Rwanda’s quest for universal health coverage Agnes Binagwaho As Minister of Health for Rwanda, I feel a duty to operationalise Rwanda’s vision for universal health coverage. Such a vision demonstrates the country’s genuine commitment to equity. Globally, universal health coverage (UHC) is recognised as a complex but powerful notion for health activists and policy-makers to rally behind as they act to improve the health of the world. I am drawn to the term’s explicit reference to providing care in a ‘universal’ fashion as, for far too long, the poor and vulnerable have been left behind. And yet I also believe that achieving true UHC requires far more than policies that ensure people are protected from the catastrophic costs of receiving health care. Such initiatives are critical, but insufficient for achieving the gains in health that the world needs to see. This article captures some of my reflections on how we have worked towards achieving UHC in Rwanda. The country has made much progress towards meeting this objective – especially considering the devastation it faced just 21 years ago, at the time of the genocide – and yet Rwanda still has a long way to go to meet its ambitious goals for a brighter and healthier future for all. Decentralisation First, the decentralisation of Rwanda’s health sector has helped us work towards geographic equity of health service delivery. By aligning the organisation of the health sector with the governance and administrative structures already in place in Rwanda – ranging from the village to the sector, district and national levels – has helped the country make progress towards this UHC goal. It has helped us to bring care where it is needed for our people. Complementary to the community health workers (CHWs) is the elaborate system of health posts, health centres, district hospitals and provincial/referral hospitals throughout the country. These facilities have been constructed under the principle of geographic equity to health care services to ensure that health care is never far from our people. For example, there are currently a few more than 500 health centres distributed throughout the country’s 416 sectors, staffed by approximately ten nurses and overseen by a physician at the district level. There are only 18 sectors without at least one designated health centre; filling this gap is a priority for the Ministry of Health so that we can further reduce the time it takes for any individual to reach a health care facility. Today, the average time to reach such care is one hour. Though we have these facilities in place, there is more we can do to improve geographic access to care throughout the land of a thousand hills, an idea that has inspired the development of health posts nationally. We have already constructed more than 400 health posts, which are staffed by a trained nurse, and we are steadily making progress to ensure that there are at least 1,800 posts distributed equitably throughout the country within the next three years – one in each cell where there is no health centre. For more advanced care, there is a minimum of one district hospital staffed by physicians and nurses, and then a higher acuity provincial or referral hospital available in each of Rwanda’s five provinces. Building, equipping, staffing and operating this intricate network of health facilities, distributed through existing administrative units, has required strong collaborations with many other ministries, including the Ministry of Local Governance, Ministry of Education, Ministry of Infrastructure and the ministry in charge of civil servants. It has also benefited from a strategic referral system that connects the health facilities together and ensures that limited resources at each site are not invested when care could be provided in a lower acuity setting. Human resources for health Staffing these numerous health facilities nationally with welleducated health professionals has required herculean efforts. Developing a cadre of qualified health personnel has been particularly challenging given that Rwanda lost a large share of its health workers during the 1994 genocide. Since that difficult time, Rwanda has embraced initiatives, such as task shifting – for example, allowing CHWs to provide care that may be provided by nurses in other settings, or permitting nurses to deliver care that may typically be provided by doctors (if they existed) – which are Community health workers Key to providing health services at the local (or village) level has been Rwanda’s robust network of 45,000 community health workers (CHWs). There are three CHWs per village, two women and one man, who are tasked with the meaningful challenge of preventing and even curing some diseases in their community, and monitoring the health of their family, friends and neighbours. CHWs are elected by their communities. This very act of involving the community to designate their representatives to the health sector signals the country’s effort to make health improvements a participatory process at all levels. It is then the Ministry of Health’s responsibility to equip these elected CHWs with the training they need to provide high-quality care as well as the equipment needed to do so. Since the majority of the country’s preventable mortality and morbidity can be reduced by intervening at the community level, Rwanda has witnessed rapid and impressive declines in the burden attributable to the scourges of HIV/AIDS, tuberculosis and malaria, as well as improvements in maternal and child health, given this effort to provide care through these incredible local leaders (Farmer et al., 2013). 100 Commonwealth Health Partnerships 2015
Commonwealth Health Partnerships 2015
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