Notable among the policies and strategies are Universal Health Insurance, Performance Based Financing (PBF), decentralisation of healthcare services, Community-based healthcare provision, and investments in e-health.
Infectious diseases, including HIV/AIDS, malaria, TB, and childhood diseases, have received priority attention. Attention to hygiene and sanitation, as well as the fight against malnutrition, has received Presidential leadership, with impressive results.
Investments in maternal and child health have put Rwanda on track to achieve the MDGs on Maternal and Childhood Mortality.
Universal Health Insurance and easy access to healthcare has reduced catastrophic out of pocket expenditure for healthcare, especially for the poorest quantile of our population. Average life expectancy at birth is now at 52 up from 25 in 2000.
The number of sick people who visit health facilities has also noticeably increased as a result of the health insurance or Mutuelles de Santé. Today, health insurance covers 92 percent of the population.
Dentists attend to a patient at King Faisal Hospital in Rwanda
Easy access to health facilities, reduced cost of healthcare services coupled with health systems innovation have enabled Rwanda to register tremendous and remarkable milestones in reducing infant mortality from 86/1000 to 62/1000, under five mortality from 152 to 103/1000, Malaria morbidity and mortality have reduced by over 60 percent and the HIV/AIDS prevalence is less than 3 percent, down from 11 percent in the year 2000. Maternal mortality has decreased from 1, 071/100,000 live births; to an estimated 383/100,000 live births in 2008.
Policies and strategies are only as good as the people who design and implement them. The government has, therefore, invested in human resource for health. From an estimated 30 doctors in the aftermath of the genocide in 1994, Rwanda now has one doctor for every 18,000 people (585 doctors), and one nurse for every 1,700. This improvement, although dramatic, is insufficient. Heavy investments in medical education, including continuing professional development for health professionals will continue to be a priority. Higher training, including at university degree level, is being offered for nurses and midwives for the first time in Rwanda’s history. Professional councils and associations have been established, and a Charter of Patients’ Rights and Responsibilities is now in use.
Today, some 150 doctors are pursuing clinical and sub-clinical specialisation in the country and abroad. This is a sea change compared to the period before 1994 when at any one time, less than 10 students would be enrolled in medical school in any given year. Since 1995, Rwanda has produced more doctors than were produced in the thirty years following her independence. It is also training them better, and providing clear career paths for them. This is true across the entire health workforce spectrum.
It is evident that development of human resources and skills alone cannot guarantee improved health care services. Thus, the Ministry of Health has put extra efforts to develop healthcare infrastructure and bridge the geographical access gap by construction of new health facilities, rehabilitation and equipment of the health facilities, as well as the improvement of the laboratory system and the development of Telemedicine.
Today, Rwanda has five referral and specialised hospitals, 41 District Hospitals and 430 Health Centers. The Private sector is increasingly involved in the provision of healthcare through the construction of private hospitals and clinics. Sixty percent of Rwandans now live within 5 km of a health facility and eighty five percent (85%) live within 10 km.
The Ministry of Health has institutionalised Performance-Based Financing (PBF) for healthcare providers. We link payments to outputs and outcomes rather than the supply of inputs. The national PBF programme has achieved significant success. For example, in just two years, utilisation of curative care services increased by 35 percent, Antenatal Care visits by 90 percent, the number of new Family Planning users by 218 percent, institutional deliveries by 61 percent, referrals for obstetric emergencies by 150 percent and general emergency referrals by 100 percent.
Over 95 percent of children have received DPT3 and immunization coverage is over 80 percent for all antigens, including new ones like the recently introduced pneumococcal vaccine.
We constantly question our assumptions and innovate. Information and Communication Technologies blur the nexus between technology and medicine, and offer solutions to seemingly intractable challenges of development.
The health sector has demonstrated the vital role of ICT in integrating health information systems, including medical records, patient management, logistics, resource tracking, human resource management, hospital management and Community-Based Interventions.
Patients in rural district hospitals increasingly have access to diagnostic and treatment support from referral centres. A nationwide electronic medical record system will be rolled out next year.
Mobile phone based systems, including TRACnet are used to collect, store, retrieve, and disseminate critical program, drug, and patient infor mation related to HIV/AIDS care and treatment. Treatment regimens, drug resistance, ARV stocks, are monitored in real time, increasing the quality of care.
Mobile phone-based systems, known in Kinyarwanda as M-Ubuzima are being used by over 45,000 Community Health Workers to improve delivery of healthcare services like family planning, reducing maternal and child death, and fighting malnutrition. The system includes a rapid SMS component that ensures that expecting mothers especially those in rural areas get skilled care during pregnancy and childbirth. This, coupled with the increasing availability of a good ambulance service, as well as community and facility-based maternal death audits, has led to a rapid reduction in maternal mortality.
Community Health Workers have made a tremendous impact on the health of their communities. From provision of family planning services, treatment of childhood fevers and diarrhoeas, promotion of sanitation and hygiene, follow up of expectant mothers, their role is increasing and is appreciated by the communities they live in. In Rwanda today, malnutrition is not simply a statistic. It has a name, and a face. The government has now established a data-base on malnutrition – so every malnourished child is known, and interventions are targeted to him/her and the family.
We have come a long way, between yesterday and today. We have a long way to go. The Policy framework is clear and coherent. Our Health Sector Strategic Plan has clear, measurable indicators through 2012. Important partnerships for health have been built within Rwandan society and external actors. The health workforce is young, gender balanced, dynamic, motivated, clean, clear headed and committed. We have the support of the Rwandan people and the entire Government. We have exemplary leadership from the President. We can only succeed, and succeed fast.
Richard Sezibera is Rwanda’s Minister of Health. He wrote this article on request from The Independent.