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IN RWANDA, HEALTH CARE COVERAGE THAT ELUDES THE U.S.

Monday, 9th of July 2012

• IN RWANDA, HEALTH CARE COVERAGE THAT ELUDES THE U.S.

New York Times, By TINA ROSENBERG

Last week’s Supreme Court decision upholding of the constitutionality of President Obama’s health care law moves the United States closer to the goal of health coverage for all. All other developed countries have it. But so do somedeveloping nations — Brazil, Thailand, Chile. These countries are mostly middle income. But one country on the list is among the poorest of the poor: Rwanda.

The point is not that Americans should envy Rwanda’s health system — far from it. But Rwanda’s experience illustrates the value of universal health insurance.  “Its health gains in the last decade are among the most dramatic the world has seen in the last 50 years,” said Peter Drobac, the director in Rwanda for the Boston-based Partners in Health, which works extensively with the Rwandan health system.

It couldn’t have happened without health insurance.

 

Shannon Jensen/Agence France-Presse — Getty ImagesWomen soothed their children after being vaccinated at a health center in Rwanda in September 2010.

Rwanda is known, of course, for the 1994 genocide that killed 800,000 Tutsi and moderate Hutu. Since 1994, the country has been ruled by Paul Kagame, at first as de facto leader and, since 2000, as president.  Kagame runs a repressive regime that equates criticism with treason; opposition journalists or politicians in Rwanda have disappeared or died mysteriously.

But Kagame is also widely admired as the most effective leader in Africa. A country in ashes 18 years ago is now safe and clean. It is one of the least corrupt countries in Africa. Per capita income has tripled — although the fact that it is now only $550 a year tells you how destitute Rwanda was.

Its most impressive gains, however, have been in health. AIDS has been cutting life expectancies in Africa and is widespread in Rwanda. Yet life expectancy at birth in Rwanda has increased from 48 to 58 — in the last 10 years. Deaths of children under 5 have dropped by half in five years; malaria deaths have dropped by roughly two-thirds. “Of all countries in Africa Rwanda is probably getting the closest to having health for all, health access for all,” said Josh Ruxin, a longtime resident of Rwanda who is the founder of the Access Project, a Rwandan-run health program.

One key reason that Rwandans are so much healthier today is the spread of health insurance.  In 1999, Rwanda’s health facilities sat unused, as the vast majority of people couldn’t afford them.   In response, the Health Ministry began a pilot project of health insurance in three districts.   In 2004, the program began to spread across the nation.   Now health insurance — called Mutuelle de Santé — is nearly universal. Andrew Makaka, who manages the health financing unit at the Ministry of Health, said that only 4 percent of Rwandans are uninsured. 

Mutuelle is a community system — premiums go into a local risk pool and are administered by communities. Until last year, Mutuelle’s premiums were about two dollars a year. This system turned out to be untenable — even two dollars a year was too much for a lot of people. (If you are a rural farmer with an income of some $150 a year, you have to spend every penny on food.)

Last year Mutuelle adopted a sliding scale.  For the wealthiest, premiums essentially quadrupled, to about $8 a year. Each visit to a clinic has a co-pay of about 33 cents. If you need to go to the hospital, you pay a tenth of your hospital bill.

Marc Hofer for The New York TimesA medical technician took a blood sample from a patient at a hospital outside of Kigali, Rwanda, in July 2010.

But now the poorest — as judged by their communities — pay nothing. The Health Ministry says that the poorest 25 percent of Rwandans get free care. (There is great pressure to over-report success in Rwanda, so this statistic, like others from the ministry, may be slightly exaggerated.)

Mutuelle is one of many changes in Rwanda’s health system. A decade ago local clinics were routinely padlocked — patients had to go search out nurses in the village. Nor was there equipment or medicine. A largely rural country of more than eight million people had only about 500 doctors, and almost all were in cities.

Now there is a well-functioning national network of thousands of community health workers at the village level. There are hundreds of clinics, all with basic equipment and a full cupboard of essential medicines. Each of Rwanda’s 30 districts has a hospital, with at minimum 15 doctors, offering basic surgical services. In three very poor districts, Partners in Health has worked with the government to reconstruct the health system from the ground up, including building three hospitals. The newest, Butaro Hospital, has been called the best in central Africa.

Partners in Health has gradually moved from delivering health services to supporting the public health system as it gets stronger. “They don’t need our help figuring out how to take care of malaria and TB,” said Drobac. “We can focus on gaps like neonatology.”

Partners in Health is also introducing innovations — it is starting Rwanda’s first cancer center — and training, helping to coordinate a program that brings nurses and specialists from 18 American universities to Rwanda to train doctors and nurses.

