REPUBLIC OF RWANDA MINISTRY OF HEALTH RWANDA ANNUAL HEALTH STATISTICS BOOKLET

Transcription

1 REPUBLIC OF RWANDA MINISTRY OF HEALTH RWANDA ANNUAL HEALTH STATISTICS BOOKLET 2012

2 Table of contents Table of contents... 1 List of Tables... 3 List of Figures... 4 Acronyms... 6 Acknowledgements... 9 Foreword Introduction Health Sector Resources Health facilities Health Facility Equipment and Utilities Communication Human Resources Morbidity and Mortality Outpatient Care Health facilities outpatient morbidity Hospitalization and Mortality Admission and mortality in health centers and hospitals Leading causes of mortality in health centers and hospitals Maternal and Child Health Family Planning Ante-natal Care (ANC) Assisted deliveries Caesarian section at hospitals Maternal Deaths Peri-neonatal health Weight at Birth and Deaths of Newborns Neonatal deaths audit Child health Child Growth Monitoring CBNP evolution Gender Based Violence Child Immunizations and ANC Anti-tetanus Immunization Community Health Workers (CHW) Program Community Case Management (CCM) HIV & AIDS... 57

3 Voluntary Counseling and Testing (VCT) PMTCT Care and treatment Male circumcision Tuberculosis Malaria Non- Communicable diseases (NCD) Neglected Tropical Diseases and Other Parasitic Diseases (NTD) Other Epidemic and Infectious Diseases division (EID) Laboratory Surgery Radiology Blood Bank and Transfusion Performance- Based Financing (PBF) Financing sources for all PBF indicators Community- based Health Insurance/Mutuelle (CBHI) Sources of Data... 79

4 List of Tables Table 1: Number of health facilities, Table 2: Number and type of health facility by district, Table 3: Minimum package of services in different facilities Table 4: Primary source of electricity in health facilities, Table 5: Sources of water in health facilities, Table 6: Internet/telephone access in health facilities, Table 7: Number of inpatient beds by health facility type, Table 8: Transport owned by district hospitals and health centers, Table 9: Basic medical equipment in District Hospitals and Health Centers, Table 10: Ratio of health workers to population, Table 11: Number of new cases among outpatient visit in health facilities Table 12: Top ten causes of morbidity in IMCI, Table 13: Top ten causes of morbidity in health centers, 2012 (>=5 years) Table 14: Top ten causes of morbidity in hospitals, Table 15: Number of deaths in health facilities, Table 16: Intrahospital mortality in health facilities, Table 17. Top ten causes of deaths in all health facilities, Table 18.Top causes of deaths in neonatology in all health facilities, Table 19: Caesarian sections in district hospitals and referral hospitals, Table 20: Causes and proportion of maternal death in Rwanda Table 21:Births and peri-natal deaths in health centers and district hospitals, Table 22:Victims of GBV patients received at District Hospital. HMIS Table 23: Immunization coverage in Table 24: Community-IMCI outcomes, Table 25: HIV tests in VCT, PIT and PMTCT Services, Table 26: HIV Seroprevalence by Age group and Sex in VCT and PIT, Table 27: Number of Couples Tested for HIV in Table 43: Male circumcisions Table 28: Contribution of CHW in Care and Treatment of TB Patients Table 29: TB cases management Table 30: Outcomes Results of New Smear+ Cohort Table 31: HIV testing of TB patients Table 32: HIV testing among TB suspects Table 34:Malariacasesat healthfacilitiesandthecommunitylevel Table 35: Non-Communicable Disease cases treated in all health facilities Table 37: Lab test conducted in the country by province tested positive Table 38: Summarizing outbreaks occurred from January to December Table 39: Type of Laboratory Exams Table 40: Type of surgery performed, Table 41: Selected surgical interventions, Table 42: Radiology exams Table 44:Bloodcollected and TTIs, Table 45: PBF Funds by Funding Source (Rwf), Table 46:Average quality scores from health center PBF quality assessments Table 47: Income and expenditure of community based insurance,

5 List of Figures Figure 1: Distribution of health facilities by type, Figure 2: Distribution of health facility by management authority, Figure 3: Sources of electricity in health facilities, Figure 4: Primary sources of water in health facilities Figure 5: Availability of ICT equipment in health facilities, Figure 6: Top ten causes of morbidity in health centers, 2012 (IMCI) Figure 7. Top ten causes of morbidity in health centers, 2012 (>=5 years) Figure 8.Top ten causes of morbidity in hospitals, Figure 9.Top ten causes of deaths in all health facilities, Figure 10.Top causes of deaths in neonatology in all health facilities, Figure 11: Trends of family planning coverage among married women, Figure 12: Facility FP coverage rates Figure 13: Map of family planning service coverage rate Dec Figure 14. The evolution in Community Based Provision of FP services in Rwanda Figure 15: Distribution of modern contraceptive users by method, December Figure 16: ANC coverage in Rwanda, Figure 17: Percentage of women attending Antenatal Care (ANC), Figure 18: Assisted deliveries, Figure 19:Figure14: Deliveries in Health Facilities by district Figure 20 : Number of maternal death by level of health facilities Figure 21: Causes of maternal deaths Figure 22: Period of maternal death Figure 23: Neonatal mortality rate Figure 24: Perinatal Mortality rate by component Figure 25: Hypothermia and neonatal deaths Figure 26: Causes of neonatal deaths Figure 27: Period of death after birth Figure 28: Reasons of neonatal deaths Figure 29: Preventable character of neonatal deaths Figure 30: Under five,infant and neonatal mortality rate,dhs Figure 31: Proportion of malaria, diarrhea and ARI in children 2-59 months treated in IMCI in health centers Figure 32: Proportional Mortality rated under 5 years (excluding neonates) Figure 33: Case fatality rate under 5 years (excluding neonates) Figure 34: Growth monitoring promotion Figure 35: Evolution of CBNP coverage and its impact on nutritional status of children Figure 36: Survivors of gender based violence by age group in district hospitals, Figure 37: Gender based violence by age group and sex in district hospitals, Figure 38: Routine Immunization coverage Figure 39: Rotavirus immunization coverage as new vaccine, May-December Figure 40: HPV vaccination coverage by province and Kigali city three doses cohort Figure 41: National HPV Immunization coverage three doses of second cohort Figure 42:Children treated by CHWs as part of C-IMCI, Figure 43: HIV Seroprevalence by Age group and Sex in VCT and PIT, Figure 44: Evolution of Health Facilities offering ART Services Figure 45: Evolution of patients on ART Figure 46: HIV Treatment Coverage Evolution Figure 47: HIV Services coverage, Rwanda Figure 48: Male circumcision performed in health facility Figure 49: TB cases notification trend,

