05 Health Steering Committee Draft

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R W A N D A N A T I O N A L L A N D U S E D E V E L O P M E N T M A S T E R P L A N - H E A L T H

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CHAPTER 1.0: INTRODUCTION-------------------------------------------------------------- 2

CHAPTER 2.0: PRESENT HEALTH SITUATION-------------------------------------------- 3

2.1:HEALTHIMPACTS------------------------------------------------------------------------- 32.1.1 Lifestyle----------------------------------------------------------------------------- 32.1.2: Environment----------------------------------------------------------------------- 32.1.3: Transportation--------------------------------------------------------------------- 4

2.2:QUALITY OFSERVICES ------------------------------------------------------------------- 52.3:PRIMARY ANDSECONDARYHEALTHCARE ----------------------------------------------- 5

2.3.1: Situation today-------------------------------------------------------------------- 11

2.4:INTERNATIONALSTANDARDS ------------------------------------------------------------12

CHAPTER 3.0: CHALLENGES AND STRATEGIES --------------------------------------- 13

3.1:DEMOGRAPHICSTRUCTURE-------------------------------------------------------------173.2:TECHNOLOGICALPROGRESS------------------------------------------------------------173.3:NEWMODELS --------------------------------------------------------------------------- 173.4:HOSPITALBEDS AND SERVICE PROVISION ----------------------------------------------- 17

CHAPTER 4.0: DISTRICT PLANNING IMPLICATIONS------------------------------------ 19

4.1:PLANNINGSTANDARDS------------------------------------------------------------------19

4.1.1: Planning Indicators---------------------------------------------------------------19Example ---------------------------------------------------------------------------------19

GUIDELINES----------------------------------------------------------------------------------- 21

REFERENCES--------------------------------------------------------------------------------- 21

LIST OF TABLES------------------------------------------------------------------------------ 23

LIST OF FIGURES ---------------------------------------------------------------------------- 23

The National Land Use and Development Master Plan is referred to as the Plan in the text


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Chapter 1.0: Introduct ion

It is evident that the health situation in Rwanda has improved during the last onedecade, but still major problems remain to be solved within the health care sector.Therefore there is a need to point out the appropriate measures at national, local,and individual levels.

However, in order to determine and understand long-term health trends, the linksbetween health status and individual economic, social structure and demographic

issues should be recognized and taken into account. Even population structure andsocio-economic characteristics are basic determinants of living conditions. Thedevelopment of the health sector needs to be considered by evaluating the currentsituation and the demands from a rapidly growing population during 2010-2020.

The health care sector includes health care facilities, accessibility to treatment andthe supply of medical personnel. However, good human health condition is morethan absence of illness and infirmity, implying that the discussion on health issuesneeds to consider other aspects than the supply of health care alone. For instance

some of other factors to be considered are; availability and access to health careunits/centers, affordability and quality of services offered are paramount issues tobe considered in planning for better health services.

It is clear that a high-quality national health status is relying on good governance ofhealth care and on the shaping of a healthy, safe and secure environment for allcitizens. The health care sector needs well-designed strategies to facilitate theestablishment of a professional, healthy and capable workforce.

Figure 1: L a Croix du Sud Polyclinic in Kigali1 and the Private Dispensary

1 The standard polyclinic in Kigali


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Table 2: Health Facilities by Districts and Provinces

Referral

Hospital

Police

/Military

Hospital

District

Hospital

Health

Center

Health

Post

Prison

Dispensary

Grand

Total

Province District

East Bugesera 1 11 1 13

Gatsibo 2 18 20

Kayonza 2 14 2 18

Kirehe 1 11 14

Ngoma 1 12 13

Nyagatare 1 18 19

Rwamagana 1 12 1 15

West Karongi 3 18 24

Ngororero 2 12 19

Nyabihu 1 16 17

Nyamasheke 2 18 1 21

Rubavu 1 9 1 11

Rusizi 2 12 1 15

Rutsiro 1 16 18


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North Burera 1 14 15

Gakenke 2 18 5 26

Gicumbi 1 21 22

Musanze 1 9 13

Rulindo 1 18 19

South Gisagara 2 12 14

Huye 1 1 14 2 18

Kamonyi 1 11 12

Muhanga 1 12 1 15

Nyamagabe 2 16 1 2 21

Nyanza 1 13 2 16

Nyaruguru 1 15 16

Ruhango 1 13 14

Kigali

City Gasabo 2 1 1 13 1 18

Kicukiro 1 8 9

Nyarugenge 1 1 8 1 12

Total 4 2 39 412 9 13 497

Source: NISR 2009

Figure 5: Health Facilities 2010 (next page)


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Table 3: Type and meaning of health care units.

