Rwanda: Quest to reduce donor dependence in community health financing

The government has turned to local solutions as a way of reducing reliance on foreign aid in the facilitation of community-based health workers.

This was said on Friday during an impact assessment workshop of the community-based health workers (CBHWs), who are currently facilitated through a World Bank project dubbed, ‘Performance-Based Financing’ (PBF).

“In the future, we expect aid funding to reduce, so we shall need alternative income sources,” said Cathy Mugeni, the director of community health unit at the Ministry of Health.

PBF is defined as a mechanism by which health caregivers are, at least partially, funded on the basis of their performance.

According to Mugeni 50 per cent of PBF money dedicated for community based health work programmes is saved to cater for sustenance of future projects, while 20 per cent is paid to individual CBHWs, and 30 per cent to CBHW’s co-operatives.

Rwanda currently has 45,000 CBHW’s grouped in 468 co-operatives, each village has a minimum of two, they are in charge of monitoring pregnant mothers, fighting malnutrition, co-ordination of vaccination programmes, among other things.

The Calf

They use a phone application system called ‘Rapid SMS’ to report the cases to health centres and the ministry.

Emery Hezagiza, the in-charge of PBF at the Ministry of Health, said starting from January, payment has been done depending on individual and not co-operative performance as was the case before.

This aims to reduce cases of individual complacence.

“Payment now will be based on the number of reports filed by individuals through rapid SMS,” he said.

Over the years, there have been isolated cases of embezzlement of funds by individuals who run the co-operatives, Hezagiza said, adding that such cases have reduced in the last two years since a competitive private auditing and management firm took over supervision.

Assupta Mukangarambe, a CBHW in Kabarore Sector, Nyagatare District, welcomed the idea of payment based on individual performance, saying it would encourage participants to put in maximum effort.

Rwanda: In the Thick of Open Heart Surgery

By Ivan Ngoboka

It is 7am, outside King Faisal Hospital theatre. I’m here to unravel the intricacies in open heart surgery, something that is often left to only the medical staff with access to the theatre to know.

A group of American surgeons, under the banner, Team Hearts, are in the country to carry out the delicate operations. The US-based charity has been offering free heart surgery services in Rwanda over the years.

Ceeya Patton-Bolman, the Team Heart’s programme coordinator, takes me through the briefing of some of the requirements observed before the surgery. Among others, she says a patient has to be at the hospital a day or two before surgery to evaluate whether they are fit.

“A patient has to under go HIV, TB, Hepatits B and C screening, urinalysis, chest X-ray, dental and full blood screen,” Patton-Bolman says.

Patton-Bolman says a patient found to be HIV-positive or has Hepatisis B or C cannot be operated on currently since there are no specialised equipment to handle them.

“This operation is too draining, so carrying out surgery on people with such ailments exposes them to too much risk,” she says.

Entrance into the theatre

Before entering, I am given green gowns, head gear and facial masks as protective gear.

The theatre is neat and smells of disinfectant, and in the centre, are two figures clad in similar garb (anaethologists) bent over a table with a patient covered in a blue sheet with a rectangular opening around the chest area-wait, the opening is on the sheet, not body, at least for now.

The medics are administering injections, I later learn its sedation to numb the patient, one of the many aspects of anaesthesia.

It’s not every day that you get to attend an open heart surgery and this opportunity is exciting enough. Whats more, the medical team are feisty and I am allowed to venture close enough, instructed on what to touch and what not.

This particular patient is a victim of rheumatic heart disease, a disease that makes a patient extremely weak with difficulty in breathing. The surgery is done to enable the replacement of the mitral valve with an artificial one that better aids the functions of the heart.

“Anaestheologist, perfusionists (a specialist who pumps a liquid into an organ or tissue, especially by way of blood vessels), cardiologists, and cardiac surgeons should agree that the patient is ready before any surgery starts,” says Alex Mucyo Katabarwa, the national nurse coordinator for cardiac care

The chest is cleaned before the surgeons get to work, incising with precision. When it comes to the chest bone (sternum), an electric scalpel (a small and extremely sharp bladed instrument) is employed to cut through.

The chest is open and one can spot the heart now, it’s a fatty ball with a blend of white and yellow that expands and compresses rapidly.

Perfusionists move to stop the heart, by planting tubes into it from the heart-lung machine (this machine temporarily takes over the heart’s role) so the sick valve (mitral valve) can easily be located and worked on.

When the heart stops, its not long before surgeons spot the mitral valve as it had earlier on been located through an eco-cardiography. You will occasionally spot a surgeon whispering or gesturing to a nurse to extend a particular tool.

The sick valve is quickly cut out, its hard to make out its exact appearance since the surgeon quickly shoves it away in his gloved, bloody hand.

