I. Introduction. Le Rwanda a connu de nombreuses difficultés au cours des deux dernières décennies : la situation économique précaire, les guerres civiles, le régime politique défaillant, l’instabilité de la sous-région des Grands Lacs, la pandémie du VIH/SIDA ; tous ces bouleversements ont plongé le pays dans l’extrême pauvreté. Au lendemain de la guerre et du génocide, le ministère de la Santé avec l’appui de différents partenaires a canalisé tous ses efforts dans la reconstruction du système de santé. Une meilleure participation communautaire à la gestion et au financement des services de santé était un des objectifs retenus dans cette reconstruction du système de santé. Pour ce faire, le ministère de la Santé, en partenariat avec le PHR (Partnership for health reform) a mis en place des mutuelles de santé « pilote » dans trois districts sanitaires (Byumba, Kabgayi et Kabutare) sur les 39 districts que compte le pays. L’objectif du ministère de la Santé était de généraliser ce système d’assurance maladie après une évaluation de ce projet pilote. Cette initiative de mise en place des mutuelles s’est heurtée au début de sa mise en œuvre à différents problèmes : le faible taux d’adhésion, les problèmes de gestion de la mutuelle, une faible implication des autorités de base dans la sensibilisation, une mauvaise qualité de soins dans certaines formations sanitaires, une utilisation abusive des services par les mutualistes, etc. Malgré ces problèmes d’autres initiatives de mise en place de mutuelles de santé ont vu le jour et continuent de s’implanter ici et là dans les districts sanitaires du pays. Dans le souci de renforcer cette réforme de financement alternatif par les mutuelles de santé, nous avons évalué l’impact des mutuelles sur l’accessibilité aux soins et le renforcement de la participation communautaire aux services de santé et nous avons proposé des voies stratégiques susceptibles d’améliorer le fonctionnement des mutuelles de santé. II. Méthodologie Pour atteindre ces objectifs de recherche, nous avons combiné trois approches différentes : la recherche qualitative qui a permis d’une part, d’analyser le processus de mise en place des mutuelles de santé au Rwanda et d’autre part, de recueillir les opinions des bénéficiaires de services de santé sur ce processus. Ensuite la recherche quantitative nous a permis d’étudier les caractéristiques des membres et non-membres des mutuelles et l’utilisation des services de santé ; enfin la recherche action nous a permis d’expérimenter les axes stratégiques susceptibles de renforcer le développement des mutuelles de santé. Cette approche méthodologique utilisée tout au long de notre travail de terrain a mené à une « triangulation méthodologique » qui est une combinaison de diverses méthodes de recherche. Dans chacune des méthodes citées, nous avons utilisé une ou plusieurs techniques : analyse de documents, observations et rencontres avec des individus ou des groupes, analyse et compilation des données de routine. III. Résultats Les résultats clés sont synthétisés selon les trois types de recherche que nous avons menés. 1. Processus de mise en place des mutuelles de santé au Rwanda et opinions des bénéficiaires Dans les trois districts pilotes (Byumba, Kabgayi et Kabutare), les mutuelles de santé prennent en charge le paquet minimum d’activités complet offert au niveau des centres de santé. À l’hôpital de district elles couvrent : la consultation chez un médecin, l’hospitalisation, les accouchements dystociques, les césariennes et la prise en charge du paludisme grave. Pour bénéficier de ces soins une cotisation de 7,9 $ EU ($ des États-Unis) par an pour une famille de sept personnes est demandée, puis 1,5 $ EU par membre additionnel et 5,7 $ EU pour un célibataire. Le ticket modérateur est de 0,3 $ EU pour chaque épisode de maladie et la période d’attente d’un mois avant de bénéficier des avantages du système de mutualisation. Des entretiens en groupes de concertation (focus groups) nous ont permis de confirmer que la population connaît l’intérêt des mutuelles de santé et qu’elle éprouve des difficultés pour réunir les fonds de cotisations pour adhérer aux mutuelles. L’analyse critique du processus de mise en place des mutuelles dans les trois districts pilotes nous a permis de conclure que les autorités locales et les leaders d’opinions étaient peu impliqués dans le processus de mise en place des mutuelles et que la sensibilisation était insuffisante. L’appui au processus de mise en place par le PHR a été jugé insuffisant en termes de temps (18 mois) et de formation de cadres locaux qui devraient assurer la poursuite de ce projet. Les défaillances évoquées ont alerté le ministère de la Santé, qui a mis en place un comité de mise en place et de suivi des mutuelles de santé. Depuis ce temps, on observe une émergence des initiatives mutualistes. Le pays compte actuellement 21 % de la population totale qui possède une certaine couverture (partielle ou totale) d’assurance maladie. 