A Call to Redefine Primary Healthcare
It was late on a Sunday afternoon in November when I met Stephanie Mukansanga. She was clutching her umbrella and a little black handbag, a tired but optimistic look on her face as she waited in front of the outpatient department at Munini Hospital in Nyaruguru district, one of 47 public hospitals in Rwanda.
The hospital is not used to conducting outpatient consultations on weekends given the shortage of clinicians; only emergency cases and cases that require hospitalization are taken care of. As I walked toward the outpatient department to greet Stephanie, I hoped she was either accompanying another patient or was here for an emergency case and couldn’t locate the emergency room.
Stephanie’s medical record revealed that she was 45 years and had walked all the way from Kivu sector — a journey of 24 miles up and down mountains and across Nyungwe Forest in the rain, to arrive at the hospital.
My hand shook the woman’s palm, which appeared to have been hardened by the handle of a hoe. Stephanie’s medical record revealed that she was 45 years old and had walked all the way from Kivu sector — a journey of 24 miles up and down mountains and across Nyungwe Forest in the rain — to arrive at the hospital. A quick examination revealed no red flags requiring emergency intervention.
As I talked to Stephanie, I learned that she has been living with hypertension for seven years. She explained that she makes this journey every month to consult with a doctor and receive medication refills. She showed me a paper that read: “Return to clinic on Monday 23 May 2016 for follow up of hypertension.” The paper was signed and stamped by a medical doctor from the hospital, and it included prescriptions for Captopril and Hydrochlorothiazide, the two anti-hypertensive medications she was taking.
Despite the time and money she has to spend on traveling and being away from home, Stephanie has never missed an appointment. This time, Stephanie decided to come on the weekend when she had a better chance of safely returning home after her consultation, given the unusually long line of patients at the clinic on Mondays. This woman’s discipline and courage to respect her doctor’s order to return to the clinic and adhere to her antihypertensive regimen despite the challenges she faced deeply touched me. I could not resist consulting with her, although her case was scheduled to be seen in the outpatient department the next day.
I started by calling the non-communicable disease (NCD) nurse in charge who was keeping the keys of the archive for this department. Initially he could not believe that I was going to see a patient who was scheduled to be seen on Monday, but after some struggle I convinced him to come to the hospital from his home nearby. We accessed Stephanie’s file, took vital signs, and conducted the necessary exams to check her hypertension before giving her a prescription refill.
By the time we finished, it was late afternoon and the rain had started up again. The nurse in the internal medicine ward offered to allow Stephanie to spend the night on a hospital bed so she could resume her journey back home with her pills in the morning. Stephanie joyfully accepted.
Stephanie’s story is heartbreaking, and yet it is not uncommon. Millions of people suffer from NCDs in low and middle income countries, where health systems are least equipped to handle the challenges that come from managing them. In May 2013, the 66th World Health Assembly adopted the Global NCD Action Plan (2013–2020). One key target? Reaching 80% availability of affordable basic technologies and essential medicines required to treat major NCDs in both public and private facilities. To achieve this target, we have to strengthen health systems at all levels of care.
Despite the remarkable successes in the Rwandan healthcare system in recent years, the management of NCDs is one clear weakness.
Despite the remarkable successes in the Rwandan healthcare system in recent years, the management of NCDs is one clear weakness. When Stephanie is ill with the flu or malaria or another common ailment, she seeks care at the Kivu Health Center, a half-mile from her home. Her long journey to Munini for hypertension consultations is a result of a lack of attention to care for NCDs in remote villages. It was a pleasure to see how happy Stephanie was to go back home early in the morning with a medication refill. I cannot imagine how overjoyed Stephanie would be if she was able to get her refills at Kivu Health Center near her home.
The Lancet’s 2008 Return to the Alma-Ata Declaration highlighted improving prevention and management of chronic disease in low-income and middle-income countries as a priority. The key recommendation was to strengthen primary healthcare facilities at the community level so that patients have access to quality care and essential medicines in the places where they live. Situating healthcare service delivery in close proximity to patients’ homes will reduce travel costs, ease long-term follow-up through regular monitoring, and improve adherence to medication.
If primary healthcare facilities in remote areas are not redesigned to offer the best quality of care for all diseases, patients like Stephanie will likely be pushed into extreme poverty and stripped of the right to live dignified lives.
Offering patient-centered care, including comprehensive treatment, at the primary healthcare level is critical. This requires ensuring adequate supplies of cost-effective and affordable medicines, proper medical equipment, functional laboratories, and significant trained personnel. If primary healthcare facilities in remote areas are not redesigned to offer the best quality of care for all diseases, patients like Stephanie will likely be pushed into extreme poverty and stripped of the right to live dignified lives.
Athanase Rukundo is a 2016–2017 Global Health Corps fellow at Health Builders in Rwanda.