eHealth Systems in Rwanda

1. eHealth Systems in Rwanda Arleen Cannata Seed World Bank Sr. eGovernment Specialist 29 January 2009

2. Background • Small, land-locked country in Central Africa (pop. 9-10 Million, few natural resources, little land left for agriculture) • 1994 genocide killed or maimed nearly 10% of population; many others fled • Very high poverty index, GNI per capita only $230-260 • High population density, mainly rural, and agriculture based economy • Poor quality infrastructure and very low internet penetration

3. Rwanda’s Goals Vision 2020 to become a middle-income country, by transitioning to an information rich, knowledge-based economy Develop human capacity as best resource and highest priority Move Rwanda into 21st century using ICT as an enabler to achieve other development goals (outlined in the NICI Plans); requested World Bank to take the lead in ICT

4. Rwanda’s Greatest Assets • Enabling Environment: Commitment, enthusiasm and urgency of President, Cabinet and Ministries; Buy-in at all levels including CSOs, NGOs, PSOs • Human Capacity: Young, energetic citizenry (65% under age of 25) with language capabilities, yet unskilled for ICT • Resources: Substantial donor support and good will; projects to address infrastructure and capacity

5. Challenges to Achieving Successful Outcomes in Health • Human Infrastructure • many patients are illiterate or uneducated beyond primary levels • most districts have only 2 doctors per 100,000 • Nurses are the backbone of the system but need more training; Kigali Health Institute is teaching basic computer literacy to new nursing students • While there is project specific training (e.g., for TRACNet or HMIS), there is no systematic formal training in eHealth technologies. IDRC is starting a program in Fall 08 to address this. • Physical infrastructure • Lack of national backbone (but this is being constructed) • Lack of good international links (but this is coming too) • Lack of reliable electricity (national grid online by 2012) • Lack of reliable back end systems, integration and interoperability of data. Each system to date developed in isolation and little interoperability. In particular need direct data transfer between Open MRS and TRACNet, and therefore onto Camerwa • Need to web-enable the databases so information accessible

6. Capacity Building Applications, Content, Services Underlying technologies and equipment Telecommunications and links PSCBP, eRwanda eRwanda eRwanda RCIP Summary of ICT support to address challenges

7. MDG Goals for Health* • Reduce child mortality (currently IMR at 86/1000, U5MR at 152/1000, immunization high) • Improve maternal health (currently MMR at 750/100,000, 50% of births attended) • Combat HIV/AIDS (currently 3-5% seriopositive), malaria (cases are 40% of health load), TB and others * Source: UNDP: National Human Development Report, Rwanda 2007

8. GoR’s Approach to Reaching MDGs for Health • GoR plays very active role as facilitator and not just as regulator; emphasis is on performance based results and not just inputs • Integrate donor funds into a fiscal framework (compact agreement) to contribute towards poverty reduction • In 2007 GoR health spending was 9.5% of total public expenditure ($12-14/pp) • Health System Strengthening (HSS): align financing and system support to results rather than inputs, and from analytic support to implementation – provide support for health finance and insurance, HR for health, governance, supply chain management and infrastructure • Initiatives for use of ICT in HSS – mainstream support and deployment of infrastructure and ICT to achieve health goals • Collaboration amongst the MoH, M of Sci/Tech and Scientific Research, RITA.

9. Ministry of Health’s Initiatives using ICT Open MRS – open source Medical Records System that tracks patient level data; data entry by mobile phone, supported by Partners in Health and CU’s Millenium Village Project (MVP); there are also installations of Fushia and other EMR systems, but moving towards Open MRS. A national rollout is planned and will require extensive training and investment (including ICT skills for how to program and maintain it). TRACPlus, TRACNet – Monthly monitoring of infectious diseases including HIV/AIDS, TB and malaria; uses mobile telephones to collect data, later available by mobile or internet. Feeds into the HMIS. All facilities providing ARTs submit reports. Camerwa – drug and medical supply management system

10. Initiatives, con’t Telemedicine – ICT to deliver health and healthcare services, information and education to geographically disparate parties, remote diagnosis and testing. Currently, two district hospitals connected to King Faisal Hospital (Telemedicine Hub) in Kigali. More will be added shortly, and project will also create a platform for biomedical imaging HMIS – integrate data collection processing, reporting and use of information for decision making. Will enhance ability of country to perform disease surveillance and enhance public health protection services. Will require an upgrade of the current MIS to accept data from TRACNet. Will also need to scale up data managers at hospital level. eLearning – instruction of A2 level nurses (some HS + 2 yrs) for promotion to A1 level (HS diploma + 2 yrs.); some lectures broadcast to the three hospitals connected

11. Mutuelles – National Insurance • Coverage: Includes 85% of rural population at secteur level. , where all primary care done. Along with the 6% of citizens who get other coverage through civil service, military or private insurance, over 91% of population covered! • Process: Primary care takes place at secteur. Referrals start in health clinics, escalates to referral hospitals, and eventually to Kigali for most serious cases • Costs: Citizen pays $2/yr and 50 cents per visit (excluding antenatal care). Gov picks up the tab for some poor; 10% of Mutuelle funds goes back to the district, and caters for the referrals coming from the health clinics, including those to hospital • Challenge: system not web-based, so while citizen can access any health clinic, the bills can be hard to track if citizen registered in a different district.

12. Conclusions • Rwanda has unique goals, assets and challenges, and this has led to unique solutions • GoR’s efforts in health have been mostly strategic and programmatic rather than regulatory. As systems become more complex, they will require both support and regulation, particularly on patient confidentiality and on standards.

13. Conclusions • There is no cookie-cutter solution and what works in Rwanda may not work in other countries but we can take Lessons Learned from them • Despite the challenges and substantial needs across all sectors, this desperately poor country does not ask “ICT or Health?”, it asks “How can we use ICT to deliver Health Services?”

14. Bibliography/Reviewers • Bibliography • eHealth Rwanda Case Study, July 2008 • OECD: Scaling up to achieve the MDGs in Rwanda, June 2006 • WHO: Collaborating Center for Telemedicine and eHealth, 2007 • Various WB publications on MAP, Health, Africa • Lancet: Innovations in Rwanda’s health system, July 2008 • GoR: Health Sector Strategy Plan • Reviewers • Caroline Kayonga, PS, MoH • Dr. Richard Gabuka, eHealth Coordinator, MoH • Miriam Schneidman, Sr. Health Specialist, World Bank • Pamela Johnson, VOXIVA • Agnes Soucat, Advisor, World Bank