Occasionally, blood spills from organs around the heart as the surgeons go about cutting. You have to be a hard specimen to endure all the sight of blood.

In my mind, assumptions are running. What would happen if this sharp knife accidentally dropped on the heart? What if there was some mistake in the cutting? But these guys are up to the job. The dexterity in their hands is like for a pugilist.

They replace the valve with an artificial one; a small, round metallic object sealed in the centre with a cross-like sign. A white sponge-like coating is used on the valve’s seal.

Its planted in the spot using absorbable stitches, and the heart is restarted to see if it functions normally with new tube. It’s monitored for a while before the team agrees that it works. The stitching starts, with the chest born is repaired, muscles and skin stitched back.

The chest is stitched and bandaged and the patient removed from the anaesthesia machine though consciousness does not return immediately. The patient is wheeled to the intensive care unit (ICU) with many tubes hanging to the mouth, nose, chest and genital area.

Katabarwa says the patient usually spends two to three days in the ICU for monitoring before they are transferred to the general ward for recovery.

“It takes six to eight weeks for a patient to achieve full recovery, but follow-up continues almost for their life time,” he says.

Currently, Rwanda is the only country in Africa that Team Hearts have extended their charitable works to.

“When we got here, it was a bit sad to learn that for a nation of 11 million people, there is no cardiac surgery hospital. Yet back in the US for every less than a million people there was one. Besides the people here are too hospitable, they encourage us to keep coming back,” Patton-Bolman says.

She added that they have conducted 102 surgerries since 2008, with a success rate of 98 per cent.

The team is made of about 250 doctors in total, but only 44 were in the country for their seventh visit.

“These specialists do not only donate their vacation time, but also pay their own air fare just to come and volunteer in this service,” Patton-Bolman says.

Currently, Team Heart has no plans of ending their operations in the country “until a speciliased cardiac hospital is established.”

The group fundraises about $250,000 (about Rwf170 million) on average annually and more than $300,000 (about Rwf202 million) worth of equipment around the US to support the project in Rwanda.

At last month’s annual three-week visit, 16 patients operated on.

However, Patton-Bolman says it has not been a smooth ride altogether.

“During the first year of operation, we had to bring every equipment, ranging from the heart lung machine to all other surgery impliments,” she says.

Experts say because of limited facilities in the country, patients with heart complications are discovered late, making treatment sometimes expensive since cases are usually advanced. The other challenge is follow-up on patiests, Patton-Bolman adds.

“Since most of us immediately depart after the exercise, it’s difficult to follow-up all the patients we have worked on,” she says.

Rwanda has only four cardiologists but for their number, the work output is tremendous, officials say.

Rheumatic heart complication, which is the commonest in the country, usually affects people aged 15 to 25 years.

Julie Carragher, the Team Heart screening coodinator who was on her second trip to the country, expressed pleasure over her participation.

” When I was asked to be a part of the team last year, I was eager to come and fulfill my dream of participating in mission work. What I experienced while here from a cardiology perspective was immeasurable, but I also enjoyed the hospitality of ordinary Rwandans,” Carragher says.

Dad, me, and the affair with newspapers.

The year is 1994; I am five and school going. Back at home, I am the table flipping pages of a copy of the New Vision (NV), still in black and white print then, and telling mom how much of a great reader I would become if I ever learnt the skill. A year into school and I couldn’t read? Slow kid? For the love of God it’s past business. Dad developed interest before it was long, and using a copy of the NV bought from the street every day, he put me on a dummy run. The artistry of getting fused letters to make sensible sound wasn’t easy to fathom, but with his unhurried instruction I made through overtime. Soon I was taking in more works of society columnists like Liliane Barenzi, Timothy Bukumunhe and the Old Fox than an Alaskan does to pot. Once in a while Dad (bless his heart) joined in solving sudoku and crossword puzzles. Whenever I was away at the farm, he made it a point to send enveloped cut outs of a favourite comic strip, Kingo. The year 2004 came, and this time Dad did not only carry home a copy of the NV  but also the Red Pepper(The Daily Monitor was always out of question for reasons known only to him). His freshly found obsession with the RP (Red Pepper) was hard to hide. And as children, through whispers and silly grins, we wondered why he spent ‘hours’ on the Mighty Hyena page. It was none of our business any way! 20 years later I had discovered John Grisham, and rubbed shoulders with Grammar Nazis. And the good old man still pays unchallenged loyalty to the NV.

Kampala Vs Kigali

By Ivan Ngoboka

You will definitely fall in love with the neat,palm-tree lined Kigali streets.The city is peppered with numbers and signs,and so easier to navigate.

The motorists in this part of the world seem more controlled;you won’t hear the un-necessary screeching and hooting .