Category Type Meaning

Secondary healthcenters Referral Hospital

Hospitals with more qualified personneland modern medical treatment- atnational level

District Hospital Hospitals at district level

Primary healthcenters Health Center

Generally a standard health carecenter with all needed services

Military Hospitalmeant for military workers but also forthe public

Police Hospital

meant for police investigations and

usual health services

Prison Hospitalmeant for prisoners but also for thepublic

Polyclinic Normally privately run health care unit

Health post where people get first treatment

Dispensary Where people get first Aid

Figure 6: The Distribution of Primary Health Facilities by Population density 2010 (next page)


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N.BGenerally, all primary health care units are meant to offer primary and basichealth treatment and if need be the patients can be given transfer tosecondary health care units.

Figure 7:Kibagabaga District Health Center.

2.3.1: Situation today

The annual population growth rate is 2.8%, the total fertility rate is 5.8, and 45% ofthe population is under 15 years of age. Life expectancy in good health at birth forthe whole population is estimated at 50 years, while the percentage of lifeexpectancy lost for men and for women is respectively 13.3 and 14.1.3

3 Source(DHS 2000 and world health report 2003, WHO)

Table 4: Life Expectancy at Birth

Year 2000 2010 2020

Life expectancy at birth

Number of years 48 50 55

Source: Rwandas Vision 2020

The maternal mortality rate has risen from 500/100,000 live births in 1992 to1071/1000 live births in 20004. The infant mortality rate rose from 85/1000 livebirths in 19925 to 107/1000 live births in 20006. The principal causes of these levelsof mortality in Rwanda remain communicable diseases, which for the majority inRwanda can be prevented through better hygiene and behavior change. Theprevalence of HIV/AIDS amongst the adult population is estimated at 13.2% inKigali city, 6.3% in other urban areas and 3.1 percent in rural areas. And it istargeted to be at 0.5 by 2012.

Malaria accounts for at least 40% of all consultations in health centers; in 2001,malaria was found to have a fatality rate of 10.12% in district hospitals and 2.7% inhealth centers.

Rwanda has 39 district hospitals, 412 health centers, and 4 referral hospitals. Dataon numbers and types of staff is showed in the table below;

4 DHS 20005 DHS 19926 DHS 2000


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When looking at the number of nurses per 1,000 inhabitants, the correlation is moreobvious with the health conditions, measured in life expectancy. Countries like

Ireland, Netherlands, Switzerland, Luxembourg, Norway, Denmark, Sweden and

Australia all have a high number of nurses within the health services, and also verygood health conditions. All OECD countries, with few exceptions, have low childmortality rates. The differences between the countries are so small that it is notpossible to recognize any correlation with the number of either physicians ornurses.

The conclusion is that Rwanda ought to increase the number of physicians and

nurses in order to improve general health care condition and services. To reach theOECD median value of 3.1 physicians per 1,000 inhabitants, the number ofphysicians has to be significantly increased if not tripled from the current 571doctors in Rwanda. To reach the OECD median value for nurses, the numbershould be doubled from 6,318 today.8

A generally reasonable assumption is that planning standards should be flexible tothe demands of modern health care and treatment methods.

Figure 8: Nurses, a vital asset for our health status today and in the future

8 Rwanda Health Statistical Booklet 2008: 32

Chapter 3.0: Challenges and Strategies

The present development of the health sector is not completely satisfactory. Thefirst key challenge is to guarantee sufficient accessibility to health posts,dispensaries, health centers, district hospitals, and referral hospitals. Issues ofgeographical accessibility of the population to health services and location of healthfacilities are of primary concern

Accessibility is to a large extent a matter of providing a network of primary healthcare with general physicians to turn to for basic medical services.

The second key challenge concerns the number of hospital beds and how toachieve the desired level for the district and referral hospitals.

The third key challenge is the absence of health planning standards and guidelinesand current low level of health care services. This could be seen in the perspectiveof poor customer care


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The fourth key challenge concerns the lack of adequate medical equipment and aclear plan of maintenance, as well as a shortage of physicians and specialists.

Finally, the fifth key challenge is a number of problems outside the health sector likeaccess to safe drinking water, environmental pollution, poor traffic safety, tobaccosmoking and a need for more everyday physical activity. The above mentionedissues are related to health and play a key role in attaining a long-term sustainablehealth status for Rwanda.