2. Caractéristiques des membres et non-membres des mutuelles de santé et utilisation des services de santé par la communauté Il a été constaté que la répartition selon le sexe, l’état civil et le statut professionnel des membres et non-membres de la mutuelle les caractéristiques ne diffèrent pas significativement entre les adhérents et les non-adhérents à la mutuelle de santé (p > 0,05). Parmi les membres, les proportions des ménages avec revenus élevés sont supérieures à celles observées chez les non-membres (p < 0,001). Quant à la « sélection adverse » que nous avons recherchée dans les deux groupes (membres et non-membres de la mutuelle), nous avons constaté que l’état de morbidité des membres de la mutuelle ne diffère pas de celui des non-membres (p > 0,05). Les personnes qui adhèrent à la mutuelle de santé s’y fidélisent au fil des années (> 80 %) et fréquentent plus les services de santé par rapport aux non-membres (4 à 8 fois plus pour la consultation curative et 1,2 à 4 fois plus pour les accouchements). Les non-membres ont tendance à fréquenter les tradipraticiens et à faire l’automédication. Bien que les mutualistes utilisent plus les services de santé que les non-mutualistes, ils dépensent moins pour les soins. 3. Axes stratégiques développés pour renforcer les mutuelles de santé Pour mettre en place les stratégies de renforcement des mutuelles de santé, cinq types d’actions dans lesquelles nous avons joué un rôle participatif ont été menés. D’abord la stratégie initiée pour faire face à l’exclusion sociale : il s’agit de l’entraide communautaire développée dans la commune de Maraba, district sanitaire de Kabutare. Ce système d’entraide, nommée localement ubudehe (qui signifie « travail collectif » en kinyarwanda), assure un appui aux ménages les plus pauvres selon un rythme rotatoire préalablement établi en fonction du niveau de pauvreté. Une autre stratégie est celle du crédit bancaire accordé à la population pour pouvoir mobiliser d’un seul coup le montant de cotisation. Cette stratégie a été testée dans le district sanitaire de Gakoma. Un effectif de 27 995 personnes, soit 66,1 % du total des membres de la mutuelle de ce district ont souscrit à la mutuelle de santé grâce à ce crédit bancaire. Les autorités politiques et des leaders d’opinions ont été sensibilisés pour qu’ils s’impliquent dans le processus de mise en place des mutuelles dans leurs zones respectives. Il a été constaté que les leaders d’opinions mobilisent plus rapidement et plus facilement la population pour qu’elle adhère aux mutuelles de santé, que les autorités politiques. Cette capacité de mobiliser la population est faible chez les prestataires de soins. Certaines mesures ont été proposées et adoptées par les mutuelles de santé pour éviter les risques liés à l’assurance maladie. Il s’agit de l’adhésion par ménage, par groupe d’individu, par association ou par collectivité ; l’exigence d’une période d’attente avant de bénéficier des avantages des mutualistes ; l’instauration du paiement du ticket modérateur pour chaque épisode de maladie ; les supervisions réalisées par les comités de gestion des mutuelles de santé et les équipes cadres de districts ; l’utilisation des médicaments génériques ; le respect de la pyramide sanitaire et l’appui du pouvoir public et/ou partenaire en cas d’épidémie. Ces mesures ont montré leur efficacité dans l’appui à la consolidation des mutuelles de santé. Enfin, l’« Initiative pour la performance » est la dernière stratégie qui a été développée pour renforcer les mutuelles de santé. Elle consiste à inciter les prestataires à produire plus et à améliorer la qualité de services moyennant une prime qui récompense leur productivité. Les résultats montrent que les prestataires de services ont développé un sens entrepreneurial en changeant leur comportement vis-à-vis de la communauté. Certaines activités du PMA (paquet minimum d’activités) qui n’étaient pas offertes ont démarré dans certains centres de santé (accouchement, stratégies avancées de vaccination, causeries éducatives, etc.). Des ressources supplémentaires ont été accordées aux animateurs de santé, aux accoucheuses traditionnelles et aux membres de comités de santé qui se sont investis plus activement dans les activités des centres de santé. L’intégration des services a été plus renforcée que les années précédentes. IV. Conclusions Les mutuelles de santé facilitent la population à accéder aux soins de santé et protègent leurs revenus en cas de maladies. Le modèle de mise en place des mutuelles de santé au Rwanda est de caractéristique dirigiste : à partir des autorités (politiques, sanitaires ou leaders d’opinions). Il ne serait pas le plus adéquat dans la participation communautaire, mais plutôt adapté à un contexte politique de reconstruction d’un pays.

