The politics and practice of initiating a public health postgraduate programme in three universities in sub-Saharan Africa: the challenges of alignment and coherence.

BACKGROUND: In-country postgraduate training programme in low and middle income countries are widely considered to strengthen institutional and national capacity. There exists dearth of research about how new training initiatives in public health training institutions come about. This paper examines a south-south collaborative initiative wherein three universities based in Ethiopia, Rwanda and Mozambique set out to develop a local based postgraduate programme on health workforce development/management through partnership with a university in South Africa. METHODS: We used a qualitative case study design. We conducted semi-structured interviews with 36 key informants, who were purposively recruited based on their association or proximity to the programme, and their involvement in the development, review, approval and implementation of the programme. We gathered supplementary data through document reviews and observation. Thematic analysis was used and themes were generated inductively from the data and deductively from literature on capacity development. RESULTS: University A successfully initiated a postgraduate training programme in health workforce development/management. University B and C faced multiple challenges to embed the programme. It was evident that multiple actors underpin programme introduction across institutions, characterized by contestations over issues of programme feasibility, relevance, or need. A daunting challenge in this regard is establishing coherence between health ministries' expectation to roll out training programmes that meet national health priorities and ensure sustainability, and universities and academics' expectations for investment or financial incentive. Programme champions, located in the universities, can be key actors in building such coherence, if they are committed and received sustained support. The south-south initiative also suffers from lack of long term and adequate support. CONCLUSIONS: Against the background of very limited human capacity and competition for this capacity, initiating the postgraduate programme on health workforce development/management proved to be a political as much as a technical undertaking influenced by multiple actors vying for recognition or benefits, and influence over issues of programme feasibility, relevance or need. Critical in the success of the initiative was alignment and coherence among actors, health ministries and universities in particular, and how well programme champions are able to garner support for and ownership of programme locally. The paper argues that coherence and alignment are crucial to embed programmes, yet hard to achieve when capacity and resources are limited and contested.

Influencing factors for prevention of postpartum hemorrhage and early detection of childbearing women at risk in Northern Province of Rwanda: beneficiary and health worker perspectives.

BACKGROUND: Reduction of maternal mortality and morbidity is a major global health priority. However, much remains unknown regarding factors associated with postpartum hemorrhage (PPH) among childbearing women in the Rwandan context. The aim of this study is to explore the influencing factors for prevention of PPH and early detection of childbearing women at risk as perceived by beneficiaries and health workers in the Northern Province of Rwanda. METHODS: A qualitative descriptive exploratory study was drawn from a larger sequential exploratory-mixed methods study. Semi-structured interviews were conducted with 11 women who experienced PPH within the 6 months prior to interview. In addition, focus group discussions were conducted with: women's partners or close relatives (2 focus groups), community health workers (CHWs) in charge of maternal health (2 focus groups) and health care providers (3 focus groups). A socio ecological model was used to develop interview guides describing factors related to early detection and prevention of PPH in consideration of individual attributes, interpersonal, family and peer influences, intermediary determinants of health and structural determinants. The research protocol was approved by the University of Rwanda, College of Medicine and Health Sciences Institutional Ethics Review Board. RESULTS: We generated four interrelated themes: (1) Meaning of PPH: beliefs, knowledge and understanding of PPH: (2) Organizational factors; (3) Caring and family involvement and (4) Perceived risk factors and barriers to PPH prevention. The findings from this study indicate that PPH was poorly understood by women and their partners. Family members and CHWs feel that their role for the prevention of PPH is to get the woman to the health facility on time. The main factors associated with PPH as described by participants were multiparty and retained placenta. Low socioeconomic status and delays to access health care were identified as the main barriers for the prevention of PPH. CONCLUSIONS: Addressing the identified factors could enhance early prevention of PPH among childbearing women. Placing emphasis on developing strategies for early detection of women at higher risk of developing PPH, continuous professional development of health care providers, developing educational materials for CHWs and family members could improve the prevention of PPH. Involvement of all levels of the health system was recommended for a proactive prevention of PPH. Further quantitative research, using case control design is warranted to develop a screening tool for early detection of PPH risk factors for a proactive prevention.

