Adolescent Health in Rwanda

Adolescents remain a neglected group in Rwanda’s health care model according to a new report on adolescent health by Dr. Agnes Binagwaho, Permanent Secretary of Rwanda’s Ministry of Health. While the country’s health care infrastructure has vastly improved since 1994, so that vulnerable groups such as mothers, infants, and people living with HIV/AIDS experience better health outcomes, few efforts focus on behavioral and preventative health care for adolescents. Dr. Binagwaho argues that adolescents are a neglected group in the country’s health care model primarily because they are considered comparatively healthy with a low disease burden. Yet the choices adolescents make today affect their health — and the health of their families — in the future, especially as these choices relate to family planning and STDs.

The new report emerges from Dr. Binagwaho’s research on the gap between the right of HIV-infected children to health services and the reality in Rwanda. Finding little research or advocacy focused on adolescent health, Dr. Binagwaho decided to undertake the task herself. She found that although adolescents may be equipped with knowledge, they lack “life skills,” for example, the ability to negotiate safer sex or to seek the help of family planning services. She offers practical suggestions for addressing this gap, including policy changes, training, and social support designed specifically for adolescents.

The report’s Executive Summary is provided below. Her full report on “Adolescent Health in Rwanda” is available here.

Executive Summary of the “Report on Adolescent Health in Rwanda,” by Dr. Agnes Binagwaho

The Government of Rwanda, supported by outside partners, has been able to significantly improve the health status and HIV services of the population in the last decade. Life expectancy increased; infant, child and maternal mortality has been reduced; and the spread of HIV/AIDS has been contained. Nevertheless, there is still a lot of room for further improvement of health care in Rwanda, in particular by increasing access to quality health and HIV care services.

One area that has been widely neglected in Rwanda is the adolescents health. A comprehensive strategy to advance health services (including STIs and HIV prevention and treatment) that meet adolescent needs is presently missing but absolutely in light of the fact that adolescents make up about a third of Rwanda’s population.

Adolescents are often perceived as healthy, since they face a relatively low disease burden. While this is true regarding traditional measures of disease burden such as DALYs, adolescents impact their immediate and their future health outcomes by their behavior today. Therefore, compared to other age groups, adolescent health and HIV status are concerned with a higher share of preventive and behavior changing health services compared to curative health services.

The key health issues faced by Rwanda’s adolescents today are related to reproductive health, including family planning, STIs and HIV – which is particularly important given its public health implications. Mental health and substance abuse are perceived as an important but less pressing health concern in Rwanda. Injuries and accident-related traumas – often a main health threat for adolescents in developed countries – seem to be less relevant in Rwanda.

Several challenges to improve adolescent health and sexual and reproductive health in particular, exist in Rwanda: Even though adolescents’ knowledge about protective health behavior and risk factors for poor health has increased, there is a clear gap between knowledge and the ability to apply it in critical situations – including situations that increase the risk of HIV infection. A lack of independence and assertiveness, such as being able to negotiate safer sex, is perceived as an obstacle to better health through reduced risk behavior.

Despite an impressive rebuilding of the whole health care system since 1994, youth-friendly health services are still widely missing. This is true for all the component of a clinical program, such as infrastructures, personnel trained to meet adolescents’ needs, and guidelines defining HIV packages for this group. 43% of the children surveyed were treated with adults, – 6 – not in a separate pediatric ward. Furthermore, 90.7% of children and their parents stated that they felt the need for the establishment of an adolescent ward. Finally, in a hierarchical society with strong roles and norms, social pressure on adolescents regarding their behavior is another factor that often hinders adolescent health seeking behavior. In particular if HIV and family planning services are not used by adolescents due to fear of social consequences, and in the absence of relevant information provided by adult family members, this can lead to worse health outcomes.

Findings in this report indicate that:

1. Policies should ensure that adolescents not only receive technical health and HIV information, but are also trained in how to apply this knowledge in their daily life. To achieve adequate adolescent training and education, health care providers have to be sensitized on this issue and enabled to provide this kind of training.

2. To ensure adolescent access to high quality health and HIV services, adequate guidelines infrastructures, and trained personnel must be available to ensure that quality youth-friendly services can be offered.

3. Social support has to be ensured for adolescents. This should include a very wide array of activities and interventions aimed at actively engaging adolescents in changing social norms limiting their access to health and HIV services. Messages concerning adolescent health, such as HIV and STI prevention and treatment, should be included whenever possible in adolescent related activities.

4. A national adolescent health policy should be developed as an instrument to establish a common policy base between relevant ministries, agencies, health partners and civil society – thereby ensuring the necessary support to provide an implementation framework and to keep institutions accountable. This policy should also define a national mechanism for coordination between government institutions, as well as between government agencies and partners working in adolescent health and HIV issues.