6 Figure 50. Malaria cases country wide by provinces Figure 51: Malaria cases by district: Top 10 leading Districts Figure 52:Map ofproportionalmorbidityformalariain health centers, Figure 53: Uncomplicated Malaria cases in OPD Figure 54: Top causes of Non-Communicable Disease cases treated at health centers and clinics Figure 55: Countrywide presence /proportion of NTDs by category (Stool tested positive) Figure 56: PBF Funds by Funding Source (%) Figure 57: Map of mutuelle adhesionrates by district,

7 Acronyms ACT Artemisinin-based Combination Therapy ANC Ante-natal Care ARI Acute Respiratory Infections ART Anti-retroviralTherapy ARV Anti-retrovirals BCG Bacille Calmette Guerinvaccination CBHI Community-based HealthInsurance CDC Center for Disease Control and Prevention CDT TBDiagnosis and Treatment Centers CHUB CentreHospitalierUniversitairedeButare CHUK CentreHospitalierUniversitairedeKigali CHW CommunityHealth Workers C-IMCI Community-basedIntegrated Management ofchildhoodillnesses CPT Cotrimoxazole-preventivetreatment CT TBtreatment centers CTX Cotrimoxazole DHS Demographicand Health Survey DHSST District Health System StrengtheningTool DOTS DirectlyObserved Treatment, Short Course DTP Dyptheria,Tetanus, Pertusisvaccination EDPRS EconomicDevelopmentand PovertyReduction Strategy EPI Expanded Program onimmunizations FBO Faith-basedOrganization FP FamilyPlanning FRW Rwandan franc GESIS Gestion du Système d Information Sanitaire G-O Gynecology-obstetrics HEPB Hepatitis Bvaccination HiB HemophilusInfluenzaB vaccination HIV&AIDS HumanImmunodeficiencyVirusand AcquiredImmunodeficiencySyndrome HFS Department ofhealthfinancing HMIS Health ManagementInformation System HNP Health, Nutrition and Population (HNP) ihris IntegratedHuman ResourceInformation System IRS Indoor residual spraying (IRS) ITN Insecticide TreatedNets IUD Intrauterine device KFH King Faical Hospital KMH Kanombe MilitaryHospital KPH Kacyiru PoliceHospital LLIN Long-lastinginsecticidal nets MCH Maternal and Child Health MOH Ministryof Health MMR Maternal MortalityRatio NGO Non-governmental Organization NID NationalIdentityCard NISR NationalInstituteof Statistics Rwanda NRH National Referral Hospital

8 NTPM+ OI OPD P0 PBF PEPFAR PIT PLHIV PMTCT RDHSSF RH RIDHS SAMU SCPS SS+ TB TPM+ TPR TRAC TTI VAT2-5 VCT WHO New PulmonaryTB OpportunisticInfections OutPatient Days Polio vaccination, dosezero Performance-basedFinancing President s Emergency Plan for AIDS Relief Provider-initiated testing PeopleLivingwith HIV Prevention ofmother tochild Transmission (of HIV) RwandaDistrict Health System StrengtheningFramework Referral Hospital RwandaInterimDemographic and Health Survey Serviced'AssistanceMédicale d'urgence ServicedeConsultation Psychosociale SputumSmear Positive Tuberculosis Positive MicroscopePulmonaryTuberculosis Test positivityrate Treatment Researchand AIDS Center Transfusion-transmissibleinfections Vaccinanatoxinetétanique(tetanus toxoidvaccine) VoluntaryCounselingand Testing World Health Organization 8

9 Acknowledgements The HMIS Unit would like to recognize the support of staff from MoH and RBC in the elaboration of this document. Most of the analyses were prepared during a workshop funded by CDC s COAG and facilitated by a team from USAID s Integrated Health Systems Strengthening project. The workshop was held in Kayonza at the end of April Many of the photos used in this year s bulletin were taken by Todd Shapera. 9

10 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. Therefore, this Annual HealthStatistical Booklet hasbeenproduced toprovideasummary ofall keystatistics of the Health Sectorin the year Thisbookletprovides policymakers,planners, andother interestedpartieswith insightintothecurrentstateofthe Health Sector.Thesestatisticsprovideabasisforpolicies,strategies,andplannedinterventionstoensure theyareresponsive to the needs of the health sectorand, crucially, are focused onaddressingcurrentpriorities thataim to improve the health of the Rwandan population. Dr Agnes BINAGWAHO Minister of Health 10

