A for­mula for health eq­uity

Financial Mirror (Cyprus) - - FRONT PAGE -

Imag­ine a coun­try where some 90% of the pop­u­la­tion is cov­ered by health in­sur­ance, more than 90% of those with HIV are on a con­sis­tent drug regime, and 93% of chil­dren are vac­ci­nated against com­mon com­mu­ni­ca­ble dis­eases in­clud­ing HPV. Where would you guess this en­chanted land of med­i­cal eq­uity is? Scan­di­navia? Costa Rica? Nar­nia? Try Africa – Rwanda, to be pre­cise. In my na­tive coun­try, health­care is a right guar­an­teed for all, not a priv­i­lege re­served for the rich and pow­er­ful. Rwanda re­mains poor, but, over the past 15 years, its health care ad­vances have gained global at­ten­tion, for good rea­son. In 2000, life ex­pectancy at birth was just 48 years; to­day, it’s 67. In­ter­na­tional aid has helped, but our achieve­ments have come pri­mar­ily from other, non-fi­nan­cial in­no­va­tions.

For starters, Rwanda has es­tab­lished a col­lab­o­ra­tive, clus­ter ap­proach to gov­er­nance that al­lows us to achieve more with the same amount of fund­ing. More­over, our civil servants em­brace prob­lem solv­ing, demon­strat­ing a level of re­source­ful­ness that has pro­duced many lo­calised so­lu­tions to hu­man devel­op­ment chal­lenges such as en­sur­ing food se­cu­rity and ad­e­quate sup­plies of clean wa­ter and hous­ing.

But per­haps the most im­por­tant fac­tor be­hind our dra­matic health­care gains has been the na­tional eq­uity agenda, which sets tar­gets for sup­port­ing the needy and tracks progress to­ward meet­ing them. Since im­ple­ment­ing this ap­proach, Rwanda has man­aged to de­crease the per­cent­age of peo­ple liv­ing in ex­treme poverty from 40% of the pop­u­la­tion in 2000 to 16.3% in 2015.

Aside from the ob­vi­ous ben­e­fits, these gains mat­ter be­cause, as UNICEF re­cently noted, a coun­try’s po­ten­tial re­turn on in­vest­ment in so­cial ser­vices for vul­ner­a­ble chil­dren is two times greater when the ben­e­fits reach the most vul­ner­a­ble. In other words, Rwanda has achieved so much so fast be­cause we are en­joy­ing higher rates of re­turn by in­vest­ing in the poor­est.

In work­ing to­ward health eq­uity, Rwanda has made ac­ces­si­bil­ity a top pri­or­ity. As of 2016, nine out of ten Rwan­dans were en­rolled in one of the coun­try’s health in­sur­ance pro­grammes. The ma­jor­ity of the pop­u­la­tion is en­rolled in the Com­mu­nity-Based Health In­sur­ance (CBHI) scheme, which has in­creased ac­cess to health­care for Rwanda’s most vul­ner­a­ble cit­i­zens by waiv­ing fees.

As a re­sult, the reach of health­care cov­er­age in Rwanda is high by global stan­dards – all the more re­mark­able for a coun­try that suf­fered the hor­rors of geno­cide a gen­er­a­tion ago. Con­sider the sit­u­a­tion in the US: while the rate of unin­sured Amer­i­cans has dropped pre­cip­i­tously un­der the 2010 Af­ford­able Care Act, the in­sured face rapid in­creases in pre­mi­ums and out-of-pocket ex­penses. Per­haps the US should con­sider adopt­ing a CBHI-type pro­gram, to re­duce fur­ther the num­ber of Amer­i­cans fac­ing fi­nan­cial bar­ri­ers to med­i­cal care.

Rwanda has crafted health care de­liv­ery with ac­cess in mind as well, by de­ploy­ing com­mu­nity health work­ers (CHWs) to the coun­try’s 15,000 vil­lages. These lo­cal prac­ti­tion­ers serve as the gate­keep­ers to a sys­tem that has re­duced wait­ing times and fi­nan­cial bur­dens by treat­ing pa­tients di­rectly – of­ten at pa­tients’ homes.

The US could also ben­e­fit from a CHW pro­gramme. The US is brim­ming with ed­u­cated young peo­ple who, as CHWs, could bridge the gap be­tween med­i­cal fa­cil­i­ties and pa­tients, thereby i mprov­ing Amer­i­can so­cial cap­i­tal and health out­comes. As Rwanda’s ex­pe­ri­ence has demon­strated, such pro­grammes not only broaden ac­cess to health care; they also lower over­all costs by re­duc­ing un­nec­es­sary hos­pi­tal­i­sa­tions.

Such pro­grammes have been shown to be trans­fer­able. Start­ing in 1997, Brigham and Women’s Hos­pi­tal sup­ported the HIV+ com­mu­nity of Bos­ton through the Pre­ven­tion and Ac­cess to Care and Treat­ment (PACT) pro­gramme. That ini­tia­tive was based on the CHW model im­ple­mented in ru­ral Haiti by Part­ners In Health – a non-profit health­care or­gan­i­sa­tion that in­te­grates CHWs into pri­mary care and men­tal health.

As a re­sult of that ini­tia­tive, the gov­ern­ment in­surer Med­i­caid spent less money on hos­pi­tal stays, and in­pa­tient ex­pen­di­tures fell by 62%. Other US com­mu­ni­ties could, and should, in­cor­po­rate sim­i­lar mod­els into their treat­ment pro­grammes for chronic con­di­tions.

In­no­va­tion is what kick-started Rwanda’s health­care re­vival, and pro­gres­sive think­ing is what drives it for­ward to­day. For ex­am­ple, health cen­ters es­tab­lished through­out the coun­try pro­vide vac­ci­na­tions and treat ill­nesses that vil­lage-level CHWs can­not, and have ex­tended ob­stet­rics ser­vices to the ma­jor­ity of Rwan­dan women.

Broad­en­ing ac­cess fur­ther, each district in Rwanda has one hos­pi­tal, and each re­gion in the coun­try has a re­fer­ral or teach­ing hos­pi­tal with spe­cial­ists to han­dle more dif­fi­cult cases. While some hos­pi­tals still suf­fer from staff short­ages, the gov­ern­ment has sought to patch these holes through an ini­tia­tive that em­ploys fac­ulty from over 20 US in­sti­tu­tions to as­sist in train­ing our clin­i­cal spe­cial­ists.

In just over two decades, thanks to home-grown so­lu­tions and in­ter­na­tional col­lab­o­ra­tion, Rwanda has dra­mat­i­cally re­duced the bur­den of dis­ease on its peo­ple and econ­omy. As we look for­ward, our goal is to ed­u­cate to­mor­row’s lead­ers to build on the eq­ui­table health-care sys­tem that we have cre­ated. This is the mis­sion of the Univer­sity of Global Health Eq­uity, a new univer­sity based in ru­ral Rwanda that has made fair­ness, col­lab­o­ra­tion, and in­no­va­tion its guid­ing prin­ci­ples.

As a Rwan­dan doc­tor who con­trib­uted to build­ing my coun­try’s health­care sys­tem from its in­fancy, I am proud of what we have ac­com­plished in so short a time. It wasn’t magic; it was a for­mula. Through con­tin­ued global co­op­er­a­tion, other coun­tries, in­clud­ing de­vel­oped ones, can learn to ap­ply it.

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