coupled with policies to ensure that the care provided is safe and held to the highest standard possible. Yet, it has always been clear that to meet the changing needs of a population that is both growing and ageing, more innovation is necessary to bolster the quantity and quality of health care providers across the country. This inspired the development of a historic seven-year partnership between the governments of Rwanda and the USA, along with dozens of American universities, to bring US medical and health care faculty to ‘twin’ with Rwandan faculty, and work collectively to educate rising health professionals, bolstering Rwanda’s health care workforce. The Rwanda Human Resources for Health programme is ongoing and illustrates the type of innovation in partnerships that we should be striving for on this quest for UHC globally (Binagwaho et al., 2013). Insurance model Rwanda has aimed to address the important challenge of mitigating financial barriers to care through its Mutuelles de Sante health insurance programme (Makaka, Breen and Binagwaho, 2012). Improving financial accessibility to health care services has a direct, clear connection with the goals implicit in UHC. Through this community-based health insurance scheme, as well as other programmes that provide coverage for civil servants and the military, more than 80 per cent of Rwandans have health insurance today. Mutuelles fundamentally subscribes to a spirit of solidarity to assure everyone has access to health care services and each person contributes towards the system in a way that is reflective of his or her financial situation. The poorest quarter of the population is not required or expected to pay for their insurance premiums or at the point of care. This does not mean the care is free; the government has assumed the important responsibility of allocating funds to ensure that these insurance premiums and co-pays are covered for the poorest 25 per cent of the population. This investment is worth every ounce of effort it necessitates as it shows our commitment to the poorest in the population. We will not leave them behind. Through this programme, we show that everyone recognises that health has value, it is not free, and we look forward to them ensuring that others can benefit from this same support once they themselves are lifted out of poverty. For the less poor, or financially better off in society, their contribution to Mutuelles is approximately US$5 (for the middle class) or $12 (for those with higher incomes) per person per year. This contribution has helped to foster a shift in mindset as Rwandans are now becoming more familiar with paying into an insurance pool even prior to receiving care; this translates into ensuring that the entire population has financial access to the same basic health care services and that no one is refused care due to their inability to pay. The programme has shown that a resourcelimited setting is more than capable of achieving high insurance coverage rates should it have the political will, vision, strategies and tools to do so, and how a community-based system can be leveraged to make this vision a reality (Lu et al., 2012). A critical challenge before us in working towards the next stage in our quest for UHC, however, is how to integrate nationally more sophisticated and advanced health care services, such as dialysis and cardiac surgery, that are currently provided through special initiatives or programmes, thereby making them available to everyone rather than just to those with sponsorships or the financial means to receive care. Rwa n d a ’s q u e s t f o r u n i v e r s a l h e a l t h c o v e r a g e Clinical safety and quality The above strategies are of no benefit if the actual service delivered is unsafe and of poor quality. This is why Rwanda is working diligently to prioritise quality of care on this quest for achieving meaningful UHC for its population. From a national level, this has involved a range of activities and policies, including Rwanda’s performance-based financing programme and its recent efforts to require hospital accreditation standards. We have also encouraged current health care professionals to take on coursework that will help them to reflect upon the quality of care they provide at their facility (Binagwaho and Scott, 2015). Encouraging both health care workers and patients to comment on how we can improve the quality of health care services that we provide will help us to make further strides in this arena. Lastly, a spirit of innovation and effective collaboration has helped Rwanda make progress towards achieving the goal of UHC. There are countless examples that demonstrate such a spirit. For instance, Rwanda has enthusiastically integrated technology into all layers of its decentralised health system, including having CHWs report on the status of each pregnant mother through a mobile-based system. Additionally, Rwanda’s governance, through a cluster-based system, helps to ensure that relevant ministries are regularly discussing their priorities and collaborating rather than competing for funds (Binagwaho, 2014). Though Rwanda has made historic progress in population health over the past two decades, I am the first to admit that we have had our share of challenges and still have a long way to go. Even when we meet a target set before us, we know that we can do even better. Not everything we have tried has been successful, but we keep trying – we keep innovating. And we are delighted to have partners globally who share this commitment accompany us in this quest for universal health coverage. Acknowledgement The author wishes to thank Kirstin W. Scott, MPhil, a PhD candidate in health policy at Harvard University and research fellow to Minister Binagwaho. AGNES BINAGWAHO (agnes_binagwaho@hms.harvard. edu) MD MPed PhD is the Minister of Health of the Republic of Rwanda. A pediatrician by training, Minister Binagwaho previously led the National AIDS Control Commission (2002–08) and served as permanent secretary in the ministry until 2011. She has published widely, including more than 90 peer-reviewed articles, and serves on the international advisory board of The Lancet, the editorial board of PLOS Medicine and of Health and Human Rights: An International Journal. She chairs the Rwanda Pediatric Society and is a member of the Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries. Minister Binagwaho is currently a senior lecturer in the Department of Global Health and Social Medicine at Harvard Medical School and clinical professor of pediatrics at the Geisel School of Medicine in Dartmouth, USA. She also serves on the international strategic advisory board for the Institute of Global Health Innovation at Imperial College London. In 2014 Minister Binagwaho became the first student to complete a PhD from the University of Rwanda. Commonwealth Health Partnerships 2015 101
Commonwealth Health Partnerships 2015
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