Catalyzing Surgical Care in a Rural District Hospital

A case for Southern Kayonza

With our plan of re-novating surgery and anesthesia care in Rwanda, we intend to renovate Rwinkwavu District Hospital as the Center of Excellence in Surgery and Chronic Care in Rwanda

The problem

Whereas surgery has traditionally been a neglected part of healthcare in resource-constrained settings, recent research and evidence reveal that surgery must become a priority in strengthening health systems and improving lives in resource-limited settings [1]. However, the provision of surgical care has been a challenge at both the global and regional levels. An estimated five billion people worldwide lack access to safe, affordable, and timely surgical and anesthesia care, and East Africa along accounts for 17 million; furthermore, Low- and Middle-Income Countries (LMICs) account for <4% of the 230 million major surgical procedures performed worldwide each year [2].

In 2015, Rwanda designed the National Surgical, Obstetric, and Anesthesia Plan (NSOAP) for 2018-2024 as a key component in helping the country to improve the service delivery of surgery and anesthesia to its population, and achieving the Vision 2050. Currently, surgical services are a part of Rwanda’s MOH-mandated emergency and essential procedures services to be availed at district hospitals and covered by community-based health insurance (CBHI). Despite the need for surgical care, an estimated 58.7% of the Rwandan population still do not have access to safe, affordable, and timely surgery and anesthesia care [3]. The situation is worse in rural areas where the ability to provide comprehensible mandated surgical care at Rwanda’s district hospitals is not quite available [4].

The case of Rwinkwavu

Rwinkwavu is located in the Eastern Province of Rwanda in Kayonza district, with a catchment population of over 150,000. The area hosts a growing number of touristic activities with Rwinkwavu District Hospital located just 30 minutes from the entrance of Akagera, the country’s largest national park. For those living on the border of the park or visiting the park and who experience an accident requiring surgery, their current best option is to be evacuated by helicopter to referral hospitals in the capital city – an option that is unfordable by the local populations who end up with poor outcomes. Kayonza District also facilitates the country’s major corridor of goods from Tanzania to Uganda and DRC, and accidents involving lorry are a cause of many life-threatening injuries [5], which require surgery.

Despite the current need for surgical care at Rwinkwavu district hospital, the provision of comprehensible surgery and anesthesia care is limited. Caesarian sections account for 92% of the surgical cases and life-saving operations conducted at RDH; most of the Bellwether package, such as open fracture reduction, and other commonly seen outpatient surgeries like laparotomy case management and biopsies, are not available.

Major existing gaps are associated with the shortage of skilled providers, poor infrastructure, patient flow systems, and early identification of surgical cases and follow up at the community level, insufficient social supports for the patients with the most needs. These challenges show the need for building resilient partnerships for effective surgery delivery at Rwinkwavu District Hospital.

The solution

To operationalize Rwanda’s NSOAP, PIH/IMB plans to renovate Rwinkwavu District Hospital as a Center for Excellence in surgery and chronic care through collaboration with MoH. The Center for Excellence will serve as the training grounds and opportunity model for 39 other district hospitals in Rwanda. Furthermore, this will be a learning center for medical students from the University of Rwanda and the University of Global Health Equity on the provision of high-quality surgical care in a rural, resource-constrained setting.

Our approach

As a part of our 5-year Strategic Plan, we will support the implementation of high-quality global surgery services in key areas such as trauma, orthopedics, abdominal emergencies, essential obstetric surgeries, and minor procedures such as wound management and burn care at RDH. The hospital services will include appropriate anesthesia, intensive and post-operative care, and rehabilitation of services appropriate to the level of surgical care provided. We will explore culturally relevant and practical care delivery mechanisms that can be adapted for community and home-based care to reduce travel time and distance to care for the patients we serve.

Partnership opportunities

To ensure the availability of timely, safe, and affordable surgery and anesthesia care in rural Rwanda, PIH/IMB in collaboration with different partners will focus on the following priorities:

First priority: Set up infrastructure by building new surgical wards and operating rooms: to achieve this, PIH/IMB opens its doors to different partners with the same vision of strengthening health systems in rural areas, as well as those with interest in helping poor communities to access health care.

Second priority: build human resource capacity hiring, training, and mentoring for critical general surgery and anesthesia competencies among both new and current providers: we will achieve this by continuing leveraging our existing partners and looking for other potential funders, and donors at both global and national levels.