Rwanda Health. Statistics. Rwanda Ministry of Health Annual Statistics

Transcription

1 Rwanda Health Statistics 1

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3 Contents Acronyms: vi Foreword 1 Introduction 2 Health Sector Infrastructure 3 Health Facilities 3 Health Facility Equipment and Utilities 7 Communication 9 Human Resources 11 Morbidity and Mortality 11 Outpatient care 11 District Hospital Outpatient Morbidity 13 Health Centre Outpatient Morbidity 14 Hospitalization and Mortality Admissions and 15 mortality in health centers and district hospitals 15 Leading causes of mortality in health facilities 16 Under five morbidity and mortality 17 Maternal and Child Health 18 Family Planning 18 Ante-Natal Care 20 Cesarean sections at Hospitals 22 Weight at birth and deaths of newborns 23 Child immunizations 24 Growth Monitoring 24 Malnutrition 25 Hospitalization for Childhood Malnutrition 25 Outpatient treatment of Malnutrition 25 Community Health Worker Program; 26 Community IMCI: 26 Sexual Violence 28 TB and HIV/AIDS 29 Tuberculosis (TB) 29 HIV /AIDS 30 VCT 30 PIT 31 i

4 Preventing Mother to Child Transmission (PMTCT) 31 HIV exposed infants follow up 33 Care and treatment 33 HIV among Groups at high risk. 33 Youth 33 Youth Sexual behavior trends analysis 34 Youth Comprehensive knowledge of HIV. 35 Female sex workers 36 Condom use 36 HIV Prevalence by Background Characteristics 37 HIV comprehensive knowledge 39 Malaria 40 Laboratory 42 SURGERY 42 RADIOLOGY 44 PERFORMANCE-BASED FINANCING: 44 COMMUNITY-BASED HEALTH INSURANCE /MUTUELLE (CBHI) 46 Sources of Data 48 HMIS 48 Rwanda National Population Projections TracNet 48 PBF 48 CBHI indicator database 48 Rwanda District Health System Strengthening Tool (DHSST) 49 Rwanda Interim DHS (RIDHS) 49 Annexes: 50 ii

5 List of Tables Table 1: Number of Health Facilities Table 2: Number and type of health facility by district 5 Table 3: Minimum package of services in different facilities 6 Table 4: Availability of power in health facilities 7 Table 5: Primary source of electricity in health facilities Table 6: Availability of water in health facilities 8 Table 7: Internet/Telephone access for district hospitals and health centers 9 Table 8: Availability of computers in district hospitals and health centers 9 Table 9: Number of inpatient beds by health facility type 9 Table 10: Vehicle access at district hospitals and health centres 10 Table 11: Facilities with selected fully functional equipment 10 Table 12: Ratio of health workers to population 11 Table 13: Number of outpatient visits in Health Centers and District Hospitals 12 Table 14: Top ten causes of outpatient visits in district hospitals in Table 15: Top 10 causes of morbidity in health centers in Table 16: Number of admissions in health facilities by gender 15 Table 17: Number of deaths reported in health facilities 15 Table 18: Top ten causes of deaths in district hospitals and Health Centers 16 Table 19: Top 10 causes of inpatient hospitalization in district hospitals and health centers among the under five in Table 20: Family Planning Users by method and units distributed 19 Table 21: Pregnant women registered for ante-natal care 20 Table 22: Location of assisted deliveries 21 Table 23: Causes of maternal death, Table 24: Caesarian sections in District Hospitals and Referral Hospital 22 Table 25: Birth and perinatal death in health centers and district hospitals 23 Table 26: Childhood vaccination and ITN distribution 24 Table 27: Nutrition status of children monitored in health centers 24 Table 28: Hospitalization for childhood malnutrition and health outcomes 25 Table 29: Outpatient treatment of malnutrition and health outcomes 25 Table 30: Sexual violence by age and gender 28 Table 31: CHWs Participation in Community DOTS 2007 to Table 32: Success rate of Sputum Smear + for Tuberculosis enrolled in Table 33: HIV testing of Tuberculosis + Patients 29 Table 34: Anti-Retroviral Therapy in Rwanda from 2007 to Table 35: Number and percentage of respondents reporting using a condom at the last sexual intercourse by type of partner, age, province and sites, (N=1,136) 36 Table 36: HIV prevalence of FCSW by background characteristics, 2010 Rwanda BSS. 37 Table 37: Distribution of Malaria diagnoses by health facility type 40 Table 38: Type of lab Tests conducted at different health facilities 42 Table 39: Type of surgery performed 42 Table 40: Selected surgical interventions 43 Table 41: Medical imagery and other diagnostic testing procedures 44 Table 42: Performance-Based Financing payments by year and PBF package 44 Table 43: Summary of CBHI income and expenditure 47 Table 44: Classification of staff categories by qualification 50 iii