These improvements have lifted Rwanda’s health system well above what most countries in Africa have. But it is the Mutuelle system that allows this care to reach all Rwandans, instead of a small percentage.

A measure of Mutuelle’s success is a tremendous increase in the use of health care facilities. Drobac said that 80 percent of people in need of AIDS treatment are getting it — a figure in Africa rivaled only by Botswana, which is 20 times richer than Rwanda. Hospital utilization rates have tripled, said Makaka. Five years ago, when giving birth in a health center cost around $25, only 20 percent of women did so. Now that it is 33 cents, 70 percent do — a big reason that deaths of mothers and children have dropped so precipitously.

Malaria — a major killer of children — is also now treated. “People were waiting for a long time to go and access care because it was very expensive,” said Makaka. A clinic visit before was 5,000 francs — about $8.30. “By the time they accessed care malaria became so severe some lost their lives or became disabled.” Today, malaria is usually diagnosed by a community health worker. She can give the first dose of an effective medicine right away, then send the patient to a health clinic for a visit that will cost a maximum of 33 cents.

The increase in clients and the payments from Mutuelle they bring has transformed hospitals. Without income, hospitals couldn’t pay doctors or buy equipment. Now that hospitals can pay, doctors and nurses are moving from cities to the countryside. “Before there was a marked concentration in cities,” said Makaka. “Now there’s equitable distribution across the nation.”

In most poor countries — and in the United States — health disasters are a leading cause of a family’s decline into poverty, but not for Rwandans. “It gives relief to people knowing that if you get sick, you don’t need to have a lot of money,” said Dr. Agnes Binagwaho, Rwanda’s health minister. “It gives you psychological stability so you can concentrate on something else. The money can be used for other things — this is very important in trying to stimulate economic development.”

Makaka said that the big challenge for Mutuelle is to begin paying for itself — currently, premiums cover only about 45 percent of costs. The rest of the money is from the government and donors, including the Global Fund to Fight AIDS, Tuberculosis and Malaria and the United States anti-AIDS program Pepfar. The need to cover costs was the reason for the sudden rise in premiums last year, which drew widespread outrage. Makaka said that as people utilize more preventive care, health bills are dropping — it costs much less to cure malaria with pills early in the illness than to have the patient die in a hospital.

But it seems unrealistic to think that the system will ever be sustainable. Rwandans may make only $550 a year, but they have the same health problems as people who make a hundred times as much. Ruxin said hospitals are seeing increasing rates of diabetes and hypertension — causes of death commonly associated with wealthy countries. And as the health system becomes more sophisticated, it will treat more and more kinds of illnesses.

Rwanda, at least, has used donors’ money wisely, employing it to build a complete health system — and to extend that system to all its citizens. “You can bring on all the diagnostic services, new technologies and specialties,” said Drobac. “But if those things can’t reach people in need, what’s the point?”

We could ask the same thing in the United States.  Rwanda, starting from nothing, decided to build a health system that includes everyone.  And it found economic value, alongside human value, in doing so.  Now we can get started.

 

• TOWARDS UNIVERSAL HEALTH COVERAGE: EVALUATION OF RWANDA’S MUTUELLES

Abstract below; full text is at http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0039282

Background

Mutuelles is a community-based health insurance program, established since 1999 by the Government of Rwanda as a key component of the national health strategy on providing universal health care. The objective of the study was to evaluate the impact of Mutuelles on achieving universal coverage of medical services and financial risk protection in its first eight years of implementation.

Methods and Findings

We conducted a quantitative impact evaluation of Mutuelles between 2000 and 2008 using nationally-representative surveys. At the national and provincial levels, we traced the evolution of Mutuelles coverage and its impact on child and maternal care coverage from 2000 to 2008, as well as household catastrophic health payments from 2000 to 2006. At the individual level, we investigated the impact of Mutuelles' coverage on enrollees' medical care utilization using logistic regression. We focused on three target populations: the general population, under-five children, and women with delivery. At the household level, we used logistic regression to study the relationship between Mutuelles coverage and the probability of incurring catastrophic health spending. The main limitation was that due to insufficient data, we are not able to study the impact of Mutuelles on health outcomes, such as child and maternal mortalities, directly.

The findings show that Mutuelles improved medical care utilization and protected households from catastrophic health spending. Among Mutuelles enrollees, those in the poorest expenditure quintile had a significantly lower rate of utilization and higher rate of catastrophic health spending. The findings are robust to various estimation methods and datasets.

Conclusions

Rwanda's experience suggests that community-based health insurance schemes can be effective tools for achieving universal health coverage even in the poorest settings. We suggest a future study on how eliminating Mutuelles copayments for the poorest will improve their healthcare utilization, lower their catastrophic health spending, and affect the finances of health care providers.