Maternal genitourinary infections and poor nutritional status increase risk of preterm birth in Gasabo District, Rwanda: a prospective, longitudinal, cohort study.

BACKGROUND: Preterm birth (PTB) is a leading cause of early childhood mortality and morbidity, including long-term physical and mental impairment. The risk factors for PTB are complex and include maternal nutritional status and infections. This study aimed to identify potentially modifiable risk factors for targeted interventions to reduce the occurrence of PTB in Rwanda. METHODS: We conducted a prospective, longitudinal cohort study of healthy pregnant women aged 18 to 49 years. Women at 9-15 gestational weeks were recruited from 10 health centers in Gasabo District, Kigali Province between September and October 2017. Pregnancy age was estimated using ultrasonography and date of last menstruation. Anthropometric and laboratory measurements were performed using standard procedures for both mothers and newborns. Surveys were administered to assess demographic and health histories. Categorical and continuous variables were depicted as proportions and means, respectively. Variables with p <  0.25 in bivariate analyses were included in multivariable logistic regression models to determine independent predictors of PTB. The results were reported as odds ratios (ORs) and 95% confidence intervals (CI), with statistical significance set at p <  0.05. RESULTS: Among 367 participants who delivered at a mean of 38.0 ± 2.2 gestational weeks, the overall PTB rate was 10.1%. After adjusting for potential confounders, we identified the following independent risk factors for PTB: anemia (hemoglobin < 11 g/dl) (OR: 4.27; 95%CI: 1.85-9.85), urinary tract infection (UTI) (OR:9.82; 95%CI: 3.88-24.83), chlamydia infection (OR: 2.79; 95%CI: 1.17-6.63), inadequate minimum dietary diversity for women (MDD-W) score (OR:3.94; CI: 1.57-9.91) and low mid-upper arm circumference (MUAC) < 23 cm (OR: 3.12, 95%CI; 1.31-7.43). indicators of nutritional inadequacy (low MDD-W and MUAC) predicted risk for low birth weight (LBW) but only UTI was associated with LBW in contrast with PTB. CONCLUSION: Targeted interventions are needed to improve the nutritional status of pregnant women, such as maternal education on dietary diversity and prevention of anemia pre-pregnancy. Additionally, prevention and treatment of maternal infections, especially sexually transmitted infections and UTIs should be reinforced during standard antenatal care screening which currently only includes HIV and syphilis testing.

Association between micronutrients and maternal leukocyte telomere length in early pregnancy in Rwanda.

BACKGROUND: Exposure to environmental stressors can lead to shorter leukocyte telomere length and increase the risk of chronic diseases. Preservation of leukocyte telomere length by reducing oxidative stress exposure and reinforcing immunity may be a mechanism by which nutritional factors delay or prevent chronic disease development. METHODS: Healthy pregnant women (aged 18-45 years) at 9-15 weeks of gestation living in Gasabo District, Kigali, Rwanda, were recruited from 10 health centers for a prospective, longitudinal study from September to October 2017 to determine possible associations between nutrition health, infectious disease and leukocyte telomere length. Anthropometric and laboratory measurements were performed using standard procedures; sociodemographic parameters and health histories were assessed via surveys, and leukocyte telomere length was assessed using quantitative PCR expressed as the ratio of a telomeric product to a single-copy gene product (T/S). RESULTS: Mean gestational age of participants (n = 297) at enrollment was 13.04 ± 3.50 weeks, age was 28.16 ± 6.10 years and leukocyte telomere length was 1.16 ± 0.22 (T/S). Younger age; no schooling vs. primary schooling; and lower levels of ferritin, soluble transferrin receptors and retinol-binding protein were independent predictors of longer telomere length in multivariable models. CONCLUSIONS: Leukocyte telomere length is an indicator of biological aging in pregnant Rwandan women. Maternal micronutrient status, specifically lower ferritin, soluble transferrin receptor levels, and retinol-binding protein levels were associated with longer maternal telomere length in contrast with some studies from North America and Europe. There were no associations between inflammation and infectious disease status and maternal leukocyte telomere length. Further studies are needed to enhance our understanding of the interplay between maternal nutritional status and infectious disease in relation to leukocyte telomere length in developing countries.

Assessing the impact of mentorship on nurses' and midwives' knowledge and self-efficacy in managing postpartum hemorrhage.

