 4 years of university, A1 three years, and A2 finished all six years of secondary school. The ‘travailler’ only completed the first three of six years of secondary school. Currently, there are no medical schools in Rwanda. If a person wants to go to medical school they must study outside of Rwanda. Pretty much all of the staff who study on the weekends go to university in Congo because it’s close, and much cheaper than studying in Rwanda. Folks who live closer to the Ugandan border typically go there to study. Consequently, most of the doctors in hospitals, at least in my region are Congolese.

Common services at health centers include:
-General Consultation: We have two rooms staffed by nurses where people come with general concerns. While people are waiting to be seen by a nurse, one of the travailler takes their temperature, weight, and records any symptoms they’re having on a sheet of paper.

-Pharmacy: Pretty much every visit to the health center includes a prescription for some kind of medicine. Antibiotics are prescribed a little too frequently for my liking, but I’m sure there are reasons I don’t understand. The pharmacy also gives out things like vitamin C, multi vitamins, and ibuprofen in addition to medicines that actually treat maladies.

The process of seeing a nurse is not a timely one. I’ve often thought that if I had to some to the health center and wait for 30 minutes or more to see a nurse for some ibuprofen just to treat a head ache that I’d be very cranky. However, there are few places to buy over the counter drugs outside of major towns in Rwanda. Not to mention that a significant portion of the population doesn’t understand how to take OTC. Not to mention, by going to the health center they’re able to use their government supplemented health insurance to get the medicine for a small fee.

-Family planning: This service is offered two days a week at my health center. Available methods include; male and female condoms, cycle beads, oral contraception and the implant in the arm. The IUD is also supposed to be an option, but you’d be hard pressed to find a nurse who knows how to insert one. Damaging myths about the various forms of contraception run rampant and may even be believed by the people who work in family planning. Culture is a big barrier to wide spread use of family planning in Rwanda.

-Vaccinations: Every Friday mothers come with their babies to be vaccinated. There’s a national scheduled for various vaccinations: at birth, six weeks, 2.5 months, 3.5 months, 6 months, and 9 months. The vaccine schedule includes BCG, 4 doses or Polio, 3 doses of DTP/Hep B/Hib, 3 doses of Pneumococus, 3 does of rotavirus, and measles.

-Pre natal consultations and PMTCT: Pregnant woman are supposed to come in for 4 visits during their pregnancy. Admittedly I know relatively little about the services provided to pregnant women. I do know that they weigh them and measure their bellies. PMTCT or prevention of mother to child transmission of HIV/AIDS is a separate service, and again one I know relatively little about.

-Delivery: Women are encouraged to deliver at the health center instead of at their homes. For fear of having to witness a birth, again this is a service I know relatively little about. The delivery room is split into two by a divider and each side has a chair. The services the nurses here provide are pretty basic, I know they can administer oxytocin but I know that if things are very complicated the women are transferred by ambulance (which I imagine is a TERRIBLE trip) to the district hospital, where there’s an alarmingly high rate of c-sections. Women are typically left alone during labor and seldom utter a peep during delivery which astounds me.

-Nutrition Services: Once a week parents with malnourished children come to have their children weighed and collect therapeutic food, either a beefed up peanut butter like substance called Plumpy Nut or a blend of sorghum, soy, and corn flour called sosoma which is used to make porridge for the kids. Unfortunately, supplies of the therapeutic foods are unreliable and not always available. Malnutrition (at least diagnosed) is not as prevalent in my area as others, typically there are 6-12 children who are malnourished enough to merit an intervention at the health center.

-Laboratory: In the lab they can test for HIV, measure hemoglobin and blood sugar levels, pregnancy tests, and syphilis. They use microscopes to analyze stool and blood samples for stomach worms, malaria, and possibly other things. My health center is one of a few in the region equipped to analyze tuberculosis samples. Once a week (Wednesdays) early in the morning they draw the blood of a dozen or more ARV patients and then take the blood to the district hospital for a CD4 count. The results take a week to receive.

