bioRxiv preprint doi: https://doi.org/10.1101/516112; this version posted January 9, 2019. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted bioRxiv a license to display the preprint in perpetuity. It is made available under aCC-BY 4.0 International license.
1 Understanding variation in maternal health service coverage and 2 maternal health outcomes among districts in Rwanda
3 4 Felix Sayinzoga1 5 Maternal, Child and Community Health Division 6 Rwanda Ministry of Health/ Rwanda Biomedical Center 7 Kigali, Rwanda 8 E-mail:[email protected] 9 PO Box 84 Kigali 10 Phone:+250788517814 11 12 Tetui Moses2 13 Makerere University School of Public Health 14 PO Box 7072, Kampala, Uganda 15 E-mail: [email protected] 16 17 Koos van der Velden3 18 Department of Primary and Community Care 19 Radboud University Medical Centre 20 Nijmegen, The Netherlands 21 E-mail: [email protected] 22 23 Jeroen van Dillen4 24 Department of Obstetrics and Gynaecology 25 Radboud University Medical Centre 26 Nijmegen, The Netherlands 27 E-mail: [email protected]
28 Leon Bijlmakers5 29 Department for Health Evidence 30 Radboud University Medical Centre 31 Nijmegen, The Netherlands 32 E-mail: [email protected] 33 Tel: +31 243613337 34 Corresponding author 35
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36 Abstract
37 Objective: To identify factors that explain variations between districts in maternal
38 health service coverage and maternal health outcomes.
39 Methods: Individual key informant interviews and focus group discussions using
40 structured topic lists were conducted in May 2015 in four purposively selected
41 districts.
42 Results: The solidarity support for poor people and the interconnectedness between
43 local leaders and heads of health facilities were identified as enablers of health service
44 utilization. Geographical factors, in particular location close to borders with mobile
45 populations and migrants, and large populations with sparsely distributed health
46 infrastructure, exacerbated by hilly topography and muddy roads were identified as
47 barriers. Shortages of skilled health providers at the level of district hospitals were
48 cited as contributing to poor maternal health outcomes.
49 Conclusion: There is a need to take into account disparities between districts when
50 allocating staff and financial resources in order to achieve universal coverage for
51 high-quality maternal health services and better outcomes. Local innovations such as
52 the use of SMS and WhatsApp text messages by health workers and financial
53 protection schemes for poor patients improve solidarity and are worth to be scaled up.
54
55 Keywords: Rwanda, maternal health, district performance, disparities, local
56 innovations
57
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58 Introduction
59 Worldwide in 2015, an estimated 303,000 women died due to complications of
60 pregnancy or childbirth [1]. Most of them died because of severe bleeding after
61 childbirth, infections, hypertensive disorders or unsafe abortions. Low and middle
62 income countries account for 99% of these deaths, with sub-Saharan Africa alone
63 accounting for roughly two-thirds (201,000 deaths in 2015) [1]. Maternal mortality is
64 one of the health outcomes that typically show very wide gaps between rich and poor
65 populations [1].
66 The 2014/15 Demographic and health survey (DHS) in Rwanda estimated the
67 maternal mortality ratio (MMR) at 210 deaths per 100,000 live births [2], which is
68 significantly less than the ratios reported in the 2010 DHS (476 per 100,000) and the
69 2000 DHS (1071 per 100,000) [3,4]. Although everything points to significant
70 improvements, deaths related to pregnancy and childbirth are still too common and
71 will need to be reduced further in order to reach the SDG target MMR of 70 per
72 100,000 by the year 2030.
73 Globally, health service coverage rates have increased but many countries are still a
74 long way from universal coverage for most essential reproductive, maternal, newborn
75 and child health (RMNCH) interventions. Furthermore, intra-country variations in
76 service coverage rates are reducing in most countries but the pace is slow. The main
77 impediments to the delivery of high-quality services are a combination of health
78 sector specific and non-health sector drivers [5]. Reliable and timely information is
79 required for effective remedial action at local, regional and national health sector
80 management levels, in order to address intra-country inequalities in maternal health
81 care.
