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Cardiovascular Journal of Africa • Volume 31, No 4 August 2020
S29
AFRICA
Part C: Clinical practice and guidelines
Health system capacity
The country had an average of 1.3 physicians and 12.04
nurses per 10 000 in 2017 and 2018, respectively, with 16
hospital beds per 10 000 people in 2006. In Rwanda, locally
relevant clinical tools to assess CVD risk and recent clinical
guidelines for CVD prevention are available.
12
Guidelines
published in 2016 by the Ministry of Health (MoH) for the
detection and management of the most common NCD include
heart failure, hypertension, cardiomyopathy andAF.
12
Clinical
algorithms to manage pharyngitis, acute rheumatic fever and
RHD are also incorporated.
12
In 2013, the Minister of Health,
Dr Agnes Binagwaho, deplored that ‘Health authorities
in many countries rely on regional estimates of the burden
of RHD given the absence of national disease registries
and underreporting or misdiagnosing of acute and chronic
cases of RHD’.
13
Rwanda’s participation in a prospective,
international, multi-centre, hospital-based registry for RHD
and rheumatic fever, the REMEDY study,
14
led to developing
a national register of people with a confirmed diagnosis of
rheumatic fever and RHD. This register started with post-
RHD valve surgery patients who were on anticoagulation.
15
Although there is a system to measure the quality of care
provided to people who have suffered acute cardiac
events, no national guidelines for the treatment of tobacco
dependence exists.
9
The national guidelines for the integrated
and decentralised management of NCD also include the
detection and management of diabetes in detail.
12
Essential medicines and interventions
All the essential medicines for CVD were reported being
available within the public health sector in 2016 and 2017.
16
Provision for secondary prevention of rheumatic fever and
RHD is available in the public health sector but not for CVD
risk stratification or the measurement of TC.
4
Secondary prevention and management
Almost 16% of hypertensive patients were receiving medical
treatment in 2012,
8
while no information is available about the
number of patients with AF on therapy or those with a history
of CVD receiving medication. The ongoing implementation
of the National NCD policy since 2015 includes integrated
and decentralised care and follow up for the most common
CVD, using electronic medical records and a health medical
information system is expected to improve data collection
and processing.
17,18
Part D: Cardiovascular disease governance
A national strategy or plan that addresses NCD, CVD and
their risk factors specifically has been developed along with
a dedicated budget for its implementation.
4,19
Integrating
RHD into the national NCD strategic plan is also underway.
20
In each ministry, the government established a Single
Project Implementation Unit.
21
Rwanda also has a national
surveillance system that includes CVD and their risk factors.
8
Although not yet adopted, a draft national tobacco control
plan has recently been finalised, and there is a national multi-
sectoral co-ordination mechanism for tobacco control.
9
The
capital city, Kigali, has been chosen as part of an international
project for a ‘smoke-free city’ supported by Vital Strategies
and the Bloomberg Foundation since 2019.
22
Collaborative projects for NCD interventions, which
include CVD, have been implemented between the MoH
and non-health ministries and civil societies in Rwanda.
23
However, the percentage of total annual government
expenditure on cardiovascular healthcare is not known.
Rwanda was included in a project, WHO-CHOICE,
incorporating a cost-effectiveness modelling tool that gathers
national data, which can be used for developing the most
effective interventions for leading causes of disease burden.
24
The model can be adjusted according to the specific needs
of the country and assists policymakers in planning and
prioritising services at a national level.
24
Whether Rwanda
has implemented the model since it became available in 2003
is unknown. However, since 2019, Rwanda has been among
the priority countries to become part of the governance
mechanism of the United Nations-initiated ‘Defeat-NCD
Partnership’, aiming to support four NCD-related areas,
national capacity building, community health scale-up,
marketplace and financing.
25
Assessment of policy response
No legislation exists that mandates health financing for CVD.
However, legislation mandating essential CVD medicines
at affordable prices has been implemented.
26
Similarly,
legislation is employed in areas where smoking is banned,
there are visible warnings on tobacco packs, advertising and
measures to protect tobacco control policies from tobacco
industry interference.
9
The excise tax of the final consumer
price of tobacco products was 54% in 2018,
9
and 38.9% for
alcohol in 2003.
27
Policies that ensure nationwide access to
healthcare professionals and facilities have been developed,
28
as well as policy interventions facilitating PA.
29
An original
‘car-free day’ initiative promoting going green, mass sport
and screening NCD risk factors, including hypertension, has
been introduced in Kigali city since 2016 and is progressively
expanding to smaller cities throughout the country.
30
There is no sustainable funding for CVD from taxation or
any taxes on unhealthy foods or sugar-sweetened beverages.
31
No legislation banning the marketing of unhealthy foods to
minors exists nor that mandating clear and visible warnings
on foods that are high in calories, sugar or saturated fats. No
policies have been implemented that ensure screening of
individuals at high risk of CVD nor policy interventions that
promote a diet to reduce CVD risk.
Stakeholder action
Non-governmental organisation advocacy for CVD policies
and programmes in Rwanda is progressing via healthcare
services.
32
Civil society through the Rwanda NCD Alliance
(RNCDA)
33
and other organisations such as Partners in
Health, Rwanda are involved in identifying, developing
and implementing the national NCD strategic plan.
25,34
No advocacy champions have been identified for RHD in
Rwanda.
Involvement of civil society in the development and
implementation of a national CVD prevention and control