6 List of Figures Figure 1: Map of Health Facilities in Rwanda, Figure 2: Distribution of health facilities by type 6 Figure 3: Distribution of health facility by management authority 7 Figure 4: Map of Outpatient utilization rate, Rwanda, Figure 5: Causes of Outpatient visits in district hospitals (updated) 13 Figure 6: Distribution of outpatient morbidity in health centers 14 Figure 7: Number of deaths reported in health facilities by gender, Figure 8: Trend of family planning coverage among married women, Figure 9: Distribution of contraceptive users by method (end 2010) 19 Figure 10: Map of coverage of assisted deliveries in Health Centers 21 Figure 11: Infant death ratio by level of health care facility as reported in 2009 and Figure 12: Children treated by CHWs as part of Community IMCI 26 Figure 13: Outcomes of Community IMCI 27 Figure 14: Nutritional status-muac by CHWs, Figure 14: Distribution of people tested for HIV/AIDS by sex 30 Figure 15: Age distribution and seroprevalence of clients tested for HIV in health facilities, Rwanda Figure 16: Voluntary Counseling and Testing during ante-natal clinics 32 Figure 17: Percent of Partner tested from 2003 to Figure 18: Circumcision Pattern of Youth Males in the 2009 Rwanda Youth BSS (N = 2,522) 33 Figure 19: Comparison of Youth Sexual Behaviors between 2006 and 2009 BSS, Rwanda 34 Figure 20: Youth Comprehensive Knowledge of HIV/AIDS, Rwanda Comparison between 2006 and Figure 21: HIV knowledge comparison between 2006 and 2010 FCSW BSS, Rwanda 39 Figure 22: Graph of proportional morbidity for Malaria in health centers 40 Figure 23: Map of proportional malaria morbidity by District Figure 24: Evolution of key Maternal and Child services (Average numbers per facility) 45 Figure 25: Evolution of Average Quality scores from Health Center PBF Quality Assessments 45 Figure 26: Map of Mutuelle Adhesion Rates by district Figure 27: Evolution du taux d adhésion aux mutuelles de santé iv

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8 Acronyms: ANC Ante-natal care ARBEF Association Rwandaise pour le Bien- Etre Familial (Rwanda Association for Family welfare) HMIS Health Management Information System ihris Integrated Human Resource Information System ART Anti-Retroviral therapy ARV Anti-Retroviral BCG Bacille Calmette Guerin vaccination ITN MCH NGO Insecticide Treated Nets Maternal and Child Health Non-Governmental Organization CPY Couple Year Protection NRH National Referral Hospital DH District hospital OPD Out Patient Days DHS Demographic and Health Survey DOT Directly Observed Treatment Short Course DTP Dyptheria, tetanus, pertusis vaccination ECG electro-cardiogram FBO Faith-based organization P0 PBF polio vaccination dose zero Performance-Based Financing RDHSSF Rwanda District Health System Strengthening Framework RH RIDHS Referral Hospital Rwanda Interim Demographic and Health Survey FP Family Planning GO gynaecology-obstetrics HC Health centre HiB Hemophelus Influenza B vaccination TB SS+ TPM+ VCT Tuberculosis Sputum Smear Positive positive microscope pulmonary tuberculosis Voluntary Counseling and Testing HIV/AIDS Human Immunodeficiency Virus/ Aquired Immunodeficiency Syndrome NID National Identity card EPI Expanded Program on Immunizations vi

9 Foreword As part of the Government of Rwanda s commitment to produce evidence-based policies and programs, it is imperative that we generate and publish reliable statistics and indicators that can be used by all stakeholders. This Annual Rwanda Health Statistical Booklet has therefore been produced to provide a summary of all key statistics from the Rwandan health sector in This Booklet will enable policy makers, planners and other interested parties to gain an insight into the current state of the Rwandan Health Sector. These important statistics provide a basis for policies, strategies and planned interventions to ensure they are responsive to the needs of the health sector and, crucially, are focused on addressing current priorities that aim to improve the health of the Rwandan population. Dr. Agnes BINAGWAHO Minister of Health 1

10 Introduction The Rwanda Annual Health Statistical Booklet 2010 has been developed to provide an overview of key statistics in the health sector for This is the second year in a row that the bulletin has been produced and the first time that there is substantial data available from two calendar years enabling an analysis of trends over time. The Booklet is divided into four chapters: Infrastructure; Human Resources; Morbidity; and Special Programs including Family Planning, TB, HIV/AIDS, Malaria and MCH. This year we have also added a section on several health financing interventions: Performance-Based Financing and Community- Based Health insurance. Other macro level financial information has not been included in this document as this is covered substantially by the National Health Accounts and other special studies and reports. This booklet aims to show key statistics in the health sector from 2010 in a concise, easily accessible manner to ensure valuable statistics are readily available to all interested users. Comparisons with 2009 will help users understand the evolving health situation in Rwanda. Data have been extracted from a variety of sources: the Rwanda District Health System Strengthening Tool (DHSST); the Health Management Information System (HMIS); TracNet; PBF databases for clinical services, community health workers; the Community-Based Health Insurance (CBHI) indicator database, and several surveys, including: the Rwanda Interim DHS and the WHO Survey of Human resources Details of all data sources are given in the annexes. This document includes data from primary health care facilities and district hospitals managed by the public sector or faith-based organisations that operate under a convention with the Ministry of Health (known as agrée ). Limited data is also included from national referral hospitals to provide a more comprehensive picture of infrastructure and disease burden. This year the Booklet also includes some data from the newly implemented Community Health Worker Information system (SIS Com). It does not include data from private sector clinics or dispensaries. 2

11 Health Sector Infrastructure Health sector infrastructure covered in this section includes health facilities and selected resources available within those facilities, such as staff, equipment, utilities and transport. It is important to note that this section draws data from multiple sources, primarily the Health Facilities Database, the WHO Human Resource Survey and the Rwanda District Health System Strengthening Tool (DHSST). The coverage of the DHSST represents a sub-set of health facilities, and therefore may not be entirely representative of the national picture. Health Facilities The number of non - private Health Facilities (HFs) in Rwanda at the end of 2010 was 579; this is up from 541 in the previous year. This increase was primarily due to the opening of 11 new health posts, 2 new Prison Dispensaries, 17 new Dispensaries and 8 Health Centers. These are classified as Referral Hospitals, District Hospitals, Health Centers, Health Posts and Dispensaries. Table 1: Number of Health Facilities Year National Referral Hospitals 4 4 District Hospitals Police Hospital 1 1 Health Centers Dispensaries Prison Dispensaries Health Posts Grand Total Source: Health Facilities Database, HMIS unit