Mémoire numérisé par la Direction des bibliothèques de l'Université de Montréal.

Thèse numérisée par la Direction des bibliothèques de l'Université de Montréal.

Philosophiae Doctor - PhD / Background: Tuberculosis (TB) is a major cause of morbidity and mortality among children (<15 years) in resource-limited countries. The World Health Organization (WHO) identified active contact screening and isoniazid preventive therapy (IPT) as essential actions for detecting and preventing childhood TB. Despite their benefits and inclusion in the policy of most National TB Programme (NTP) guidelines of the resource-limited countries, there is still a wide gap between policy and implementation. The implementation of contact screening for active case finding might be improved by the decentralised use of the Xpert MTB/RIF test in gastric lavage (GL) specimens, but this has not been previously assessed. Furthermore, although the provision of IPT to eligible child contacts has been a focus for implementation by the NTP of Rwanda since 2005, implementation has not previously been evaluated. The assessment of IPT uptake and adherence as well as associated factors could be informative for the programme. Therefore, we aimed to assess the diagnostic yield of Xpert MTB/RIF in GL among child contacts with suspected pulmonary tuberculosis (PTB) and the uptake of and adherence to IPT by eligible child contacts to make recommendations towards strengthening TB diagnostic and prevention in children in Kigali, Rwanda. Methods: The proposed study setting Kigali, the capital city of Rwanda, was the location for 30% of the national PTB case notifications in 2013-14.A conceptual framework based on ecological theory was used in this study. Quantitative, qualitative and mixed (using both quantitative and qualitative research methods in one study) research methods were applied, and various research designs were used depending on the research questions. The study involved a cross-sectional analysis of the diagnostic yield of Xpert MTB/RIF in GL among all child contacts with suspected TB. Across-sectional and prospective cohort study design was used to assess the uptake and adherence of IPT among eligible child contacts.

