Establishing Health Equity In Rwanda

Rwanda's Health Minister shares her nation's remarkable story

Agnes Binagwaho, Minister of Health, Rwanda. Image by M.R.F. Buckley

Over the past two decades, the small central African nation of Rwanda has experienced one of the steepest improvements in health in modern times. Maternal and infant mortality rates have been cut in half and life expectancy has doubled.

Agnes Binagwaho, Rwanda’s Minister of Health, a pediatrician and a Harvard Medical School senior lecturer in global health and social medicine, visited on March 11 to share both the remarkable story of her nation’s health transformation and her vision for the next generation of changes, many of which are just beginning.

“I’m going to bring you on a journey to my country,” said Binagwaho, addressing a group in the Armenise Amphitheater.

Binagwaho’s talk, titled “The Equity Imperative: Building and Strengthening the National Health System in Rwanda,” included a review of the tremendous strides that the Republic of Rwanda has made in providing efficient and effective health care to its citizens since the end of the 1994 genocide.

Binagwaho was invited to speak about the health care in Rwanda by the HMS Department of Global Health and Social Medicine. She also joined Betsy Nabel, the president of Brigham and Women’s Hospital and HMS professor of medicine, to speak about the Human Resources for Health consortium in a public presentation at Brigham and Women’s on March 12.

Global Solidarity

Much of Rwanda’s success can be attributed to global solidarity, Binagwaho said. Recent dramatic increases in funding for global health have enabled countries like Rwanda to make significant investments,  strengthening fragile public health infrastructures.

Even with help from donor nations and international agencies, however, the path hasn’t been easy, she said. Nor has Rwanda reached the end of the journey.

“There is lots of money coming in, but it is very fragmented,” said Binagwaho. “Every agency has its own set of rules and paperwork; a different proposal has to be submitted to every agency even if the project is the same,” she said.

This aid differentiation necessitates extensive, costly and time-consuming coordination efforts—and it can sometimes feel like a miracle needs to occur in order for anything to happen, she said.

“You don’t need a miracle. You need to take health issues as a systemic problem,” Binagwaho said. “We know the problem and we know what the end point should look like. It’s the in-between that we have to figure out,” she added.

In developing countries especially, all aspects of health care need to be considered in conjunction with the treatment of a specific disease.

In order to address malaria, for example, it is not enough to think solely about targeting the malaria parasite, but also about how to deliver the necessary drugs to patients, and how to ensure that patients follow-up for treatment, as well as a host of other details that are essential to the success of any health care system, Binagwaho said.

A Systemic Approach

Rwanda has demonstrated success in its systemic approach to various health issues. In the past 20 years, the country has seen dramatic reductions in child mortality, in death from infectious diseases and in other previously catastrophic diseases.

In the year 2000, for example, nearly 20,000 people were dying from AIDS; that number is now close to 5,000 deaths annually. Similarly, in the past decade, the country saw a nearly 71 per cent decrease in the rate of child mortality and a decrease in maternal mortality rates by nearly 60 percent. The average life expectancy is now 56 years, up from 28 years in 1994.

“As a pediatrician, that makes me very happy,” said Binagwaho.

At the core of this success and of Rwanda’s vision for its health system going forward are several important programs, including its community health worker program and the mutuelles de santé insurance program, Binagwaho said.

The hierarchy of health care workers, beginning with community health workers, ascends to specialists at referral hospitals. Community health workers elected from among the population of a village are the first point-persons for patients. They are trained to understand the needs of their fellow villagers and are able to immediately assess each situation.

“Eighty percent of the burden of disease is addressed here,” said Binagwaho. “They are trained to deal with the most common ailments and have helped changed the face of Rwandan public health.”

When a community health worker is unable to resolve a problem, a text message is sent to dispatch a health care professional from a local health center. “The rapid SMS system has now reduced geographic barriers for patients,” Binagwaho said.

If community health workers or the health centers are unable to help, then the patient is seen at a district hospital and, ultimately, can be sent to a referral hospital. At this stage, low-income patients only pay 10 percent of the cost of seeking treatment at a referral hospital.

“Even then,” said Binagwaho, “we assess every patient on a case-by-case basis and forgive costs if need be. So now, financial barriers have been reduced as well.”

Universal Health Care

The mutuelles de santé insurance program, a form of universal health care, has been essential not only to treat each individual patient, but to also ensure broader health equity.

 “The insurance is based on solidarity,” said Binagwaho. “People pay into the system according to their salary, but the quality of care is the same for everybody.”

As such, it is possible to achieve equity, she said. Insurance plans are devised based on biological need, not cost.

“Gender equity is automatic and age equity is automatic,” Binagwaho said.

At the separate Brigham and Women’s lecture, Binagwaho discussed the Human Resources for Health (HRH) program, an initiative between the Rwandan Ministry of Health and a consortium of U.S. institutions, funded by the U.S. government and the Global Fund. Partners in Health and the Clinton Health Access Initiative are also involved. Faculty from Harvard Medical School, Brigham and Women’s and Boston Children’s Hospital are actively involved in the initiative, teaching and working alongside Rwandan colleagues at hospitals throughout Rwanda.

The HRH consortium, a seven-year program launched in 2012, brings roughly 100 physicians every year from nearly two dozen U.S. medical, nursing, dental and midwifery schools and affiliated institutions to Rwanda to train Rwandan clinicians and allied health professionals. The goal is to create a self-sustaining medical education in which these HRH participants become a population of specialists within Rwanda who go on to train the next generation of health professionals there.

This goal is especially important, said Binagwaho, because now that Rwandans are surviving infectious disease, they are dying of non-communicable diseases. Cancer rates, for example, are growing among the Rwandan population, but among the 10.6 million Rwandans, there are no oncologists, Binagwaho said.

Borrowing Chickens

Using a chicken-and-egg analogy, Binagwaho explained that by borrowing “chickens” from the U.S., she hopes to hatch Rwandan “eggs” that will grow into self-sustaining “chickens” that will in turn produce “eggs” of their own.

The collaboration is not one-sided. The community health system in Rwanda has been so successful that Binagwaho hopes to provide the U.S. with the tools to implement a similar approach to primary care, specifically with techniques aimed at raising rates of adherence and compliance to treatment and tackling complex chronic diseases.

Ultimately, for Binagwaho, health is a fundamentally social issue.

“Health is tied into family structure, economics, nutrition and a host of other things,” she said. “If you were to study heart disease, you’d have to know about the heart’s relationship with the lungs, with the liver, with other parts of the body. If you only take the heart into consideration, you’ll kill the whole body,” she said. “It’s all about the systemic approach.”