The growing population and the development of treatment methods coupled withincreasing access to medical insurance seem to be the major drivers of bedrequirements over the planning period of the coming 10 years.

Population scenarios give estimates of the future size of the population in Rwandaand age group distribution. The demographic structure probably still is the mostpredictable driver of future health services requirements. However, thedevelopment of medical treatment methods and the organizing of open health careversus hospital health care is probably of greater importance than demography,

and at the same time they are factors of greater uncertainty.

Table 6: Malaria prevalence among children under five years of age.

Province 2005 in %

Number of

children

2008

in %

Number of

children

East 22.6 482 5.3 1,121

West 8.0 490 0.6 1,181

North 5.6 360 1.2 813

South 19.6 563 3.0 1,225

Kigali City 15.3 151 1.9 323

Source: IDHS 2007/2008 and RDHS 2005

Table 7: HIV prevalence by province among VCT9

Provi nce 2005 2006 2007 2008

East 9.9 8.1 4.9 3.7

9 VCT means; Voluntary Counseling and Testing

West 7.3 5.6 3.6 2.3

North 6.1 4.9 3.1 2.4

South 7.7 7.7 5.2 3.5

Kigali City 15.2 13.5 9.2 7.4

HIV prevalence (VCT) 9.3 7.4 4.7 3.3

Source: Statistical year book 2009, page 18

Table 8: Prevalence of Tuberculosis in Rwanda.

Indicators 2005 2006 2007 2008

Number of cases 7720 8265 8014 7841

Therapeutic success (in %) 76 84 86 86.2

Failure rate (in %) 1.5 2 2.4 3

TB/HIV (in %) 18 32 37.5 34.1

Tested + Tuberculosis (in %) 13.7 11.3 6.6 6.6


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Death rates associated with

tuberculosis (in %) 6 6 4.8 5

Source: NISR 2009 page 29, IDHS 2007/2008

Figure 9: Malaria Prevalence among children under five years by Province;

Figure 10: HIV/AIDS Prevalence by Province in Rwanda. (See next 2 pages)


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Table 9: Ratio of health workers/hospital beds to population in 2008.

Staff category NumberRatio topopulation

Hospital beds 11724 1.28

Doctors 571 15780

Midwives 35 260590

Nurses 6318 1444

Source: statistical year book11

Table 10: Vision 2020 Health Indicators and Projections.

Indicator

Baseline

2000

Target

2010

Target

2020

International

Level

Rwandan

population 7,700,000 10,200,000 13,000,000

Literacy level 48 80 100 100

Life expectancy

(years) 49 50 55

Women fertilityrate 6.5 5.5 4.5

Infant mortality107 80 50

11 NISR 2009, statistical year book page 43

rate (0/00)

Maternal

mortality rate (

0/00.000) 1070 600 200

Child

Malnutrition

(Insufficiency in

%) 30 20 10

PopulationGrowth rate (%) 2.9 2.3 2.2

HIV/AIDS

prevalence rate

(%) 13 11 8

Malaria-related

mortality (%) 51 30 25

Doctors per

100,000

inhabitants 1.5 5 10 10

Nurses per

100,000

inhabitants 16 18 20 20

Laboratory

technicians per

100,000

inhabitants 2 5 5

Source: Vision 2020.


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Example Kayonga District Plan Map below with catchment radius of 5 Km for health facilitiesshows the proposed and existing health facilities within the standards set by

Ministry of health as the maximum walking distance.Figure 11: Distribution of Health Facilities in Kayonza District 2010 (next page)


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GuidelinesThe aim is to achieve a sustainable health status for Rwandas more than 10 millionpopulations. Planning, modernization, more doctors and nurses, better training andsalaries are key issues to address.

Guidelines - Health

Hospitals

Planning standards for hospital beds need to becontinuously revised in accordance with the developmentof modern treatment methods and on assumptions offuture trends for hospital overnight admissions, lengths ofstay and day case admissions.

A standard of about 5 hospital beds per 1,000 inhabitantsshould be established. This figure might even be lower in

the future. Therefore, all future development of healthservice supply should be prepared for uncertainty and theplanning standards should be revised regularly.

Medical Professionals

The number of physicians within the health servicesshould be increased from the present rate of 0.06physicians per 1,000 inhabitants to a level of 5, notforgetting to adjust the figures to anticipated population

growth.