11 Introduction Ministry of Health: Annual Health Statistical Booklet 2012 The Ministry of Health (MOH) developed the Rwanda Annual Health Statistical Booklet 2012 in order to provide an overview of the key statistics in the health sector for 2012.This is thefourthyearthatthebooklethas beenproducedandthefirsttimethat themohhashad substantialdatafromtwocalendaryears,thereby enabling analysisoftrendsovertime.inaddition,theresultsofthe2010demographicandhealthsurvey (DHS) were released earlyin 2011and have allowedthe ministrytocompare routinelycollected servicedata with keyindicators fromthis population-based survey. Thebookletisdividedintofour chaptersentitle: Infrastructure;HumanResources;Morbidity;andSpecial Programs.TheSpecial programschapterincludesnationaldataonfamily planning(fp),tuberculosis(tb), HIV&AIDS,malariaandmaternaland childhealth(mch).thisyear,thebookletalsoincludesasection on health financing interventionsincludingperformance-based financing(pbf)andcommunity-based health insurance.other macro-levelfinancialinformationhasnotbeenincludedinthisdocument,as thisiscovered substantiallybythe National Health Accounts and otherspecial studies and reports Thisbookletaims to at showing key statisticsinthehealthsectorfrom2011in aconcise,easilyaccessiblemanner toensurethatthisvaluabledataisreadilyavailabletoallinterestedparties. Comparisonswithdatafrom2010 willhelp users to understand the evolvinghealth situation in Rwanda. Data havebeenextractedfromavariety ofsourcesincludingtherwandadistricthealth System Strengthening Tool (DHSST), the Health Management Information System (HMIS), TracNet, PBF databases for clinical services, the Community HealthWorkerInformationsystem(SIScom),the Community-basedHealthInsurance(CBHI)IndicatorDatabase,andseveralsurveys,including therwanda Interim DHS2010. Details of alldata sources areincluded in Annex1 Thisdocumentincludesdatafromprimary healthcarefacilitiesanddistricthospitalsmanaged by thepublic sectororfaith-basedorganizations(fbos)thatoperateunderaconventionwiththemoh.limiteddatais also includedfromnationalreferralhospitals(nrhs)toprovideamorecomprehensivepictureofrwanda s infrastructureanddisease burden. The bookletdoesnotinclude datafromprivatesector clinicsor dispensaries, as theseonly beganto report systematicallyin

12 Health Sector Resources Healthsector infrastructurecovered in this section includeshealth facilitiesandselected resources availablewithin thosefacilitiessuchstaff,equipment,utilities,andtransport. Itisimportanttonotethatthissectiondrawsdata frommultiplesources,primarilythe Rwanda HealthFacilitiesDatabase,theMOH shumanresourcedatabase(ihris),and the On-line survey (Limesurvey). The coverage of the On-line survey representsa sub-setofhealth facilitiesand, therefore,may notbeentirelyrepresentative ofnationalconditions. Health facilities Thenumberofhealthfacilities inrwanda, including the privates, attheendof2012was748, upfrom 720in theprevious year(seetables1and2). Thisincreasewasprimarily duetotheopeningof19new Privatedispensaries and9healthcenters.inthetablesandfiguresbelow,thesefacilitiesareclassifiedasreferralhospitals,district hospitals,healthcenters,health posts, police/military hospital, privatedispensaries, private clinics and prison dispensaries. Table 1:Number of health facilities, Heath Facility type National Referral Hospitals District Hospitals Police/Military Hospital Health Centers Prison Dispensaries Health Post Private Dispensaries Private Clinics NA NA 60 Total Source: HMIS National Health Facility Database,

13 Table 2:Numberandtypeofhealth facilitybydistrict,2012 District National Referral Hospitals District Hospitals Police/Mi litary Hospitals Health Centers Health Posts Prison Dispensaries Private Dispensaries Private Clinics 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 Total Source: HMIS National Health Facility Database, 2012 Total Of the748 healthfacilities58%are healthcenters,5%district hospitals,8%healthposts and15%private dispensaries and private clinics(seefigure 1).Therearealsofive referral hospitals,onepolicehospitals 1,and 16prisondispensaries.This analysis, usingdata fromthe HMIS NationalHealth FacilityDatabase include private health facilities which that are in the system. The table3 givesclassificationof minimumpackage ofservices provided byeach healthfacilitytype. 13

14 Figure 1: Distributionofhealth facilitiesbytype, 2012 Source:HMIS National Health Facility Database, 2012 Table 3:Minimumpackageofservices indifferentfacilities HealthFacilities Minimum Package ofservicesprovided NationalReferralHospitals Advanced inpatient/outpatientservices, surgery, laboratory,gynecology, obstetrics, andradiology;specialized services includingophthalmology, dermatology,earnoseand throat (ENT), stomatology,andphysiotherapy District Hospitals Inpatient/outpatientservices, surgery, laboratory, gynecology, obstetrics,andradiology HealthCenters Prevention activities,primaryhealth care,inpatient, referral, Maternity Dispensaries HealthPosts Primaryhealth care,outpatient,and referral Outreachactivities(i.eimmunization, familyplanning, child growth monitoring,anc) Referralhospitals alsoservealsoasteachinginstitutions for nurses, doctors andpharmacists. For example: Ndera Hospital is a referralhospitalformentalhealth.asshowninfigure 2,publichealthfacilitiesrepresent55%ofthetotalnumberof non-privatehealth facilities in Rwanda,andanadditional22%are run by faith-basedorganizations (FBOs), 20% by privateorganizations, 2% by communities, and1%by parental organizations. 14

15 Figure 2: Distributionofhealth facilityby managementauthority,2012 Health Facility Equipment and Utilities Due to delays implementing the District Health Systems Strengthening Tool survey in 2012, the MOH HMIS unit adapted an on-line survey tool (Limesurvey) to conduct a survey on infrastructure in all health facilities. In total, 748 health facilities responded to the survey (100% response rate), 41 of which are district hospitals and 451 health centers. According to this survey, 67% health facilities have electricity from the national power grid,41% use Generator, 33% use Solar energy, 0.3% use Biogas and 1% use other. Figure 3: Sources of electricity inhealthfacilities, 2012 Source: Lime survey Tool, 2012 TheLimeSurvey alsoshowed improvementsinavailabilityofreliableelectricitysourcesbetween2011and2012.there wasahighincreaseintheproportionoffacilitiesconnectedtotheelectricitygrid,whichrosefrom51%in2011to 64%in2012.Solarenergyusedecreasedfrom26%in2011to22%in2012.Mostotherelectricitysourcesremained proportionallythe same (see Table 4). 15

