The Rwandan Experience
Strengthening Primary Healthcare & Expanding Access
Three decades ago, members of the World Health Organization (WHO) led a shift in thinking about primary healthcare (PHC). The WHO defines PHC as essential healthcare based on scientifically sound and socially acceptable methods and technology. To make universal healthcare accessible to all people, PHC systems must be strengthened. Political crises, resource constraints, inadequate infrastructure, and other challenges make access to PHC a faraway dream for many communities in the developing world.
Rwanda, the country where I have spent most of my life, is no stranger to these challenges. The nation experienced a serious political crisis with the 1994 genocide, a tragedy that resulted in the loss of about one million human lives. This catastrophic conflict destroyed much of Rwanda’s socioeconomic and health infrastructure. The loss of the majority of the country’s health practitioners coupled with deep poverty combined to severely hamper access to basic healthcare services in the years immediately following the genocide.
Despite lingering challenges in some parts of the country, Rwanda has made remarkable improvements in its health sector, particularly among the most vulnerable, over the last couple decades.
Despite lingering challenges in some parts of the country, Rwanda has made remarkable improvements in its health sector, particularly among the most vulnerable, over the last couple decades. The government has invested significantly in strengthening PHC systems through decentralization of services from central administrative structures into communities. In addition to decentralizing the health system, the government and its partners in the civic sector have also empowered community members to participate in designing the best health solutions for their needs.
As a result, Rwanda’s healthcare system is now set up to efficiently deliver care for many of the country’s citizens. Rwanda is making steady progress on solving the two major challenges that remain: 1) rectifying the shortage of doctors and medical personnel to deliver quality healthcare at the PHC level, and 2) expanding access to PHC to all Rwandans.
To tackle this problem at the primary healthcare level, community health workers are being trained in more advanced healthcare service delivery techniques and procedures including delivery and maternal and newborn care.
While more medical schools and universities have been established to train health practitioners in Rwanda since 1994, most trained personnel are assigned to secondary and tertiary level facilities. To tackle the problem of a lack of trained personnel at the PHC level, Rwanda is implementing creative solutions. Community health workers are now being trained in more advanced healthcare techniques and procedures including delivery and maternal and newborn care.
Another key intervention has been the rollout of a community-based health insurance scheme locally called “Mutuelle de Santé.” This nonprofit scheme provides a voluntary membership that comes with access to a healthcare provider. Since its establishment in 1999, Mutuelle de Santé membership has significantly increased — between 2004 and 2012, enrollment increased from 27 percent to over 90 percent. Benefits are provided through risk pooling and an ethic of mutual aid solidarity. This solidarity and trust stirs up members who are susceptible to risk to put together their resources for common use.
As a Global Health Corps fellow working at Gardens for Health International, I had the opportunity to meet and talk to Muhoza Justin, who is in charge of community health insurance at Muhoza Health Centre. In his work at the centre over the past four years, Muhoza explained that he has seen community health insurance membership rise slowly but surely to cover about 95 percent of the total area population. Members receive affordable quality care services close to home, leading to the renewal of their membership and word of mouth endorsement that prompts non-members to join.
I also spoke with Uzamukunda Beatrice, who used community health insurance to access health services at Muhoza Health Center. Beatrice shared that a little over two years ago when she came to Muhoza Health Centre for her first delivery, she was not covered by insurance. The four days she spent in maternity care racked up a bill of more than 65,000 Rwandan francs (approximately $79). It took Beatrice years to pay the thousands of Rwandan francs out of pocket. During her second delivery, Beatrice incurred a cost of 82,567 Frw (approximately $100), but thanks to her new community health insurance membership, she is paying less than a dollar for all of her services.
Rwanda is steadily moving towards achieving health equity through creative, collaborative problem solving. The world should take notice.
The WHO Constitution holds “…the highest attainable standard of health as a fundamental right of every human being.” It defines the right to health as “access to timely, acceptable, and affordable health care of appropriate quality.” Rwanda is steadily moving towards achieving health equity through creative, collaborative problem solving. The world should take notice.
Jean Bernard Ndayishimiye is a 2016–2017 Global Health Corps fellow at Gardens for Health International in Rwanda.