-ARV: not every health center distributes anti-retro viral drugs to people with HIV/AIDS and I’m not sure what the criteria are. My health center does indeed offer ARV services, in all we have 535 people who come to get some form of medicine. Three days a week we give out medicine and one day a week (Fridays) we give out CD4 results. There are two nurses, a social worker, a data manager, and myself who work in the service. By far, the biggest staff of any service. The social worker helps hand out medicine, but also counsels people and makes home visits to people too sick to come to the health center or fall out of compliance with their regimen. The data manager is in charge of entering patient information into the national database. I just kind of lumped myself into this service after shadowing most of the other services. Before people see the nurses to collect their medicine, they give me their appointment card with an identifying number which I used to pull their chart which records visits and then put them back in numerical order after the data manager has entered the visit into the database.

-Community Health: There are two staff who work in community health. They are in charge of supervising the CHWs, one works part time in nutrition, and the other manages environmental health, which is mostly just visiting homes/public places to make sure they have good hygiene.

-At the health center there are separate wards for women, children, men, and post partum women if they need to stay overnight for observation. The dorms are pretty basic with a mosquito net, a terribly thin and uncomfortable mattress, and bedding. If someone has to stay at the hospital their family is responsible for bringing them food. The small cantina on the premises offers some basic food like bread, amandazi (like fry bread), bananas and pineapple, biscuit, tea, and the popular sorghum porridge.

-Mutuele: This is the national health insurance service. There are four staff who work in Mutuele and are not actually staff of the health center. There’s a head of the service, an accountant, a receptionist in charge of managing patient accounts, and another worker who helps track expenses incurred. Both the health center and Mutuele keep a record of costs and then reconcile with each other each month. The first two people mentioned are responsible for tracking payments for Mutuele (often it’s bought in installments) and writing Mutuele cards in addition to going into the community to mobilize people into buying Mutuele. It’s supposed to be mandatory for every person not otherwise covered in Rwanda, but for subsistence farmers (the majority of the population in my community) finding the money to buy Mutuele on a yearly basis is often a huge barrier.

-Non medical staff: The titulaire has his own office along with the head accountant for the health center. There’s a staff person in charge of tracking the costs for each service provided to charge Mututele. There’s another accountant on staff responsible for minor things, and three janitors who are always cleaning something or other.

-At the next level is the district hospital which has doctors on staff. Despite passing the hospital every time I go to my banking town (at least once a month) I’ve never visited my district hospital. I do know, like many health centers and schools, it was privately built by an organization of churches in England but overseen by the Ministry of Health. There’s a English woman named Sheila who spends most of her time there running the place and because of her presence, there are a lot of foreign doctors who come and work in various specialties for months at a time. I’m not sure if that’s the case at other district hospitals, but I see it as a real blessing considering that we’re so far from specialists in Kigali and to travel there means hours on terrible roads and a lot of money.

The district hospital has a team of what they call ‘Community Supervisors’ who visit health centers on a monthly basis to review monthly reports and offer technical assistance. They also send a doctor on a monthly basis to consult ARV patients.

At the top level, you have Rwanda’s National Reference Hospital King Faisal. I have no idea what happens there, but it’s where all the expats go, and where PCVs go for any tests they might need. I DO know that they don’t have aloe vera.

There you have it, Rwanda’s health care structure.



3 Sep

About a year ago, after some time away from my region (I think it was for my IST) I was on my way home and saw all these new street signs at various places. It would be another couple of months before I found out they were marking Rwanda’s latest tourism effort, the Congo-Nile trail. The trail runs between Gisenyi on the Northern end of Lake Kivu and Kamembe, the city (town?) on the Southern end of Kivu.

Tourists can rent bikes and hire a car to bring things behind them or hire porters and walk the trail in 5 – 10 days. If you’re a Peace Corps Volunteer on break from teaching you can call on your fellow PCVs and bring a tent for those places where there are no volunteers. Living on the trail means that I’ve hosted a couple groups of PCVs who have done the trail.

My PCV neighbor to the South, who happens to be in my same group (RW5H3) and I live about a days’ trek from each other. So after months of talking about how we should make the trek between our houses we set a date, Saturday July 21st.

She arrived Friday late afternoon, spent the night and a little before 8 am we set out. On the way we ran into one of my coworkers (the same one who was worried about me surviving the heat in Bugarama) who, like most of the people I told expressed a lot of concern about our decision to ‘do sport’. Like with all the others I turned it into a game, asking him how many hours he thought we’d use for the walk.