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82 The present study was conducted to obtain an in-depth understanding of the factors
83 that explain variations between districts in maternal health outcomes, including
84 certain emergency obstetric care indicators, and identify the prevailing barriers and
85 enablers to improve maternal health.
86 Materials and Methods
87 Study setting
88 We performed a mixed-methods study combining individual interviews and focus
89 group discussions that were conducted in May 2015 in four districts: Bugesera,
90 Gicumbi, Nyagatare and Rwamagana. These districts had a combined population of
91 around 1.65 million people [6-9; see Table 1].
92 93 Table 1: Demographic and geographic information
Bugesera Gicumbi Nyagatare Rwamagana Province Eastern Northern Eastern Eastern
Area 1,288 km2 829 km2 1,741 km2 682 km2
Population in 2013 361,914 395,606 466,944 313,461
Population density 280/km2 480/km2 243/km2 460/km2
# of health centres 16 24 21 15
# of hospitals 1 1 1 1
Distance to Kigali 35 km 55 km 161 km 60 km
94 95
96 The districts were chosen on the basis of their performance on a set of key maternal
97 health indicators, which included four service coverage, four service process
98 indicators and four health outcomes, according to data reported in 2013 through the
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99 national health formation system (Table 2) [10]. Bugesera district was selected
100 because of its relatively good performance on all three types of indicators. Gicumbi
101 district was chosen because of its good performance on health outcome indicators, but
102 poor performance on service coverage indicators, which seemed rather contradictory.
103 For Rwamanaga it was the reverse: high service coverage rates, but poor health
104 outcome indicators. Nyagatare was included in the study because of its relatively poor
105 overall performance in 2013.
106
107 Table 2: Selected key indicators for the four districts in 2013 and the national 108 average (rank numbers indicated in brackets, <1> indicating the best performing 109 district, and <30> the worst performing district).*
National Bugesera Gicumbi Nyagatare Rwamagana average district district district district (range) Service coverage indicators Pregnant women with 1st antenatal 51% 34% 46% 69% 45% care visit in 1st trimester of <11> <22> <12> <3> (15-84) pregnancy Pregnant women with four or 42% 27% 22% 62% 35% more standard antenatal care visits <9> <20> <24> <3> (9-74) 4.5% 3.1% 9.1% 4.4% 4.5% Deliveries at home <17> <11> <28> <15> (0.6-10.3) Women who delivered and 65% 60% 63% 63% 58% attended at least one postnatal <11> <18> <13> <14> (22-86) care visits Process indicators 2-5 Tetanus toxoid vaccinations 66% 67% 59% 70% 74% received <26> <24> <30> (18> (59-100) High-risk pregnancies detected 3.9% 9.4% 6.1% 6.9% 9.4% during antenatal care visits
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Reported cases of maternal death 7 3 16 5 269 in health facilities <15> <6> <25> <12> (2-32) Reported cases of maternal death 3 2 6 0 48 in community <24> <16> <30> <1> (0-6) 110 * source: National health management information system (references 6-9 and 10) 111
112
113 Data collection techniques and tools
114 All interviews and focus group discussions (FGDs) were conducted in English (by
115 TM) and Kinyarwanda (by a Rwandan research assistant). Interviewees and
116 participants in focus group discussions were allowed to express themselves in
117 Kinyarwanda, English or French. In order to provide structure to the discussions, a
118 topic list was developed, which was used in a flexible manner, with ample room to
119 elaborate on issues that were raised during the interviews.
120 Sixteen FGDs were conducted (four in each district) with community health workers;
121 nurses working at the district hospital (recruited from the maternity, antenatal clinic
122 and neonatology department); the hospital director together with senior nurse
123 managers from health centres (three facilities, one from each of three sectors chosen
124 randomly per district); and the district director of health together with social affairs
125 officers working at sector level (three sectors per district). In Bugesera district, three
126 additional individual key informant interviews were conducted: one with a technical
127 assistant from one of the development partners, the second with the district hospital
128 director and the third with a senior political leader (the vice-mayor in charge of Social
129 Affairs). All interviews were voice-recorded and afterwards transcribed verbatim (in
130 English) by a research assistant.
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131 Data analysis
132 A code manual was compiled inductively, based on the interview topic list with key
133 questions and the verbatim reports of each of the FGD. The actual coding, which
134 involved assigning codes to relevant data segments, was carried out by one of the
135 researchers (MT) with the help of MAXA QDA software (version 2.1.2 for Macs).
