A Change in National Psyche
What the US can Learn about Health Access from Denmark and Rwanda
Every time I see a New York Times alert about the Affordable Care Act (ACA) light up my phone screen, I feel anxiety tighten in my chest. Since the election, we have been bombarded with mixed messaging as to the state of the ACA — from immediate repeal and replace, to repeal and hold, to a mysterious plan awaiting us all at the end of this year, to keeping “Obamacare” as is.
I have been a strong supporter of ACA from the start. I do not agree with all of the pieces of the legislation, and I do not think it is perfect, but I adamantly believe in equitable health access for all. The ACA has achieved this beyond any legislation passed in the U.S. And, as President Obama stated, I am willing to support and fight for an alternative plan that expands access and lowers the price of care beyond what ACA has been able to achieve. However, leaving lives in limbo through the threat of a repeal with no strong alternative plan in place is playing with fire. Lawmakers cannot forget that through ACA, we have been able to achieve the lowest uninsured rates that the U.S. has ever seen. Further, the law has sparked a mentality change in the U.S. psyche. As a nation, we no longer see health insurance as a pure economic good; we are starting to embrace access to affordable coverage as a necessity for all citizens.
Health system successes from two unique countries can provide insight in this time of transition in the U.S. Denmark and Rwanda, two countries where I’ve worked and studied public health, have very different reputations. Denmark is known as the happiest country in the world, and Rwanda as a country that has thrived after suffering a horrific genocide. On the surface, Rwanda and Denmark could not be more different. Rwanda is a developing nation while Denmark is one of the wealthiest nations in the world. Rwanda’s population of roughly 11 million is double that of Denmark’s. The life expectancy in Denmark is 80 years from the time of birth, while the life expectancy in Rwanda is 61 for males and 71 for females.
The list can go on and on. However, after spending time in both of these countries and more fully understanding the cultural undertones and beliefs that define policies in each nation, I have seen similarities in perceptions around health services in Denmark and Rwanda. Namely, I have witnessed how both of these nations are focused on ensuring equitable access to care. Although neither have achieved this goal completely, both Denmark and Rwanda face their unique health challenges through the lens of quality and equity.
Through this lens, both Denmark and Rwanda have recognized the importance of providing affordable coverage and the importance of focusing on primary care delivery. The Danish healthcare system provides free services to all of its citizens. With the goal of providing the best quality of care at the lowest cost, the Danish system seeks to utilize primary care as a means of ensuring appropriate basic care to all patients. General practitioners act as gatekeepers for the healthcare system and, therefore, regulate a patient’s access to the rest of the system to reduce costly secondary and tertiary visits. This system is very popular within Denmark, and patient satisfaction far exceeds patient satisfaction in the U.S. Further, despite the fact that Denmark provides universal coverage, it spends ~11% of GDP on healthcare compared to the ~18% spent in the U.S.
In 1999, Rwanda launched its pilot national health insurance program, Mutuelles de Santé. Today, 91% of Rwandans have health insurance, which is the highest percent to be covered in Africa. Leveraging community health workers (CHWs) to provide primary care in hard to reach areas, refer people to clinics when needed, and educate people on the benefits of having health insurance, Rwanda has made large strides in improving health outcomes. For example, between 2000 and 2011, the mortality rate for tuberculosis fell from 48 per 100,000 cases to 12. Recognizing the importance of affordable coverage and implementing a system that allows people to access primary care has enabled successes within Rwanda.
The U.S. is very different from Denmark and Rwanda. No single practice that has improved health outcomes or expanded healthcare coverage in those countries can be identically replicated in the U.S. However, an overt focus on providing quality and equitable care is a lesson that the U.S. can take away from these nations’ successes. The mentality shift is already rippling through the U.S. population, as constituents are now demanding affordable and equitable coverage as a necessity: 64% of consumers want insurance to be more affordable and 62% think lowering health services costs should be a priority. I truly hope that we can shift away from the polarizing “he said, she said,” Republican vs. Democrat debate to a debate that starts from a core belief in health as a human right. Only then can we move forward to achieve equitable, high-quality, and affordable care in the U.S.
Julia Fenelon is a Global Health Corps fellow at the Clinton Health Access Initiative in Rwanda.
