Eliminating Health Inequities in Rwanda:

Determination to Defy the Odds and Achieve the Seemingly Impossible

Women soothing their children after being vaccinated at a health center in Rwanda in September 2010. Source: Agence France-Presse — Getty Images.

Twenty-two years ago, Rwanda experienced the worst tragedy of the 20th century: the 1994 genocide. Life became a luxury. The country plunged into an abyss and there was no other way to go except up. In the aftermath of the genocide, the economy of the country was reduced to rubble. With most services and facilities non-existent, rebuilding was a priority. Theorists, historians and economists predicted that it would take more than four decades for the country to recover.

With limited resources, Rwanda defied all odds. Like the proverbial Phoenix, it rose from the ashes and proved scholars, economists, and historians wrong. In less than two decades, Rwanda achieved tremendous development in all sectors, especially the health sector.

Eliminating Health Inequities

Rwanda has made significant strides towards eliminating geographic and financial hindrances to access to health, including through the implementation of a community-based health insurance (CBHI) scheme, commonly known as Mutuelle de Santé. Mutuelle de Santé, established in 2004, ensures that every Rwandan can access quality health care. The program is currently being reinforced to ensure increased subscription by reforming the contribution system so that all subscribers can pay their premiums on a sliding scale based on their income. For those in the lowest income category, the government and its various partners fully meet their health insurance premiums each year.

In an additional effort to bridge the health care access gap created by financial constraints, the government of Rwanda has made a move to make subscription to a health insurance scheme mandatory for every Rwandan. While this draft law is still under parliament review, all Rwandans must now subscribe to some kind of health insurance or risk very high medical costs.

To address inequalities brought about by geographical barriers to access to health care, the government of Rwanda has scaled up the construction of health facilities in all parts of the country.

The health care referral system, which ensures that there is a health facility at every administrative level of the national structure, is being implemented at the national, district, sector, and cell levels. The government has ambitiously pursued the establishment of a strong national referral system which ensures that Rwandans at all administrative levels have access to health care with the capacity to deal with any and all afflictions. Under this referral system, five national referral hospitals with the capacity to deal with more advanced healthcare procedures have been set up and are continuously being equipped with human and capital resources.

At the district level, there is at least one hospital in each of Rwanda’s 30 districts that handles the health care needs of that particular district. Similarly, across all 416 sectors of Rwanda, at least one fully staffed health centre (centre de santé) is available. At the cell level, the government is in the process of setting up health posts (poste de santé) to ensure close proximity of health care services to people in this second-to-smallest administration level in Rwanda.

At the lowest administrative unit in Rwanda’s decentralized system, the village (umuduguddu), the Ministry of Health and its partners provides access to health care by employing at least three health advisors. Each of the three personnel have skills in different health issues (for instance maternal and child health) and all have the necessary equipment to offer health support to the citizens at this level of national administration.

The government of Rwanda is also working on improving the health practitioners’ skills through training. Currently all general medicine certified doctors are being training and supported to attain specialization in at least one particular medical care field, and nurses are also being trained to improve the quality of care.

The Ministry of Health is simultaneously implementing a program called performance based financing, which allocates bonus pay to health practitioners based on the quantity and quality of work done. Because of this approach, medical practitioners are increasingly taking the lead in encouraging patients to visit the hospital, particularly in the case of maternal health. Practitioners are starting to understand that the more patients they serve and the better the the quality of services they offer, the higher their performance based financing bonus will be.

This system has two benefits: it can attract college students to study medical professions to increase the number of doctors and health personnel in the country, and it can be an incentive for medical personnel to consistently provide quality care to patients.

According to the World Health Organization (WHO), Rwanda’s maternal mortality ratio decreased by 77 percent between 2000 and 2013. Rwanda’s Ministry of Health reported that under five child mortality was reduced by more than 70 percent. The National Institute of Statistics of Rwanda found that life expectancy increased from 28.26 in 1994 to 66.7 in 2015.

These humble achievements indicate that Rwanda is on the right path to eliminating health inequities, but more efforts are needed to maintain these gains and continue to improve. Rwanda’s success proves that no matter the odds, determination can change a situation: from a state where life was considered a luxury, to a state where health is an unshakable and enjoyed human right. With determination, health inequities can be eliminated.