Innovations in Rwanda's health system: looking to the future

Rwanda is making substantial progress towards improvement of health and is working towards achievement of the Millennium Development Goals, which is a challenging task because the country has had genocide in 1994, has few natural resources, is landlocked, and has high population growth. Like many impoverished sub-Saharan countries, Rwanda's health system has had an uncoordinated plethora of donors, shortage of health staff, inequity of access, and poor quality of care in health facilities. This report describes three health system developments introduced by the Rwandan government that are improving these barriers to care-ie, the coordination of donors and external aid with government policy, and monitoring the effectiveness of aid; a country-wide independent community health insurance scheme; and the introduction of a performance-based pay initiative. If these innovations are successful, they might be of interest to other sub-Saharan countries. However, Rwanda still does not have sufficient financial resources for health and will need additional external aid for some time to attain the Millennium Development Goals. 2008 Elsevier Ltd. All rights reserved.sch_iih372pub54

Micronutrients and T-cell subsets: a comparison between HIV-infected and uninfected, severely malnourished Rwandan children

Objective: To determine the levels of CD4+ cells and micronutrients in HIV-infected and uninfected severely malnourished children. Design: Cross-sectional study in two centres. Setting: Children admitted to the malnutrition units in Kigali and Butare, Rwanda. Patients: A total of 112 children aged 2 months to 5 years presenting with severe malnutrition (weight for height Z-score -3 SD +/- oedema). Fifty-two (46.4%) were HIV-infected. Methods: CD4+ counts, selenium, zinc and copper levels were measured. The percentage of CD4 cells was calculated as a proportion of total lymphocyte count. Results: The mean age of the 52 HIV-infected children (18 months) was lower than of the 60 uninfected children (26 months) (p=0.01). Six (11.5%) of the HIV-infected had oedematous malnutrition compared with 50% of the uninfected group. The mean (SD) CD4+ count was 1054 (780) in the HIV-infected and 1579 (721) in the uninfected group (p=0.001). The CD4+ count was also significantly lower in the HIV-infected group than in the uninfected group for the ages 36 mths (p=0.001). In HIV-infected children, 17% had severe immunosuppression (25%) compared with 9%, 12% and 80% in the HIV-uninfected group, respectively (p<0.001). Approximately one-third in both groups had low levels of selenium and zinc and 77% had raised levels of copper. In multivariate analysis there was significant correlation between selenium and CD4+ (r=0.36, p<0.001) in HIV-infected children and no correlation of zinc and copper to CD4+%. In HIV uninfected children, CD4+% was related to selenium (r=0.282, p=0.03) and to zinc (r=0.264, p=0.047) but not to copper. Conclusions: In severely malnourished children with HIV infection, low CD4+ levels are associated mainly with HIV infection. There was no significant difference in levels of selenium, zinc and copper between HIV-infected and uninfected children

Rwanda's health system: some concerns Authors' reply

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Determinants of nonadherence to a single-dose nevirapine regimen for the prevention of mother-to-child HIV transmission in Rwanda

Not the final published versionObjectives: To describe experiences, and identify factors associated with nonadherence to a single-dose nevirapine (SD-NVP) regimen for the prevention of mother-to-child transmission (PMTCT) of HIV in Rwanda. Methods: In April to May 2006, using a case-control design at 12 PMTCT sites, we interviewed HIV-infected women who did not adhere (n = 111) and who adhered (n = 125) to the PMTCT prophylaxis regimen. Nonadherence was defined as mother and/or infant not ingesting SD-NVP at the recommended time or not at all and adherence as mother-infant pairs who ingested it as recommended. Results: Only 61% of nonadherent women had received SD-NVP during pregnancy or delivery. Among nonadherent women who received SD-NVP, 80% ingested it at the recommended time, representing 49% of all nonadherent women. Only 7% of their newborns ingested SD-NVP. Multivariate logistic regression showed that unmarried women, less educated women, women who made 2 or less antenatal care visits, and those offered HIV testing after their first antenatal care visit were more likely to be nonadherent to PMTCT prophylaxis. Not disclosing one's HIV status to someone aside from a partner was also associated with nonadherence in mother-infant pairs. Conclusions: Sociodemographic factors, health services delivery factors, and a lack of communication and social support contributed to nonadherence to PMTCT prophylaxis in Rwanda

Pregnancy desires, and contraceptive knowledge and use among prevention of mother-to-child transmission clients in Rwanda

Objective: To understand pregnancy intentions and contraception knowledge and use among HIV-positive and negative women in the national prevention of mother-to-child transmission (PMTCT) program in Rwanda. Design: A cross-sectional survey of 236 HIV-positive and 162 HIV-negative postpartum women interviewed within 12 months of their expected delivery date in 12 randomly selected public-sector health facilities providing PMTCT services. Methods: Bivariate analyses explored fertility intentions, and family planning knowledge and use by HIV status. Multivariate analysis identified socio-demographic and service delivery-related predictors of reporting a desire for additional children and modern family planning use. Results: HIV-positive women were less likely to report wanting additional children than HIV-negative women (8 vs. 49%, P < 0.001), and although a majority of women reported discussing family planning with a health worker during their last pregnancy (HIV-positive 79% vs. HIV-negative 69%, P = 0.057), modern family planning use remained low in both groups (HIV-positive 43% vs. HIV-negative 12%, P < 0.001). Condoms were the most commonly used method among HIV-positive women (31%), whereas withdrawal was most frequently reported among HIV-negative women (19%). In multivariate analysis, HIV-negative women were 16 times more likely to report wanting additional children and nearly 85% less likely to use modern family planning. Women who reported making two or less antenatal care visits were 77% less likely to use modern family planning. Conclusion: Our results highlight success in provision of family planning counseling in PMTCT services in Rwanda. As family planning use was low among HIV-positive and negative women, further efforts are needed to improve uptake of modern methods, including dual protection, in Rwandan PMTCT settings