Tackling Rwanda's health problems

June 15, 2005 -- For the past 18 years, Sister Dina Nyiranuma, has worked in a health centre in one of the poorest and most densely populated neighborhoods of Kigali, Rwanda's capital.

From its relatively humble beginnings as a dispensary in 1973, the Biryogo Health Centre -- of which Sister Nyiranuma is now director -- has expanded and now offers its patients a full range of services. They address issues such as malnutrition, reducing child and maternal mortality, the burden of malaria and HIV, but also increasing enrollment in primary schools.

With about 300 patients a day, the Biryogo Health Center offers one of Kigali's poorest neighborhoods a holistic approach to health with preventive and clinical services, as well as community support -- including schooling for young children and nutritional support.

The Biryogo Health Centre is a classic example of a successful public -- private partnership working in Rwanda -- a country still dealing with the legacy of the tragic genocide in 1994.

The Challenges

World Bank president Paul Wolfowitz will meet Sister Nyiranuma during his visit to Rwanda -- a country in which the government has been commended for its progress in rebuilding its health infrastructure since the events of the mid 1990s and for providing leadership and vision in health systems reform and in tackling the HIV/AIDS epidemic.

Rwanda, like most post conflict countries, is off track to meet several of the Millennium Development Goals (MDG), the international set of targets to be reached by the year 2015. The child mortality rate is 198 per 1000; the infant mortality rate 107 per 1000, and the maternal mortality rate 1,071 deaths per 100,000 live births. These indicators are significantly worse than the average of Sub-Saharan Africa. Severe malnutrition is at 24%. Malaria is endemic is the first reason why people seek medical consultation.

Fertility is high in Rwanda -- on average a woman has six children. The rapid population growth is a major public health and development issue. Rwanda is also severely affected by the HIV epidemic, although HIV -5.1%- is much lower than the average of Eastern and Southern Africa. It's estimated there's some 420,000 Rwandans who are HIV positive

The Progress

But, since the genocide of 1994 which resulted in a massive loss of health professionals, a destruction of health infrastructure, and general impoverishment of the population, Rwanda has made remarkable progress in rebuilding its health system. The progress is shown in selected health indicators. Ninety six percent of children in the country are now fully immunized. People's use of basic health services increased from 0.25 visits per capita in 2001 to close to 0.4 in 2004, and the HIV epidemic is contained. Enrollment in community based health insurance schemes has also dramatically increased from 7% to 27% between 2003 and 2005, a unique case in Sub Saharan Africa.

During his visit to the Biryogo Health Centre, Wolfowitz will have the chance to hear first hand the challenges faced by dedicated providers delivering services to contribute to achieving the ambitious targets of the MDGS. He will meet also children and women suffering from malnutrition as well as HIV/AIDS affected people from the neighborhood.

Results Oriented Support

The Government of Rwanda -- with backing from the Bank -- supports a results-oriented approach to the health sector.

"Drawing on best practices, the Government of Rwanda supports the Biryogo health center as most health centers of the country through a results oriented approach, providing public subsidies to deliver high impact services primarily in rural areas including immunization, assisted delivery at birth and treatment of malaria", says Minister of Health, Hon. J.D. Ntwawukuriryayo.

Block grants are also given to districts to help decentralize the health sector and promote healthy practices among households: hand-washing with soap, use of insecticide treated nets to combat malaria, good nutrition, sanitation and AIDS awareness and prevention. The government also supports the expansion of innovative community health insurance schemes which covers more than 400,000 families.

Bank Support

The World Bank has provided support to the health sector through an annual US$65 million Poverty Reduction Support Credit (of which US$50 is a grant and US$15 is a credit). In order to focus attention on results, the Poverty Reduction Support Credit is assisting the government to expand a successful performance based scheme for nutrition, maternal and child health, malaria and HIV/AIDS services.

"This is a way to not only empower and motivate service providers, but also to focus attention on expanding access to basic services, such as antenatal care, family planning and obstetrical care, "says World Bank senior health specialist in the Africa region, Miriam Schneidman.

"If they deliver the services, then they'll receive additional resources which can be reinvested at the health facility," Schneidman says.

The World Bank also supports Rwanda's efforts to combat HIV/AIDS with a five year US$30.5 million grant for prevention, treatment and care support for those living with HIV/AIDS. The grant -- given through the Rwanda HIV/AIDS Multi-Sectoral Project -- is part of the Africa HIV/AIDS Multi-Country Action Program, known as MAP, which covers close to 30 countries. The grant funds have been used to expand the activities of prevention of HIV as well as access to AIDS treatment through public-private partnerships, with roughly half of those administered by faith based organizations like the one running the Biryogo Health Centre.

So far more than 1,500 people are now on life saving antiretroviral therapy -- with a 95 percent compliance rate. The goal is to reach at least 2,350 people. More than two-thirds of those on treatment are women -- as in Rwanda, women have been disproportionately affected by HIV/AIDS.

The grant funds are being used for far more than just treatment of HIV positive people. More than 70 organizations have received funding for social mobilization, income generation schemes, awareness raising and voluntary counseling and testing with some 100,000 people tested in the first 18 months

The Bank's support has been targeted to some of the country's most underserved provinces -- where the grant funds are making a difference. "This program has a strong pro-poor focus, supporting treatment through public-private partnerships, with services now offered in remote areas and to some of the poorest people" Schneidman says.

The Bank has worked in close partnership with other development partners (United Kingdom, European Union, Sweden, African Development Bank, USAID, Belgian, WHO, UNICEF, the US Center for Disease Control and Prevention, Global Fund and the Clinton Foundation etc ) under the government's leadership.