12 Figure 1: Map of Health Facilities in Rwanda, 2010 Source: Health Facilities Database, HMIS unit 2010 The number and type of health facility per district is shown in table 2 4

13 Table 2: Number and type of health facility by district District Referral Hospital District Hospital Military/ Police Hospital Health Centre Dispensary Prison Dispensary Health Post # of Health Facilities BUGESERA BURERA GAKENKE GASABO GATSIBO GICUMBI GISAGARA HUYE KAMONYI KARONGI KAYONZA KICUKIRO KIREHE MUHANGA MUSANZE NGOMA NGORORERO NYABIHU NYAGATARE NYAMAGABE NYAMASHEKE NYANZA NYARUGENGE NYARUGURU RUBAVU RUHANGO RULINDO RUSIZI RUTSIRO RWAMAGANA Grand Total Source: HMIS National Health Facility Database. Excludes private health facilities and FOSACOM Of the 579 health facilities, 76% are health centers, 7% District Hospitals, 8% Health Posts and 6% Dispensaries (see Figure 1). There are also 4 Referral Hospitals, 1 Police Hospitals1 and 18 prison Dispensaries. This analysis, using data from the HMIS National Health Facility 1 Note: since 2006 Kanombe Military Hospital serves as a District Hospital for the general population in Gasabo district, so it has been re-classified as a District Hospital in this analysis. 5

14 Database, encompasses health facilities managed by the public sector or Agrees (faith-based organizations), but does not include private health facilities which administrative districts have not systematically registered. Figure 2: Distribution of health facilities by type Source: HMIS National Health Facility Database The minimum package of services provided by the main categories of facilities is summarized below: Table 3: Minimum package of services in different facilities Health facilities National Referral Hospital District hospitals Health centres Dispensaries Health posts Minimum package of services provided Advanced inpatient/outpatient services, surgery, laboratory, gynaecology, obstetrics; radiology, specialized services: ophthalmology, dermatology, ENT, stomatology, physiotherapy. Inpatient/outpatient services, surgery, laboratory, gynaecology obstetrics, radiology Prevention activities, Primary health care, in patient, referral, maternity Primary health care, outpatient, referral Outreach activities (immunization, family planning, growth monitoring, antenatal care) Two of the four referral hospitals also serve as teaching institutions for doctors and pharmacists. Ndera hospital is the referral hospital for mental health. Two other facilities, Kanombe Military hospital and Kacyiru Police hospital, cover the surrounding civilian population in addition to the Rwandese Defence Forces and the National Police 6

15 Public health facilities represent 64% of the total number of non-private health facilities in Rwanda, with 28% run by Faith-Based Organizations referred to as Agrée, 1% parastatal, 5% private and 2% by Communities. Figure 3: Distribution of health facility by management authority Source: HMIS National Health Facility Database 2010 Health Facility Equipment and Utilities According to the Rwanda District Health System Strengthening Tool 2, a web-based database maintained by all of the districts with data on 465 Health Facilities (of which 41 were DH, Kanombe Military Hospital and Kacyiru Police Hospital, and 424 HCs), 19% of health centers and 2% of district hospitals had no access to power in 2009 a figure that has been nearly halved to 15% of health centers and 0% of district hospitals in The improvements have come about mostly because of additional sites being added to the power grid and with the purchase and of generators and solar installations. Table 4: Availability of power in health facilities Health Centers District Hospitals Power Status 2009 % 2010 % 2009 % 2010 % No power 79 19% 64 15% 1 2% 0 0% Some power (inconsistent grid, generator or solar) % % 6 15% 8 20% Connected to grid (with consistent access) % % 34 83% 33 80% Total Source: Rwanda District Health System Strengthening Tool, The District Health System Strengthening Tool also showed improvements between 2009 and The DHSST did not include health posts or dispensaries 7

16 The number of health centers with power increased from 81% to 85% of health centers from 2009 to 2010 respectively. There was a slight increase in the proportion of facilities connected to the electricity grid from 43% in 2009 up to 46% in In most of heath facilities using solar energy and generator, power may not be sufficient. Most other electricity sources remained proportionally the same. Table 5: Primary source of electricity in health facilities Primary Electricity Source 2009 Percentage 2010 Percentage Electricity grid % % Generator 54 12% 49 11% Solar energy % % Biogas 2 0% 1 0% Other 40 9% 7 2% No power 21 5% 40 9% Total Source: Rwanda District Health System Strengthening Tool, Water supply did not change between 2009 and 2010 roughly one quarter of the facilities is connected to the national water supply grid. According to the DHSST the proportion of facilities using local surface water in 2009 is 18% same in Table 6: Availability of water in health facilities Primary Water sources 2009 Percentage 2010 Percentage Local Water System % % National Grid % % Rainwater Harvesting 95 21% 93 20% Local Surface Water 84 18% 86 18% Well or Borehole, Covered 6 1% 3 1% Well or Borehole, Uncovered 4 1% 4 1% Tanker Truck 2 0% 3 1% Unknown 1 0% Source Doesn t Exist 12 3% Total Source: Rwanda District Health System Strengthening Tool,