For many years the United Nations (UN) has sought to coordinate its numerous agencies and other humanitarian relief actors during responses to natural disasters and complex emergencies. Its success in this endeavor has been mixed. Through an analysis of three different humanitarian relief operations-the Rwanda genocide in 1994, the North Atlantic Treaty Organization's intervention in Kosovo in 1999, and the floods of 2000 in Mozambique-this paper describes more fully the conditions under which coordination efforts occur. Specifically, this essay argues that successful and effective coordination in each particular crisis depends on the extent to which certain capacity and contextual conditions were present. In addition, it suggests that the often-touted "coordination by command" approach, a top-down style of coordination, should not be assumed by the UN since, as the literature suggests, this notion is quite contentious among nongovernmental organizations and United Nations staff alike. This paper critiques the utility of pursuing this model and offers instead an alternative vision of a pragmatic facilitation role for UN agencies in humanitarian relief operations / Master of Public and International Affairs

The aim of this study is to investigate the outcomes of the Land Consolidation Programme (LCP) in household food productivity. The implementation of the 2004 Rwandan National Land Policy (which incorporates LCP) has been one of the Rwandan government strategic attempts to improve the livelihood of the Rwandans. In this study we look at some of the social-economic factorsbenefited by household farmers through the LCP since its implementation in 2007. In Sub-Saharan Africa many people depend on land for their livelihood and consequently, one of the obvious negative impacts has been the fragmentation of land. Historically the customary land management, in which inheritance is the major mode of land acquisition, has been the main way of allocating land in African societies. This communal tenure is viewed as unstable and leads to detrimental implications, in the form of mismanagement and overexploitation of the available land. The demographic pressure has also aggravated the issue of land scarcity and land fragmentation. The latter has consequences on agricultural productivity since it makes harder the efficient use of land. In this study the researcher explores the outcomes of the LCP in Rwanda as a type of land reform that aims at preventing fragmentation of land and enhancing the livelihood of household farmers. For achieving this objective, the study used a case study of household farmers from Gisenyi village of Bugesera district (in Rwanda) who are involved in the LCP since its implementation. Empirical data was obtained through in-depth interviews with 20 household farmers and 8 key informants. The emphasis in the study was put on investigating the state of household food productivity in Gisenyi. The study was guided by the property right theory and its basic conceptual assumption of enhancing the income through credit access. The findings of the study demonstrate that household farmers in Gisenyi village have benefited from the LCP. Household farmers confirmed that agricultural productivity has increased due to the new farming techniques brought by the programme. The study concludes that once the programme is properly and fully implemented, the LCP will highly enhance food self-sufficiency situation in Rwanda, improving also the livelihood of rural areas through other benefits such as infrastructure development.

Student Number :0418716K - MA research report - School of Geography, Archaeology and Environmental Studies - Faculty of Humanities / As a continuously growing industry worldwide, tourism has often demonstrated its role as a vital tool in the advancement of economies through direct domestic and foreign exchange earnings and through the employment and investment opportunities it can generate. African countries, mainly in sub-Saharan Africa, often over-reliant on one or two sectors for economic development, have recognised the potential of the tourism industry to diversify local economies and contribute to poverty alleviation, economic regeneration and stability, affording many Africans the opportunity to participate in and benefit from tourism. The participation of local populations in Africa’s tourism industries, however, is often limited to employment opportunities. Travel by local tourists is often overlooked by members of the tourism industry, and is often considered a luxury by many in the local population. The role of domestic tourism and its importance for the creation of a sustainable tourism industry has been widely acknowledged, but limited writings on the subject exist and few tourism policies include domestic tourism, neglecting its potential. The emergence of a new African middle-class, equipped with more of a disposable income and influenced by Western lifestyles, has proven that such potential does in fact exist. Those living in Africa as well as members of the Diaspora have shown more of an interest in leisure travel and represent a new tourism market. Globally, the impact of domestic tourism has been shown to have had a great impact on the tourism economies of several countries, demonstrating that African countries can only serve to benefit from participating in domestic tourism. This research report provides a case study of Rwanda, an African country emerging from war and devastation, aiming to rebuild itself economically, socially and politically. The country has chosen tourism as one of its main economic drivers for poverty reduction and economic development. While the industry is succeeding, an over-reliance on international visitors in such a volatile region threatens the sustainability of the industry. The development of a domestic tourism industry, as has been demonstrated in other countries, offers the opportunity to generate a more diverse and economically sustainable domestic tourism industry. This research focuses on the potential impact of such a domestic tourism industry on Rwanda’s tourism economy and as a result, on the country’s economy as a whole.