Background Despite medical technology advancement, postpartum hemorrhage remains the top universal cause of maternal mortality. Factors note the inconsistency in recognition and timely treatment of women experiencing it, which suggests healthcare professionals' mentorship about postpartum hemorrhage. Methods The study recruited 141 nurses and midwives and used instruments adapted to knowledge and self-efficacy to assess the impact of mentorship on nurses' and midwives' knowledge and self-efficacy in managing postpartum hemorrhage. Results There was an increase in knowledge from 68% prior to mentorship up to 87% and self-efficacy from 6.9 to 9.5 average score out of 10. Knowledge and self-efficacy correlated moderately positive at pre-mentorship (r=0.214) and strongly positive at post-mentorship (r=0.585). The number of mentorship visits attended was associated with post-mentorship knowledge scores (r=0.539) and post-mentorship self-efficacy (r=0.623). Conclusions Mentorship about management of postpartum hemorrhage increases nurses' and midwives' knowledge and self-efficacy in managing postpartum hemorrhage.

Incremental cost and health gains of the 2016 WHO antenatal care recommendations for Rwanda: results from expert elicitation.

OBJECTIVES: High-quality evidence of effectiveness and cost-effectiveness is rarely available and relevant for health policy decisions in low-resource settings. In such situations, innovative approaches are needed to generate locally relevant evidence. This study aims to inform decision-making on antenatal care (ANC) recommendations in Rwanda by estimating the incremental cost-effectiveness of the recent (2016) WHO antenatal care recommendations compared to current practice in Rwanda. METHODS: Two health outcome scenarios (optimistic, pessimistic) in terms of expected maternal and perinatal mortality reduction were constructed using expert elicitation with gynaecologists/obstetricians currently practicing in Rwanda. Three costing scenarios were constructed from the societal perspective over a 1-year period. The two main inputs to the cost analyses were a Monte Carlo simulation of the distribution of ANC attendance for a hypothetical cohort of 373,679 women and unit cost estimation of the new recommendations using data from a recent primary costing study of current ANC practice in Rwanda. Results were reported in 2015 USD and compared with the 2015 Rwandan per-capita gross domestic product (US$ 697). RESULTS: Incremental health gains were estimated as 162,509 life-years saved (LYS) in the optimistic scenario and 65,366 LYS in the pessimistic scenario. Incremental cost ranged between $5.8 and $11 million (an increase of 42% and 79%, respectively, compared to current practice) across the costing scenarios. In the optimistic outcome scenario, incremental cost per LYS ranged between $36 (for low ANC attendance) and $67 (high ANC attendance), while in the pessimistic outcome scenario, it ranged between $90 (low ANC attendance) and $168 (high ANC attendance) per LYS. Incremental cost effectiveness was below the GDP-based thresholds in all six scenarios. DISCUSSION: Implementing the new WHO ANC recommendations in Rwanda would likely be very cost-effective; however, the additional resource requirements are substantial. This study demonstrates how expert elicitation combined with other data can provide an affordable source of locally relevant evidence for health policy decisions in low-resource settings.

Cost of antenatal care for the health sector and for households in Rwanda.

BACKGROUND: Rwanda has made tremendous progress in reduction of maternal mortality in the last twenty years. Antenatal care is believed to have played a role in that progress. In late 2016, the World Health Organization published new antenatal care guidelines recommending an increase from four visits during pregnancy to eight contacts with skilled personnel, among other changes. There is ongoing debate regarding the cost implications and potential outcomes countries can expect, if they make that shift. For Rwanda, a necessary starting point is to understand the cost of current antenatal care practice, which, according to our knowledge, has not been documented so far. METHODS: Cost information was collected from Kigali City and Northern province of Rwanda through two cross-sectional surveys: a household-based survey among women who had delivered a year before the interview (N = 922) and a health facility survey in three public, two faith-based, and one private health facility. A micro costing approach was used to collect health facility data. Household costs included time and transport. Results are reported in 2015 USD. RESULTS: The societal cost (household + health facility) of antenatal care for the four visits according to current Rwandan guidelines was estimated at $160 in the private health facility and $44 in public and faith-based health facilities. The first visit had the highest cost ($75 in private and $21 in public and faith-based health facilities) compared to the three other visits. Drugs and consumables were the main input category accounting for 54% of the total cost in the private health facility and for 73% in the public and faith-based health facilities. CONCLUSIONS: The unit cost of providing antenatal care services is considerably lower in public than in private health facilities. The household cost represents a small proportion of the total, ranging between 3% and 7%; however, it is meaningful for low-income families. There is a need to do profound equity analysis regarding the accessibility and use of antenatal care services, and to consider ways to reduce households' time cost as a possible barrier to the use of antenatal care.