17 Communication In 2010, all district hospitals were connected to the internet (up from 88% in 2009), 98% had cell phone coverage (up from 95% in 2009). The improvements were made in internet connectivity at the health center level with 65% having access to the internet in 2010 as opposed to 41% in The proportion of health centers with cell phone coverage increased from 90% to 97%. Table 7: Internet/Telephone access for district hospitals and health centers Facility type Internet Cell Phone Coverage District Hospitals 36 88% % 39 95% 40 98% Health Centers % % % % Source: Rwanda District Health System Strengthening Tool, All district hospitals have more than one computer facilities in At health center level the situation improved dramatically during 2010 as only 5% of health centers had no computer facilities (down from 17% in 2009) and 86% had more than one computer (up from 69% in 2009). Table 8: Availability of computers in district hospitals and health centers Health Centers Hospitals Availability of functioning computers No computers 71 17% 22 5% 0 0% 0 0% 1 computer 60 14% 37 9% 1 2% 0 0% >1 computer % % 40 98% % N % % % % Source: Rwanda District Health System Strengthening Tool, 2009 & 2010 The table bellow shows the number of beds by health facilities types. Overall, bed/inhabitants ratio is one bed for 587, 9259 inhabitants in 2010 compared to one bed for 585,7581 inhabitants in 2009 Table 9: Number of inpatient beds by health facility type Facility types District Hospital 6,602 6,664 Health Center 9,283 9,585 Referral Hospitals Total 16,834 17,208 Source: DHSST and reports from Referral Hospitals The percentage of district hospitals with ambulance services didn t change in 2009 to At the health center level the proportion of facilities with ambulances increase from 15% to 16%. This is likely to be due to the transfer of some vehicles to district hospitals as part of the rationalization of the SAMU ambulance network. The Rwanda District Health System Strengthening Framework further indicates that all District Hospitals and 90% of Health Facilities have access to at least one form of transportation, including 4x4 vehicles, cars, motos or pickup. 9

18 Table 10: Vehicle access at district hospitals and health centres District hospitals Health Centers Vehicle type 2009 (N=41) 2010 (N=41) 2009 (N=421) 2010 (N=425) Ambulance 39 95% 39 95% 64 15% 66 16% Any type % % % % Source: Rwanda District Health System Strengthening Tool, 2009 and 2010 According to the DHSST, 90% of hospitals and 95% of health centers have a microscope and 83% of hospitals and 88% of health centers have a refrigerator, 90% of hospitals and 97% of health centers have an autoclave and 65% of health centers have an incinerator. Table 11: Facilities with selected fully functional equipment District Hospital Health Center 2009 (N=41) 2010 (N=41) 2009 (N=421) 2010 (N=425) Binocular Microscope 35 85% 37 90% % % Refrigerator 35 85% 34 83% % % X-Ray 34 83% 37 90% n/a n/a% n/a n/a% Autoclave 38 93% 37 90% % % Anesthesia machine 38 93% 37 90% 6 1% 0 0% Incinerator 37 90% 34 83% % % Source: Rwanda District Health System Strengthening Tool, 2009 and

19 Human Resources In 2010 there were 604 doctors and 8202 nurses/midwives working in Rwanda. Based on 2010 data from the ihris, this corresponds to a ratio of 1 doctor per 17,240 inhabitants, 1 midwife per 66,749 inhabitants and 1 nurse per 1,294 inhabitants. This situation has improved since 2009 when the worst off district had nearly 1,405 inhabitants per nurse. The greatest increases were in the categories of Administrative staff (largely attributable to the inclusion of Mutuelle staff, data managers and cashier in this category during 2010) and midwives whose numbers more than doubled between 2009 and The only category that saw a reduction was that of paramedical and pharmacist a worrisome trend that could be due to the promise of more lucrative careers in private sector. Table 12: Ratio of health workers to population Staff Category Population/ % change HW 2010: Doctors , % Nurses , % Midwives , % Paramedical ,449-17% Pharmacist ,623-35% Laboratory Technician , % Administrative and support Staff % Source: Rwanda District Health System Strengthening Tool, Ministry of health: Human resources database 2010 Morbidity and Mortality Morbidity data for this booklet is from the HMIS with a health facility reporting rate of 93.5%. It does not include records from National Referral Hospitals or private facilities. Outpatient care In 2010 the total number of new cases seen at HCs and DHs was 9,028,140 of which 8,437,850 (93.4%) were seen in HCs, 590,290 (6.6%) at DHs and 214,512 at referral hospitals. During 2010, the primary curative care utilization rate was approximately 0.81 visits per inhabitant (8,437,850visits/10,412,820 population excluding community based integrated management of child hood illnesses (C-IMCI) by CHW s) almost the same as in

20 Table 13: Number of outpatient visits in Health Centers and District Hospitals Health Service level % change Health Centers 7,996,598 8,437, % District Hospitals 544, ,290 8% CHW Home Based care , % Referral Hospitals 214, ,278-8% Total 9,481,389 10,139, % Source: National HMIS database 2010, CHW Health Information System 2010, Figure 4: Map of Outpatient utilization rate, Rwanda, 2010 The high OPD utilization rate may be due to the increased availability of ambulances and mutual membership. It is also important to note the contribution of community health workers in the provision of community based care since the introduction of community integrated management of childhood infections (IMCI). The number of OPD seen by CHWs has increased about 23%. The proportion of reportage is 98% while in 2009, only 66% of the CHW cooperatives reported. The diseases treated are childhood infections including fever/ malaria, acute respiratory infections and diarrhoea. 12