136 The coded data were then collated into provisional themes. These were then reviewed
137 by two of the other researchers to verify whether the themes were appropriate in
138 relation to the coded extracts and the entire dataset, before arriving at the final set of
139 themes.
140
141 Results
142 The study results are presented in two parts, of which the first involves common
143 enablers and barriers across the four districts. The second part presents unique factors
144 that explain variations in performance across the four districts.
145 Common enablers and barriers
146 The increased rates of antenatal care attendance and delivery at a health facility
147 observed over the past decade and – at least in part – the relatively low numbers of
148 reported maternal deaths can be attributed partially to the community meetings that
149 are being organized by local leaders. Community health workers (CHWs), whose role
150 is to educate and sensitize communities about health and other social matters, take
151 part in these meetings and actively discuss their experiences in the field. FGD
152 participants argued that concrete actions such as building health centres so as to bring
153 services closer to the population, ensuring emergency referrals through an efficient
154 ambulance system, and promoting enrolment into community health insurance are
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155 being implemented across the country so as to increase geographical and financial
156 access to maternal health services. In addition, the government’s efforts to increase
157 staffing levels, train health workers, motivate them, and establish performance
158 contracts that stipulate zero tolerance of negligence and substandard services were
159 cited as key factors that had a positive influence on service quality.
160
161 Respondents across the four districts demonstrated a high level of interconnectedness
162 between actors within the health system and good teamwork between health workers
163 and social welfare officers, particularly in maternal health. This was illustrated with
164 examples such as: mixed teams of medical doctors, nursing staff and administrators
165 from the district hospital conducting weekly supervision tours to health centres within
166 their district; and the monthly coordination meetings, in which staff give an account
167 of their respective activities and performance. This had enhanced transparency of
168 operations and accountability for underperformance, and led to more solidarity across
169 teams. It was enhanced by what some of the respondents termed as ‘a supportive
170 political environment’.
171
172 In addition, the ‘rétro-information’ received by health centres on patients they had
173 referred to the district hospital was reported to enhance learning and motivate service
174 providers both at the referring health centre and those at the hospital. The use of short
175 message service technology (rapid SMS) through mobile telephones allowed CHWs
176 to easily contact health centre staff (and vice versa), report on key health indicators,
177 respond to emergencies and mobilize life saving medical care. SMS messages were
178 also being used to remind CHWs who among the pregnant women in their respective
179 villages (secteurs) was due for her next antenatal consultation.
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180 “When we send a rapid SMS, we get the response immediately. If you send a message
181 with a request for help when one of your patients has a problem, you get an
182 ambulance very quickly. This very important for us.” (FGD with CHW in Nyagatare
183 district)
184 All the respondents emphasized the importance of having a district governance
185 system in place that is responsive to local needs. Respondents expressed a high level
186 of trust in their local leaders, particularly in maternal health matters. They sometimes
187 created local by-laws to deal with local problems and generally applied zero tolerance
188 to adverse practices, such as long waiting times for patients or absence from work
189 among health workers. Respondents in all four districts described themselves as
190 ‘highly motivated’ to do a good job and achieve targets, not only for maternal health
191 indicators but also for everything else listed in their performance contracts. These
192 contracts comprise personal and collective targets, which are evaluated periodically.
193 For professional health workers, the salary payments are contingent on their
194 performance, which is evaluated twice a year or every quarter.
195
196 There also appeared to be a strong internal motivation and personal drive. This was
197 illustrated by many respondents who emphasized they were keen to serve their
198 communities and claimed to strive for excellence. Some said they would not be
199 satisfied unless the antenatal consultations coverage rate attained 100%. Others were
200 proud not to have had a single case of maternal death in their area for a year or more.