Self-reported pregnancy-related health problems and self-rated health status in Rwandan women postpartum: a population-based cross-sectional study.

BACKGROUND: Self-rated health status (SRH) can be used as a predictor of morbidity and mortality. Postpartum self-rated health has been used to estimate maternal morbidity and postpartum problems. Reproductive history factors are associated with poor self-rated health postpartum. This study investigated prevalence of self-reported health problems during first, second, and third trimesters of pregnancy, delivery, and postpartum. In addition, this study investigated SRH in Rwandan women up to 13 months from partus. METHODS: This population-based, cross-sectional study collected data in 2014 using structured interviews (N = 921). Univariable analysis was used to identify variables that were associated with poor self-rated health status (poor-SRH). Logistic regression analyses were performed to identify factors associated with poor-SRH at one day, one week, and one month postpartum and at the time of the interview. RESULTS: Mean time between latest delivery and the time of interview was 7.1 months. Prevalence of anaemia, hypertension, diabetes mellitus during pregnancy, and severe bleeding during pregnancy and labour were 15.0, 4.9, 2.4, and 3.7 %, respectively. The prevalence of poor-SRH was 32.2 % at one day postpartum, 7.8 % at one month, and 11.7 % at time of the interview. Hypertension during pregnancy and significant postpartum haemorrhage were associated with poor-SRH at one day and one week postpartum. Severe bleeding during pregnancy and labour were associated with poor-SRH at one week and one month postpartum. Infection and anaemia during pregnancy were associated with poor-SRH at one month postpartum and at the time of interview. The Kaplan-Meier curves illustrate restitution of health for most women during the study period. CONCLUSIONS: This population-based study reports a high prevalence of poor SRH status among Rwandan women in the early postpartum period. Identified factors associated with poor-SRH were severe bleeding, hypertension, infection, and anaemia during pregnancy and postpartum haemorrhage. These factors may be prevented or reduced by providing more frequent and specific attention during pregnancy and by providing timely measures that address complications during delivery, including adequate postpartum care.

Risky sexual behaviors and their associated factors within high school students from Collège Saint André in Kigali, Rwanda: An institution-based cross-sectional study.

Background: Risky sexual behaviors (RSBs) remain public health concerns in adolescents from sub-Saharan Africa (SSA), and these practices may increase vulnerability to reproductive health problems if no early healthcare strategies are implemented. While previous studies reported that adolescents are engaged in these RSBs due to diverse influences such as the teenage stage, urbanization, and change in the environment they experience, there is a shortage of studies on RSB among adolescents in SSA. This study assessed the magnitude of RSBs and the RSB-associated factors among in-school adolescents. Methods: School-based cross-sectional study was conducted among 263 Saint Andre school students in Kigali, Rwanda, from July 3, 2020, to September 30, 2020. Systematic random sampling techniques were employed. All data were entered into Epi-Data and analyzed using SPSS version 25. Chi-square tests and multivariable logistic regression analyses were applied to determine factors associated with risky sexual behaviors. Confidence intervals (CIs) of 95% and 5% for statistical significance were maintained. Results: Of 263 participants, 109 (41%) experienced RSB in their lifetime. Among them, 66 respondents (60.55%) utilized contraceptive methods to prevent sexual and reproductive problems that can be caused by unprotected sexual intercourse. The students who experienced domestic violence had increased odds of experiencing RSB [odds ratio (OR) = 4.22; 95% CI: 1.6-11.23] than their counterparts. Those in grade 11 (OR = 2.68; 95% CI: 1.06-6.78) and grade 12 (OR = 4.39; 95% CI: 1.82-10.56) were more likely to practice RSB than those in grade 10. Alcohol users were almost more likely to experience RSB (OR = 3.9; 95% CI: 1.97-5.5) than their counterparts. Those who lived away from their biological parents had higher likelihood of experiencing RSB (OR = 2.5; 95% CI: 1.14-4.42) than those who lived with one or both parents. Students who experienced peer pressure were more likely to engage in RSB (OR = 3.9; 95% CI: 2.01-7.51) than their counterparts. Conclusion: Promoting specific intervention programs built upon the factors associated with RSB among high school students needs to be prioritized.