16 Table 4:Primarysource ofelectricityinhealthfacilities, Primary Electricity Source 2011 Percentage 2012(N=363) Percentage Electricity Grid % % Generator 41 8% 33 9% Solar Energy % 81 22% Biogas 0 0% 1 0% Other 0 0% 15 4% Source:LimeSurvey Tool,2012 According to the LimeSurvey, the proportion of facilities using local surface water rose from 17% in 2011 to 50% in2012 (see Table 5).This differencemay have been due to lack of clarity on the definition of local water system. Table 5: Sources of waterin health facilities, Water sources Number % Number2 % Local Water System 82 17% % National Grid % % Rainwater Harvesting 95 20% % Local Surface Water % 13 4% Well or Borehole, Covered 4 1% 1 0% Well or Borehole, Uncovered 1 0% 1 0% Tanker Truck 7 1% 29 8% Other 12 3% 5 1% Source:Limesurvey Tool,2012 Figure 4: Primary sources of water in health facilities Source:Limesurvey Tool,2012 Communication On 371 Health facilities 8% use Fiber optic, 8% use Wireless, 85% use Wireless Modem (MTN,Tigo, Airtel, 16

17 Rwandatel) and 3% donot have access to the internet. All district Hospitals have access to internet. Table 6:Internet/telephoneaccess in health facilities,2012 Types of communication Number of Health Facilities % Internet (N=371) Wired - DSL or Fiber-optic 30 8% Wireless 29 8% Wireless Modem (MTN, Tigo, Airtel, Rwandatel) % No internet 10 3% Other (VSAT) 2 1% Cell phone (N=344) Cell phone coverage(mtn,tigo,etc) % Source:LimesurveyTool,2012 In 2012, Health facilities which have desktop are 81% have 1 to 5, 15% have more than 5 and 5% don t have; for Laptops 83% have 1 to 5, 8 % have more than 5 and 9% don t have; for printers 90% have 1 to 5, 5% have more than 5 and 4% don t have. Figure 5:Availabilityof ICT equipment in health facilities, 2012 The table below shows the number of beds by health facilities types. Overall,thebed/inhabitantsratioremains the sameat1.6 bedsforevery1, 000 inhabitants inboth 2011and2012. Table 7:Numberofinpatientbeds byhealthfacilitytype, Facility types DistrictHospital 6,663 6,742 Health Center 9,684 9,756 Referral Hospitals Total 17,293 17,418 Source:RwandaHMIS software,2011and2012 At District Hospitals, 14% have one ambulance and 86% have more than 1 ambulances, 43% have one vehicle,43% have more than 1 vehicle and 14% don t have vehicles. At Health Center 15% have one ambulance and 85% don t have ambulances;11% have one vehicle, 1% have more than one vehicles and 87% don t have vehicles 17

18 Table 8: Transport owned by districthospitalsand health centers, 2012 Type Facility District Hospitals (N=28) of Health centers (N=322) Types of transport One % More than 1 % None % Ambulances 4 14% 24 86% 0 0% Facility owned Car/vehicles 12 43% 12 43% 4 14% Pickup/truck for transport of goods 12 43% 9 32% 7 25% Motorcycles 7 25% 18 64% 3 11% Bicycles 1 4% 1 4% 26 93% Ambulances 48 15% 1 0% % Facility owned Car/vehicles 37 11% 4 1% % Pickup/truck for transport of goods 5 2% 0 0% % Motorcycles % % 66 20% Source:LimesurveyTool, 2012 Bicycles 21 7% 3 1% % Regardingthefacilities equipmentsupplies,the survey found that, in 2012 in District Hospitals 60% have 1 to 5 Microscope, 16% more than 5 and 24% don t have Microscope,92% have 1 to 5 X-Ray,76% have 1 to 5 autoclave, 12% have more than 5 Autoclave and 12% don t have Autoclave. In Health Centers 91% have 1 to 5 Microscopes, 1% had more than 5 Microscope and 9% don t have Microscope. Table 9: Basic medical equipment in District Hospitals and Health Centers, 2012 Type of Facility Basic medical 1 to 5 % More % None % equipments than 5 District Binocular 14 56% 6 24% 5 20% Hospitals Microscope 15 60% 4 16% 6 24% (N=25) Refrigerator 10 40% 15 60% 0 0% X-ray 23 92% 0 0% 2 8% Autoclave 19 76% 3 12% 3 12% Anesthesia 22 88% 0 0% 3 12% Health (N=321) centers machine Binocular % 1 0% % Microscope % 2 1% 28 9% Refrigerator % 2 1% 52 16% X-ray 4 1% 0 0% % Autoclave % 0 0% % 18

