A focus on cancer care and the nursing role in Rwanda

INTRODUCTION

Rwanda is known as “the land of 1,000 hills.” It is renowned for its breath-taking scenery and has been referred to as a tropical Switzerland (Ferguson, 2017). Bordered by Burundi, Uganda, Tanzania, and the Democratic Republic of Congo, it lies in the heart of East Africa. It is a country of extraordinary biodiversity with incredible wildlife living among its volcanoes, mountain rainforest, and sweeping plains. It is home to some of the most precious wildlife and ecosystems the world has ever seen (Rwanda Tourism, 2020).

The country is 26,338 square kilometers of land and contains 12.8 million people. Rwanda rates as the most densely populated mainland African country with 525 people per square kilometer (See Table 1). Eighty-three percent of the people live in rural areas, gathered in nuclear family compounds on the hillsides and engaged in subsistence farming (Macrotends, 2020; FAOSTAT, 2017). It is predominantly an agricultural country growing dry beans, sorghum, bananas, corn, potatoes and cassava as primary crops (Indexmundi, 2020). The living conditions for Rwandans vary considerably depending on the four socioeconomic categories of the Ubudehe system (The Borgen Project, 2020).

Table 1.

Contrasting Rwanda and Canada Population Indices

Population indicators: Contrasting Rwanda and Canada
Indices	Rwanda	Canada
Land mass	9525 mi2	3,511,022 mi2
Population	12.8 million	37.8 million
Population density	525/km2 (1360/mi2)	4/km2 (11/mi2)
Median age	20.0 years	41.1 years
Infant births	30.9/1000 population	10.3/1000 population
Life expectancy at birth	70.0 years	82.96 years
0–14 years of age	41.4%	16%
Infant mortality	22.6/1000 live births	3.9/1000 live births
Mortality <5 years	91/1000 live births	6.8/1000 live births
Maternal mortality	540/100,000 live births	24/100,000 live births
Urbanization	17.6%	81.3%
Fertility rate	4.1/woman	1.5/woman
Literacy (15+ who can read/write)	70.8%	99%
Religion	Roman Catholic 43.7%	Roman Catholic 42.6%
	Protestant 37.7%	Protestant 23.3%
	Adventist 11.8%	Other Christian 4.4%
	Muslim 2%	Muslim 1.9%
Language	Kinyarwanda, French, English, (Swahili)	English, French

In 1994, a genocide left the country devastated (Ferguson, 2017). The governmental, economic and societal infrastructure was in tatters (Rugema et al., 2015). Rwanda was left the poorest country on the continent at that time with the lowest life expectancy and highest child mortality. Many healthcare professionals had been killed or fled and health facilities were destroyed during the genocide.

Recovery since that time has been incremental, but remarkable in terms of reconstruction and Rwandan reconciliation. Life expectancy has more than doubled since the 1990s and the country can be held up as a model for how a resource-poor country can build healthcare systems from almost nothing (Borgen, 2020; Binagwaho et al., 2014).

HEALTHCARE SYSTEM

The healthcare system in Rwanda is decentralized and multilayered (Human Resources for Health program, Rwanda, 2020; Stefan et al., 2013). Each village has three community health workers elected by villagers who do primary care in the community (Krakauer et al., 2018). Dispensaries provide outpatient and primary healthcare while health posts are engaged in outreach activities (immunization, antenatal care, family planning); healthcare centres offer primary care, maternal and child healthcare, prevention and some inpatient care; district hospitals provide both inpatient and outpatient care; and national referral hospitals provide specialist, tertiary level care.

A 2018 assessment recorded a total of 1,497 health facilities countrywide, of which 786 are public, 550 are private (includes private health posts), and 161 are government subsidized, faith-based facilities (i.e., FBO). Health posts (n = 670) constitute the majority of health facilities followed by health centres (504). There are five national referral teaching hospitals, four provincial hospitals, three referral hospitals, 36 district hospitals, and five private hospitals. In addition, Gatagara Orthopedic Centre, Inkuru Nziza Orthopedic Centre, and Huye Isange Rehabilitation Centre are considered specialized hospitals. There are 124 clinics, of which 13 are specialized clinics and 15 are polyclinics. The remainder of the private facilities is comprised of 135 dispensaries (Rwanda Biomedical Centre, 2018).

The system is a universal healthcare model supported by both state and private insurance. Up to 91% of the population is covered by a community-based health insurance system (i.e., Mutuelles de Sante). Individuals pay to a community-based fund and can draw from it when they need medical care (Binagwaho et al., 2014).