Prevalence and Factors Associated with Hypertension Among HIV Positive Patients on Antiretroviral Therapy: A Hospital-Based Cross-Sectional Study in Rwanda.

Introduction: The human immunodeficiency virus (HIV) and the use of antiretroviral therapy (ART) are influential elements contributing to hypertension, which is a public health concern particularly in sub-Saharan Africa where its underdiagnosis and limited investigation persist. Moreover, hypertension prevails at higher rates among individuals living with HIV (PLWH) in comparison to the general population. Therefore, our study determined the prevalence of hypertension and its associated factors among PLWH who are undergoing ART treatment at Byumba District Hospital. Methods: A cross-sectional study design was conducted among 406 PLWH over the age of 14 years who were undergoing ART within the HIV department. We performed statistical analyses using STATA version 13. Significant independent variables identified in the bivariate analysis were further exported in a multivariable logistic regression model to ascertain their association with hypertension. This model elucidated factors associated with hypertension, presenting outcomes through odds ratios and their respective 95% confidence intervals, with statistical significance set at p < 0.05. Results: The prevalence of hypertension was 24.7%, which means that roughly 1 in 4 PLWH were hypertensive. Notably, individuals aged 41 years and above demonstrated a significant association with heightened hypertension [AOR = 4.49; 95% CI = 2.45-8.21, p < 0.001] in contrast to those aged between 14 and 40 years. Additionally, smokers [AOR = 12.12; 95% CI = 4.48-32.74, p < 0.001] and individuals with a family history of hypertension [AOR = 4.28; 95% CI = 1.01-18.13, p = 0.049] demonstrated a higher likelihood of hypertension than their counterparts. Moreover, alcohol consumers [AOR = 5.5; 95% CI = 2.75-10.9, p < 0.001] had an increased likelihoods of hypertension compared to non-drinkers. Lastly, diabetics were almost 6 times more likely to be hypotensive [AOR = 4.50; 95% CI = 2.55-7.95, p = 0.018] when compared to those without diabetes. Conclusion: Our findings strongly underscore the urgency for the implementation of targeted programs aimed at enhancing awareness and comprehension of the factors and potential complications tied to hypertension among PLWH. Such programs could be integrated into routine HIV care services to provide patients with the information and skills required to manage their hypertension effectively.

Risk factors for postpartum haemorrhage in the Northern Province of Rwanda: A case control study.

BACKGROUND: Postpartum haemorrhage (PPH) remains a major global burden contributing to high maternal mortality and morbidity rates. Assessment of PPH risk factors should be undertaken during antenatal, intrapartum and postpartum periods for timely prevention of maternal morbidity and mortality associated with PPH. The aim of this study is to investigate and model risk factors for primary PPH in Rwanda. METHODS: We conducted an observational case-control study of 430 (108 cases: 322 controls) pregnant women with gestational age of 32 weeks and above who gave birth in five selected health facilities of Rwanda between January and June 2020. By visual estimation of blood loss, cases of Primary PPH were women who changed the blood-soaked vaginal pads 2 times or more within the first hour after birth, or women requiring a blood transfusion for excessive bleeding after birth. Controls were randomly selected from all deliveries without primary PPH from the same source population. Poisson regression, a generalized linear model with a log link and a Poisson distribution was used to estimate the risk ratio of factors associated with PPH. RESULTS: The overall prevalence of primary PPH was 25.2%. Our findings for the following risk factors were: antepartum haemorrhage (RR 3.36, 95% CI 1.80-6.26, P<0.001); multiple pregnancy (RR 1.83; 95% CI 1.11-3.01, P = 0.02) and haemoglobin level <11 gr/dL (RR 1.51, 95% CI 1.00-2.30, P = 0.05). During the intrapartum and immediate postpartum period, the main causes of primary PPH were: uterine atony (RR 6.70, 95% CI 4.78-9.38, P<0.001), retained tissues (RR 4.32, 95% CI 2.87-6.51, P<0.001); and lacerations of genital organs after birth (RR 2.14, 95% CI 1.49-3.09, P<0.001). Coagulopathy was not prevalent in primary PPH. CONCLUSION: Based on our findings, uterine atony remains the foremost cause of primary PPH. As well as other established risk factors for PPH, antepartum haemorrhage and intra uterine fetal death should be included as risk factors in the development and validation of prediction models for PPH. Large scale studies are needed to investigate further potential PPH risk factors.

