By Neal Emery
Over the last decade in Rwanda, deaths from HIV, TB, and malaria dropped by 80 percent, maternal mortality dropped by 60 percent, life expectancy doubled — all at an average health care cost of $55 per person per year.
Amidst the barrage of stories about failing states and civil wars that characterize the dour American media coverage of the developing world, the reinvention of Rwanda offers hope. Since the genocide with which its name is still synonymous in the United States, Rwanda has doubled its life expectancy and now offers a replicable model for delivery of high quality health care with limited resources.
Dr. Paul Farmer, Chair of the Department of Global Health and Social Medicine at Harvard Medical School and co-founder of Partners In Health, says that, “Rwanda has shown on a national level that youcan break the cycle of poverty and disease.”
In the wake of the genocide that killed nearly one million people in 1994, such a turnaround seemed nearly impossible. Rwanda was a failed state mired in poverty and chaos. The genocide decimated Rwanda’s health facilities and workforce, allowing infectious diseases to run rampant and more than one in four children to die before their fifth birthday. Normally in such situations, economic development stagnates because disease cripples workers and the national economy, leaving the country too poor to effectively reduce the burden of disease. With a life expectancy of only 30 the year after the genocide, Rwanda looked poised to follow this pattern.
Over the last ten years, Rwanda’s health system development has led to the most dramatic improvements of health in history. Rwanda is the only country in sub-Saharan Africa on track to meet most of the Millennium Development Goals. Deaths from HIV, TB, and malaria have each dropped by roughly 80 percent over the last decade and the maternal mortality ratio dropped by 60 percent over the same period. Even as the population has increased by 35 percent since 2000, the number of annual child deaths has fallen by 63 percent. In turn, these advances bolstered Rwanda’s economic growth: GDP per person tripled to $580, and millions lifted themselves from poverty over the last decade.
The rest of the world, wealthy countries and well as poor, can learn from Rwanda’s rapid rise. Too often, though, experts imply that Rwanda’s results are inseparable from the genocide.
In this explanation, the genocide created a “clean slate” on which Rwanda could build a new health system thanks to an influx of health aid from wealthy countries feeling guilty about what happened. However, in the years immediately following the genocide, Rwanda received the least health aid of anywhere in sub-Saharan Africa, as many organizations wrote the country off as a lost cause. Even today, Rwanda achieves its superb improvement while spending only $55 per person on health care and public health per year — 22nd among the 49 countries in sub-Saharan Africa.
Rwanda achieves exceptional results not from how much money they spend on health, but from how they spend it. A recent article in BMJ, led by Farmer, examined World Health Organization data and sought to identify why Rwanda developed so rapidly, and to clarify the lessons for other countries. Rather than a single cause, the authors identified a series of interconnected factors that contributed to the country’s turnaround.
First and foremost, credit belongs to the government of Rwanda’s centralized planning. In 2000, the Rwandan government created a plan, called Vision 2020, to develop economically into a middle-income country over the next two decades. Dr. Agnes Binagwaho, Rwanda’s Minister of Health, explained that “health is a key pillar of our development” and that without improving health, they will never alleviate the country’s poverty.
The government has stressed coordination between sectors and requires all government ministries to create plans to deal with certain cross-cutting issues such as HIV and, as of 2011, non-communicable diseases such as cancer and cardiovascular disease, too. In the case of foreign aid, the government has taken leadership on aid allocation to fit within Vision 2020. If funding organizations or NGOs want to work in Rwanda, they must fit within that plan and meet transparency and accountability standards, or they will be asked to leave.
As the Global Fund, PEPFAR, and other organizations made unprecedented health aid available for disease-specific programs targeting HIV in the early 2000s, Rwanda has used this money to build a robust system of primary care. According to Dr. Binagwaho, Rwanda decided to use this money to build health systems because HIV does not exist in a vacuum — if an HIV program does not address the associated problems such as tuberculosis and malnutrition, it will fail.