We walked at a comfortable pace, stopping often to take pictures and greet people along the way. I was happy to be able to get some pictures of the rice paddies which are my favorite part of the moto ride to/from site. It was also nice to be able to snap pictures of the scenery a bit removed from my site since strangers aren’t big fans of unexplained cameras. Conversely, sometimes a mob of people wanting their pictures taken breaks out if I start taking pictures.

We were generous with the rest breaks and more than a couple times we were greeted by various moto drivers from my village, tracking our progress and trying to convince us to take a moto. It was fun to hear their exclamations on our progress or the fact that we were resting, yet again. Sometimes though, we took a break to distance ourselves from people we’d rather not share the road with.

Around 1:30 we arrived at a lovely place that is owned by the British lady who runs the regional hospital. She bought some land on a peninsula and built a retreat center. The most magical part of all is that the average Rwandan isn’t allowed since it’s primarily for hospital staff (there are a lot of doctors who come from all over the world). However, if you’re white and know the name of the woman who runs the hospital then you’ll have no problem. The magical thing about this place is that you can eat in public, expose your upper legs and generally do whatever you like without invoking the stares of everyone around you.

By this time my feet were already starting to hurt. We rested for 2 hours, eating the snacks we had brought along and chatting with some of the missionaries who had arrived early for their annual conference of missionaries working in central Africa.

A weird thing happened on the way in. We encountered a group of kids who did the usual asking for candy and money. Then one of them uncharacteristically tried to grab the bottle of water in the outside pocket of my backpack. So I let him know what was up in Kinyarwanda. The kids then became more aggressive and taunting so I did what my coworkers do when kids are flocking us as we go to sport, I picked up a stick and waved it at the a bit. Usually that does the trick, no actually hitting of children necessary. These kids did back off, but they still leered at us. It was really strange because I’ve never encountered kids who actually tried to reach for something (other than the pickpockets at bigger markets). The other PCV I was with thinks it was because of all the small white kids they saw coming and going from the retreat center. Abazungu adults are a common site for Rwandan kids but abazungu kids for some reason rock their world.

We left paradise around 3, feet still hurting and calves REAL tight. As we got closer to where I usually catch a taxi the sky turned dark and the wind picked up. For awhile we wondered if we’d have to call it a day early on account of the rain. After an hour or so we reach the taxi town and stopped for something more substantial to eat and some fanta to raise our blood sugar.

At this point it hurt to sit, to stand and to walk. But the brochettes (meat sticks) and fanta we had did us good. The original plan was to get to K’s site, shower and then go out to a local restaurant. However, she had the foresight to know that we probably wouldn’t be able to leave her house once we got there. With the threat of rain gone we set out once again for the last bit which had the steepest hills, of course.

We arrived a little before 7, about 30 minutes after the last of the sunlight. The good part was that we didn’t have to greet too many people K knows or answer too many questions. Indeed she was right, after we bathed we were not in any kind of shape to go back out. So we ate some of the bread we bought, had a cup of tea and started a movie, which I watched maybe 25 minutes of before I passed out.

The next morning we got up early and hobbled out to catch a taxi to Kamembe where we treated ourselves to the charming atmosphere and deliciousness that is breakfast at La Petite Colline. For $5 you get a thermos of African Tea or coffee, an omlette with 3 pieces of bread and a plate of fruit. It was a nice little energizer before our Camp GLOW meeting. Though because of the blisters on our feet we had to take motos from the bus station to the hotel.

A couple guys at the place we had brochettes estimated that it’s 27 kilometers from my site to K’s. Add another 3 km for the detour to paradise and we walked about 30 kilometers that day. In all it took us 11 hours though about 3 of that was used for resting. Meaning that we walked a total of 8 hours. Considering that my feet started hurting after the first four, and that every step of the last 2.5 or so was painful, I can’t imagine how people do that for 5 or more days at a time without the conveniences of their own homes and sleeping on the ground. I used to think I wanted to get into backpacking in the US, but after this experience I’m rethinking that. Unless you nice folks out there can share your secrets of getting your feet in shape. Needless to say I have no desire to tackle the Congo-Nile trail in its entirety.