CANCER CARE CAPACITY

In Africa, cancer is currently the third leading cause of death following communicable and cardiovascular disease (World Life Expectancy, 2020). There were 10,704 new cancer cases diagnosed in 2018 in Rwanda and 7,662 cancer-related deaths (Globocan, 2020). As with other countries in Africa, Rwanda is expecting the incidence of cancer to increase over the next few decades and is working to prepare for the increased burden (Farmer et al., 2010).

Table 2.

Cancer Care in Rwanda

Characteristic	Information
Doctors	19/100,000 population
Nurses	66/100.000 population
Cancer incidence	(2018) 10,704
Cancer mortality	(2018) 7,662
Frequent female cancers	Cervix uteri – 12.2% Colorectal – 7.8% Breast – 10.6% Stomach – 7.5%
Frequent male cancers	Prostate – 15.6% Stomach – 9.8% Liver – 10.7% Colorectal – 7.9%
Cancer centres	Butaro Hospital
	Rwanda Cancer Centre – opened 2012 1,700 patients/year 24 inpatient beds – adult and pediatric Chemotherapy available through partnership with Partners in Health
	King Fissal Hospital Chemotherapy available (client pays) Only MRI Machine
	Kanombe Military Hospital Opened cancer centres – 2018 2 linear accelerators

Note: There are regular outreach programs organized by the School of Nursing and Midwifery to identify breast abnormalities.

In February 2020, the Ministry of Health announced a five-year plan for cancer control aimed at reducing cancer morbidity and mortality (RBA, 2020). Among the priority strategies included in the plan are sensitizing the population against smoking, drinking alcohol, fried foods, and intake of sugar, and promoting exercise and vaccination. Plans also include working to have prostate, colon, breast, and ovarian cancers detected at the health centres with the anticipation that diagnosis will occur at an earlier stage of disease.

Currently, although surgery is available in district hospitals, chemotherapy is only available at two centres for the time being: Butaro Hospital in the North and King Faisal Hospital (KFH) in Kigali. Butaro Cancer Centre of Excellence (BCCOE) has a cancer program run in collaboration with Partners in Health and offers chemotherapy to individuals in need. Patients travel from across Rwanda and from surrounding countries such as Burundi and the Democratic Republic of Congo for treatment. Recently, a new cancer care centre was opened at the Rwanda Millitary Hospital (RMH) where two linear accelerators were introduced for radiotherapy in 2018. They are anticipating they will be able to add concurrent chemotherapy in the near future (Mutabazi - Cancer Care Rwanda, 2020).

Given more than 60% of new cancer diagnoses in low-resource countries are made at a late stage of disease (Stefan et al., 2013; Torre et al., 2016), both prevention and earlier detection as well as palliative care are priorities for the country. In 2011, the Government of Rwanda, in collaboration with two U.S. firms, launched a comprehensive national cervical cancer prevention program that includes vaccination of girls between 12 and 15 years and modern molecular diagnostic screening for women. Completed by nurses and physicians, the screening is available to women. Rwanda was the first nation in Africa to offer a comprehensive prevention program that incorporates both HPV vaccination with GARDASIL [Human Papillomavirus Quadrivalent (Types 6, 11, 16 and 18) Vaccine, Recombinant] and HPV testing (Mosaic, 2020).

In 2011, Rwanda launched a Palliative Care Policy together with Standards and Guidelines for Practice and became one of the first developing nations to do so (Krakauer et al., 2018). The commitment stated in the policy is to provide all Rwandans with an incurable illness high-quality, affordable palliative care to meet their physical, social, psychological, and spiritual needs by 2020. Providing care for chronically ill and dying individuals and their families is also a critical part of the plan. Additionally, a home-based practitioner program has been launched with the aim of providing two practitioners per district to provide palliative care at home and link patients with relevant services (Stefan et al., 2013).

Kibagabaga District Hospital was the first to adapt palliative care services by training its multidisciplinary team (e.g., nurses, physicians, physiotherapists, anesthesiologists). The emphasis was on prescription and availability of morphine because it was very limited. This hospital served as an inspirational hospital to other hospitals in Rwanda and its team trained other hospital staff all over the country. There was also a decentralization of palliative care services at community level involving community health workers and the creation of the Rwanda Palliative Care and Hospice Organization. This was based on a survey conducted among palliative care patients that revealed more than 70% of them preferred to receive palliative care services at home (Ntizimira, 2018)

In 2014, the country developed its own local morphine production and distribution program (Medical Brief, 2020; Newtimes, 2020). As a result, the per capita consumption of morphine has risen. Prior to that time, it was estimated that 98% of end-of-life pain was not managed well (Shetty, 2010). There are now multidisciplinary teams for palliative care in each of the four district hospitals and desks in charge of palliative care in all referral and provincial hospitals with two nurses trained in palliative care and a home-based palliative care program started with the goal of having two trained home-based practitioners to provide basic palliative care in the home and link patients with necessary services (Krakauer et al., 2018).