Every tarmac road here seems armed with a wide walk-way;I like that Tim and I,can make half-drunk strolls,late in the night without the fear of being mugged. Thanks to the friendly, AK47/Uzi-gun wielding army men and police,always on watch.

The army generals here seem more down-to-earth,most times an appointment won’t be necessary,you will bump into one at the parking lot,and talk like you have known each other for a life time.

Missing Kampala

Despite the serenity and organization of Kigali,why am I still nostalgic about the dusty,chaotic,filth-filled Kampala,a yearlater?

Why do I still miss the errant Kampala taxi driver,who will deliberately aim their speeding automobile at you then after shout out ‘oyo mwasamu’ after they missed hitting you by inches?

Why is it hard to forget the loud-mouthed,half-clean boda-boda chauffer,who will get you hoping on their two wheeler,like one riding on horse back,in the name of dodging potholes?

The ‘street pastor’who will at best just crane their neck into your car to warn you about judgement day that is abound, or at worst even pick and run away with a valuable!

Why do I feel it’s hard to do without the typical Jinja-road traffic police officer, who will pull you over for an offense and hold hostage, till you slip a UGx5000 note in their hand?

My admiration is still fresh, of the middle aged man on the streets who will fake blindness so as to beg , till some sharp dude tries to make away with their loot, or the pickpocket who will take off with your phone then go like “kano akasimu kasente ntono, lwaki tokesonyiwa,”if you tried giving chase.

How I miss,the self-crowned opinion leaders;the Frank Gashumba and Charles Rwomushana’s of this World!

Oh Uganda,the country that started my story.I love and miss you.

Real human interaction is on it’s deathbed , and social networks are responsible

By Ivan Ngoboka

Entrance into this popular hangout, three girls seemingly in their early 20’s line the lounge on high stools.

Two of them from the far-end, have their heads bent, obviously engrossed with their phones, they occasionally look at each other ,and share smiles .

Their colleague in the centre, has arms crossed, with head pointed to the roof, and seemingly gazing at nothing in particular, she yawns, rubs eyes, and stretches .

It ‘s clear that she is thirsty for real interaction from her accomplices, but none of them seems to notice, they are buried in the world of texting , and they do so with speed and precision, you would think they are out to coin that Guinness World record.

The other day I woke up to news of a woman who fell in an uncovered city street manhole, as a result of text-walking. It was so bad ,yes very bad, I had to walk by the window for a smoke!!

Mean while, Alma has suddenly become squint-eyed , but still refuses to break bond with his lighty smart phone, even after repeated warnings from the optician that it could be responsible for his blurred vision.

The head-strong bloke doesn’t admit addiction to the gadget. His reaction is eerily similar to that of an alcoholic when confronted about drinking.

His problems won’t be ending soon though ,lately he’s been complaining of neck and back pain ……bend-texting obviously the culprit.

In other news……Angella and her Aunty are intimate , but verbal communication rarely comes their way, yet none is deaf or dumb. Intera-texting is the lingua-franca, they will do so at the living room couch for hours in the evening, occasionally falling in fits of laughter with out ever lifting their heads to look at each other.

The coffee tabled before them always ends up losing it’s steam, remaining untouched………………intera-texting on going…………

Props to those who stray


By Ivan Ngoboka

That person you care about with an exclusive passion is human and so mood swings are inevitable.One morning the relationship could come to a screeching end.

 So what does a poor sister or brother do?  Hit the gallows, tie a noose around their neck and hang? Or apply for brain conditioning so as to forever erase and forget anything bordering on dating and relationships?

That’s the price we pay for throwing ourselves wholly to fellow humans , whose weaknesses equal or are even worse off than our own.  Don’t despair though; there is one dependable cure  – alertness – always having  a backup plan so that when you get thrown out here some else  receives you from the other  end with  open arms. 

  And to achieve this, it takes creating an extensive network of partners and employing a clever mind to keep each one of them  secret so you can enjoy all their “services” without deprivation or fear of being busted. 

 Away from that, one of the reasons we exist  is to explore life, experimenting with everything whenever we  can, it comes with thrill. By the time we leave this world there is a relative level of experience or  satisfaction gathered . 

 Zeroing down to relationships,there are countless members of the opposite sex who appear too “endowed” to miss out on. It gets to that point of leaving us swearing about “meeting them all before we die”.

But how does one get to experience this when they are forever tied to a relationship with a boring or  bothersome scoundrel? In these murky economic waters,having a “backup plan” may save one from the gold digger type of girlfriend,especially if the other alternative is  more considerate in financial demands.   

 In conclusion, it’s important to understand that each of us is an autonomous individual with the freedom to do whatever we want with our lives, so we shouldn’t let certain people ‘own’ us like  we are items.Kick away fears of being accused of infidelity. After all, we all get a little naughty sometimes. I believe this is the truest description of a REAL man or woman.