201 One of the community health workers explained her personal motivation:
202 “I feel lucky to be a CHW, because it serves my community, Imana (God) will reward
203 us. I’m proud; it’s not for the money that I’m doing this. Sometimes we sacrifice by
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204 neglecting farming or our own household chores.” (FGD with community health
205 workers in Bugesera district)
206 Three distinct operational barriers for providing good quality services were brought
207 up, which all had a financial dimension: partial performance of the community health
208 insurance scheme (mutuelles de santé), non-functional medical equipment and
209 inadequacy of water supply at hospitals and health centres. Some of the health
210 workers interviewed were of the opinion that the insurance premiums paid by
211 members of the public were barely sufficient to cover the cost of services that health
212 facilities are expected to provide. Patients who do not have health insurance at all put
213 this system further under pressure.
214 “There is a limit to which the cost of services can be covered by the revenues from
215 health insurance premiums. For a delivery, for instance, we use up to ten pairs of
216 gloves; beyond that, the health insurance doesn’t cover the cost.” (FGD with nurses,
217 Rwamagana district.)
218 Unique factors
219 While some of the enablers and barriers to delivering quality services and achieving
220 favourable maternal health outcomes are common across the four districts, some
221 factors are unique and seem to explain some of the variation in performance among
222 districts.
223 The relatively high coverage of maternal health services attendance in Bugesera
224 district can be explained by the solidarity support for poor people to utilise health
225 services through a local scheme that FGD participants termed as “ingobyi”. This
226 scheme can take the form of payment of transport costs or exemption to pay the
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227 annual premium for health insurance. It is illustrated by the following quote from one
228 of the FGD:
229 “The community contributes 300 francs per week;1 if it is a poor family of ten people,
230 we may pay the health insurance premium for six of them. Ingobyi is highly valued in
231 the community and supported by our local leaders.”(FGD with CHW, Bugesera
232 district.)
233
234 The good performance in coverage indicators in Rwamagana district was explained,
235 at least in part, by the interconnectedness between local leaders and the heads of
236 health facilities, which is facilitated by a WhatsApp group. It is being used by nearly
237 50 people to exchange information, coordinate activities and support each other on
238 various topics. The group has been critical in responding to logistical challenges and
239 providing advice to its members.
240
241 The low maternal health service coverage rates in Gicumbi and Nyagatare districts
242 were attributed to their locations, close to Rwanda’s borders with Uganda and
243 Tanzania, respectively. These two districts have large mobile populations and
244 migrants, from Rwanda itself or from nearby countries. According to the respondents,
245 migrants are often not enrolled in health insurance and they are mostly poor people,
246 which limits their access to care. The problem of mobile populations is illustrated by
247 the following quote:
248 “They don’t have permanent settlements; they can be away for three or four weeks
249 before coming back again. This makes follow up very difficult. Some of them don’t
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250 even have insurance. This has increased the number of home deliveries in our
251 district.” (FGD with CHWs in Gicumbi district)
252 The same two districts also have relatively large populations, compared to the other
253 two districts included in the study and most other districts in Rwanda, along with
254 sparsely distributed health infrastructure. This is exacerbated by the hilly topography
255 (in Gicumbi) and the poor network of muddy roads (Gicumbi and Nyagatare). It
256 delays the response to requests for emergency ambulance transport and eventually
257 makes it difficult to reduce the number of home deliveries. This, it was argued, limits
258 access to maternal health services.
259 “Our district is the biggest and we have only one district hospital. We receive
260 pregnant mothers who have walked long distances; many cannot afford the cost of
261 transport by motor bike.” (FGD with CHWs, Gicumbi district)
262 The size and composition of the health workforce is not adequate compared to the
263 population size and the disease profile. The shortage of clinical specialists at district
264 hospitals was a cause for concern, especially in Nyagatare district which is relatively
265 far away from referral hospitals in the capital Kigali. This also happens to be the
266 district with the largest population.