In order to meet the growing population the number ofnurses should be increased from the present rate of1.3nurses per 1,000 inhabitants to about 10 atleast.

Incentives in the public health sector should be improved

in order to achieve a better service quality through bettermotivated personnel. Health care personnel should alsobe offered better training.

A system for licensing and controlling the private healthcare sector should be introduced in order to guaranteequality of services.

Lifestyle and Safety Aspects

A healthy lifestyle should be promoted by increasingaccessibility to facilities of physical exercise, offeringsports, recreation and physical training. Public informationabout the connection between individual health andenvironmental risk factors should be improved throughschool programs and media channels.

Important issues like road safety, water quality, sanitationand inadequate diet habits should be issues in everydaywork towards a healthy population.


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REFERENCES

Ministry of Finance and Economic Planning and Ministry of Health,2006: Scaling up to achieve the Health MDGs in Rwanda,June 2006.

Ministry of Finance and Economic Planning, 2007: EconomicDevelopment and Poverty Reduction Strategy, 2008-2012.

Ministry of Health, 2009: Norms and Standards 2009.

Ministry of Health, 1992: Rwanda Demographic and HealthSurvey 1992



Ministry of Health, 2005: Rwanda Health Sector Strategic Plan2005-2009.

Ministry of Health, 2009: Rwanda Health Statistical Booklet 2009.

National Health Accounts Rwanda 2006 with HIV/AIDS, Malaria,

and Reproductive Health Subaccounts. Health Systems20/20, June 2008. Bethesda, MD: Health Systems 20/20project, Associates Inc.

National Institute of Statistics of Rwanda, 2007: InterimDemographic and Health Survey 2007/2008.

National Institute of Statistics of Rwanda, 2007: Rwanda NationalPopulation Projection 2007-2020.

National Institute of Statistics of Rwanda, 2008: RwandaDevelopment Indicators- 2006.

National Institute of Statistics of Rwanda, 2008: Rwanda inStatistics and Figures 2008.

National Institute of Statistics of Rwanda, Ministry of HealthRwanda, and Macro International Inc. 2008: RwandaService Provision Assessment Survey 2007. Calverton,Maryland, U.S.A.: NIS, MOH, and Macro International Inc.

World Health Organization: World Health Statistics, 2009. WHOPress, Geneva.


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LIST OF FIGURESFIGURE1:LACROIX DUSUDPOLYCLINIC INKIGALI AND THEPRIVATEDISPENSARY.....2FIGURE2:MISUSE OFWETLANDAREA INKIGALI.............................................................3FIGURE3:POORQUALITYWATERSYSTEM INKIGALIHOUSINGAREA............................4FIGURE4:BADTRAFFICSOLUTIONSCONSTITUTE ASEVERHEALTHHAZARD. ..............4FIGURE5:HEALTHFACILITIES2010................................................................................7FIGURE6:THEDISTRIBUTION OFPRIMARYHEALTHFACILITIES .....................................9FIGURE7:KIBAGABAGADISTRICTHEALTHCENTER.......................................................11

FIGURE8:NURSES,A VITAL ASSET FOR OUR HEALTH STATUS......................................13FIGURE9:MALARIAPREVALENCE AMONG CHILDREN UNDER FIVE YEARS ....................14FIGURE10:HIV/AIDSPREVALENCE BYPROVINCE INRWANDA...................................14FIGURE11:DISTRIBUTION OFHEALTHFACILITIES INKAYONZA ....................................19

LIST OF TABLES

TABLE1:NUMBER OF BEDS BY HEALTH FACILITY TYPE AND BY SERVICE ........................5TABLE2:HEALTHFACILITIES BYDISTRICTS ANDPROVINCES..........................................6TABLE3:TYPE AND MEANING OF HEALTH CARE UNITS....................................................9TABLE4:LIFEEXPECTANCY ATBIRTH............................................................................11TABLE5:NUMBER OFSTAFFWORKING INHEALTHSECTOR ........................................12TABLE6:MALARIA PREVALENCE AMONG CHILDREN UNDER FIVE YEARS. ......................14TABLE7:HIVPREVALENCE BY PROVINCE AMONGVCT.................................................14TABLE8:PREVALENCE OFTUBERCULOSIS INRWANDA.................................................14TABLE9:RATIO OF HEALTH WORKERS/HOSPITAL BEDS TO POPULATION......................18

TABLE10:VISION2020HEALTHINDICATORS ANDPROJECTIONS.................................18

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05 Health Steering Committee Draft