21 District Hospital Outpatient Morbidity The most frequent outpatient services provided by district hospitals were dental and ophtalmogical care. Together they represent almost one third of outpatient visits (35%) up from 20% in An acute respiratory Infection (ARI) and cardiac disease represents respectively 8% and 4% of the total consultation Table 14: Top ten causes of outpatient visits in district hospitals in 2010 Disease Group <5 years 5 years and above Total Cases % of Total Diseases of teeth and gums 5, , ,417 21% Eye diseases 7,513 73,860 81,373 14% ARI 16,451 28,486 44,937 8% Cardiological problems 2,008 24,122 26,130 4% Gastro-intestinal disorders - 24,456 24,456 4% Physical trauma 1,413 15,801 17,214 3% Urinary tract diseases ,586 16,368 3% Malaria 4,955 10,432 15,387 3% Skin diseases 2,493 12,310 14,803 3% Gyneco & obstetric diseases 78 13,824 13,902 3% All other diagnoses 25, , ,247 34% Total 66, , , % Source: National HMIS database 2010 Figure 5: Causes of Outpatient visits in district hospitals (updated) Source: National HMIS database

22 Health Centre Outpatient Morbidity The picture is quite different in the health centers, where infectious diseases are the primary cause of outpatient morbidity: ARI, intestinal parasites and malaria account for well over half of the outpatient morbidity (56%). There was very little change in the distribution of morbidity at the Health Centers level since 2009, where malaria cases represented 16% of outpatient s consultation versus 8% in 2010 Table 15: Top 10 causes of morbidity in health centers in 2010 Disease Group Under 5 Over 5 years Total cases % of Total ARI 1,027,131 2,227,647 3,254,778 39% Intestinal parasites 161, , ,094 9% Malaria 148, , ,153 8% Diseases of bones and joints 1, , ,673 7% Gastro-intestinal disorders 1, , ,588 5% Diseases of teeth and gums 37, , ,088 4% Skin diseases 101, , ,543 5% Physical trauma 30, , ,147 5% Diarrhoea 175, , ,577 4% Eye diseases 58, , ,365 2% All other diagnoses 75, ,325 1,064,844 13% Total 1,819,409 6,618,441 8,437, % Source: National HMIS database 2010 Figure 6: Distribution of outpatient morbidity in health centers Source: National HMIS database

23 Hospitalization and Mortality Admissions and mortality in health centers and district hospitals Data on mortality in this report comes exclusively from health facility reports in the HMIS. They do not include deaths in the community that were not registered at a health facility. As a result, the mortality figures are likely to underestimate the true level of mortality in the country. The total number of admissions in Health Centers and District Hospitals increased by 9% from 419,117in 2009 up to 456,341 in Sixteen percent (16.5%) of all admission in 2010 were children under 5 years of age and roughly two-thirds (73%) were female. Total deaths among patients admitted in DHs, HCs were 5,171 in 2010, down from 5,022 in The proportion of death to total death is high for male (54%) than female (46%). Excluding data from referral hospitals for which total number of admissions are not reported, this results in a health facility death rate of 1.6%, down from 1.7% in The number of death decreased in health centers by 8% from 369 in 2009 to 341 in 2010, this can be attributed to availability of ambulances that have facilitated in referrals of complicated cases to district hospitals. This is, of course, an underestimate of overall mortality rates because it does not include deaths in the community, in referral hospitals or in the private sector. Table 16: Number of admissions in health facilities by gender Gender <5 years >=5 years Total % <5 years >=5 years Total % Females 41, , ,583 70% 34, , ,220 73% Males 47,927 78, ,534 30% 40,877 83, ,121 27% Total 89, , , % 75, , , % Source: National HMIS database Table 17: Number of deaths reported in health facilities Deaths % of change Health Centers % District Hospitals % Referral Hospitals 2,147 2,055-4% Total 7,115 7,602 7% Source: National HMIS database

24 Figure 7: Number of deaths reported in health facilities by gender, 2010 Source: National HMIS database Leading causes of mortality in health facilities The leading cause of death in district hospitals was malaria, accounting for 13% of total deaths in 2010 as compared to 22% in The other major causes of deaths are HIV & opportunist infections (9%), ARI (9%), Cardiac diseases (5%) and premature birth (5%). Table 18: Top ten causes of deaths in district hospitals and Health Centers Row Labels 2010 % Malaria % ARI % HIV & IOS 506 9% Premature birth 441 8% Cardiac diseases 412 7% Tuberculosis 223 4% Malnutrition 192 3% Diarrhoea diseases 188 3% Malignant tumors 139 3% Physical injuries 125 2% Others % Total % Source: National HMIS database

25 Under five morbidity and mortality During 2010, 1811 under five deaths were reported both from health centres and district hospitals. This represent one third of total death. In 2010, 95 % of the under five deaths in health facilities were in district hospitals. Neonatal and < 1 mortality death contributes for 70 % to the under five mortality, of which 49 % is among neonates. Prematurity was reported among 49 % of the neonatal deaths. Among the 896 neonatal deaths reported in 2010 in health facilities, 571 (64 % died with the 6 days). It appears that neonatal deaths are mainly linked to poor delivery. Causes of neonatal deaths are being investigated through the initiation of child death autopsy in health facilities.. The main causes of under five deaths in heath facilities are prematurity (23.4 %), respiratory tract infections (15.5 %), Malaria (10.5 %), malnutrition (6.9%) and diarrhoea (4.8 %). Disease specific case fatality rates are the highest in prematurity (19.4 %), congenital abnormalities (13.2 %), AIDS /OI (8 %) and Malnutrition (5.6%). Table 19: Top 10 causes of inpatient hospitalization in district hospitals and health centers among the under five in 2010 Diseases Number of Cases % to total cases Number of deaths % to total death Case fatality rate Respiratory tract infections 26,535 35% % 1.1% Diarrhoea 17,319 23% 90 5% 0.5% Paludisme 9,745 13% % 2.0% Malnutrition 2,327 3% 130 7% 5.6% Prematurity 2,279 3% % 19.4% Physical Trauma 1,576 2% 9 0% 0.6% Skin diseases 523 1% 13 1% 2.5% Gastro-duodenal diseases 359 0% 10 1% 2.8% Congenital abnormalities 333 0% 44 2% 13.2% Other % % 4.1% Total cases % % 2.4% 17