Accessing cancer diagnosis and treatment services remains challenging for individuals and their families (Farmer et al., 2010; Shulman et al., 2014). For individuals diagnosed with cancer, financial concerns are of paramount importance given they face prolonged hospitalizations and the need for frequent clinic visits. Part of the national cancer control strategy is to provide financial support for transportation and nutritional supplements (RBA, 2020).

Since November 2017, one very promising initiative is underway following an award to the City of Kigali by the International Union Against Cancer (UICC, 2017). This was a Learning City Initiative for Cancer Care. The aim of the award was to support an inter-sectorial collaboration to enhance cancer control. The Kigali Team conducted a needs assessment in August 2019. A total of 126 professionals from 32 institutions and 80 cancer patients took part in the needs assessment. The Team recently released its priority planning document and identified the following actions:

1. Creating a platform for communication and information sharing between different institutions involved in cancer care.

2. Improving access to quality, safe and affordable cancer medicines.

3. Standardizing clinical management of prioritized cancers in all institutions providing cancer care.

4. Providing comprehensive support to cancer patients and their families throughout the different stages of care.

5. Training to improve human resources in all disciplines related to cancer care.

NURSING PREPARATION

Nursing preparation in Rwanda began in the 1940s with missionaries, but eventually moved into private and public schools. In 1996, Kigali Health Institute (KHI) was established with advanced nursing and midwifery education. The Institute awarded an advanced diploma and later introduced the Bachelor and Master’s degrees in nursing (Mukamana et al., 2015).

Specifically aimed at increasing the number of nurses in the country, the Ministry of Health (MOH) started five Schools of Nursing and Midwifery in 2007. Subsequently, in 2013, a Human Resources for Health (HRH) Program was initiated by the MOH and all higher learning institutions (including the five nursing and midwifery schools) were fused into one University of Rwanda under the Ministry of Education. This development set the stage for the design of eight tracks for specialization in nursing under the Masters of Nursing Curriculum in 2015. One of the specialty tracks was oncology nursing.

Formal cancer nursing preparation began in 2015. The Masters in Nursing Program is a two-year, four-semester, post graduate program. There are nine common learning modules that are shared with seven other specialty tracks (e.g., critical care, neonatology, pediatrics, nephrology, perioperative, medical surgical) and three cancer-specific modules including clinical practice in Rwandan hospitals that manage cancer patients (Butaro Cancer Centre, Kabuga Hospice and Palliative Care, and home care in collaboration with the Rwanda Palliative Care and Hospice Organization). The cancer modules cover such topics as cancer screening and diagnosis of different adult and pediatric cancers, palliative and end-of-life care, psychosocial care, and rehabilitation. Upon completion of the program the students are awarded a Master of Science in Nursing (MScN) with a specialization in oncology nursing. The first cohort (n = 9) graduated in August 2017 and the second (n = 9) in November 2019. The third cohort is currently enrolled and completing their second term. During the program, the students complete a dissertation thesis in addition to their theoretical and practical coursework.

The other initiative that has been undertaken to prepare cancer nurses occurred at Butaro Cancer Centre of Excellence. In 2015, nurses were instructed through a brief training program about cancer preventative and early identification measures (i.e., clinical breast examination). Additionally, nurses from Butaro district and health centres were trained on the screening for cervical cancer using vision inspection with acetic acid (VIA) through a 10-day curriculum (five on theory and five for practice) (Uwinkindi et al., 2018).

Finally, there is a need for human resource capacity building, mostly regarding PhD preparation in oncology nursing, to continue educating nurses in the oncology field. It is also important to find opportunities to travel for observational or clinical placements outside the country to gain further skills. Initial steps have been taken to establish a network of cancer nurses in the country. The early leaders would like to see a formal association emerge for cancer nursing. This would help with the development of the specialty and advocacy for its future growth.

CONCLUSION

Providing cancer care in Africa is challenging. Clearly, nurses are on the frontline of this care and require knowledge and skill beyond their basic nursing preparation to care for cancer patients and their families. The capacity to prepare specialists in cancer nursing is growing slowly, but needs to be fostered to continue to develop and growth effectively.