Two students just got hepatitis vaccination Xinhua News Agency/Getty Images

A Formula for Health Equity

What could an economically advanced country like the United States possibly learn from the health-care success of a tiny, impoverished African country like Rwanda? Two things: how to broaden access and improve health outcomes while sharply reducing the cost of care.

KIGALI – 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?

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Try Africa – Rwanda, to be precise.

In my native country, health care 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 localized 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 health-care 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 noteda 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 programs. The majority of the population is enrolled in the Community-Based Health Insurance (CBHI) scheme, which has increased access to health care for Rwanda’s most vulnerable citizens by waiving fees.

As a result, the reach of health-care 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 program. The US is brimming with educated young people who, as CHWs, could bridge the gap between medical facilities and patients, thereby improving American social capital and health outcomes. As Rwanda’s experience has demonstrated, such programs not only broaden access to health care; they also lower overall costs by reducing unnecessary hospitalizations.

Such programs 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) program. That initiative was based on the CHW model implemented in rural Haiti by Partners In Health – a non-profit health-care organization 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 programs for chronic conditions.

Innovation is what kick-started Rwanda’s health-care 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 homegrown 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 health-care 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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