Economic attributes and childhood stunting in Rwanda: case study of the City of Kigali.

Introduction: stunting in under five children is a great concern in low and middle-income countries including Rwanda. While over the past decades different developing countries have made remarkable efforts improving their economic growth, there is mixed evidence and lack of consensus on the impact of economic development on nutrition improvement. The objective of this study was to assess the relationship between economic attributes and childhood stunting in the City of Kigali. Methods: this was a retrospective cross-sectional and comparative study documenting the period 2010-2017. Stunting in under five children was analyzed in relation to the economic attributes which include the household consumption per capita, annual household income and level of poverty. The analysis was done at the level of district. Official reports from the National Institute of Statistics of Rwanda provided data on both economic attributes and stunting. Results: in some situations, the improvements in economic attributes such as increase in average household consumption per capita and increase in annual household income are followed by the reduction of stunting in under five children. However, in some other situations, the reduction of the level of poverty and the increase of annual household income was not translated into the reduction of stunting. Conclusion: improvements in some economic attributes do not necessarily translate into reduction of stunting in under five children. Further studies are needed to understand possible lead forces underlying this situation including establishing the proportion of household income spent on children´s nutrition as well as possible inequity and inequality in wealth distribution.

Prevalence of dental caries and associated risk factors in children living with disabilities in Rwanda: a cross-sectional study.

INTRODUCTION: several studies have been done on children with disabilities, and the results have shown that these particular individuals are more prone to developing various abnormal oral conditions. However, little is known about the oral health conditions among children with disabilities in Rwanda. This study aims to determine the prevalence of dental caries and associated risk factors among children with disabilities. METHODS: a cross-sectional study conducted among 226 randomly selected children living with physical disabilities; learning, intellectual and developmental disabilities; deafness, blindness and hearing impairment disabilities aged between 7 and 20 years old, who live and/or are under the care of NYANZA Home de la Vierge des Pauvres (HVP) GATAGARA. Bivariate and logistic regression analyses were done using SPPS version 20 at 95% confidence interval. The significance level was set at p<0.05. RESULTS: the prevalence of dental caries found in children with disabilities is 42.4%. In bivariate analysis age (p=0.003), frequency of sugary food consumption (p=0.001) and oral hygiene status (p=0.000) are respectively significantly associated with dental caries. In logistic regression model, children who take once or more times per day sugary food like biscuits, cake, chocolates and sweets are almost 6 times higher at risk of developing dental caries [OR: 5.945, CI: 1.187; 29.774, P=0.03) while a good oral hygiene status was protective against dental caries [OR: 0.296, CI: 0.159; 0.550, P=0.000]. CONCLUSION: dental caries is a reality among children living with disabilities. Appropriate measures should be taken to protect these children and these measures should mainly focus on identified factors.

Universal health insurance in Rwanda: major challenges and solutions for financial sustainability case study of Rwanda community-based health insurance part I.

