Heart Failure and Cardiac Ultrasound Training in Rural Rwanda

Sheila Klassen, M.D. 

Cardiovascular Disease and Global Health Equity Fellow at Harvard Medical School

PGY 5

10/10/2019

As my month in rural Rwanda draws to a close, I’ve had some opportunity to reflect on the successes and the challenges of healthcare provision in this country. I was able to spend 4 weeks doing simplified heart failure and echocardiography training across 7 hospitals in the country. It meant a lot of time traveling and many hours on the road, but it also gave me an appreciation of health care delivery in Rwanda.

Giving out completion certificates after heart failure and echo
training course. 

There is a large emphasis on community in Rwanda which is encouraged by the government. There is a community event called Umuganda every last Saturday of the month where citizens are required to meet with their local communities and either perform manual labour tasks to better their communities such as filling in potholes or helping an older neighbor patch their leaking roof. Other Umuganda activities include having community meetings on security or other local issues. Years ago, the government distributed approximately 3 million cows to rural the rural population as a way of both decreasing malnutrition and creating industry. This has resulted in lower priced milk for Rwandans and in addition has created a sustainable export to neighboring countries. Community members who own cows that eventually calve are required to give away these calves to those do not own cows at no cost. Communities often gather at church on weekends, and the local water pumps are always overrun with children who meet daily to fill their jugs (running water in homes is not yet available). This community engagement could be a strength in health care delivery as community members look after each other. There is potential for shared medical appointments where members of the same community who have similar medical problems (diabetes, high blood pressure) have medical appointments with healthcare providers together so that they can both support each other and alleviate the burden on the few healthcare providers that are in country.

One of my trainees performing an echocardiogram in a rural
Rwandan hospital. 

Spending time in rural hospitals, it was gratifying to see my trainees very capably performing cardiac ultrasound and managing heart failure patients appropriately. They still required support and voiced a need for ongoing mentorship but this was a big leap from where they started, which was next-to-no skill in managing heart failure and cardiac disease.

Challenges are still many. Limited resources, limited training opportunities, limited expertise, and lack of infrastructure due to lack of resources still pose barriers to adequate health provision in the country. Providers are accustomed to providing care without resources which can make them complacent. There is a very high volume of patients because of the level of poverty of the population and high frequency of the socioeconomic determinants of poor health. At the same time, there is provider scarcity. Procurement of supplies, transportation of medical equipment, and biomedical support is all limited. Despite these challenges, Rwanda has pulled itself from its status as a broken state and poorest country in the world after the 1994 genocide to a growing health system with stable infrastructure. There is a way forward. Capacity building and training as well as continued resource support, possibly involving public private partnerships can continue to benefit the country and improve the health of its population. I’m glad I was able to use this travel grant to both share my cardiac knowledge with Rwandan healthcare providers and be part of Rwanda’s rebuilding as a country.