Rwanda Non-communicable Diseases National Strategic
REPUBLIC OF RWANDAMINISTRY OF HEALTHP O BOX 84 KIGALIwww.moh.gov.rwRwanda Noncommunicable DiseasesNational Strategic PlanJuly 2014 – June 2019
TABLE OF CONTENTSExecutive summary . 4Preface by the Hon. Minister of Health. 5List of abbreviations and acronyms. 71Introduction and objectives. 91.1 Background and objectives of the document . 91.2 Planning process . 92Situational Analysis . 102.1 Demographics and epidemiology of NCDs . 102.2 Accessibility to NCDs service . 122.3 Cross cutting gaps among NCDs . 132.4 Clusters analysis: burden of disease, priorities and gaps . 142.4.1 Cluster 1: Cardiovascular, diabetes, and chronic respiratorydisorders . 142.4.2 Cluster 2: Cancers . 172.4.3 Cluster 3: Injuries and disabilities . 192.4.4 Cluster 4: Oral and eye health . 212.4.5 Cluster 5: Palliative care . 253Objectives and Strategies . 293.1 Strategic log frame and NCDs objectives. 293.2 Improved access and quality of care . 303.2.1 Availability of NCDs service . 313.2.2 Ensure quality of NCD service . 323.2.3 Ensure readiness of NCD services through improvement ofsupply chain, equipment, laboratory and internal process . 333.3 Improved general knowledge about prevention of risk factors andearly detection . 353.3.1 Community awareness . 363.3.2 Health facility awareness . 373.3.3 Screening and outreach programs . 384Development of a reliable M&E system, coordination and fund raising384.1.1 Improve the national response for prevention and control ofNCD 394.1.2 Inter-sectorial coordination and fund mobilization . 39
4.1.3 Develop partnership for research . 404.1.4 Design a reliable mechanism for systematic data collection andstrengthening the Monitoring and Evaluation system for NCDs . 405Costing and gap analysis . 425.1 Objective and process . 425.2 Costing methodology . 435.3 Costing results . 435.4 Funding estimates and gap analysis . 446Implementation plan for the financial year 2014-2015 . 456.1 Priorities and action plan 2014-2015 . 456.2 Monitoring and evaluation framework . 466.3 Key financial gaps to be filled for the entire planning timeframe . 467Conclusions . 478Bibliography. 49Annex 1: Prioritization tables for clusters . 54Annex 2: Cross cutting gaps identified during planning workshops . 61Annex 3: Costing details . 63
EXECUTIVE SUMMARYAccording to the Rwandan National statistics 2013, the Rwandanpopulation is ageing and the demand of NCDs service from people in 40’and 50’ is likely to increase.The WHO Rwandan burden of disease of NCDs and Injuries account 42%of the total deaths on the age group 10-40 surging to 63% in the over 40’s.Decentralized and comprehensive NCDs services are currently provided toa limited number of facilities.The vision for Rwanda is to have the entire population in Rwanda protectedfrom premature morbidity and mortality related to NCDs. The target is todecrease mortality of under 40’s of 80% by 2020 and save around 8,300 livesper year.In order to reach our target Rwanda should aim at the following outcomes:1. Improved access and quality of care;2. Improved general knowledge about prevention of risk factors andearly detection;3. Development of a reliable M&E system, coordination and fundraising.The yearly cost to reach the targets is around 20 billion RWF per year or 30million USD. Even if the trend of the resource available is increasing, thefinancial gap remains high at 15 million USD (50% unfunded). Incomparison with mortality of other diseases, the fight against NCDs appearsunderfunded.Given the funds available, the priorities for this year are to start thedecentralization of service to district hospitals and to reinforce the demandfor service by community awareness and early detection.In order to save more lives and reach our targets we still need to raise fundsinvestment in equipment, CHWs, M&E, supervision and coordination.
