Use,microbiological effectiveness and health impact of a household water filter intervention in rural Rwanda—A matched cohort study

Unsafe drinking water is a substantial health risk contributing to child diarrhoea. We investigated impacts of a program that provided a water filter to households in rural Rwandan villages. We assessed drinking water quality and reported diarrhoea 12–24 months after intervention delivery among 269 households in the poorest tertile with a child under 5 from 9 intervention villages and 9 matched control villages. We also documented filter coverage and use. In Round 1 (12–18 months after delivery), 97.4% of intervention households reported receiving the filter, 84.5% were working, and 86.0% of working filters contained water. Sensors confirmed half of households with working filters filled them at least once every other day on average. Coverage and usage was similar in Round 2 (19–24 months after delivery). The odds of detecting faecal indicator bacteria in drinking water were 78% lower in the intervention arm than the control arm (odds ratio (OR) 0.22, 95% credible interval (CrI) 0.10–0.39, p < 0.001). The intervention arm also had 50% lower odds of reported diarrhoea among children <5 than the control arm (OR = 0.50, 95% CrI 0.23–0.90, p = 0.03). The protective effect of the filter is also suggested by reduced odds of reported diarrhoea-related visits to community health workers or clinics, although these did not reach statistical significance.     

‘Paying for performance’ in Rwanda: does it pay off?

The study analyses strengths and weaknesses of the ‘Paying For Performance’ (P4P) approach rolled out in the Rwandan health sector since 2002. It uses three research methods: a cross‐sectoral literature review on P4P, its history and its context; 69 mostly semi‐structured interviews conducted in Rwanda; and an analysis of factors eventually confounding the impact evaluation of the Rwandan P4P approach. It is argued that P4P approaches can be traced backed in written form over four millennia and that considerable negative effects are reported throughout history. All side effects were found again in various forms in the Rwandan health sector. One particular side effect –‘gaming’– seriously threatens to affect the quality of health services. It is argued that P4P implicitly (and unintentionally) promotes a questionable concept of human ‘labour’ and that its focus on improving indicators rather than systemic changes can be regarded as vertical and counter‐productive. Two alternatives to the current P4P system are briefly depicted, and further research on the described challenges is recommended.     

Implementing radiotherapy in Africa: Focus on the needs in Rwanda

Cancer care is a concern in low- and middle-income countries. The needs of structure to treat patients are huge. Because of the cost of radiotherapy, and the need for highly specialized workers, providing radiation therapy in these nations is a challenge. However, some solutions exist that can dramatically improve future care. In this article, we reviewed the plight of cancer treatment organization in Africa, and more specifically, the status of radiotherapy needs and concerns within Rwanda.     

Health systems strengthening through insurance subsidies: the GFATM experience in Rwanda

The Global Fund Against AIDS, Tuberculosis and Malaria (GFATM) approved only three 'health systems strengthening' projects ever, one of them in Rwanda. This project intends to enhance financial access to health care by subsidising health insurance for the poor in order to combat the three diseases successfully. It was submitted to a mid-term evaluation in 2007. The findings of this evaluation are presented and triangulated with experience gained through several years of membership in the Rwandan Country Coordinating Mechanism and the multi-stakeholder 'Working Group on Mutuelles ': The GFATM-funded project improved dramatically the financial access of its target group, the very poor – reaching approximately one Rwandan in six. Because of the established rigid regulatory framework, its impact on other population strata was more ambiguous. Improved financial access went hand-in-hand with growing health service utilisation and improvements in the population's health status, including better control of AIDS, tuberculosis and malaria. This success was achieved with limited financial resources. In consequence, interventions that strengthen health systems should always be considered for a prominent – if not a priority role – in GFATM-funded projects.     

Preparing for microbicide trials in Rwanda: Focus group discussions with Rwandan women and men

The acceptability and feasibility of microbicide studies and future microbicide use are influenced by existing norms and values regarding sexual and contraceptive behaviour. In preparation for microbicide research in Rwanda, focus group discussions were conducted to assess sexual and contraceptive behaviour, preferences for vaginal lubrication, and hypothetical acceptability of microbicides among Rwandan women and men. Seven focus group discussions were conducted among sexually active married women, unmarried women, sex workers, female students, older women and men living in Kigali, Rwanda, and an additional group of women living in a rural area. The results indicate that condom use is low among Rwandan men and women and that condoms are mainly used by men during commercial sex. Women have limited power to negotiate condom or family planning use. Vaginal hygiene practices are very common and consist primarily of washing with water. Lubrication during sex is highly preferred by both men and women. Hypothetical microbicide acceptability after an explanation of what microbicides are and a demonstration with lubricant jelly was high.

