How Rwanda brought its healthcare system back to life

90% of the people in the African nation have health insurance, and life expectancy has increased by 19 years since 2000, says Agnes Binagwaho

How Rwanda brought its healthcare system back to life

IMAGINE a country where 90% of the population is covered by health insurance, 90% of people with HIV are on a drug regime, and 93% of children are vaccinated against common communicable diseases, including HPV.

Where would you guess this enchanted land of medical equity is? One of the Scandinavian countries? Costa Rica? Narnia?

Try Africa: Rwanda, to be precise.

In my native country, healthcare is a right guaranteed for all, not a privilege reserved for the rich and powerful. Rwanda remains poor, but, over the past 15 years, its healthcare advances have gained global attention, for good reason.

In 2000, life expectancy at birth was just 48 years; today, it’s 67. International aid has helped, but our achievements have come primarily from other, non-financial innovations.

For starters, Rwanda has established a collaborative, cluster approach to governance that allows us to achieve more with the same amount of funding.

Moreover, our civil servants embrace problem-solving, finding localised solutions to human development challenges, such as ensuring food security and adequate supplies of clean water and housing.

But the most important reason for our dramatic healthcare gains has been the national equity agenda, which sets targets for supporting the needy and tracks progress towards them.

Rwanda has decreased the percentage of people living in extreme poverty from 40% of the population, in 2000, to 16.3%, in 2015. Aside from the obvious benefits, these gains matter because, as Unicef recently noted, a country’s potential return on investment in social services for children is two times greater when the benefits reach the most vulnerable.

Rwanda has achieved so much so quickly because we are enjoying higher rates of return by investing in the poorest.

In working toward health equity, Rwanda has made accessibility a priority. As of 2016, nine out of 10 Rwandans were enrolled in one of the country’s health insurance programmes.

The majority of the population is enrolled in the Community-Based Health Insurance (CBHI) scheme, which has increased access to healthcare, for Rwanda’s most vulnerable citizens, by waiving fees.

As a result, the reach of healthcare coverage in Rwanda is high by global standards — all the more remarkable for a country that suffered the horrors of genocide a generation ago.

Consider the situation in the US: While the rate of uninsured Americans dropped precipitously under the 2010 Affordable Care Act, the insured face rapid increases in premiums and out-of-pocket expenses.

Perhaps the US should adopt a CBHI-type programme to reduce further the number of Americans facing financial barriers to medical care.

Rwanda has made healthcare accessible by deploying community health workers (CHWs) to the country’s 15,000 villages. These local practitioners serve as the gatekeepers to a system that has reduced waiting times and financial burdens by treating patients directly, and often at their homes.

The US could also benefit from a CHW programme. The US is brimming with educated young people who, as CHWs, could bridge the gap between medical facilities and patients, thereby improving American social capital and health outcomes.

Such programmes not only broaden access to healthcare; they also lower overall costs by reducing unnecessary hospitalisations.

Such programmes are transferable. Starting in 1997, Brigham and Women’s Hospital supported the HIV+ community of Boston through the Prevention and Access to Care and Treatment programme.

That initiative was based on the CHW model implemented in rural Haiti by Partners In Health — a non-profit healthcare organisation that integrates CHWs into primary care and mental health.

As a result of that initiative, the government insurer, Medicaid, spent less money on hospital stays, and in-patient expenditures fell by 62%. Other US communities could, and should, incorporate similar models into their treatment programmes for chronic conditions.

Innovation is what kick-started Rwanda’s healthcare revival, and progressive thinking is what drives it forward today. For example, health centres established throughout the country provide vaccinations and treat illnesses that village-level CHWs cannot, and have extended obstetrics services to the majority of Rwandan women.

Broadening access further, each district in Rwanda has one hospital, and each region in the country has a referral or teaching hospital with specialists to handle more difficult cases.

While some hospitals still suffer from staff shortages, the government has sought to patch these holes by employing faculty from 20 US institutions to assist in training our clinical specialists.

In just over two decades, thanks to homegrown solutions and international collaboration, Rwanda has dramatically reduced the burden of disease on its people and economy.

As we look forward, our goal is to educate tomorrow’s leaders to build on the equitable healthcare system that we have created.

This is the mission of the University of Global Health Equity, a new university based in rural Rwanda that has made fairness, collaboration, and innovation its guiding principles.

As a Rwandan doctor who contributed to building my country’s healthcare system from its infancy, I am proud of what we have accomplished in so short a time.

It wasn’t magic; it was a formula. Through continued global co-operation, other countries, including developed ones, can learn to apply it.

Agnes Binagwaho, a former minister of health of Rwanda, is vice-chancellor of the University of Global Health Equity. She is a 2017 inductee into the US National Academy of Medicine.

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