19 Anesthesia machine Source:LimesurveyTool, 2012 Ministry of Health: Annual Health Statistical Booklet % 0 0% % 19

20 Human Resources In 2012 there were 683 doctorsand 9,230 nurses/midwivesworkingin Rwanda. Based on 2012 data fromthe MinistryofHealth Human ResourcesDatabase(iHRIS), thiscorrespondsto aratioof1 doctorper15,428inhabitants, 1 midwife per 23,364 inhabitants, and1 nurseper 1,200inhabitants.This situationhasimproved over the last years as showed in the table below (10). Thenumberofhealthcarestaffincreased mostsignificantlyamong paramedics, pharmacists, and midwives(table10). Accordingtothetablethe mostsignificantincreaseswere among, Paramedics(103%), Midwives (88%), Pharmacists (19%), EnvironmentalOfficers(10%), and Doctors(9%). Theonlycategorythatsawa reduction waslab technicians and social workers. Table 10:Ratio ofhealth workersto population, StaffCategory 2011 Population/ health workers %Change Population/health workers in 2012 Doctors , % 15,428 Nurses 8,273 1,296 8,779 6% 1,200 Midwives , % 23,364 Mental Health 140 N/A 75,266 Paramedical ,339 1, % 7,899 Pharmacist , % 106,437 Laboratory Technician 1,187 9,030 1,164-2% 9,053 Administrativeand 2,156 4, % 4,264 SupportStaff SocialWorkers 1,192 8, % 10,665 Environmental Officers , % 41,485 Educators , % 74,206 Source:MOH s Human Resources Database,2012, MoH Human Resource department 20

21 Morbidity and Mortality Data on morbidity and mortality presented in this booklet are from the R-HMIS Database. This analysis did not cover private facilities because they are not yet reporting regularly to the Ministry of Health. Data from referral hospitals are included in the database, but they have not been reporting regularly and the HMIS team was obliged to contact them for the availability of the presented data. The reporting rate of morbidity and mortality data from health centers, district hospitals and provincial hospitals was almost 99%. Outpatient Care In 2012, health facilities have received a total of 8,331,011 new patients (Table 11). Among them: 7,757,135 (93.1%) were patients seenin health centers, 457,259 (5.5%) in district hospitals, 114,605 (1.4%) in referral hospitals, while 273,322 (3.3%) were treated by community health workers (CHWs) practicing community-based integrated management of childhood illnesses (C-IMCI). Table 11: Number of new cases among outpatient visit in health facilities During the year 2012, the primary health care utilization rate was approximately 0,8 visits per inhabitant (8,331,011 visits/ 10,537,222). Health service level % change Health centers 7,996,598 8,437,850 6,985,028 7,757,135 11% District hospitals 544, , , ,259 3% CHW Home-based 514, , , ,322-7% care Referral hospitals 214, , , ,605-48% Total 9,271,472 9,977,851 7,942,938 8,331,011 9% Source: National HMIS Database, 2011; CHW Health Information system, ; R-HMIS, 2012 The table above shows that there was an increase in outpatient visits in 2012, as compared to The increase in the total number of new cases in 2012 may be the result of improved financial accessibility (community based health insurance coverage).reductions in number of children treated at community level are likely due to reduced treatment of malaria cases due to shortages of rapid diagnostic tests. Suspected malaria cases were therefore referred to health centers where the numbers of cases of malaria show a corresponding increase. 21

22 Health facilities outpatient morbidity Table 12: Top ten causes of morbidity in IMCI, 2012 Rank Diseases groups Health Center Percentage of all cases 1 Pneumonia 122, % 2 Diarrhea 108, % 3 Malaria 75, % 4 Febrile disease very severe 21, % 5 Acute Ear infection 13, % 6 HIV infection (probable or suspected) 10, % 7 Bacterial infection severe or very severe 6, % 8 Bacterial infection local 4, % 9 Mastoiditis 2, % 10 Other diseases 232, % Total 598, % Source: R-HMIS, 2012 The most frequent causes of health centers based IMCI treatment were pneumonia, diarrhea and malaria. Together, they caused more than a half of all IMCI outpatient visits (51.3%) in 2012 (Table 12 and figure 6). The reduction of pneumonia cases in children may be due to the introduction of pneumococcal vaccine in the routine vaccination. IMCI visits represented 7.7% of all outpatient visits in health centers in Since 2012,IMCI cases have been separately presented from other outpatient visits because it is a policy newly implemented in by Rwanda for all under 5 children to be treated under IMCI protocolsin an effort to meet MDG 4 targets which focus on the reduction of child mortality. Figure 6: Top ten causes of morbidity in health centers, 2012 (IMCI) Source: R-HMIS,

23 Table 13: Top ten causes of morbidity in health centers, 2012 (>=5 years) Rank Diseases groups Health Center Percentage of all cases 1 Acute Respiratory infections 1,682, % 2 Intestinal parasites 569, % 3 Physical trauma 406, % 4 Malaria 399, % 5 Gastritis and duodenitis 375, % 6 Teeth and gum Infections 306, % 7 Skin Infections 190, % 8 Urinary Tract Infections 186, % 9 Eye problem 163, % 10 Diarrhoea 153, % Other diseases 3,322, % Total 7,757, % Source: R-HMIS, 2012 In 2012, the most frequent causes of outpatient visits in at health centers for >=5 years were ARIs and intestinal parasites (Figure 7 or Table 13) as it was in Other diseases count for a big proportion (42.8%) because the list of diseases has been shortened in the national database in order to consider only priority diseases. Figure 7. Top ten causes of morbidity in health centers, 2012 (>=5 years) Source: R-HMIS,

24 District and Provincial Hospitals Outpatient Morbidity In 2012, the main causes of all outpatient visits in district and provincial hospitals were teeth and gum infections (21.5%), eye problems (19.8%), Acute respiratory infections (6.8%), Physical traumas other than fractures (6.4%) - see Table 14 and Figure 8. Table 14: Top ten causes of morbidity in hospitals, 2012 Rank Disease groups <5 years >=5years Total cases Percentage of all cases 1 Teeth and gum Infections % 2 Eye problem % 3 Acute Respiratory infections % 4 Physical traumas % 5 Gastritis and duodenitis % 6 Urinary Tract Infections % 7 Gynecological problems % 8 Diarrhea with no dehydration % 9 Bone and Joint disorders % 10 Intestinal parasites % Other diseases % Total % Source: R-HMIS,