PREFACE BY THE HON. MINISTER OF HEALTH“ the world stands at a crossroads in the movement to confront the rapidlygrowing burden of non-communicable diseases such as heart disease, cancer, diabetes,and respiratory disease. We now face the challenge of equipping health systems withthe means to adequately prevent, treat and monitor this group of complex chronicconditions the complexity of this task is enormous and its urgency fierce, but thereis no question of whether we possess the tool to meet it head on. History will judgeus by our efforts to meet the challenge.”Dr. Agnes Binagwaho, Rwanda Minister of Health, March20121ForewordThe National Non-Communicable Diseases (NCDs) Strategic Plan 20142019 is results from the experiences and lessons learnt from the globalconcern to prevent and control NCDs. This is also in the effort to find waysto expand access to health care for NCDs, as they are a significant and oftensilent killer, particularly in low-income countries and low-income areas ofmiddle income countries. This strategic plan builds on the National NCDsPolicy 2013, the Rwandan Health Sector Strategic Plan 2013-2018, and theRwandan Economic Development and Poverty Reduction Strategy II(EDPRS), 2013-2018.The Government of Rwanda recognizes that the problem of access tohealth care for all health conditions, particularly NCDs is not only a healthsector issue, rather a multi-sectorial challenge that needs all sectors to worktogether in synergy so as to deliver a comprehensive health care packagewith fully community participation. Specifically, the full health care packagefor NCDs prevention and control is made of the community sensitizationfor behavioral change, primary and specialized health care and treatment,and prevention and control of NCDs risk factors.The elaboration of this strategic plan is a clear statement of the Governmentof Rwanda’s commitment to decrease significantly the mortality andmorbidity related to NCDs by implementing the full package of NCDsprevention and control as defined by the National NCDs Policy, 2013. Thisstrategic plan aims at reaching 6 key strategic objectives as defined by theWorld Health Organization (WHO) to prevent and control NCDs and theirrisk factors, and this concord with the 6 key strategic objectives for NCDsas outline in the Rwandan HSSP III 2013-2018. These key strategicobjectives will guide the Ministry of Health and its partners in theimplementation of NCDs prevention and control programs. This includes1Agnes Binagwaho, “Meeting the Challenge of NCD: We Cannot Wait,”Global Heart 7, no. 1 (March 1, 2012): 1–2, doi:10.1016/j.gheart.2012.01.004(Binagwaho, 2012).
the community mobilization and strengthening the capacity of decentralizedhealth structures for program design, implementation, monitoring andevaluation for the provision of holistic and sustainable health care servicesto communities with their full participation, this through district communityhealth plans which will be integrated in the overall district plan.It is hoped that all stake holders for this strategic plan will rise to challengeand provide both technical and other resources necessary to move thisforward. The Government of Rwanda is committed to lead this multisectorial process to achieve the set objectives and ensure that the wholecountry is fully implementing the NCDs health care package at all levels, thedecentralized NCDs interventions playing the rightful role in sustainabledevelopment of Rwanda.Dr Agnes BINAGWAHOMinister of Health of Rwanda
LIST OF ABBREVIATIONS AND ACRONYMSCBHICommunity-Based Health InsuranceCDCCenter of Diseases ControlCHUKCentre Hospitalier Universitaire de KigaliCHWsCommunity Health WorkersCVDsCardiovascular DiseasesDHsDistrict HospitalsDPOsDisabled People's OrganizationsECGElectrocardiogramEDPRSEconomic Development and Poverty Reduction StrategyEMRElectronic Medical RecordFHIFamily Health InternationalHCHealth CenterHRHHuman Resources for HealthHIV/AIDSHuman Immunodeficiency Virus/ Acquired Immunodeficiency syndromeHMISHealth Management Information SystemHSSPHealth Sector Strategic PlanIECInformation Education CommunicationIMRIndividual Medical RecordsKIHKigali Health InstituteLMICLow and Middle Income CountriesM&EMonitoring and EvaluationMDGMillennium Development GoalsMDRMultidrug ResistanceNCDsNon-Communicable DiseasesNGOsNon-Governmental OrganizationsNISRNational Institute of Statistics of RwandaNURNational University of RwandaOBPObjectives-Based PlanningPIHPartners in HealthPWDsPersons living with disabilitiesRBCRwanda Biomedical CenterRDARwanda Diabetes AssociationDHSDemographic Health Survey
TBTuberculosisTWGTechnical Working GroupUNUnited NationsWHOWorld Health Organization
