The health sector in Rwanda was deeply affected by the 1994 genocide, a dark period in the country’s history during which more than 1 million lives were lost and another 2 million people were displaced as refugees. Among the dead and displaced were health professionals. As a result of the ensuing civil war, the health sector was devastated. In the 18 years since, Rwanda has made remarkable steps towards recovery, particularly by restoring national security and overall stability, reinvigorating the economy and other sectors, including, the health sector.
Rwanda is a small, landlocked country located in central East Africa with a population of 11,038,000 people. Gross national income is approximately $1,260 (purchasing power parity). Life expectancy at birth is 60 years, which is higher than the regional average.
Communicable diseases (HIV/AIDS, TB, Malaria), perinatal and nutritional conditions constitute the most pressing health priorities for Rwanda. A third of all deaths are attributed to non-communicable diseases, including cardiovascular disease, cancer, diabetes, injuries and respiratory diseases. Per capita expenditure on health is $135 (PPP).
Rwanda is also though the first country in Africa to develop and implement a stand-alone national palliative care policy, a national palliative care strategic plan and practice standards. Launched by the Ministry of Health in April 2011, this ground-breaking policy commits the country to providing all Rwandans suffering from life threatening and limiting illnesses, with high quality and affordable palliative care services to meet their physical, psychological, social and spiritual needs by 2020.
The development of palliative care is Rwanda is significant because multi-disciplinary palliative care for patients with any disease is rarely integrated into the public health care system at any level in Africa. Yet, in Rwanda, we have developed palliative care services at Kibagabaga Hospital, a district general hospital located in the capital city, Kigali, and linked these services to home care.
Kibagabaga Hospital, serves the catchment area of Gasabo District, which includes 60% of the population of Kigali. Here, we initiated an adult and pediatric pain relief and palliative care program in 2009 utilizing short-term technical assistance and training by foreign experts. The program offers inpatient and home care services provided by trained physicians, nurses, social workers and pharmacists. Basic training in palliative care and home hospice care is provided by Rwanda Hospice Palliative Care Center and Palliative Care Association of Rwanda (RHPCC&PCAR), a private home hospice organization that has entered into an agreement with Kibagabaga Hospital, by signing a memorandum of understanding.
Initially, 2 physicians and 1 nurse were sent to Mulago Hospital in Uganda, supported by FHSSA (Foundation Hospice in Sub-Saharian Africa) and APCA (Africa Palliative Care Association) to receive necessary training in skills applicable to integrating the palliative care framework at Kibagabaga Hospital. Locally, continuing education is provided to support the professional development of the personnel involved. Administrators, general practitioners and nurses are continually being sensitized to palliative care. In addition, the Ministry of Health recently approved a palliative care training curriculum for government-employed community health workers with the intention of expanding access to and making sustainable, community-based palliative care.
Kibagabaga Hospital is the national referral center for palliative care. As of March 2013, 60 patients have received inpatient palliative care there. The majority were discharged home where follow-up care continues. Anecdotal reports indicate a high level of patient and family satisfaction with the palliative care services provided at Kibagabaga Hospital. Previously, palliative care was only available to those with sufficient resources to seek such services abroad. Now, patients with end-stage diseases in Rwanda have access to palliative care at their doorstep.
At the beginning of the program, the death rate for inpatients receiving palliative care was 3% and the bed occupancy rate was 85%. The average number of inpatients receiving hospital-based palliative care at Kibagabaga Hospital was 30, whereas the average number of patients receiving community-based palliative care in the community was 3. Most patients and their families preferred hospital-based palliative care over community-based palliative care. Since the initiation of the palliative care program, the average number of patients receiving hospital-based palliative care is 4 and the average number of patients receiving community-based palliative care is 25.
We ensure that each department of Kibagabaga Hospital is a focal point for palliative care. The continuum of care from the hospital setting to the community is maintained by nurses from Rwanda Hospice Palliative Care Center who are supported by Physicians and nurses from Kibagabaga Hospital.
Being a physician in charge of patients with life-threatening is an opportunity to be part of the development of my country in health sector; I feel honored to be there for many patients who share their smiles to our team. Challenges, weakness, strength are upstairs to make us better. I’m very grateful for special persons who made my life and sense of my professional career: Dr. Eric L. Krakaeur, Dr. Susan D. Block and Dr. Andy Billings.
I feel naked by the number of patients with life-threatening who die every day without any appropriate support, I feel naked by the number of patients who die with moderate and severe pain. I feel naked by the quantity of morphine used per year in Rwanda which is not enough for the whole country. I feel naked by the mentality of a physician who fears to use morphine because of myths. I feel naked when I am not able to help.
But I am not ashamed because I cannot do everything but nor must I do nothing.
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