26 Maternal and Child Health Family Planning Figure 8: Trend of family planning coverage among married women, Source (Demographic and Health surveys) Routine family planning data are reported from both health centers and district hospitals. At the end of 2010, a total number of 708,265 women of reproductive age were reported as continuing users of contraceptive methods in health centers and districts hospitals (up 31% from 541,483 in 2009). Couple years of protection, family planning indicator based on the distribution of contraceptive commodities, also increased by 36%, from 773,672 to 1,045,218 during the same period The calculation assumes, that among the women of reproductive health 49 % are women in union and that 76% of family planning users are women in union. Therefore Family planning coverage for women in union is 44.7%. The most used method is Depo provera (66%) and Pills (18.5%). Surgical methods (0.1%) and DIU (1%) are not commonly used probably because they require qualified personnel and training. 18

27 Table 20: Family Planning Users by method and units distributed Method Continuing users at end of Dec New Users Units distributed CYP Implant 81, ,48 135, ,778 Injectable: Depo-Provera 467, ,299 1,575, ,827 Oral contraceptives (pills) 130,912 72,914 1,395,557 93,038 Natural FP cycle beads 7,347 3,638 17,509 35,018 IUD 2, ,093 24,826 Natural FP self-observation 5,179 7, ,508 Barriers 11,500 8, ,294 7,944 Surgical Contraception ,280 Grand Total 708, ,999 4,084,127 1,045,218 Source: National HMIS database 2010 Figure 9: Distribution of contraceptive users by method (end 2010) Source: National HMIS database

28 Ante-Natal Care A total of 321,388 pregnant women registered for Ante-Natal Care (ANC) in This represents a decrease in ANC coverage rate of 75.3% from 78 % in 2009 (343,164 new registrations). This decrease might be explained by the overestimation of the number of expected pregnancies. Nevertheless, of the women who registered a higher proportion had at least one standard visit (increase from 25% to 30%), and the proportion who had 4 standard visits increased from 14% to 16%. The proportion of high risk pregnancies are almost the same as in 2009 (16%) and 2010 (15%). Table 21: Pregnant women registered for ante-natal care Description Total % of new registrations Total New registrations 323, ,388 % of new registrations Standard Visit 1st trimester 81,221 25% 96,032 30% Standard Visit 2nd trimester 145,027 45% 134,883 42% Number of women with 4 standard visits 44,555 14% 52,286 16% High-risk pregnancies screened 52,280 16% 47,419 15% % High-risk pregnancies referred 14, % 13, % Source: National HMIS Database 2009/2010 High risk pregnancies referred to the next level of care represent 28% of the total number of high risk pregnancies screened during ANC sessions (almost the same 28% in 2009). This low percentage of referral rate of high risk pregnancies is probably a major contributor to the maternal deaths that occurred in health centers. Assisted deliveries A total of 243,046 assisted deliveries were reported during 2010, of which the vast majority were normal deliveries (86%) and more than two thirds (68%) were in health centers. The maternal health policy promotes delivery in health facilities where the delivery is conducted by a trained health professional in order to reduce any complications that may arise during childbirth. 20

29 Figure 10: Map of coverage of assisted deliveries in Health Centers If we compare the figure for assisted deliveries in the health centers, district hospitals and referral hospitals to the total number of expected deliveries we can estimate the coverage of assisted deliveries at 56.8% in 2010, a decrease as compared to 61% in The decrease in assisted deliveries could be attributed to the fact that the number of expected deliveries which is used as denominator to calculate the assisted delivery coverage is overestimated due to the increased use of family planning, resulting in reduction/underestimation of the coverage. Maternal deaths recorded in health centers and district hospitals are almost the same in 2009 and 2010 Table 22: Location of assisted deliveries % Location of delivery Normal deliveries Dystocic Total Maternal Deaths Normal deliveries Dystocic Total Maternal Deaths change in maternal deaths Health , % Centers District 46,491 26,272 72, , * +23% Hospitals Referral 2,436 2,868 5, % Hospitals Total 223,134 30, , ,685 31, , % Source: National HMIS database 2009/ KFH, CHUK, CHUB. Maternal deaths occurring in health facilities were 221 out of 243,046 deliveries. This corresponds to a health facility Maternal Death Ratio of 91 deaths per 100,000 in health centers and district hospitals. This is well below the RIDHS figure of 690/100,000, but the two figures are not comparable because of the 21

30 methods of collection used and the fact that the RIDHS also includes maternal deaths and unassisted deliveries in the community. Among all deliveries, the main maternal complications in 2010 are per anal tear (0.43%), Bleeding (0.28%), Infections (0.27%). Table 23: Causes of maternal death, 2010 Causes of death Number maternal death % Severe bleeding % Malaria % Septicemia % Eclampsia % Other infections % Unknown causes % Obstructive labor % Other causes % Anesthesia complications % IO/HIV % Amniotic embolism % Heart failure % Pulmonary embolism % Anaemia in pregnancy % Total % Sources: Maternal death audit, MCH/MOH, 2010 Cesarean sections at Hospitals Cesarean section rate slightly increased by 6.7% from 34% in 2009 up to 36.3% in Overall, the high rate of caesarian section may be partly due to the increased availability of ambulances and better referral of high risk pregnancies. Table 24: Caesarian sections in District Hospitals and Referral Hospital Health #deliveries #dystocic #caesarean caesarean #deliveries #dystocic #Caesarean caesarean Facility deliveries % of total deliveries section % of total section Type delivery delivery District 72,763 26,272 24,189 34% 73, % Hospital Referral 5,304 2,868 1,814 34% 3,835 1,875 1,701 35,70% Hospital TOTAL 78,067 29,140 26,372 34% 77,505 30, ,20% Source: National HMIS database 2009, 2010, Reports from Referral hospitals 22