1 INTRODUCTION AND OBJECTIVES1.1Background and objectives of the documentThe process of planning of Non Communicable Diseases (NCDs) started inJuly 2013 when the Hon. Minister of Health Dr. Agnes Binagwahoannounced at the inaugural meeting of the NCD Synergies network thetarget of decreasing the NCDs mortality by 80% for people under 40 by2020 or “80x40x20". Since then the Rwandan Biomedical Center has takenthe lead to draft and implement a clear strategy to reach the 80x40x20target.The key challenge of the strategic planning process was the lack of internalreliable data about the burden of disease for NCDs that might haveinformed a strong evidence based approach for planning. Given thelimitation of data, 3 progressive phases were identified with the goal ofhaving a data driven, ambitious, realistic and cost effective NationalStrategic Plan for NCDs. Key objectives for the period 2014-2019 include:1. Phase 1: “Understanding phase”. To be carried out in the next 2 yearand concerning the following strategic goals:a. Goal 1: Pick the low hanging fruits by addressing the obviousneeds and priorities;b. Goal 2: Design a reliable mechanism for systematic datacollection and analysis and develop a one-year plan for itsimplementation.2. Phase 2 and 3: “Planning and implementing phase”. To be carried outfrom 2015 on and relative to:a. Goal 3: Review and develop an ambitious, realistic and costeffective plan for the remaining 3 years 2016-2019, based onthe information collected by the mechanism implemented bythe goal 2 and implement the plan in the following 3 years.1.2 Planning processAccording to the strategic goals reported above, the planning methodologywas based on the combination of qualitative considerations from expertsand the best available quantitative evidences.A series of workshops took place during the month of March 2014involving staff from Referral Hospitals, the RBC/NCD division, developingpartners, MOH/clinical service, RBC/MPPD, RBC/NRL. The goals of theworkshops were to have consensus on the burden of disease for eachmedical condition, carry out a prioritization exercise and identify for eachprioritized medical conditions the gaps and the suggested strategies.Following the completion of the prioritization exercise and the identificationof gaps and strategies, the planning team reviewed all the activities and
produced an initial costing. The costing was then analyzed in a dedicatedworkshop with the goal to find efficiencies by integrating activities andfinding the most cost effective way to deliver services.The last step of the process was the estimation of the funding available infrom different sources of funds and the relative gap analysis. This last stepwas strongly supported by the Health Financing Unit.2 SITUATIONAL ANALYSIS2.1 Demographics and epidemiology of NCDsAccording to 2013 National Statistics2, in the last 36 years Rwanda has morethan double its population’s size growing from 4.8 million of 1978 to almost10.5 million of 2013.The growth of the population is explained by the combination of 2 keyindicators (see figure below). While from one side the life expectancy hassurged from 46 years in 1978 to almost 65 years in 2012, on the other sidethe average number of children per woman has decrease sharply from 8.6children in 1978 to around 4 children in 2012.The combination of the 2 indicators outlines the fact that the Rwandanpopulation is ageing and the health system will gradually need to adjust to agreater demand of Non Communicable Diseases (NCDs) services frompeople in the 40’s and 50’s as it is expected that the trends of life expectancyand fertility will continue in line with the national targets.7098.6Life Expectancy 19781991Life expectancy at birth (years)20022012Total fertility rateSource 1: Rwanda Statistical Yearbook 201328Rwanda Statistical Booklet 2013 (NISR, 2013)Average number of children per womanFigure 1: Life Expectancy and average number of children per woman (TFR)
Even though the demand on NCD’s service might soon come from over40’s, estimated data3 shows that while in less than 10 years old only 14% ofthe overall mortality is due to NCDs and injuries, in the age group 10-40and over 40 the mortality due to NCDs skyrocket to 42% and 63%respectively.Figure 2: Rwanda deaths by broad cause by age (GBD 2010)8,0007,0006,000Deaths5,000 10NCDs andInjuries 14%10-40NCDs andInjuries 42% 40NCDs andInjuries 63%4,0003,0002,0001,0000Communicable, Maternal, Neonatal, NutritionalNCDsInjuriesSource 2: Global Burden of disease 2010The data of the Rwandan Global Burden of Disease (GBD) estimated bythe WHO gives also important information about the epidemiology ofNCDs in Rwanda. Between 10 to 40 years old the major part of the NCDsand Injuries mortality is due to road accidents and interpersonal violence(25%) with the remaining part is represented by cancer (3%), cardio vasculardiseases (4%) and other NCDs (9%).In the older range over 40’s the NCDs epidemiology changes and the maincauses of mortality are mainly represented by cardiovascular diseases (26%),cancer (10%) and other NCDs (12%) while injuries mortality drop down to8%.In order to double check the reliability of the WHO data, the figures ofdeaths due to injuries reported in the GBD were compared with the nationaldata of the injury registry held by referral hospitals (CHUK, CHUB). Theinjury registry data indicates that around 15% of the overall deaths inhospitals are caused by injuries. This figure is almost aligned with thenational estimate of the GBD of 11%. The discrepancy of 4% might be3Global Burden of Disease 2010 for Rwanda
