The Integration of Palliative Care in Rwanda Health System

1. REPUBLIC OF RWANDA
MINISTRY OF
HEALTH
The Integration of Palliative Care in
Rwanda Health System
Dr. Marie Aimee MUHIMPUNDU ,
MD, MSc
THET Annual Conference
London 23rd -25th October,
2017

2. Rwanda’s economic growth has resulted in a
reduced fertility rate, in turn reducing maternal and
child mortality rate and aging the population.
1
46.4
53.7
51.2
64.4
8.6
6.9
5.9
4.2
3
4
5
6
7
8
9
20
25
30
35
40
45
50
55
60
65
70
1978 1991 2002 2012
TotalFertilityRate
LifeExpectancyatbirth
Life Expectancy and TFR
77.8%
58.9%
56.7%
44.9%
39.1%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
1994 2000 2005 2010 2014
Poverty rate

3. DALYs due to NCDIs in Rwanda, Global Burden of
Disease, 2015
2

4. NCDs Burden in Rwanda
•NCDs, a global public health problem, the cause of high
mortality, 36 million (63%) deaths of the 57 globally
•Expected to increase in LMICs
•Increased risk due to adoption of western lifestyle,
urbanization and globalization
•In 2016, NCDs were 25% of total cause of consultation at
health facilities and deaths account for 29% deaths
• More than 70% of funds allocated to the referral board is used
for chronic kidney diseases, heart diseases and Cancers

5. NCDs Risk Factors
• Tobacco use is at 12.9%
•Alcohol use is at 41.3% ( measured the quantity consumed not the
alcohol %)
• Obesity 2.7 % and overweight 13.5%
•Hypertension is 15.9%
• Diabetes 3%
• Urban 6.6%
• Indoor and outdoor pollution plays role in exacerbation of chronic
respiratory diseases

6. Palliative Care introduced in 2011
Vision
All people living with life limiting illnesses in Rwanda will have
access to quality palliative care services delivered in an affordable
and cultural manner by 2020
Key Strategies
•Integrate PC in the health system
•Public awareness
•Improve accessibility and quality of care
•Develop human resource capacity
•Reinforce operational research

7. In 2012, INTEGRATE supported PC activities in
Rwanda
Sites:
• 3 hospitals supported
• CHUK, Rwamagana and Kibagabaga
Key achievements
• Training of HCP ( 60 ToT), 120 HCP from DH, 60 HCP from HC
and 30 local mentors
•Advanced training: post graduate diploma and mentorship from
UK team
•Clinical Placement ( 12 in Uganda and 52 in country)

8. Phase 2 from 2015 to 2017
Sites:
• 7 hospitals supported
• Byumba, Kinihira, Nyamata Kiziguro, CHUB, Kabutare and
Remera Rukoma
Key achievements
• Training of HCP 624 HCP from DH, 270 HCP from HC, 174
Community HCWs
• 6 curriculum developed ( 3 already implemented :Mmed Internal
medicine, mentorship and supersion and HBCP)
• 3Clinical Placement

9. Overview of the Rwandan Health System
Teaching & Tertiary
hospitals
~ 250
~ 255, 000/
MDT ( 5
staff)
National
(~12 m)/
PC desk
Health care
delivery system
Av.Catchment
area pop/ HR
for PC
Health
centers
Health posts
No. of public
facilities / CHWs
499
408
45,000
District hospitals
~ 23
000/ 2
nurses in
182 HC
Type of service offered
▪ Specialized hospitals serving the entire country
▪ Medical training
▪ Provide government defined “minimum package of
activities at the peripheral level (MPA)
▪ This includes complete and integrated services such as
curative, preventive, promotional, rehabilitation services
▪ Supervise health posts and CHWs operating in their
catchment area
Community-based :
• Prevention, screening and treatment of
malnutrition
• Integrated Management of Child Illness (CB-IMCI)
• Provision of family planning
• Maternal Newborn Health (C-MNH)
• DOT HIV, TB and other chronic illnesses
• Behavior change and communication
Provinces
(4)
Sector (416)
District (30)
▪ Provide government defined “Complementary package of
activities (CPA) (C-section, treatment of complicated
cases,..
▪ Provide care to patients referred by the primary health
centers
▪ Carry out planning activities for the health district and
supervise district health personnel
36
8
▪ Services provided are similar, albeit reduced from, that by
Health Centers.
▪ Established in areas which are far from health centers,
▪ Services include curative out-patient care, certain
diagnostic tests, child immunization, growth monitoring for
children under five years, antenatal consultation, family
planning, and health education
Village (14,837)
Cell (2148)
Administrative
structure
Community
Health
Workers
Provincial
hospitals
4
200 HBCPs

10. Key Achievements
M&E and
Surveillanc
e System
Improved
access and
Quality of
Care
Governance
&Awarenes
s
Universal Health Coverage Is Solution
• National policy and strategic plan stand alone then integrated in NCDs
• Public awareness through the media
•Celebration of the World palliative care day
• Capacity building at health facility level
• PC desk at referral and provincial hospitals
• Multidisciplinary teams at DH and HC
• Home based care
• Availability of all forms of morphine
• Services included in the community based health insurance
scheme
• Indicators for PC included in the health information system
• Part of the integrated supervision and data quality assurance
Implementation Process of NCDs EMR Module
• M&E Tools

11. National Level
• Set up national Palliative Care Technical Working Group
(PTWG)
• Harmonization of Training curriculum/Manual
• TOTs
•Coordination of HBCPs
• Development of PC Legal Framework
• M&E/Research
District Level
• Set up district PC Multidisciplinary Team
• Quantify and Procure Morphine
• Provide PC services
• Capacity building including for Health Centers
• M&E/Research ; Report to next level
Training institutions
• Integration of PC in pre-
service training
HC Level
• Set up Palliative Care Team
• Quantify and Procure Morphine
• Provide PC services
• Capacity building ( Case discussion)
• M&E; Report to next level (DH)
Community Level
Home based Care Practitioners
•Provide NCDs and PC basic services & supervise
morphine use at home level,
• M&E/; Report to next level (HC)

12. Lessons learnt from the Partnership
▪Regional collaboration
– Mentorship
– Clinical placement
– Training facilitation
▪The model served to scale up at decentralized level
▪Involvement of other sectors ( education, local government)
– Pre-service training
– Sustainability of the services
– Awareness of the population
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