31 Weight at birth and deaths of newborns In 2010, all public and FBO (agree) health facilities reported 241,277 deliveries registered in their records. These records indicate that 14,621 newborns, or 6.0% of all recorded births for the year, had a weight less than the acceptable birth rate of 2.5 Kg. Low birth weight is a risk factor for death in infancy. As one would expect with effective referral of high risk pregnancies, the percentage of low birth weight deliveries is substantially higher at district hospitals. Table 25: Birth and perinatal death in health centers and district hospitals Facility Type Total births Total deaths Births < 2.5 kg % low BW Total births Total deaths Births < 2.5 kg % low BW Health Centers % % District Hospitals % % Total , % % Source: National HMIS database , data unavailable from referral hospitals Health facilities reported that among 241,277 births registered in Health Centers and District Hospitals during 2010, 4591 died in-utero or within hours of birth, representing a proportional mortality of 1.9%, almost the same in %. Figure 11: Infant death ratio by level of health care facility as reported in 2009 and 2010 Source: National HMIS database 2009, Number of infant deaths (intrauterine+newborns)/total deliveries 23

32 Child immunizations Based upon routinely reported data from health facilities, immunization coverage decreased for all antigens since 2009, at least a decrease of 10%. This is most probably due to the overestimation of the denominator (children <1), as explained above real coverage rates will be determined by a population survey (DHS 2010). This is illustrated by a mini-survey ( number of households) held in November 2010 in the Northern Province. The proportion of children < 1 was 2.5 % (contrary to the 4.1 % used by HMIS) and the coverage rate of fully vaccinated children was 92 %. Table 26: Childhood vaccination and ITN distribution Indicator Number % coverage Number % coverage Polio O 291,069 72% 253, % BCG 324, % 289, % Polio 1-DTP-HepB/Hib1 322, % 288, % Polio 2-DTP-HepB/Hib2 322, % 288, % Polio 3-DTP-HepB/Hib3 321, % 290, % Measles 345, % 297, % Children who received Insecticide Treated Nets 247,589 61% 163, % Source: National HMIS database Growth Monitoring Children were monitored for nutrition status passed from 2.7 million times in 2009 to around 2.3 million in This does not represent the number of children weighed because each child is supposed to be monitored monthly, however it does suggest that an average of 193,000 children are monitored each month at health centers. When combined with the CHW growth monitoring reported below, nearly half a million children are monitored each month. In 2010, for all monitored children 9.1% have malnutrition compared to 10% in 2009 Table 27: Nutrition status of children monitored in health centers Green Yellow Red Oedema % Mal- Age Green Yellow Red Oedema % Malnourished nourished ,268 50,637 10, % 5% months ,693 65,822 16,605 1, % 11.4% months ,149 51,154 13,350 1, % 10.5% months ,294 53,265 14,389 2, % 11.1% months Total 2,419, ,878 54,668 6, % % Source: National HMIS database

33 Malnutrition Hospitalization for Childhood Malnutrition 2,136 people were hospitalized for malnutrition in 2010, up from 1,920 in Deaths of people hospitalized for malnutrition were also down substantially, suggesting more effective case management of malnutrition. Table 28: Hospitalization for childhood malnutrition and health outcomes Registrations Status Year Level of care New Cases Old Cases Recovered Referred to Hospital Lost to follow up 2009 < 5 years 1, , >= 5 years Total 1, , < 5 years >= 5 years Total Source: National HMIS database 2009, 2010 Died Outpatient treatment of Malnutrition people received outpatient treatment for malnutrition in 2010, down slightly from in For all discharged patients 83 % of recovered as compared to 80% in Deaths of patients treated for malnutrition as outpatients were also down slightly, especially in the over 5 year age group. These figures reveal a worrying statistic: nearly 9% of children who registered for care were lost to follow up. Table 29: Outpatient treatment of malnutrition and health outcomes Registrations Status Year Level of New Old Recovered Referred Lost to Died care Cases Cases to Hospital follow up 2009 < 5 years >=5 years Total < 5 years >=5 years Total Source: National HMIS database

34 Community Health Worker Program; Community IMCI: During 2010, Over 743,589 children were treated by CHWs comparing to 462, 104 in The innovative Community Health Worker program began to produce useful data for the first time in 2009 with the roll-out of the Community Health Worker Information System (SISCom). A major focus of CHWs has been on community integrated management of childhood infections (IMCI). Three major ailments: fever, pneumonia and diarrhoea. Over two third children treated presented with fever symptoms (77%), cough/cold symptoms were next with 12%. Figure 12: Children treated by CHWs as part of Community IMCI Source: SISCom

35 The SISCom data also suggest that outcomes of CHW IMCI treatment are generally good. 88% were reported cured, while less than 10% were referred and a very small proportion 0.02% died while under the care of the CHW. The mortality data should be interpreted with caution. Figure 13: Outcomes of Community IMCI Source: SISCom 2010 In addition to providing community IMCI, CHWs are involved in nutrition monitoring using simple middleupper arm circumference measuring tapes. During 2009, CHWs monitored the nutritional status of children more than times (an average children were monitored each month). For the year, less than 1% of the measurements were in the red zone and another 4% were in the yellow zone. Malnutrition rate is high in the following districts: Rusizi (12.3%), Huye 11.5%, Ngororero 9.9% and Gakenke 9%. The districts with low malnutrition rate are Nyarugenge 1.3%, Gasabo 1.2%, Gisagara 1.1%, Ruhango 1%, Kicukiro 1% and Ngoma 0.7%. Figure 14: Nutritional status-muac by CHWs, 2010 Source: SISCom