explained by the high level of emergency care provided by CHUK to roadtraffic injuries that might not be applicable to other hospitals around thecountry.2.2 Accessibility to NCDs serviceOne of the key priorities outlined in the Health Sector Strategic Plan III isthe accessibility (geographical, community health and financial,) to qualityhealth service.The provision of comprehensive NCDs service in Rwanda started in 2005when an innovative model to provide NCDs service in rural settings waspiloted in 3 districts (see map below). The model has been based on anintegrated approach establishing NCDs programs in 3 district hospitalswhere Rwandan doctors and nurses had protected time to practice side byside with international professionals, becoming mentors for the colleaguesof the hospital and of all the health centers in the relative catchment area.During the years the model has evolved and included the community healthworkers or other identified people in the community to follow up adherenceto treatment on the patient.Outside the 3 districts covered by the pilot project the strategy to provideNCDs service at decentralized level has been based on providing one-offdidactical training to specific personnel of district hospitals and the trainingof medical students at central level through the HRH program.According to the data of the Integrative and Supportive supervision4 whilearound 80% of the district hospitals had at least one staff trained in NCDsonly 2 district hospitals (5%) have the capacity to perform systematically theHbA1c to diabetic patients.Data of the integrated supervision integrated supported by the reflectionsraised during the planning workshops suggest that while staff has beentrained, the comprehensive NCDs service still need to be made availablecountry wide.4ISS performed by RBC/MOH in February/April 2014
Figure 3: District with comprehensive NCDs servicesSource 3The following sub-chapters report the analysis of programmatic gapsdivided by:1. Cross cutting gaps among NCDsand2. Specific programmatic gaps of NCDs clusters2.3 Cross cutting gaps among NCDsThe table reported in the annex B reports the gaps identified during theplanning workshops regarding the health systems (Human Resource,Infrastructure, Equipment, Supply chain, Health financing). In summary keythemes identified across all the clusters are: The lack of specific equipment, mainly at district level affects theprovision of decentralized NCDs services; There are challenges on the supply chain and on the availability ofspecific NCDs drugs and consumables. The issues affect thereadiness of NCDs services; The quantity and quality of human resources is not sufficientespecially at decentralized level. Challenges of staff retention andmotivation affect the effective provision of quality services; Poor data collection on NCDs cases;
Clinical Services and procedures should be improved (palliative care,medical follow up, referral system, rehabilitation, counseling).The following paragraphs will investigate the specific gaps and priorities ofeach cluster.2.4 Clusters analysis: burden of disease, priorities and gapsThe following sub-chapters report for each programmatic area, the keyinformation available on the burden of disease, th
The vision for Rwanda is to have the entire population in Rwanda protected from premature morbidity and mortality related to NCDs. The target is to decrease mortality of under 40’s of 80% by 2020 and save around 8,300 lives per year. In order to reach our target Rwanda should aim at the
The Economics of Non-Communicable Diseases in Indonesia report was written by Bloom, D. E., Chen S., McGovern M., Prettner K., Candeias V., Bernaert A. and Cristin S. 3 4 6 9 11 12. The Economics of Non-Communicable Diseases in Indonesia 3 Overview and purpose Non-communicable diseases (NCDs) have been
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EPIDEMIOLOGY OF NON-COMMUNICABLE DISEASES LEARNING OBJECTIVES 1. List risk factors relevant to selected non-communicable diseases 2. Identify general concepts, risk factors, healthy lifestyle, risk modification, primary and secondary prevention of NCD 3. Explain the importance of periodic examinations 4.
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Communicable Disease Control vi 5.2 Introduction 92 5.3 Mosquito-borne Diseases 93 5.4 Flea-borne Diseases 106 5.5 Louse-borne Diseases 111 5.6 Snail-borne Diseases 116 Review Questions 126 CHAPTER SIX: SEXUALLY TRANSMITTED DISEASES 122 6.1 Learning Objectives 12
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