Sustainable gain, says Dr. Binagwaho, only comes when programs build capacity and integrate all aspects of health care. In addition to building hospitals and clinics, Rwanda trained 45,000 community health workers that provide in-home care and psychosocial support for HIV patients as well as basic primary care for the rest of their communities. Community health workers bring health care into people’s homes and reach those who otherwise might not receive care. To create a financial incentive to coordinate care, a performance-based financing system pays hospitals, clinics and community health workers to follow-up on patients and improve primary care. All the while, Rwanda increased from 870 people on HIV treatment in 2002 to more than 100,000 in 2012 while retaining 92 percent of patients in care — compared to 50 percent in the United States — not in spite of but because of the investments in primary care.
In order to ensure that all citizens have adequate access to health care, Rwanda provides universal health insurance and focuses particular attention on providing for vulnerable populations. The community-based health insurance program, Mutuelles de santé, has more than halved average annual out-of-pocket health spending and significantly cut the rate of households experiencing health care bills that force them into poverty. Mutuelles receives half of its funding from international donors and half from annual premiums of less than $2 per person. For hospital care, patients pay a copayment of about $0.35 plus ten percent of the total hospital bill.
Given the poverty of many in Rwanda, these low premiums still price out a significant slice of the population. The government of Rwanda is committed to equitable health services and Dr. Binagwaho says, “Whatever we do, we make sure that the poorest and most vulnerable have benefits too. We do not just do things for people who can access healthcare normally.” After finding that the utilization of health care lagged in the poorest fifth of the population, in 2010 the government began to subsidize premiums and co-payments for those living in extreme poverty through the support of The Global Fund to Fight AIDS, Tuberculosis, and Malaria. For Rwanda, health equity is both a matter of ethics and epidemiology: Access to health care for all citizens is a prerequisite for controlling diseases such as HIV — and for continued economic growth to lift more Rwandans out of poverty.
Just as the Ministry of Health responded to research on health utilization by cutting for the poorest, Rwanda bases all health policies on available health data. Dr. Binagwaho explains that, “You will not succeed in bringing up a strategy or policy that is not backed up by evidence” — policies not justified by robust data are rejected. The government relies on what Dr. Farmer calls “burden and gap analysis,” first looking at what problems cause the most ill health and then identifying the areas where an affordable, effective intervention can fill the gap. The goal of this analysis is to ensure that every dollar goes as far as possible. As Rwanda brings infectious diseases under control, non-communicable diseases make up an increasing share of burden of disease.
In 2011, for example, Rwanda seized upon the new Gardasil vaccine to inoculate its populace against cervical cancer, the leading cause of cancer in women. Providing all three doses of the vaccine posed a challenge in rural areas, but Rwanda’s robust system of primary care and thousands of community health workers supported the effort that reached 93 percent of eligible girls.
To further reduce the impact of cervical cancer, Rwanda has integrated the vaccine with increased programs in screening to catch the disease earlier and improve treatment outcomes for women with cervical cancer. Now, with the HPV vaccination program rolled out, the government of Rwanda looks to improve care for those with cancer by expanding comprehensive cancer treatment program into district hospitals as well as Partners in Health’s new Butaro Cancer Center of Excellence — the country’s first dedicated cancer hospital. By making scientific certainty central to policy planning, Rwanda addresses coming challenges and ensures the efficiency and efficacy of proposed programs.
For Syria and Mali, Haiti and Yemen, Rwanda’s rebuilding should offer hope that they, too, can remake their countries and recover from crises in the coming decades. While the specific context of Rwanda cannot be replicated, Dr. Farmer contends that Rwanda’s focus on evidence-based policy, central planning, health systems, and equitable access to care should be heeded both by countries looking rebuild their health system and those with strong systems already in place. “In our commitment to understanding complexity,” said Farmer, “we need to not forget that there are generalizable lessons to delivering care that are not acceptable to ignore.”
While the United States still exceeds Rwanda in most traditional health metrics (such as life expectancy), and its hospitals and medical care surpass those in Rwanda, U.S. health outcomes still falter because too many patients fall through the cracks. The U.S. health system relies too heavily on doctors and hospitals to provide care. A growing body of research suggests that more frequent health care use and higher costs may lead to poorer health.
Farmer believes that, if the United States extended health care into the community like Rwanda, care for chronic diseases would markedly improve while costs would over time drop. Indeed, community-based pilots in the United States have proven effective in settings from inner-city Boston torural Mississippi. Innovations in resource-squeezed places like Rwanda give hope that health care can be both equitable and affordable.