INTRODUCTION: Universal Health Coverage (UHC) has engaged attention of policy makers at both global and country levels. UHC is one of three strategic priorities of World Health Organization's (WHO) general program of work for 2019-2023, and it is then a global health priority. Rwanda Community-Based Health Insurance is considered the vehicle for UHC and Universal Health Insurance in Rwanda. CBHI was officially introduced in 1999/2000 and through 2011/2012 Rwanda was not far from effective UHC. However, since then, CBHI faced chronic financial deficit. This study aims to assess challenges facing Community-Based Health Insurance financial sustainability and to propose indicative solutions. METHODS: quantitative, qualitative, analytical, longitudinal (2011-2018) and documentary mixed methods were applied. One National Pooling Risk (100%), 15 Community-Based Health Insurance districts (50%) and 60 Community Based Health Insurance sections (13.33%) were randomly selected and included in the study. To assess major challenges, "analyzing qualitative data G3658-6 approach" and "prioritization hanlon method" were used. RESULTS: the study highlighted five major challenges: (i) disproportionate risk-equalization in the social health insurance contributory system; (ii) unit cost exceeding individual income (premium plus other revenues and subsidies); (iii) imperfection in funding mobilization and recovery; (iv) cost-escalation; (v) diseconomy of scale; and the study proposed indicative solutions including injection of additional funding and shifting from current fee-for-service payment to fully active strategic purchasing mechanisms as accompanying measures. CONCLUSION: CBHI financial sustainability is achievable, but this is contingent upon persistence of political commitment efforts to achieve UHC, correction of highlighted imperfections and injection of additional funding to allow Rwanda Community-Based Health Insurance to meet and/or exceed its cost in the long-term.

Identification of Bunyamwera and Possible Other Orthobunyavirus Infections and Disease in Cattle during a Rift Valley Fever Outbreak in Rwanda in 2018.

In 2018, a large outbreak of Rift Valley fever (RVF)-like illness in cattle in Rwanda and surrounding countries was reported. From this outbreak, sera samples from 157 cows and 28 goats suspected to be cases of RVF were tested to confirm or determine the etiology of the disease. Specifically, the hypothesis that orthobunyaviruses-Bunyamwera virus (BUNV), Batai virus (BATV), and Ngari virus (NRIV)-were co-circulating and contributed to RVF-like disease was tested. Using reverse transcriptase-polymerase chain reaction (RT-PCR), RVFV RNA was detected in approximately 30% of acutely ill animals, but in all cases of hemorrhagic disease. Seven cows with experienced abortion had positive amplification and visualization by gel electrophoresis of all three segments of either BUNV or BATV, and three of these were suggested to be coinfected with BUNV and BATV. On sequencing, five of these seven cows were conclusively positive for BUNV. However, in several other animals, sequencing was successful for some but not all segments of targeted viruses BUNV and BATV. In addition, there was evidence of RVFV-orthobunyavirus coinfection, through RT-PCR/gel electrophoresis and subsequent Sanger sequencing. In no cases were we able to definitely identify the specific coinfecting viral species. This is the first time evidence for orthobunyavirus circulation has been molecularly confirmed in Rwanda. Furthermore, RT-PCR results suggest that BUNV and BATV may coinfect cattle and that RVFV-infected animals may be coinfected with other orthobunyaviruses. Finally, we confirm that BUNV and, perhaps, other orthobunyaviruses were co-circulating with RVFV and contributed to the burden of disease attributed to RVFV in Rwanda.

"Not taken seriously"-A qualitative interview study of postpartum Rwandan women who have experienced pregnancy-related complications.

BACKGROUND: There is limited knowledge on the women's experiences of pregnancy-related complications in Rwanda. This study aimed to investigate women's experiences and perceptions of specific complications during pregnancy and delivery and the consequences of these complications on postpartum health and family situation. METHODS: Data were collected through individual in-depth interviews (N = 15). Participants who experienced complications such as postpartum haemorrhage, caesarean section due to prolonged labour/dystocia, pre-eclampsia, or fistula and who were 13-24 months postpartum were invited to participate in the study in July 2015. Interviews were held in Kinyarwanda, digitally recorded, transcribed verbatim, translated into English, and analysed using qualitative content analysis. RESULTS: Most participants reported that they were previously unaware of the complications they had developed, and they claimed that at discharge they should have been better informed about the potential consequences of these complications. Most participants blamed the health care system as the cause of their problems due to the provision of inadequate care. Participants elaborated different strategies for coping with persistent health problems. Pregnancy-related complications negatively affected participants' economic situation due to increased health care expenses and lowered income because of impaired working capacity, and participants expressed fear of encountering the same pregnancy-related health problems during future pregnancies. CONCLUSIONS: The findings of this study demonstrate how participants felt that inadequate health care provision during pregnancy, delivery, and the postpartum period was the source of their problems. Participants reported different coping strategies to improve their respective life situation despite persistent health problems. Women's individual postpartum experiences need to be considered and actions taken at the policy level and also by the local community, in terms of the quality of antenatal and postpartum care services, and in sensitizing the local community about the existence of these complications and preparing the community to support the affected women.