Rotavirus is the most common cause of severe gastroenteritis among children <5 years of age worldwide and is responsible for 453,000 deaths among children in this age group. More than half of these deaths occur in sub-Saharan Africa. Because of the tremendous global burden of rotavirus, vaccine development and introduction has been a high priority for several international agencies, including the World Health Organization (WHO) and GAVI. Two live, attenuated, orally administered rotavirus vaccines, a pentavalent bovine-human reassortant vaccine (RV5; RotaTeq® (Merck and Co, Inc, Pennsylvania)) and a monovalent vaccine (RV1; Rotarix™ (GSK Biologicals, Rixensart, Belgium)) based on a human rotavirus strain, are licensed and available for use in many countries worldwide. Pre-licensure clinical trials of each of these vaccines in high and middle-income countries demonstrated high efficacy (85-98%) against severe rotavirus disease. Further studies conducted in low-income countries of Asia and Africa found modest efficacy (50%-70%) of these vaccines against severe rotavirus disease. However, the public health impact of vaccination (in terms of burden of severe rotavirus disease prevented by vaccinating a given number of children) is greater in developing countries because of the substantially higher baseline rotavirus disease burden in these settings. In 2009, the World Health Organization recommended the inclusion of rotavirus vaccine in the national immunization programs of all countries globally and particularly in those countries with high child mortality due to diarrhea. Of the 16 countries recently approved by GAVI for rotavirus vaccine introduction, 12 countries are located in Africa. As rotavirus vaccines are introduced into national immunization programs, monitoring their impact is a high priority for several reasons. There is a need to assess the effectiveness of these vaccines in routine use to ensure it parallels that of pre-licensure trials, particularly when used in developing countries. Assessing the impact of vaccination on disease burden in countries such as Rwanda will be vital to understanding the full public health benefit of the vaccine. The primary purpose of this program evaluation is to determine the impact of pentavalent rotavirus vaccine on rotavirus and all-cause diarrhea morbidity following introduction into the national immunization program in Rwanda in May 2012. Additionally, this evaluation will document changes in circulating strains over time pre- and post-vaccine introduction. It will also strengthen support for economic evaluation of treating diarrhea versus introduction of new vaccine in routine immunization. Methodology Various studies have been implemented since 2011 in the health sector in Rwanda to reach the goal of this thesis. First, we analyzed data for all-cause, non-bloody diarrheal disease among children <5 years of age from the routine health management information system (HMIS) in Rwanda from January 2008 through December 2011, The objective of this analysis was to determine whether routinely collected health information on national diarrhea hospitalizations, in-hospital deaths, and outpatient visits can be used to monitor the impact of rotavirus vaccine. We used data from the health management information system (HMIS) in Rwanda to describe trends in all-cause, non-bloody diarrhea hospitalizations and outpatient visits among children <5 years of age from 2008 to 2011 prior to vaccine introduction. Second, we evaluated the economic burden attributable to hospitalization for diarrhea among children aged less than 5 years in Rwanda. This was a prospective costing study where medical records and hospital bills for children admitted with diarrhea at 3 hospitals were collected to estimate costs. Interviews with the child’s caregivers provided medical costs incurred before and after hospitalization and the household costs. Third, we analyzed and tried to understand the introduction and delivery cost per dose or per child of the three new vaccines in Rwanda including the rotavirus vaccine for domestic and external financial resource mobilization. Fourth, we determined the rotavirus prevalence rates and circulating genotypes directly pre- and post-introduction of the RotaTeq rotavirus vaccine in May 2012. Stool samples were collected from 1,847 children <5 admitted to 8 surveillance sites for acute gastroenteritis (AGE) and tested for rotavirus antigens by enzyme immunoassay. Fifth, to monitor the effect of rotavirus vaccine in Rwanda, we studied trends in the number of hospital admissions for diarrhea and rotavirus before and after the introduction of the rotavirus vaccine. We conducted a time-series analysis to examine trends in admissions to hospital for non-bloody diarrhea in children younger than 5 years in Rwanda between Jan 1, 2009, and Dec 31, 2014, using monthly discharge data from the HMIS.Result All-cause, non bloody diarrheal hospitalizations and outpatient visits among children <5 years of age in Rwanda from 2008 to 2011 peaked during the June to August dry season, coinciding with the rotavirus season. The bulk of the diarrheal disease burden occurred in children <1 year of age. Average medical costs for each child for the hospitalization were $44.22 ± $23.74 and the total economic burden per hospitalization was $101, of which 65% was borne by the household. The unit cost of introducing rotavirus vaccines 2012 was 22.69 US. Among the 397 stool samples that were genotyped, 5 G types (G1, G4, G8, G9, and G12) and 3 P types (P[4], P[6], and P[8]) were identified. G8 (30.3%), G9 (28.0%), and G1 (19.7%) were the most prevalent G types, while P[8] (52.0%) and P[4] (32.6%) were the most prevalent P types. There was a significant amount of mixed G genotypes (12.1%), while mixed P types were less common (5.1%). G8P[4], G9P[8], and G1P[8] were the most prevalent strains, accounting for 27.8%, 24.3%, and 15.3% of all specimens, respectively.Compared with the 2009–11 pre vaccine baseline, hospital admissions for non-bloody diarrhea captured by the HMIS fell by 17–29% from a pre-vaccine median of 4051 to 2881 in 2013 and 3371 in 2014, admissions for AGE captured in pediatric ward registries decreased by 48–49%, and admissions specific to rotavirus captured by active surveillance fell by 61–70%. The greatest effect was recorded in children age-eligible to be vaccinated, but we noted a decrease in the proportion of children with diarrhea testing positive for rotavirus in almost every age group.ConclusionGiven the stable and consistent trends and the prominent seasonality consistent with that of rotavirus, HMIS data should provide a useful baseline to monitor rotavirus vaccine impact on the overall diarrheal disease burden in Rwanda. Active, sentinel surveillance for rotavirus diarrhea will help interpret changes in diarrheal disease trends following vaccine introduction. Other countries planning rotavirus vaccine introduction should explore the availability and quality of their HMIS data.Households often bear the largest share of the economic burden attributable to diarrhea hospitalization and the burden can be substantial, especially for households in the lowest income quintile.The cost of introduction of new vaccines (rotavirus) is less than the cost of treating the diarrhea diseases. The number of admissions to hospital for diarrhea and rotavirus in Rwanda fell substantially after rotavirus vaccine implementation, including among older children age-ineligible for vaccination, suggesting indirect protection through reduced transmission of rotavirus. These data highlight the benefits of routine vaccination against rotavirus in low-income settings. / Doctorat en Santé Publique / info:eu-repo/semantics/nonPublished

This study aims to explore the effectiveness of reconciliation in post-genocide peace building. Peace activists believe that reconciliation is necessary after a post-war conflict to ensure regeneration and lasting peace. Past research has shown that there are successful and failed cases when implementing reconciliation mechanism, however there is a lack of understanding why some models of reconciliation have succeeded, while others have failed, an aspect that is not fully explored. Therefore this study aims to explore how reconciliation is approached and implemented across different contexts, Rwanda and Cambodia, so as to understand why it brings success or failure in these contexts. The results are analyzed with the help of John Paul Lederach’s four components for reconciliation, justice, truth, mercy and peace, and compared the generated results with the previous research. The main results show that reconciliation has failed in Cambodia and Rwanda. In accordance with John Paul Lederach’s theory, there is a hindrance towards reconciliation in Cambodia because of lack of Justice and Truth as the main concepts and is identified as a structural dimension. In the case of Rwanda, there is a lack of Mercy and Truth and is identified as a relational dimension.

This thesis constitutes an interpretive ethnography of children’s educational experiences in rural Rwanda. It advances a theoretical argument for conceptualizing subjectivity, one which attends to how impersonal forces of political economy and history converge to inform children’s awareness, expectations, and perceptions of possibility. A decade ago, children from poor families in Rwanda had few opportunities to continue their studies beyond primary school. With the government’s recent introduction of basic education, more children now have access to more years in the formal education system—yet, poor education quality excluded them from meaningful participation within that system. Study findings suggest that children’s schooling functions as a contradictory resource: the same education policy reforms that aim to transform Rwanda into a knowledge-based economy have also introduced the perception of inequalities along the lines of economic status, ethnicity, language, and geographic location. The core of my study included a collaboration with 16 focal students. Their subjective experiences were the microcosm through which I investigated the nexus of individual and collective processes. Students grappled with what value their education had, what status it would confer, and whether it would lead to opportunities for social mobility. However, in absence of alternatives, most felt obliged to continue their studies—even as their educational experience produced a growing sense of disillusionment.