Reduced premature mortality in Rwanda: lessons from success

Top Cited Papers
Open Access
Publisher Website
Google Scholar
Abstract
Reining in AIDS: a blueprint for strengthening health systems The Rwandan government laid ambitious plans to scale up access to health services in the years immediately after the genocide. Its Vision 2020 strategy for equitable social and economic development, produced in 2000, emphasised health as a pillar of the national cross-sector approach to reducing poverty. Funds for implementation were scarce, however, and AIDS and tuberculosis epidemics, compounded by a heavy burden of malaria and food insecurity, caused substantial premature death and disability.2 In December 2002, only 870 of the tens of thousands of Rwandans with advanced HIV disease were receiving antiretroviral therapy—most in private clinics in Kigali, and many erratically.6 In the early 2000s, new funding mechanisms, most notably from the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) and the US President’s Emergency Plan for AIDS Relief (PEPFAR), substantially increased development assistance for health, but these funds were often restricted to specific programmes, especially for HIV. It soon became apparent that advocacy and funding alone do not guarantee that quality health services will reach those who need them most. Rwanda sought to control AIDS, tuberculosis, and malaria, building a stronger health system as it did so. Integration of disease-control programmes was recognised as a worthy goal. From the start, Rwanda’s AIDS programme was characterised not only by efforts to integrate prevention and control but also by attention to concomitant problems such as tuberculosis and malnutrition, and to strengthening the healthcare system. As Rwanda’s minister of health, Dr Agnes Binagwaho, says: “If you give Rwanda money to save the life of the oldest person in Rwanda today, we will make sure that the infant born tonight benefits too.” Disease specific or “vertical” funding from the Global Fund and PEPFAR was used to rebuild the country’s health infrastructure and develop robust platforms for primary care.7 Similar approaches had been successful in rural Haiti.8 Scale-up of AIDS services began in cities and towns and then expanded into the rural regions in which most Rwandans live. In June 2012, 108 113 people with advanced HIV disease in Rwanda were receiving antiretroviral therapy, making Rwanda (along with much richer Botswana) one of only two countries in sub-Saharan Africa to achieve the United Nations goal of universal access to antiretroviral therapy.9 Rwanda’s HIV epidemic has remained at a prevalence of about 3% for the past seven years.10