Complete Genome Sequences of 20 Nontyphoidal Salmonella Isolates from Rwanda.

Nontyphoidal Salmonella enterica strains are major foodborne pathogens with global public health importance. Foodborne salmonellosis can be life-threatening, especially in sub-Saharan Africa. We report the complete genome sequences of 20 nontyphoidal Salmonella enterica strains isolated in Rwanda. The reported 20 bacterial chromosomes and 8 plasmids each belong to 1 of 9 nontyphoidal Salmonella serotypes.

Factors Contributing to Low Adherence to Community-Based Health Insurance in Rural Nyanza District, Southern Rwanda.

Background: Community-based health insurance (CBHI) schemes are an emerging mechanism for providing financial protection against health-related poverty. In Rwanda, CBHI is being implemented across the country, and it is based on four socioeconomic categories of the "Ubudehe system": the premiums of the first category are fully subsidized by government, the second and third category members pay 3000 frw, and the fourth category members pay 7000 frw as premium. However, low adherence of community to the scheme since 2011 has not been sufficiently studied. Objective: This study aimed at determining the factors contributing to low adherence to the CBHI in rural Nyanza district, southern Rwanda. Methodology: A cross-sectional study was conducted in nine health centers in rural Nyanza district from May 2017 to June 2017. A sample size of 495 outpatients enrolled in CBHI or not enrolled in the CBHI scheme was calculated based on 5% margin of error and a 95% confidence interval. Logistic regression was used to identify the determinants of low adherence to CBHI. Results: The study revealed that there was a significant association between long waiting time to be seen by a medical care provider and between health care service provision and low adherence to the CBHI scheme (P value < 0.019) (CI: 0.09107 to 0.80323). The estimates showed that premium not affordable (P value < 0.050) (CI: 0.94119 to 9.8788) and inconvenient model of premium payment (P value < 0.001) (CI: 0.16814 to 0.59828) are significantly associated with low adherence to the CBHI scheme. There was evidence that the socioeconomic status as measured by the category of Ubudehe (P value < 0.005) (CI: 1.4685 to 8.93406) increases low adherence to the CBHI scheme. Conclusion: This study concludes that belonging to the second category of the Ubudehe system, long waiting time to be seen by a medical care provider and between services, premium not affordable, and inconvenient model of premium payment were significant predictors of low adherence to CBHI scheme.

A Review of Bunyamwera, Batai, and Ngari Viruses: Understudied Orthobunyaviruses With Potential One Health Implications.

Bunyamwera (BUNV), Batai (BATV), and Ngari (NRIV) are mosquito-borne viruses of the Bunyamwera serogroup in the Orthobunyavirus genus of the Bunyaviridae family. These three viruses have been found to cause disease in both livestock animals, avian species, and humans. Thus, these viruses pose a potential threat to human public health, animal health, and food security. This is especially the case in the developing nations, where BUNV and NRIV are found, mainly in Africa. BUNV and BATV are fairly well characterized, while NRIV is not well characterized owing to only sporadic detection in human and animal populations in Africa. Reassortment is common among bunyaviruses, but NRIV is believed to be the only natural reassortant of the Bunyamwera serogroup. It resulted from a combination of BUNV S and L segments and the BATV M segment. This indicates at least some level co-circulation of BUNV and BATV, which have no historically been reported to overlap in geographic distributions. But as these viruses are undercharacterized, there remains a gap in the understanding of how such reassortment could occur, and the consequences of such. Due to their combined wide range of hosts and vectors, geographic distributions, potential severity of associated diseases, and potential for transmissibility between vertebrate hosts, these viruses represent a significant gap in knowledge with important One Health implications. The goal of this review is to report available knowledge of and identify potential future directions for study of these viruses. As these are collectively understudied viruses, there is a relative paucity of data; however, we use available studies to discuss different perspectives in an effort to promote a better understanding of these three viruses and the public and One Health threat(s) they may pose.