The Minister of Health looks at the maternal healthcare system in Rwanda
Maternal Health We asked Dr. Diane Gashumba what needs to be done to improve maternal health, and what brought about the changes we've already seen?
What needs to be done today?
- Strengthen collaboration and coordination across sectors and harmonise existing policies to address the social determinants of poor maternal health outcomes. This will help to identify major obstacles and the most effective coordination mechanisms.
- Implement and monitor a harmonised, integrated and sustainable package for essential maternal health. It should include promotion, prevention and treatment interventions, commodities and innovative technologies at hospital, health centre and community levels. The cost-effectiveness of interventions must also be researched.
- Build training institutions for managers and health care providers in integrated Reproductive Maternal Neonatal, Child and Adolescent Health (RMNCAH) care, so that staff at all levels, from the community upwards, are able to deliver quality, integrated and client-centred services.
- Strengthen health systems and research towards universal coverage of RMNCAH services, paying attention to the deployment and retention of health staff.
- Strengthen financial and geographical access to services by under-served and vulnerable groups/beneficiaries and use the Health Management Information System (HMIS) to monitor equity.
- Intensify health promotion efforts to increase community knowledge and skills on maternal health interventions and promote health seeking behaviour.
- Strengthen governance systems and accountability (joint planning, budget allocation, implementation, monitoring and evaluation) of integrated RMNCAH interventions at central, decentralised and community levels, including public-private partnerships and performance-based contracts (Imihigo, meaning 'vow to deliver’).
Healthy mothers in Rwanda are contributing to the development of maternal health.
What has brought about the changes so far?
In the last 15 years, Rwanda has reduced its maternal mortality ratio from 1,071 out of 100,000 (1.071%) to 210 out of 100,000 (0.21%) in 2015.
In the same period, mortality rates of children under five years old have dropped from 196 out of 1,000 (19.6%) to 50 out of 1,000 (5%).
Now, 91% of deliveries occur in health facilities and 99% of women attend at least one antenatal care (ANC) visit.
The HPV vaccine has been introduced into the vaccination calendar and all girls aged 12 years are targeted by the programme through collaboration between all health and education services and the local governments. Much of this success has been attributed to many factors: upmost is a political will to improve the life of Rwandans – especially women and children. Also, strengthening the referral system, building health care facilities, community-based health insurance and community health interventions help continue this success.
It is fantastic news that Rwanda has cut it's maternal mortality rate from 1.071% to 0.21% in the last 15 years.
What strategies have contributed to progress in Rwanda?
Accountability system: Performance Contracts with districts (Imihigo) to achieve the goals that each district assigns as key indicators of development (including health). The indicators of maternal and child health, including Reproductive health, are among the priorities.
Community engagement: Every village has three community health workers, one of whom is responsible for giving pregnant women hygiene and nutritional counselling, encouraging them to attend antenatal care visits, accompanying them at the health facility during childbirth and attending the recommended post natal visits. This has contributed to universal health coverage.
Audit of the maternal and child deaths: Monitoring maternal deaths to identify correct measures necessary to prevent similar deaths in community and in health facilities.
Rapid SMS for alert: The alert system tracks the maternal and neonatal life cycle, ensuring that critical points in the cycle are documented and sent electronically by community health workers in all villages.
Health financing strategies, including community-based health insurance, to ensure universal access to health services.
Performance Based Financing (PBF) in the health sector for both health facilities staff and community health workers.
Strong focus on adolescents: Youth corners, youth centres and the introduction of comprehensive sexual education (CSE) curriculum in schools
Strong Public-Private Partnership: Good collaboration between the Government of Rwanda, the Civil Society and the private sector.
Professor Janet Dewan talking to a pre-surgical patient with Rwandan medical student, Oda, translating, at Kibagabaga Hospital.
Where do you see Rwanda's maternal healthcare in the future?
Reductions in maternal mortality have been dramatic since 2000 and the Millenium Development Goal 5 (MDG), to improve maternal health, was met. Even if Rwanda has achieved the MDG5 target, maternal mortality ration (MMR) is still high and more needs to be done to achieve the MMR Sustainable Development Goals (SDG) target and eliminate all avoidable maternal deaths.
"Greater male involvement and increased social mobilisation for early antenatal care could also be improved."
Almost all pregnant women attend at least one antenatal care (ANC) visit, but only 44% complete the four recommended ANC visits, up from 43%. Attendance for ANC could be improved through early detection of pregnancy, using urine pregnancy tests in the community, for example. Initiatives such as, using pregnancy tests and the use of ultrasound at health centres, are under exploration.
The integration of HIV prevention and treatment services into ANC has resulted in a high uptake of couple counselling and testing for HIV (84% of male partners) and high access to antiretroviral therapy (ART) for those found to be HIV-positive. Opportunities also exist for the integration of sexual reproductive health checks, family planning and cervical cancer screening into ANC. This calls for closer integration of programmes in maternal and reproductive health and non-communicable diseases.
"Rwanda has increased contraceptive use, at one of the most rapid rates worldwide."
A Maternal Death Surveillance and Response (MDSR) system has been established to strengthen capacity in identifying responses that need to be implemented to eliminate avoidable maternal deaths. There is a need to improve the monitoring mechanism of the implementation of recommendations made by MDSR committees.
Between 2000 and 2010, Rwanda increased contraceptive use at one of the most rapid rates worldwide, from 10% to 45%. During the same time period, fertility dropped from 6.1 children per woman to 4.2.
The future is looking bright for the health of mothers and children in Rwanda.
photo credits: IOWD