267 Respondents in Gicumbi and Rwamagana indicated that having a nursing school gives
268 them extra nurses and midwives who come for practice sessions. They seem to be a
269 bit better off in terms of workload of their nursing staff, as they have the advantage of
270 interns who complement their regular staffing levels. Medical equipment was reported
271 to be in short supply in some of the district hospitals and health centres. In
272 Rwamanaga district, several health facilities experienced shortages of running water,
273 which some respondents considered a health hazard.
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274
275 Discussion
276 This multifaceted qualitative study has identified factors that explain variations
277 between districts in maternal health outcomes, as well as enablers and barriers to
278 improve maternal health. The interconnectedness between local leaders and head of
279 health facilities and the solidarity support for poor people (in one of the districts) were
280 identified as enablers of health service utilisation. Having large mobile populations,
281 high numbers of migrants, and geographical remoteness of sparsely distributed health
282 infrastructure, exacerbated by hilly topography and muddy roads, were identified as
283 barriers. Shortages of health providers skilled at the level of district hospitals were
284 cited as contributors to poor outcomes.
285
286 Similar to most other low- and middle-income countries, Rwanda has shaped its
287 national health system according to the framework promulgated by WHO, which is
288 composed of six building blocks [11]. While most of these building blocks are
289 relatively easy to conceptualize, it is not always easy to operationalise and make them
290 work at all levels of the health system. An earlier study has shown that district health
291 managers in Rwanda hold rather strong opinions about what works well in the health
292 sector and what actually makes it work: they considered the dense network of
293 community health workers and the health insurance system as factors that have
294 contributed most to Rwanda’s good achievements [12]. They also indicated the
295 importance of good managerial skills and the culture of continuous monitoring of key
296 indicators. The present study confirms this.
297
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298 It is uncontested that good governance and leadership are key ingredients of a well
299 functioning health system [13,14]. It includes for instance clarity of direction at the
300 national level, strategic planning, effective oversight and accountability for
301 performance. The present study has shown that this also applies to the local level.
302 FGD participants demonstrated strong commitment to achieving national goals and
303 adhering to national strategies, embodying a great deal of purpose and trust in the
304 activities that they and their colleagues undertake to promote health in their respective
305 districts. They also expressed solidarity with people in society who do not have easy
306 access to health services, and emphasized the importance of intersectoral
307 collaboration and good communication with local leaders. This is what one could
308 refer to as ‘responsiveness’. It is this readiness to respond to local needs and to
309 indications that certain targets might not be met without some extra effort, which
310 might explain the overall increase in health service utilization in Rwanda, observed
311 for already more than a decade [2].
312
313 Without a functional health information system, which relies on the timely provision
314 and close monitoring of a selected number of key health indicators, the district-level
315 stakeholders interviewed in this study would not have been in a position to display the
316 vigilance that transpired in the interviews and FGD. The provision of mobile phones
317 to community health workers and the use of rapid SMS to promote antenatal
318 consultations has motivated community health workers to do what is expected of
319 them and it has increased their self-esteem [15].
320
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321 Adequate health care financing, including funding of all the necessary support
322 services, such as supervision, supply chain management and transportation, are
323 widely considered essential for a health system to thrive [16]. The present study has
324 brought out some challenges at the district level to provide adequate coverage to
325 immigrants and internal migrants who in many cases do not have medical insurance.
326 This explains the low coverage of use of maternal health services in Nyagatare and
327 Gicumbi districts, at least in part. One district (Bugesera) has its own local social
328 solidarity mechanism in place in an effort to ensure equitable access, which has
329 contributed to the high maternal health service coverage rates.
330
331 Health workforce adequacy is an issue in Rwanda, as the number of staff with clinical
332 expertise does not always seem to match the requirements [17]. In the case of
333 Nyagatare district, some interviewees and FGD participants did mention that the
334 district was much less popular among health workers than other districts due to its
335 geographical location (far from Kigali, with few opportunities for leisure) compared
336 to the other districts included in the study. The fact that two of the other district
337 hospitals have nursing schools attached to them – which is also the case for Nyagatare
338 district hospital – was cited as a factor that helped alleviate the high workload of
339 nurses and midwives.
