Africa: Rwanda's Lessons on Universal Health Coverage

Health Minister Dr Diane Gashumba vaccinates a child against measles and rubella in 2017.
19 September 2019
guest column

Rwanda, the land of a thousand hills, is clean, orderly and blessed with great weather. It also has achieved universal health coverage. During a recent visit there as part of my Atlantic Fellows for Health Equity at George Washington University, I learned more about what this looks like in their country. As a physician who advocates for health in my country of Nigeria, I was very interested to learn about the lessons they could offer.

Of course, the people of Rwanda have gone through deep trauma in their national development - particularly the 1994 genocide against the Tutsis. Over one million Rwandans were killed, thousands fled the country and victims were intentionally infected with HIV. Rape was a weapon of the genocide.This year, Rwanda celebrates 25 years since the genocide - Kwibukab25. The theme is, "remember, unite, renew". It is commendable that the nation speaks about it and there is a museum to educate people so they can remember and prevent a recurrence.

Rwanda has come a long way in 25 years and their health statistics are among the best in Africa. For instance, above 96% of Rwandans have health insurance, qualifying it as universal health coverage; routine immunization coverage is 99%; and under five mortality rate is 37.9 per 1000 live births.

Mother to child transmission of HIV is 1.5%. Further, the country is clean and has stable electricity. I was pleasantly surprised when groceries I bought were packaged in paper bags - there is a ban on use of plastic bags in Rwanda.

My cohort and I were hosted by Butaro communities, Staff of Partners in Health and faculty of the University of Global Health Equity (UGHE) in Butaro. The drive from Kigali to Butaro was a foray through nature with great views. It was like driving right up into the clouds, with the campus located on hills at an altitude of over 6,700 feet. It was beautiful there. Across my education there, I took note of the lessons that other countries like mine can learn from Rwanda's achievement of universal health coverage.

First, I observed that achieving universal health coverage is about political will and not how rich a country is. Rwanda's leadership understood early on that without health there is limited economic growth. Therefore, Rwanda's vision 2020 document articulates health as a precursor for economic development. Rwanda demonstrates that political will for universal health coverage even with a GDP of $9.5 billion compared to other African countries such as Nigeria, South Africa, Egypt with GDPs of $397 billion, $366 billion and 88 billion respectively.

Second, universal health coverage means taking healthcare right to communities where people reside. Community health workers are the backbone of healthcare in Rwanda. There is a network of community health workers - 45,000 of them. I had the privilege of visiting one to learn about the work they do. He took us to one of his clients, a 45-year old widow on mental health treatment. It was a very emotional experience and I cried listening to her narrate her experience. I imagined what it must have been like for her as a  widow looking after six children and dealing with mental health disease. I cried because I know there are many women like her
without any mental health support across villages globally. At the end of the visit, I was happy because the widow is now stable, on treatment and receiving support from her village health worker and the district hospital.

Third, partnerships are paramount in the successes achieved by Rwanda in healthcare. The partnership between "Partners in Health" and The Government of Rwanda, for instance, should be emulated across by other countries. This partnership led to the establishment of the University of Global Health Equity (UGHE) and Butaro Hospital. The university brings medical education to the community. I met and was inspired by young African medics supported by their international colleagues saving lives.

Lastly, technological advances can complement existing knowledge and infrastructure. The Government of Rwanda, for example, is equipping District Hospitals and Health Centers with 4G internet to improve quality of healthcare delivery. I now understand why the world's first drone delivery of blood, drugs, vaccines and other commodities is operational in Rwanda. A company called Zipline is providing this drone delivery service. While at UGHE, I watched drones deliver blood to the Butaro hospital close by. Zipline recently opened shop in Ghana where it would be supplying drugs and commodities to 2,000 health facilities.

Overall, Rwanda's work culture is captured in this statement made by one of the health sector leaders who lectured my group at UGHE, "We  are not here to complain but to find solutions".

There are still challenges in Rwanda, of course. The country deals with social issues such as poverty, increasing mental health needs and the West questioning
President Kagame's leadership style. Despite these, massive positive changes have taken place since the end of the genocide and that should be an inspiration to us all. If they can achieve universal health coverage, then we in other countries can, too.

Dr. Ifeanyi M. Nsofor MBBS is a medical doctor, the CEO of EpiAFRIC and Director of Policy and Advocacy at Nigeria Health Watch. He is a 2019 Atlantic Fellow for Health Equity at George Washington University  and a Senior New Voices Fellow at the Aspen Institute. You can follow him on Twitter @ekemma.

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