Improving health outcomes through concurrent HIV program scale-up and health system development in Rwanda: 20 years of experience

Abstract

The 1994 genocide against the Tutsi destroyed the health system in Rwanda. It is impressive that a small country like Rwanda has advanced its health system to the point of now offering near universal health insurance coverage. Through a series of strategic structural changes to its health system, catalyzed through international assistance, Rwanda has demonstrated a commitment towards improving patient and population health indicators. In particular, the rapid scale up of antiretroviral therapy (ART) has become a great success story for Rwanda. The country achieved universal coverage of ART at a CD4 cell count of 200 cells/mm3 in 2007 and increased the threshold for initiation of ART to ≤350 cells/mm3 in 2008. Further, 2013 guidelines raised the threshold for initiation to ≤500 cells/mm3 and suggest immediate therapy for key affected populations. In 2015, guidelines recommend offering immediate treatment to all patients. By reviewing the history of HIV and the scale-up of treatment delivery in Rwanda since the genocide, this paper highlights some of the key innovations of the Government of Rwanda and demonstrates the ways in which the national response to the HIV epidemic has catalyzed the implementation of interventions that have helped strengthen the overall health system.

Community-Based ART Programs: Sustaining Adherence and Follow-up

“…In 2015, investigators from the government of Rwanda, PIH, and other groups reviewed the history of community-based ART scale-up in Rwanda and showed how the national HIV response yielded benefits to the country’s overall health system; Fig. 2 illustrates the successful scale-up of ART services, which now reach more than 150,000 patients in Rwanda [34]. To achieve such successes, Rwandan health authorities have relied heavily on task shifting: nurses run primary health care clinics and prescribe HIV treatment.…”

A case–control study of HIV infection and cancer in the era of antiretroviral therapy in Rwanda

“…In the era of cART, prolonged survival of PHIV in conditions of partial immune reconstitution is expected to give more time for the long‐term sequelae of carcinogenic viruses to manifest themselves as infection‐related cancers. Rwanda has implemented comprehensive nationwide access to cART since 2005,7 with the proportion of people living with HIV receiving cART estimated at 68% in 2014, rising to 80% in 2016, (http://aidsinfo.unaids.org). 8 HIV prevalence in Rwanda is estimated to have been stable from 2005 to 2015 at about 3% among adults age 15–49 9…”

Newspaper coverage of maternal health in Bangladesh, Rwanda and South Africa: a quantitative and qualitative content analysis

“…The 1994 genocide in Rwanda destroyed the country's healthcare system and drove hundreds of medical workers into exile, which in turn affected maternal morbidity and mortality. 16 Rwanda launched a community-wide health insurance scheme to address the health system crisis, supported by the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), and this scheme made care affordable for many women. 16 In addition, voluntary community health workers (CHWs) trained in basic maternal health services are playing a crucial role in reducing Rwanda's MMR.…”

“… 16 Rwanda launched a community-wide health insurance scheme to address the health system crisis, supported by the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), and this scheme made care affordable for many women. 16 In addition, voluntary community health workers (CHWs) trained in basic maternal health services are playing a crucial role in reducing Rwanda's MMR. 16 17 The CHWs provide family planning education and services, and monitor pregnant women within their community.…”