Résumé

L'acceptabilité et la faisabilité des études sur les microbicides et de l'usage de ces derniers à l'avenir subissent l'influence de normes et de valeurs existantes, relatives aux comportements sexuels et reproductifs. Dans le cadre de la préparation de la recherche sur les microbicides au Rwanda, des discussions de groupes focus ont été menées pour évaluer les comportements sexuels et reproductifs, les préférences en matière de lubrification vaginale et l'acceptabilité hypothétique des microbicides chez les femmes et les hommes du Rwanda. Sept discussions de groupes focus ont été menées avec des femmes mariées, des femmes célibataires, des travailleuses du sexe, des étudiantes, des femmes plus âgées et des hommes sexuellement actif(ve)s, vivant à Kigali au Rwanda, ainsi qu'avec d'autres femmes vivant dans une zone rurale. Les résultats indiquent que le taux d'usage du préservatif est faible chez les hommes et les femmes rwandais(es), et que les préservatifs sont principalement utilisés par les hommes pour les rapports sexuels avec les travailleuses du sexe. Les femmes ont peu de pouvoir pour négocier le recours aux préservatifs ou au planning familial. Les pratiques d'hygiène vaginale sont très courantes et consistent principalement en lavages avec de l'eau. Aussi bien les hommes que les femmes ont manifesté une forte préférence pour la lubrification qui se produit au cours des rapports sexuels. L'acceptabilité hypothétique des microbicides (après explication de ce que sont les microbicides et une démonstration avec du gel lubrifiant) s'est révélée très importante.

Resumen

La aceptación o la viabilidad de los estudios sobre microbicidas y el futuro uso de estas sustancias están influenciados por normas y valores existentes con respecto a conductas sexuales y de contracepción. En preparación para un estudio sobre microbicidas en Ruanda, se llevaron a cabo grupos de discusión para evaluar la conducta sexual y de contracepción, las preferencias por lubricaciones vaginales y la hipotética aceptación de microbicidas entre mujeres y hombres de Ruanda. Se llevaron a cabo siete grupos de discusión entre mujeres casadas y activas sexualmente, mujeres solteras, trabajadoras sexuales, estudiantes femeninas, y mujeres y hombres mayores que viven en Kigali, Ruanda y un grupo adicional de mujeres que viven en zonas rurales. Los resultados indican que el uso del preservativo es bajo entre mujeres y hombres de Ruanda y que sólo los usan los hombres cuando intercambian sexo con prostitutas. Las mujeres tienen un poder limitado para negociar el uso del preservativo o la planificación familiar. Las prácticas de higiene vaginal son muy comunes y consisten principalmente en el lavado con agua. Ambos, hombres y mujeres, prefieren la lubricación en sus relaciones sexuales. Muchos aceptarían hipotéticamente el uso de microbicidas (después de explicar qué son los microbicidas y demostrarlo con un lubricante de vaselina).     

The social vagina: labia elongation and social capital among women in Rwanda

Far from being an individual concern, vaginas are located within complex socio-cultural settings. The acceptability of policies that focus on health-promoting behavioural change is influenced by values regarding normative gender and sexual roles. In Rwanda, the elongation of the labia minora through manual manipulation is not an individual act but takes place in social groups and thus cannot be fully understood by focusing one's attention solely on the individual-related behavioural components but, rather, on the social environment in which it exists. This paper aims to increase knowledge about labia elongation and assesses whether this vaginal practice produce social capital.     

Sexual transgression and social disconnection: healing through community-based sociotherapy in Rwanda

A distinguishing feature of the 1994 genocide against the Tutsi and the preceding 1990–1994 war in Rwanda was the social intimacy of the crimes committed. The legacy of this kind of violence includes distrust in social relations within communities and families, an increase of violence in everyday social interaction, transgressive sexual engagements, and a range of psychological problems. Many people feel nostalgia for their past social life, but are unable to change their current situation. In 2005, a community-based sociotherapy programme was introduced into this context of mental and social distress. The goal was to help people regain feelings of dignity and safety and to reduce distress. This paper is based on qualitative research, in particular, case studies. It explores how sociotherapy, as a specific form of peer group counselling, may facilitate the healing of suffering related to issues of sexuality, violence within the family and the breakdown of social connections on a community level.     

Primary eye care in Rwanda: gender of service providers and other factors associated with effective service delivery

Objective To assess factors associated with high output of recently trained medical personnel in Rwanda. Methods Nurses and village health workers (VHW) from all health centres in Rubavu district were included. Data were collected during focus group discussions and through one‐to‐one interviews. Follow‐up interviews were carried out in January 2009. Results There was a wide range from none to all VHW referring people to a health centre. VHW brought more people to the health centre if there was a visiting ophthalmic clinical officer from the Eye Unit offering free screening. VHW output varied; male VHW brought 66.7% of patients identified (regardless of the sex of the health centre nurse), while female VHW brought 5.2 times as many people if the health centre nurse was male compared to if the nurse was female. Conclusion Changes in training curriculum and support and supervision of health workers trained in primary eye care (PEC) are likely to lead to improved outputs. Information efforts should reinforce that male and female nurses have the same training and skills in PEC.     

Thresholds for health insurance in Rwanda: who should pay how much?

Community-based health insurance schemes were introduced in Rwanda in 1999 and now cover 27% of the population. Due to widespread poverty, it remains unclear to what degree poorer population strata can be anticipated to pay into the system. This study investigates the extent to which the Rwandan population can financially contribute to obtain health insurance. More specifically, researchers explored the relationship between resource mobilization for the health system and the ability to provide community-based health insurance across socio-economic strata. Data from six household surveys are analysed revealing a consistent pattern: the goals of maximizing health revenue and maximizing participation in community-based health insurance are mutually exclusive. However, the upper three quartiles of the Rwandan population are able to contribute 1 US dollar per capita per year. In order to extend coverage to the poorest quartile, a corresponding subsidy for the coming years has to be considered.