Background: This summer I traveled to Rwanda with a program called Engineering World Health. Along with eighteen other students, I am spending 9 weeks in Rwanda—4 taking language and medical device repair classes and the remaining 5 weeks fixing medical equipment in one of the hospitals here. Earlier this week all of the students had the opportunity to visit one of the hospitals in Kigali, the capital. We started to comprehend some of the complex challenges faced by healthcare systems in developing countries.
Last Monday and Tuesday I visited a Rwandan hospital for the first time. “CHUK” (Centre Hospitalier Universitaire de Kigali) is one of the teaching hospitals in Rwanda and is generally regarded as one of the best here. It was striking how different it looked from a typical American hospital.
Almost all of the buildings are single story, and all are disconnected. In order to get from the radiology wing to the maternity ward (or between any other departments), you must walk across a road (not a public road, just one inside the hospital grounds. But as we’ll see later, this is actually a major problem). At a glance, the hospital seemed to have most of the modern equipment you would expect in a U.S. hospital—monitoring systems, hospital beds, infant incubators, bili lights, imaging equipment, etc.
However, closer examination revealed many omissions. First, there are no private patient rooms. Instead, all patients in a particular wing are lined up along a wall with a curtain to partially separate them (the curtain is considered a luxury here, as many hospitals do not have them). The beds all appeared to be manually operated (not automated) and many had no railings. I did not get a chance to see an operating room but I am curious what the conditions are.
While touring the hospital, I met an American radiologist who is here in Rwanda for two years working to improve the quality of care through the Human Resources for Health Program. I had the chance to speak more with him. He had some very interesting and surprising (at least to me) insights about medical care in Rwanda. He first described challenges he has met in the radiology department. CHUK is lucky in that it has one of only two CT scanners in the country. Yet, it faces a slew of issues. First, there is no good way to store and back-up patient data. Instead, he loads any cases he wants to save onto a personal external hard drive. Also, the multiple power outages each day can make uninterrupted scanning difficult. Not to mention that much of the staff is inadequately trained.
When he initially arrived, the workflow was very inefficient. Sometimes, people who needed emergency CT scans would have to wait days, or else another patient would have to be bumped from the schedule. Why is it such a problem to bump a low priority patient and simply reschedule them for another day? As it turns out, it’s a huge problem: some patients travel for more than day to get to the hospital and even sell their livestock to pay for a service as expensive as a CT scan. (The National Healthcare here is actually very affordable, at least by American standards. Rwandans pay approximately $6 USD per year for the insurance, which covers 90% of the cost of any treatment. But for an expensive scan, 10% of the cost can still mean having to sell one’s goat). Even if that patient was able to sell their goat to get the scan, asking them to stay in Kigali for another day could be beyond their financial capabilities. Now, emergency patients can be worked into the schedule without needing to bump another patient due to increased inefficiencies. However, there’s still a lot of room for improvement.
The roads bisecting the different wings of the hospital are peppered with potholes full of potholes—not just small bumps but gaping holes that are ~6 inches deep and over 1 foot in length. Which means wheeling patients on hospital beds without rails between wards in the darkness of night is completely out of the question. Which means the CT scanner is effectively useless for half of every day. People may grumble about high costs and inefficiencies in the U.S. healthcare system, but at least we can use our scanners 24 hours a day 7 days a week.
And what happens if the machine breaks? It can take days to secure the proper equipment and a trained technician to fix it. In the case of some medical equipment, a technician must first fly to another country (for example, France, which has happened in the past) to be trained in how to fix the equipment. Then, assuming they can obtain and install the parts, the equipment can return to use—days or even weeks later.
But the complexity of the problems underpinning healthcare in Rwanda do not stop there. Many of the native Rwandan doctors are poorly trained. This stems in part from the poor medical training here in Rwanda. But the issue is even more systemic: the government requires 3 years of service from all newly graduated doctors. On the surface, this is important and beneficial because it prevents brain drain (new doctors leaving the country so they can make more money elsewhere). However, it also means that brand new doctors are practicing without much practical experience—no internship, no residency, and certainly no fellowship. Even though they are supposed to be supervised for the first year, they often are not. And when they are supervised, another poorly trained doctor often provides the ‘supervision.’ What does this all mean? For the first years of a physician’s career (arguably their most formative) their medical knowledge is being informed not by evidence-based medicine but by some extent of trial and error. For example, they might give a patient the wrong treatment but the patient still gets better, or they might give the patient the right treatment but the patient still gets worse. Either way, being unsupervised can encourage bad habits, which leads to bad doctors and poor healthcare quality. (Perhaps this could actually be considered ‘evidence-based,’ but the evidence is poor and one-off cases can misinform young doctors.)
Currently, just 725 doctors serve 11.5 million people in Rwanda (roughly 1 doctor per 16,000 people), an astounding undersupply of doctors. Compare that to the U.S. where there are 209,000 primary care physicians (which does not include specialists) for 314 million people, or roughly 1 doctor per 1,502 people. The Rwandan Ministry of Health plans to double the number of medical school graduates in the next year to address this problem. Does that seem like a tall order? Consider this: 6 years ago Rwanda’s Ministry of Education abruptly changed from teaching all students in French to teaching in English without adequately training the teachers the new language. Much like the language change the abrupt increase in medical school graduates is likely to be fraught with issues. And consider this; the current medical school graduates are poorly trained and have a lack of supervision. So doubling the output of doctors, even if it could be done in just a year, is unlikely to increase the quality of care delivered.
Despite the shortcomings in Rwanda’s healthcare system, the country has progressed tremendously. In 1994, decades of ethnic tensions and one-sided massacres of Tutsi people by Hutu people culminated in a genocide of over a million people. The largely successful reconciliation process spurred improvements in the economy, political structure, and healthcare delivery. The average life expectancy rose from 27 in the early 1990s (the lowest in the world at the time) to 63 in 2011. The national health insurance program means that almost all Rwandans are insured. HIV, TB, and malaria deaths have dropped by over 80% in the last decade. Partners in Health, a nonprofit healthcare organization, has a much more comprehensive and visually appealing glimpse of the improvements (infographic). It is easy to fault the Rwandan healthcare system upon seeing their facilities for the first time, but the numbers tell a fuller picture: while there is a lot of room for improvement, healthcare has progressed significantly in the past two decades.
The experience of walking through the halls of a Rwandan hospital and seeing the patients has been humbling. Many students, myself included, focus on research and design projects that aim to improve healthcare. But we often overlook the complex challenges that could undermine any solution we propose. Building a better CT scanner might save a few lives in a country like Rwanda, but optimizing workflow for the device they already have or even repaving the hospital roads could save appreciably more lives.
For more information about my travels in Rwanda and the history of Rwanda (especially the 1994 Genocide, which has shaped the last two decades of the country) visit www.neilrens.wordpress.com