September 14, 2017

Universal Health Coverage: How Rwanda is moving forward with healthcare for all

Here is a scenario of two girls. The first girl has access—to a smartphone, strong education systems, and routine health exams— and thus, access to the potential of a healthy life. The second girl lives in a slum and is lucky to have one good meal per day. She does not have access to proper sanitation, misses school when she menstruates, and has a very high chance of becoming pregnant before she finishes secondary school. She was born into a scenario which has isolated her from choice and control over her personal well-being.

This is how Dr. Matshidiso Moeti, World Health Organization (WHO) Regional Director for Africa, closed her opening speech at the first WHO Africa Health Forum in June 2017.  This juxtaposition is a powerful portrayal of how path dependence can determine health accessibility, whether you are urban, rural, rich, or poor. The health inequity that exists today and Moeti’s words serve to galvanize action among thought leaders and policymakers to ensure true universal health coverage – one that leaves no one behind.

What does Universal Health Coverage really mean?  
According to the WHO, Universal Health Coverage (UHC) means that “all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship.”

How do we make UHC a reality? Although UHC is fantastic in theory, it’s difficult to accomplish. At the June forum, there were several key messages expressed by high-level officials on how key stakeholders can work together to achieve UHC. These include:

  1. Invest now, not later
    Investing now, means investing resources, money, and most of all, time.  West Africa’s recent Ebola outbreak revealed how vulnerabilities in health systems can drastically compound global health crises and how up-front investments in health programming can be much more cost-effective than treating issues as they arise.  Informed by past experiences, leaders suggest that if we invest time, resources, and money now, we can help fragile systems become strong, sustainable, and capable of withstanding the next epidemic.
  2. Find complementary partners
    Public-private partnerships play a powerful role in achieving universal healthcare. Private sector actors can augment programming set by policymakers with structured, rigorous approaches to ensuring efficient and effective spending.
  3. Seek new cost-effective solutions
    Resources are limited and valuable.  As such, it is important to find targeted solutions that are the most effective and appropriate for local contexts, not simply because they are “new and shiny.” Innovation is very important but evaluation of cost-effectiveness and added value of new solutions is necessary.
  4. Build capacity at the community level
    If not specified otherwise, there is a possibility that national and international funding may work toward broad development and miss intended beneficiaries in the process.  Admittedly, broad development is good. However, it may take longer for its impact to be felt by suffering individuals today.  Leaders at the WHO forum proposed that funding be decentralized so that it reaches the community level and directly impacts those who may need it most at the time they need it.

RWANDA: A Case Study

If we take a closer look at Rwanda, a small, landlocked country in East Africa, we can see how some of these key messages have already been put to practice. Rwanda has significantly advanced universal health coverage with its community-based health insurance program (or CBHI), Mutuelles de Sante (Mutual Health)

Overall, Rwanda has seen incredible uptake in its insurance program; coverage has expanded from less than 7 percent of the CBHI target population in 2003 to 74 percent in 2013.  In this program, funds are used to help subsidize care for the citizens and clinic functionality.  This allows citizens to access care and pay for services based on a tiered premium system according to socioeconomic standing.

This type of coverage is further enabled by the Rwandan governance structures put in place. The central government agencies are responsible for policy formulation and regulation while the district is responsible for local planning and coordination of the delivery of public services. As such, funding for health care delivery and health systems is decentralized at the district level to ensure targeted programming that fits the needs of each individual community.

Health centers are given financial autonomy to plan activities according to their needs and the needs of the community, which is beneficial in increasing access to care, yet creates a significant financial burden. In Rwanda, 85% of the population seeks health services at the public, primary health center level so health centers support many citizens.  And yet, while supporting a significant portion of the population, health centers sometimes wait several months to be reimbursed for all services rendered during patient visits. In the meantime, they are incredibly resourceful in delivering quality care with the funds they have.

Over the past two months, I have been working for a Rwandan NGO called Health Builders that works with local governments to build strong primary health care systems and increase health center management capacity.  Most of the nation’s primary health care centers are run by nurses or clinicians who have the medical background necessary to care for its patients but not necessarily the administrative skills to manage operations efficiently and cost-effectively.  Because these centers already operate with scarce resources, Health Builders recognizes that strong health administration skills, including budgeting and financial planning, are crucial to the delivery of quality care.

My task has been to create an Excel-based financial analysis tool for health centers to help health center administrators better manage their assets, think more strategically about how they spend those assets, and operate more efficiently.  I have worked closely with the health centers to understand their daily challenges with a human-centered design approach and I have been able to develop a tool tailored to their needs.

Over the next month, I will continue to work with the Health Builders’ team and the health centers they serve to make this a sustainable, useful endeavor. This internship has truly demonstrated the inherent interdisciplinary nature of development and reaffirms why I find myself at Duke University pursuing an MBA and a certificate in Health Sector Management.

With the inextricable link between health and development, strengthening the country’s health infrastructure is an incredibly important step toward phased efforts to recovery and rebuilding.  As the development community continues to strive for full universal healthcare, we can take away many lessons from Rwanda to ensure that the two girls in Dr. Moeti’s example have equal opportunity and access to care around the world.