25 Figure 8.Top ten causes of morbidity in hospitals, 2012 Ministry of Health: Annual Health Statistical Booklet 2012 Source: R-HMIS, 2012 Hospitalization and Mortality Admission and mortality in health centers and hospitals In this report, data on mortality concern exclusively information collected from health facilities through HMIS. Deaths that happened in the community are reported only in the MCHsection (maternal deaths), because they are notified by CHWs in their monthly reports and available in Community health database (SISCom). The total number of deathsreported in 2012 was This represents an increase of 23% (39% in health facilities, 29% in district and provincial hospitals) (Table 15). Table 15: Number of deaths in health facilities, Deaths % change Heath centers % District hospitals 5,206 6,000 7,715 29% Referral 2,055 2,012 2,094 4% hospitals Total 7,602 8,319 10,237 23% Source: R-HMIS, 2012 This increase does not suggest any weakness in case management, but rather increases in admissions during the year in 2012 (548,068 admissions) from which deaths are inevitable in a number that should be higher than in 2011 (509,023 admissions) (Table 16). The table also indicates that the average duration of stay for discharged patients was double in hospitals (4.8 days) compared to Health centers (2.4 days). This is likely because only minor cases are hospitalized in health centers (mostly for observation), while more severe cases are referred to district hospitals. Table 16: Intra hospital mortality in health facilities, 2012 Facility type Admission Deaths Discharged Number of % Average days intrahospital duration of discharged mortality stay Health centers 272, , , % 2.4 days Hospitals 275,872 7, ,240 1,273, % 4.8 days Source: R-HMIS,

26 Leading causes of mortality in health centers and hospitals Ministry of Health: Annual Health Statistical Booklet 2012 As shown in table 17, by far the major leading cause of mortality for all ages in health centers, district and provincial hospitals in 2012 was neonatal illness with 22% of all the reported deaths. These were followed by pneumopathies, cardiovascular disease, malaria, obstetrical problems and physical trauma/fractures, all with around 5% each. Table 17. Top ten causes of deaths in District Hospitals and Health Centers, 2012 Rank Cause of death Total % of total 1 Neonatal illness 2,722 33% 2 Pneumopathies 660 8% 3 Cardio-vascular disease % 4 Malaria % 5 Obstetrical problems % 6 Physical Trauma and Fractures % 7 HIV/AIDS opportunistic infections % 8 Diarrhea 335 4% 9 Cancer % 10 ARI % All other reported deaths % Grand Total 8143 Source: R-HMIS, 2012 Although referral hospital staff have been trained to report using the RHMIS, deaths from referral hospitals were not reported according to diseases in This is a major gap that should be resolved next year as referral hospitals receive most of cases with complications and are expected to record higher death rates than district hospitals and health centers. Figure 9.Top ten causes of deaths in all health facilities, 2012 Source: R-HMIS, 2012 The following analysis breaks out the causes of neonatal deaths because neonatology is a very sensitive service that is supposed to be managed with a special attention to reduce child mortality and meet the MGD 4. The 26

27 major leading causes of deaths in neonatology are Prematurity [22 to 37 weeks] (43%), Asphyxia (32%) and other neonatal infections (10%). Only these three causes account for 85% of all causes of neonatal deaths. Table 18.Top causes of deaths in neonatology in all health facilities, 2012 Rank Cause of neonatal death 2012 % of total 1 Prematurity (22 to 37 weeks) 1,157 43% 2 Asphyxia % 3 Neonatal infections Other % 4 Congenital malformation 159 6% 5 Respiratory infections 58 2% 6 Hypothermia 24 1% 7 Tetanus Neonatal 6 0% 8 Skin infections 3 0% 9 Meningitis 3 0% All other causes of neonatal morbidity 192 7% Total neonatal deaths Source: R-HMIS, ,722 Deaths from the community are not included and they are analyzed in MCH module. As noted above, data from referral hospitals are still missing in the Rwanda HMIS database. They are also likely to include a good number of neonatal deaths. Figure 10.Top causes of deaths in neonatology in all health facilities, 2012 Source: R-HMIS,

28 Maternal and Child Health Ministry of Health: Annual Health Statistical Booklet 2012 Family Planning Figure11 shows the trends inmodern familyplanningcoverage formarriedwomen, from1990 to2010. Family planning coverage has increased substantially from10% in 2005to 45% in Figure 11: Trends of family planning coverage among married women, Routine family planning data are reported from both health centers and district hospitals. At the end of 2012, 797,898 (40%) women of reproductive age were reported as continuing users of contraceptive methods in health centers and district hospitals (Figure 12) with an increase of 9%.This increase is slightly affected by the fact that the denominator was reduced for 2012 with the results of the 2012 census. Although facilities do not report women in union separately from other contraceptive users, a special analysis was done to estimate facility based coverage of women in union. For this analysis the proportion of married women years encountered during the DHS 2010 sampling was applied to the denominator (women of reproductive age), and the proportion of married women among family planning users encountered to the numerator (users at the end of the month). This results in an estimate that is very close to the DHS 2010 contraceptive prevalence rate among married women (44% as opposed to 45%) and suggests that the facility-based family planning coverage rates can be used as a proxy for survey-based contraceptive prevalence rates. 28

29 Figure 12: Facility FP coverage rates Source: R-HMIS, 2012 Coverage of family planning services is not uniform across the country as you can see from the map below (figure 13). This is calculated based on the data reported by health centers and district hospitals and does not include many private facilities nor pharmacies that distribute contraceptives directly to clients. This situation most likely explains why the urban districts of Kigali have relatively low service coverage rates on the map. Districts in Eastern province appear to be doing better with family planning coverage than others. 29

