Rwanda: Health Sector Reforms to Boost Retention of Medical Personnel

With the rise of deadly non- communicable diseases (NCDs), there is a need to increase the number of medical personnel and curb their turnover. This has since triggered new reforms meant to reverse this negative trend on Rwanda’s health sector, according to the Ministry of Health.

Though infectious diseases and associated mortality rates have declined over the years thanks to efforts invested in tackling them, non-communicable diseases (NCDs) are on the rise and threaten Rwandans’ life expectancy gains, if nothing is done to reverse the trend, Health Minister Sabin Nsanzimana told members of Parliament on May 11.

It was during the budget hearing for the financial year 2023/2024, with the Parliamentary Committee on National Budget and Patrimony.

He indicated that the mortality rate of NCDs such as high blood pressure, diabetes and cancer, and other chronic diseases, have surpassed those of infectious diseases, adding that there were very few health care workers which limited efforts to deal with NCDs.

Data from the Ministry of Health show that the mortality rate of infectious diseases dropped from around 80 per 1,000 people [in question] in 2,000 to about 40 in 2010 and about 30 in 202o.

But, the mortality rate associated with NCDs went down from 40 per 1,000 people [in question] as of 2000, to about 35 in 2010, before rising to 40 in 2020.

The Ministry of Health, Nsanzimana said, has been working on new reforms — projected to last for four years — to tackle this NCD burden, along with infectious diseases. Their implementation was expected to begin in the upcoming fiscal year 2023/2024.

The reforms include producing more healthcare workers and retaining them; strengthening primary healthcare (especially through community health system reform), and strategic acquisition of medical equipment.

Increasing the number of healthcare workers

Nsanzimana said that Rwanda currently has one healthcare worker (HCW) per 1,000 population, which is far short of the minimum of four doctors per 1,000 population as recommended by the World Health Organization (WHO).

At the current rate, he warned, it would take 185 years for Rwanda to reach the WHO target with a view to achieving Sustainable Development Goal 3 (SDG 3), which seeks to ensure healthy lives and promote well-being for all at all ages.

If that is the case, he said, the diseases in question would have had their toll on the country’s economy and caused many other damages.

Reaching that target was necessary because it can help the country to tackle both infectious diseases and NCDs, he indicated.

Importantly, Nsanzimana said, the medical reforms seek to increase by four times the production of healthcare workers in the country over the next four years in order to reach the WHO target of at least four HCWs per 1,000 people (by 2028). The healthcare workers include doctors, midwives, and nurses.

Community health workers to manage NCDs

For primary health care which covers health centres, health posts and community health workers (CHWs), Nzansimana said there are many reforms being made, some of which will start in the upcoming fiscal year (2023/2024), where they will be entrusted with offering an extended medical service package.

The objective of this move is to ensure that diseases are treated at the community level (by trained community health workers) before they get severe.

“For instance, we will add first aid to the services they can offer, so that they are able to manage urgent medical cases such as a person who falls down (faints) in the community. First aid is very important, and we had a gap there,” he pointed out.

The second, he said, is about NCDs where community health workers can carry out tests for conditions such as blood pressure.

“It is something easy considering the testing devices we use such that a CHW can be trained in how to operate them so as to help a resident know the rates of their blood pressure, as well as sugar levels in their blood,” he said.

He indicated that those are simple medical services that can be offered at the community health worker level, instead of increasing the number of people who seek treatment at hospitals.

Addressing small salaries of medical personnel, retention cost

On the remunerations of medical personnel in Africa’s public health care system, Nsanzimana said they realized that Rwanda was among countries that pay smaller salaries to medical consultants than others.

“We pay a doctor $958 — and that is a specialist consultant — while countries like Zambia have reached $3,000; South Africa $7,000, Kenya $4,000; and Nigeria about $2,000,” he said.

“In fact, you find that it is us in Rwanda who are still at the low level, and that is why our specialist who has reached a good level, often leaves us. We have started observing that,” he pointed out.

He added that some healthcare workers are heading to European countries, where it seems they need many medical personnel, “and we might risk even losing the few we had here”.

In these reforms, he said, retention was considered and “we realize that if swiftly implemented, we can save a lot, but if it is delayed, we can lose a lot”.

“For instance, we lose more than $500,000 when one doctor at the consultancy level leaves us,” he said, citing a specialist cardiologist.

Yet, what we should do to keep him/her is about a fifth of that cost,” he said.

For a nurse who has reached an advanced level, we lose over $300,000 [when he/she exists in the country’s health system], especially those who can run a medical surgery room as the lead, or head a hospitalisation unit.

Strategic acquisition of medical equipment

To address the high expenditure being incurred on the procurement of medical equipment, which was stemming from the fact that there were many people involved in the supply chain — middle people — Nsanzimana said that strategic acquisition of such equipment has been considered.

He said that this will be achieved through proper planning for the required medical equipment, and procuring them in bulk directly from manufacturers, then paying them in installments.

Such an approach, he said, “has started and there are major [pharmaceutical] factories that we have started to engage with, whereby their proposal was already submitted to the Government for consideration, and what remains is to sign an agreement for them to start providing us with equipment.”

“You find that a Magnetic Resonance Imaging (MRI) that we would buy at $2.5 million, is priced at $1.6 million under the strategic acquisition proposal, yet it is the same equipment,” he said, indicating that implies about $1 million additional cost that would be incurred in case of the current procurement process.

The cost of reforms

According to data from the Ministry of Health, the reforms could cost between $237 million (about Rwf260 billion) and over $1.15 billion (about Rwf1.3 trillion), depending on the number or scale of the required interventions.

For instance, Nsanzizmana said that increasing the number of healthcare workers would cost about $293 million (for the full programme).

However, since such funding might not be readily available, they put it in phases. These include the essential category consisting of $95 million financing of scholarships for essential faculties (programmes) — such as anesthetics — which people are not interested in pursuing since they realise that they will have to pay debts accumulated upon their study completion as they take a relatively long period.

On retention and motivation of medical personnel, he said that there is a full proposal that the Ministry of Health was discussing with other concerned public entities.

Here, he said, addressing the gap in the performance-based financing (PBF) for medical personnel, alone, would cost more than $20 million; while the full incentives and motivation programme would require more than $549 million.