Tour of an Urban Clinic in Gitega

I learned so much today while touring a local urban health center, where to begin? There are so many aspects about how HIV prevention has been addressed in Rwanda that are incredibly impressive, on a world-wide scale. We had some visitors from Guyana visiting today (through this week), and they were discussing the problems which they are having in establishing similar couples counseling and testing sites as well as prevention of mother-to-child-transmission (PMTCT) clinics in their country and it really put into perspective how incredibly progressive Rwanda is. The biggest problem they seem to be having is a lack of male-partner involvement in health awareness. Men there do not seem to want to be HIV-tested, come in for regular health visits, or be involved in the family planning necessary for prevention of mother to child transmission. Amazingly in Rwanda's HIV health centers, I've been told the partner involvement is >85%, largely due to President Kagame's nationwide speech advocating the importance of HIV prevention and couples counseling in 2003. When we asked some of the male patients at a local urban clinic what made them want to come into clinic with their wife, they were really matter of fact about how they want to know their own HIV-serostatus and that of their partner in order to prevent transmission to their future children. (I guess we would tend to think that's a pretty obvious reason, but I think globally from what I've heard it really isn't yet.) One gentleman explained how marriage is a partnership and he knows that his health affects his spouse's, and how that idea must start at the family/community level in order to make an impact. I think the Guyanan visitors wanted to put him in their pocket and fly him home to Guyana. :)

The key to Rwanda's success seems to be the genuine partnership between local communities and health centers, outside sponsors/NGOs and most importantly the Rwandan government, which I've learned is really quite involved with improving HIV prevention and education. Antiretroviral medication is available freely for all HIV-infected persons in need from urban health centers (without the need for any health insurance). Rwanda does have the option of a national health plan which costs $2/year (of which ~90% Rwandese possess). The insurance covers some medical costs, but not all. Our clinic offers that national health plan to all enrolled patients as well as general medical care and long-term contraceptives. Due to logistics and funding issues, the clinic is able to refer the patient back to the original health clinic that they visited initially in order to receive the free ARTs, but we are not able to provide that treatment on site. The government has a 5-year plan to eliminate MTCT transmission. In speaking with an NGO here that works closely with the government-run health centers, he also said that they are working on advocating male circumcision for all males using a new plastic device (currently being developed in Israel, as I recall) that actually kills the foreskin cells and can be removed one week later. Not totally sure on the details of how it works, but it sounds interesting as a non-surgical approach for male circumcision, which has proven to be an effective method of prevention.

And they have this really neat program of accountability called Rwanda Performance Based Financing in which the government (in conjunction with USAID and other groups), establishes certain goals and indicators (in all a lot of non-health fields as well, including education and agriculture) with hospitals and other facilities to reach within a year. For example within our field, at an urban health center, there may be a goal to HIV-test X number of couples within a year. If the goal is met, the clinic will receive Y Rwandan Francs/couple tested, and that money feeds back to the facility itself to expand operations. If you don't achieve the goal, the finances allotted to the establishment is proportional to the success of the indicator. There is a QC process where a health director from another province would come to your province and evaluate the success of the goal, and vis-versa. This idea of setting goals (I've been told) is even present at the community grassroots level where communities will establish common indicators of health (# bednets distributed, # couples tested, agriculture needs). There is a sense of competition between regions on meeting these quality of life indicators and annually, community leaders meet to discuss and identify problems they are having and ask other local regions if they have similar problems and if so, how they were able to resolve them. Pretty neat! Needless to say President Kagame is quite popular amongst the people, and has definitely made it a priority to implement accountability at all levels to improve the quality of life here in Rwanda. Anyway, there's much more I could say, but I need to get home before another terrential downpour. Forgot my raincoat at home, so it's going to be a sloppy jog home!