30 Figure 13: Map of family planning service coverage rate Dec Ministry of Health: Annual Health Statistical Booklet 2012 Source: R-HMIS, 2012 The Family Planning program is implementing new strategies to avail FP services near the population including Community Based Provision (CBP) and outreach strategies supervised by health centers. The acceptance rate to FP services has increased in the last 2 years from 20% to 22 % including the adherence to CBP. Also the number of clients served by CHWs has been increased as the training continues across the country. 30

31 Figure 14. The evolution in Community Based Provision of FP services in Rwanda The figure 14 shows that the most used method of modern contraception in Rwanda is Depo-Provera (61%), followed byoral contraception (20%), then implants (13%). The surgical methods (1%) and intra uterine devices (IUDs) (2%) are not commonly used, probably because they can only be administered by qualified personnel who would also need special training. Surgical methods include tubal ligation for women and vasectomy for men both performed only by trained medical doctors. 31

32 Figure 15: Distributionof modern contraceptive usersbymethod, December2012 Source: National HMIS Database,

33 Ante-natal Care (ANC) Figure 15 shows that, in Rwanda, almost pregnant women attend ANC appointments at least once in their pregnancies (98%). Figure 16: ANC coverage in Rwanda, Sources: DHS, The trend shows a reduction of coverage in ANC and especially for those who do their first ANC visit during the first quarter and those who attend the 4 standard ANC visits (Figure 16). This may be due to under-reporting as a significant proportion of ANC have been provided through national referral hospitals or private health facilities, which did not report through the HMIS at the time. It could also be due to an inaccurate projection of expected pregnancies (4.1% of total population), which does not take into consideration the rapid adoption of family planning services. 33

34 Figure 17: Percentage of women attending Antenatal Care (ANC), 2012 Sources: National HMIS Database, 2011 and 2012; DHS, 2010 Assisted deliveries HMIS data showed Rwanda s assisted delivery rate at approximately 87.6%, which is high than the DHS 2010 estimate of 69% and it shows a increase compared to 2011 (64%). This is likely due to under-reporting and denominator issues as mentioned for Antenatal care Visit. Figure 18: Assisted deliveries, Sources: National HMIS Database,

35 The figure below shows that the 3 districts with highest health facility delivery coverage are Nyarugenge,Nyamasheke and Bugesera while the lowest coverage is observed in Nyaruguru, Kamonyi and Nyamagabe. Figure 19:Figure14: Deliveries in Health Facilities by district Source:NationalHMISDatabase2012 Caesarian section at hospitals Thepercentage ofcesareansectionsamongalldeliveries is14.3% in 2012 (Table 19). Among hospital deliveries, cesarean sections slightly decreased from45.3% in2011 to41.8% in2012. Table 19: Caesarian sections in district hospitals and referral hospitals, Health Facility Type Cesarean Cesarean Deliveries Dystocic Cesarean sections as Dystocic Cesarean sections as Deliveries deliveries sections % of total deliveries sections % of total deliveries deliveries 88,334 41,784 40,037 45% 94,373 41,311 39, % District Hospital Referral 4,752 1,643 2, % 4,449 2, % Hospital Total 93,086 43,427 42, % 98,822 41, % Sources: RHMIS Database

36 Maternal Deaths Number of maternal death in health facilities The biggest number of maternal deathswere reported in District hospitals, the trend shows also a decrease of this number between 2010and Until now referral hospitals do not report in HMIS database, but since 2010 the HMIS unit has requested these data annually especially for the prepartion of this bulletin.for the data on maternal deaths that occurred in community, they started to be reported by community health workers since 2010, through the SISCOM (Community Health Information System). Figure 20 : Number of maternal death by level of health facilities Sources: National HMIS, SISCOM and Maternal Death audit Database 2009 to

37 Causes of maternal death in Rwanda 2012 The total number of maternal deathsthat occurred in health centers and district hospitals in 2012that are reported through ther-hmis database was169. For better surveillance of maternal death, there are now 3 sources of data:: R-HMIS database, weekly reportsfrom District Hospitals and maternal death audits. In 2012, there were a total of 218 maternal deaths reviewed using maternal death audits and the main causes of death still the remained the same as last year: Severe bleeding, infections and eclampsia. In these audit reports, Maternal death in the community is not included, so there is virtually no difference fromyear 2011,when the number of maternal deaths reported was 221. Table 20: Causes and proportion of maternal death in Rwanda 2012 Causes Number % Severe bleeding 98 45% Septicemia 32 15% Eclampsia 25 11% Paludisme 6 3% Abortion 8 4% Amniotic Embolism 4 2% Severe anemia 1 0% Cardiopathy 4 2% Spine anesthesia Complication 4 2% Other 16 7% Unkwown 20 9% Total % Source: HMIS database and MDA from MCH department 37

38 The most common causes of maternal death in 2012 werepost-partum hemorrhage (31%), septicemia (15%) and eclampsia (11%). This trend shows that the distribution of the 3 most common causes has not changed since Figure 21: Causes of maternal deaths Source: Maternal death audit (MCH Department) Period of maternal death This chart shows that most maternal deaths occurred during thepost-partumperiod(54%). Figure 22: Period of maternal death 38

39 Peri-neonatal health This graphic shows how the neonatal mortality has decreased during the past five years along with the national target according to the EDPRS 1. Figure 23: Neonatal mortality rate Source: Report DHS and MDG target. Perinatal Mortality rate This graph shows the frequency of still birth among the perinatal mortality which is high at 17 per 1000 live births. The total perinatal mortality is 28.6 per 1000 live births. Figure 24: Perinatal Mortality rate by component. Source: HMIS 2012 The graph above shows that nearly 50% died before birth. This proportion is high and stillbirths are the main contributor to perinatal deaths, meaning mucheffort is still is required to improve ANC visits and labor surveillance to reduce stillbirth rates. 39