36 Sexual Violence Over four thousand and five hundred cases of sexual violence were reported by district hospitals (4,577) and one-third (33%) of these cases had objective symptoms of sexual violence. Ninety-five percent of the cases investigated were among females (95%). The largest group of victims was females between 5 and 18 years of age (57%). Males represented about 5% of the cases investigated; the percentage is the same as in 2009 (5%). Table 30: Sexual violence by age and gender 2010 % change Type of case < 5 years 5 18 years >18 years Total from 2009 F M F M F M Number of cases with symptoms 18% of sexual violence Number of cases received at 22% the hospital suspected of sexual violence Source: National HMIS database

37 TB and HIV/AIDS Tuberculosis (TB) In 2010, 7065 TB patients were registered; 6434 (91%) new cases, 442(6.3%) retreatment cases and 139(2, 7%) other cases. The notification rate of all TB cases was 70/100,000 inhabitants and it was 41.4/100,000 inhabitants for the new smear-positive pulmonary cases. Over ninety percent (97.9%) of all TB patients registered in 2010 were tested for HIV. The seroprevalence of HIV was 31.8% among TB patients, ranging from 23% among new smear-positive and 42% among all other cases. About all cases (97.2%) co infected with TB- HIV received Cotrimoxazole-preventive treatment (CPT). The community based DOTS covers 30 out of 30 districts. Table 31: CHWs Participation in Community DOTS 2007 to 2010 Year # of districts Population covered Suspected cases Total Detected by CHW Number of positive suspects Total Detected by CHW % of suspected cases detected by CHW % suspected positive detected by CHW ,235 5,840 2, % 13.2% % 9.7% Source: TRAC Plus/ TB Unit Report The participation of CHWs is most significant in relation to the administration of treatment: 48.1% of patients registered in 2010 in the districts concerned have received DOTS from CHWs. 10% of all suspected cases were sensitized by CHWs and 9.7% of all confirmed cases were referred to health facilities by CHWs. In 2010 the success rate of treatment by CHWs (97%) and overall treatment success rate (84.8%). Table 32: Success rate of Sputum Smear + for Tuberculosis enrolled in 2009 Success rate of Sputum Smear + Overall Success rate of patients followed by CHW Total under Cured Completed treatment Success rate treatment , (8.2%) 84.8% 97% (78.7%) Source: TB program annual report 2010 Table 33: HIV testing of Tuberculosis + Patients HIV testing Total TB patients TB patients tested Tested Number of HIV positive Number of HIV positive under CMX (97.9%) 2198(31.8%) 2,137 (97.2%) Source: TB program annual report

38 HIV /AIDS VCT During 2010, a total of 1,862,642 people were tested through voluntary counseling and testing services (up from 1,393,018 in 2009) and 1,641,752 (88%) knew their test results. Each year, the average number of people tested voluntary in all health facilities was increased of 25%. The number of VCT sites increased from 403 to 434. (TRAC Plus/ HAS Unit 2009 & 2010 Annual Reports). The pie chart below describes the distribution of tests by gender, 54 % of those tested were female. Figure 14: Distribution of people tested for HIV/AIDS by sex Source: TRACPlus/HAS Unit 2010 Annual Report In 2010, about half of those tested were in the age group over 25 years (44.7%). The seroprevalence of HIV is high among people aged above 25 years (3.1% down from 3.6% in 2009). In the age group below 18, the seroprevalence was estimated at 0.7% (down from 0.9% in 2009); in the age group between 18 and 25 years, the seroprevalence was estimated at 1.7% (down from 1.9% in 2009). The chart below shows the percentage of people tested and the percentage of people with HIV Positive by age group. 30

39 Figure 15: Age distribution and seroprevalence of clients tested for HIV in health facilities, Rwanda 2010 Source: RBC/TRACPlus/HAS Unit 2010 Annual Report. PIT In Rwanda, Provider initiated testing (PIT) was rolled out in all health facilities in 30 December 2010, health facilities have already started to provide PIT services and patients have been counselled and 5339 (2.8%) tested HIV positive. Preventing Mother to Child Transmission (PMTCT) With regard to Prevention of Mother to Child Transmission of HIV/AIDS (PMTCT), the number of women who were receiving Ante-Natal-Care services in PMTCT settings is 307, 904. Among them (96.5 %) accepted to be tested for HIV and 99% of the women tested returned for information about their HIV serological status. Among women tested for HIV in ANC services during the year 2010, 8343 were HIV positive (2.8% of HIV seroprevalence in pregnant women in PMTCT). 31

40 Figure 16: Voluntary Counseling and Testing during ante-natal clinics Source: RBC/ TRACPlus/HAS Unit 2008/2009/2010 Annual Reports. Rwanda has also started to implement the new WHO recommendations of provision of ARV triple therapy to the HIV-infected pregnant women starting at 14 weeks of pregnancy. The launching was done on 15 th November In total, 8072 HIV-infected pregnant women received ARV prophylaxis and triple therapy prophylaxis constituted. HIV-infected pregnant women were estimated to 10,310, 78% of them received ART prophylaxis. From January to December 2010, (84%) of partners of pregnant women have been tested and 6125 of them tested HIV positive (2.4% of HIV seropositivity). The number increased along the years. Figure 17: Percent of Partner tested from 2003 to 2010 Source: RBC/ TRACPlus/HAS Unit 2008/2009/2010 Annual Reports. 32