Just days before the onset of campaigns for Presidential elections on July 15 this year, President Kagame met and interacted with thousands of community health workers from across Rwanda’s 30 districts. This interaction was more than merely symbolic. The 58567 Community Health Workers are part of the solid foundation on which health services in Rwanda are built. For rural communities and for poorer sections of urban communities, community health workers play roles that ensure that people who would otherwise not be able to access care do so, at health facilities or, where necessary, in their own homes.
Usually, when people talk about the advances Rwanda has made over the last 30 years since the civil war and the genocide against the Tutsi ended, the focus is on such things as the grand projects that are show-cased. These include roads, sports facilities, Rwandair, hotels, and the eye-catching cleanliness of its capital city, Kigali, and other cities and towns around the country, plus the modern buildings that seem to spring up like mushrooms everywhere. To many observers, these come to mind when Rwandans talk of their government’s capacity for thinking big. However, there is much more going on that is much less noticed than the big, unmissable projects.
One of the areas in which significant progress has been made is health. There is a great deal that can be pointed to by anyone paying attention to the health sector to underline the tremendous work and effort that have gone into building it. It is in rural areas and among less well-to-do sections of society that one gets a fuller measure of the transformation that has taken place and, in many ways, is still unfolding. The impact of transformation can be seen at the level of specific health outcomes, such as maternal and infant mortality rates, which have fallen significantly; immunisation rates, which are high; and access to family planning services, which has increased significantly, among others. Why is the Government of Rwanda so deliberate in its focus on the health sector?
Almost every government in Africa aspires to improve the quality of life for its citizens. These aspirations are captured in the statements officials make about the imperative to channel resources into the social and productive sectors. In reality, however, one finds that in the same countries the health sector would have collapsed or will be in the process of collapsing because of lack of both human and financial resources, and key inputs. In Rwanda, however, the government has gone beyond making fancy declarations of intent on the health sector and actually put money where its mouth is, as it were. What makes Rwanda different? The difference lies in the government’s understanding that, if it is to stand a good chance of achieving its aspirations of socio-economic transformation, a healthy population is of critical importance. Only a healthy population can work and be productive. And only focused investment in the health sector can guarantee a healthy population.
One of the most important decisions the government made in its aspirations to ensure that Rwandans become and remain healthy was to introduce health insurance. Health insurance comes in three schemes. One covers public servants, while another covers members of the armed forces. The third and more significant than these two is community health insurance, commonly known as mutuelle de santé. This covers the rest of the population, bringing total coverage to well over 90 percent of the entire population. It is notable that the introduction of mutuelle de santé was contentious. Some in the donor community, as well as some public health experts opposed it on the grounds that it would penalise the poor, particularly the poorest of the poor. Their argument was that the poor would not be able to afford the annual premium, which would in turn exclude them from accessing care.
There was also the view which ran counter to the 1987 Bamako Initiative, and which had been embraced by some governments, that health services should be provided free of charge, and that this was the only way to ensure that poor people have access. For purposes of clarity, a key principle underlying the Bamako Initiative was that service users should contribute to financing the running of health facilities so as to help cover their running costs, which would improve both the quality of delivery and access.
By the time the Government of Rwanda sought to introduce mutuelle de santé, research had shown that free health services were unaffordable for many governments, and that the decision to not oblige service users to share costs had translated into lack of even the most basic of supplies at health facilities. In other words, it had caused the very lack of access that opponents of health insurance claimed to seek to prevent. Unwavering in its commitment to delivering services of high quality and ensuring universal access, the Government of Rwanda went ahead and introduced community health insurance, with built-in mechanisms to ensure that the indigent who could not afford to pay premiums had theirs paid for them.
Years down the road, mutuelle de santé has impacted health services in many ways. First, it has cultivated a sense of entitlement to services in the minds of users. This has translated into expectations about how they should be received and handled, which is the essence of holding providers to account. This sense of entitlement is seen in the large numbers of people that turn up at health units to be attended to, even for the most mundane of ailments, once they have paid their premiums. The numbers are reported to decline once the period of coverage has expired, only to go up again once new premiums have been paid.
Second, although the amounts contributed per individual are generally small, collectively they add up to significant amounts that boost the resources injected into the sector by the government and its development partners. This has raised the quality of delivery overall, as well as ensured that tertiary care is available to ordinary folks at no cost, which in countries where health services are “free” of charge, is unthinkable.
All in all, the introduction of mutuelle de santé, the recruitment of tens of thousands of volunteer community workers, the purchase and distribution of ambulances to health facilities across the country, plus other elements such as a functioning referral system, all buttressed by robust accountability mechanisms, have combined to lift up the standards of service delivery in the health sector. Clearly, thinking big in post-genocide Rwanda is not simply about mega infrastructure projects, but also about endeavouring to improve quality of life for ordinary citizens, in ways that seek to leave no one behind. Is it all smooth sailing? Hardly. Numerous challenges remain, but there is no lack of will and drive to tackle them.