40 Weight at Birth and Deaths of Newborns The Tablebelow showsthe numberofbirths, perinataldeaths,and lowbirth weightbabiesbornathealthfacilities in Rwanda in2011 and 2012.Theproportion ofperi-nataldeathsdecreasedfrom42.1 per1,000 livebirths to 28.6 per1,000births in2012.lowbirthweightdeliveriesdecreased from7.9%in 2011to 5.9%in 2012at districthospitals.thesepositive trends reflectthe overalldecreasein lowbirth weightbabies from4.7%in 2011to 4.5%in 2012(Table21). Table 21:Birthsand peri-nataldeaths inhealthcentersand districthospitals, Health Facility Total Births < % low birth Births < % low birth Type Total Deaths Total Births Total Deaths Births 2.5 kg weight 2.5 kg weight Health 190,077 1,500 5, % 189,304 2,057 7, % Center District 90,244 3,802 7, % 98,395 6,152 5, % Hospital Total 285,071 5,585 13, % 287,699 8,209 12, % Sources:NationalHMIS Database, 2011 and 2012 Neonatal deaths audit Neonatal and child death audits started in all district hospitals in January 2011.In 2011 health facilities audited 923 neonatal deaths and in 2012 the number of neonatal deaths audited increased from 923 to 2,632. Neonatal cases audited are from 39 hospitals. Eighty-eight percent of those deaths occurred in district hospitals, 7% in referral hospitals and 5% occurred in HC. Forty-nine percent of deaths were premature newborn and 58% had low weight at birth Hypothermia and neonatal deaths The following graph shows that hypothermia is the main complication which is associated with neonatal death. Seventyfive percent of all new born had hypothermia when they were admitted in neonatology services. To fight against hypothermia, training health providers on essential new born care, with insistence on resuscitation and prevention of hypothermia, must be continued. Figure 25: Hypothermia and neonatal deaths Source : Neonatal and child death audit 40

41 Causes of neonatal deaths Neonatal asphyxia is the first cause of neonatal mortality followed by complications of prematurity and neonatal infections. Congenital abnormalities represent 8%.For 5% of all cases, the cause of death was unknown, meaning that the follow up of these cases must be improved during hospitalization. Analysis shows that 53% of deceased newborns didn t cry at births. Figure 26: Causes of neonatal deaths Source: Neonatal and child death audit Period of death after birth A big proportion of newborns die between 30 minutes and 48 hours after birth. Eighty-eight percent of deaths occurred in early neonatal period and 12% in late neonatal period. Figure 27: Period of death after birth Source: Neonatal and child death audit,

42 Reasonsfor neonatal deaths In almost one third of the cases, neonatal death can be attributedto late health seeking behavior for mother or neonate (32%). In 26% of cases the deaths were attributed to insufficient follow-up or decision-making during labor and in 24% to insufficient follow up or management of neonate. For this reason training health providers on emergency obstetric and neonatal care must be continued and introducing clinical audit of asphyxia could contribute to the reduction of neonatal death associated with asphyxia. Figure 28: Reasons of neonatal deaths Source: Neonatal and child death audit Preventable character of neonatal deaths The audit shows that 76% of occurred deaths could be preventable if some measures were taken during labor, neonate management after birth or follow up in hospitalization. Figure 29:Preventable character of neonatal deaths Source: Neonatal and child death audit 42

43 Child health Ministry of Health: Annual Health Statistical Booklet 2012 The graph below indicates a generalreduction of < 5 mortality from 2005 to 2010, but neonatal mortality among <5 mortality is going slowly. Figure 30: Under five,infant and neonatal mortality rate,dhs

44 Proportion of malaria,diarrhea and ARI in children 2-59 months treated in IMCI in health centers According following graph, 21% of under 5 years have been treated of malaria at national level. The highest proportion is observed in Nyagatare District with 59% and the lowest in Rutsiro District. At national level 38% of received children are treated for ARI with high proportion in Gicumbi and Ngororeo districts, while the lower proportion is observed in Nyagatare District. Concerning diarrhea, the national proportion of treated cases is 30% with high proportion in Rubavu,Musanze and Nyaruguru District. Figure 31: Proportion of malaria, diarrhea and ARI in children 2-59 months treated in IMCI in health centers Sources:NationalHMIS Database 2012 Proportional mortality and case fatality rate (CFR) The 3 leading causes of under 5 deaths are ARI, Diarrhea and Malaria. These 3 top killer diseases in under 5 represent almost 60% of the total deaths that occur in under 5 childrenfor other childhood diseases:11% of children under 5 were admitted for trauma & burns, 10% for Malnutrition and 5% were admitted for HIV/AIDS related diseases. 44

45 Figure 32: Proportional Mortality rated under 5 years (excluding neonates) Source : RHMIS Database 2012 As indicated in the second graph, the case fatality rate (CFR) for HIV/AIDS very high (20%) and is followed by trauma and burns (5%), malaria (3%), and UTI (2%). The case fatality rate of the other main killers (ARI and diarrhea) areboth around 1%. Figure 33: Case fatality rate under 5 years (excluding neonates) Source:RHMIS Database

46 Child Growth Monitoring The figure below shows that Child Growth Monitoring Promotion continues in all the districts but the coverage is still low. The cost of CBNP is high which explains low coverage and partner support. Figure 34: Growth monitoring promotion Source: SISCOM database 2012 CBNP evolution Acute malnutrition has reduced from 8.30% to 1.08% from 2009 up to This can be attributed to the increased efforts in the elimination of malnutrition since 2009; Nutrition education has also been increased using CHW and even the media; Radio broadcast especially.another added factor is the high level of political commitment for national leaders in the fight against malnutrition. CBNP utilization has increased; it should also impact on the nutrition status of the children. It has also been observed that referral rates from the community to health facilities are low. Figure 35: Evolution of CBNP coverage and its impact on nutritional status of children 46