340
341 The promotion of maternal and child health was seen as a joint responsibility of
342 several Government departments and this has translated into very close, almost day-
343 to-day working relations between civil servants, community health workers and
344 village/sector leaders. The critical role of frontline workers as intermediates between
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345 the community and the formal health sector has recently also been confirmed in a
346 study that explored how relationships influence performance in Malawi [18]. In
347 another recent study on health district productivity in Cambodia, Ensor et al.
348 considered the impact of health policy changes on health sector efficiency. Higher
349 efficiency was associated with more densely populated areas and with the presence of
350 health equity funds [19]. While the former may not apply to Rwanda – as virtually the
351 entire country is densely populated – the latter may hold as well.
352
353 A limitation of the study is that it did not look in an in-depth manner at quality of care
354 issues. Interviewees did acknowledge that poor quality of care may impact on
355 patients’ demand for services, but they did so mostly by referring to circumstances
356 beyond their own control that affected the quality of care in a negative manner.
357 Neither did the study try to assess whether health workers had the right technical
358 background to provide quality maternal health services. It is worth noting though, that
359 Rwanda does have a mechanism in place to conduct maternal death audits, and the
360 country is currently in the process of institutionalizing ‘near-miss’ audits and
361 confidential enquiries into maternal deaths [20]. Some studies recently reported
362 rather high rates of postpartum haemorrhage and infection, as causes of maternal near
363 miss and death [21,22]. This suggests there is a need for improvement of quality of
364 care at the level of district hospitals, where the majority of deliveries occur.
365 Conclusions
366 Disparities between districts in maternal health outcomes are partly attributed to
367 environmental factors, such as topography, population pressure and migration. The
368 two dimensions over which district managers have control are: (1) the functionality of
369 the district health system, in particular local leadership, health information, funding of
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370 support services and health workforce issues; and (2) the extent to which supportive
371 intersectoral activities are being undertaken. There is a need to take into account
372 disparities between districts when allocating staff and financial resources in order to
373 achieve universal coverage for high-quality maternal health services and better
374 outcomes. Further research would be useful to explore the potential of scaling up
375 successful local initiatives, such as the use of SMS and WhatsApp group messages
376 and local financial protection schemes.
377
378
379
380 DECLARATION
381
382 Ethics approval and consent to participate
383 The protocol for this study was approved both by the National Health Research
384 Committee (NHRC/2015/PROT/006) and the Rwanda National Ethics Committee
385 (105/RNEC/2015). Informed consent was obtained from all interviewees.
386
387
388 Competing interests
389 The authors declare that they have no competing interests.
390
391 Funding
392 This work was supported by the Netherlands Organisation for Scientific Research
393 (NWO/WOTRO), which funded the Maternal Health and Health Systems in South
394 Africa and Rwanda research project (MHSAR) as part of a larger research programme
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395 entitled “Global Health Policy and Health Systems”, and a Share-Net International
396 small grant.
397
398 Authors’ contributions
399 FS contributed to the study design, data collection , data analysis, interpretation and
400 writing of the manuscript. TM led the data collection and performed the initial
401 analysis. KvdV and JvD contributed to the study design and writing of the
402 manuscript. LB provided critical intellectual input to the study design, participated in
403 the field work and contributed to data analysis and interpretation and to the writing of
404 the manuscript.
405 Acknowledgements
406 The authors thank the administration and staff of Bugesera, Gicumbi, Nyagatare and
407 Rwamagana districts, especially those who participated in the interviews and focus
408 group discussions : community health workers, nurses working at the district hospital
409 (maternity, antenatal clinic, neonatology department), senior nurse managers from
410 health centres , district directors of health , district hospital directors, social affairs
411 officers working at sector level, and the technical assistant and vice-mayor in charge
412 of Social Affairs in Bugesera district. Special thanks go out to Ms Malka Karangwa
413 and Ms Maartje Kletter for their participation in data collection.
414
18 bioRxiv preprint doi: https://doi.org/10.1101/516112; this version posted January 9, 2019. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted bioRxiv a license to display the preprint in perpetuity. It is made available under aCC-BY 4.0 International license.
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