Kurinda ubuzima mu Rwanda

Muraho mwese! Mumeze mute (How are you)? It's time for another blog post about Rwanda. This month, I'm tackling an issue requested by Grandma: healthcare in Rwanda. I'm not as educated as many others when it comes to this, so I've embedded a link to a New York Times article which you can access by clicking on the title of this post. Also, there is another link to follow for more information: http://www.jointlearningnetwork.org/content/mutuelles-de-sante

Healthcare is an important issue in any country. I remember being asked about the American healthcare system many times when I was studying in France, and who can forget the great healthcare debate in Congress in 2010? In Rwanda, the topic is of particular interest, as there are a number of health challenges facing this small country, including malaria, HIV/AIDS, tuberculosis, and complications related to childbirth. Rwanda's response to these challenges has been to implement a national health insurance system and build an extensive network of health centers and hospitals to provide care to its citizens.

The access to healthcare, as far as the facilities go, is very good in Rwanda. There are basic health centers at the sector level (a sector is an administrative division, similar to a county in the U.S.). With 416 sectors in a country the size of Maryland, this means that people do not have to travel far to get to one of these centers. I estimate that it would be no more than a 2-hour walk to the nearest health center for any Rwandan. At these health centers, basic services are offered, including basic vaccinations (e.g. Hepatitis A, B, and C), simple operations (e.g. circumcision), family planning, pre-/post-natal care, essential/generic drugs, and HIV/AIDS or other testing (depending on the facilities). At the health center in my district, most of their work deals with pregnancies and childbirth, but they've also done condom demonstrations and HIV/AIDS testing at my school, free vaccinations against HPV for girls in the area, and free circumcisions for males in the area.

Bigger hospitals are found in larger areas; there are two within 8 kilometers of my village in two different directions. These hospitals offer the same services as the small health centers, plus caesarian sections, other minor/major surgical operations, medical imaging (where available), more blood tests (most have laboratories), and an ambulance to transport patients who need it. I've briefly seen one of the nearby hospitals, and the facilities are basic but certainly adequate. I, myself, have only ever been a patient at the biggest hospital in the country: King Faisal Hospital in Kigali. I went there for a doctor visit, and it was a very nice hospital from what I saw, though I didn't see what kind of equipment and labs they have.

Access to care in these facilities is assured to almost all Rwandans through health insurance. In 2003, Rwanda launched the Community-Based Health System (CBHS), officially requiring every Rwandan to possess some form of health insurance. Of course, in reality not everybody has health insurance, but according to figures I saw a staggering 92% do! Compare this to the U.S., where between 85% and 90% have health insurance, and it's clear that Rwanda is doing something right. Certainly the cost of the insurance is a contributing factor to the success of the program: the cost for the public plan is 1000 RWF per year, or roughly $1.67 each time the earth orbits the sun. Patients pay a 10% service fee up front for each visit, but that is the only additional cost.

Health insurance is provided through companies called mutuelles, a French word, and there are two major ones in Rwanda: Mutuelle de Sante and La Rwandaise d'Assurance Maladie (RAMA). In addition, there are Military Medical Insurance (MMI) and private insurance companies to round out the coverage options. As this is a government program, it is financed as much as possible by the Rwandan government through their revenues. But, as Rwanda still relies heavily on foreign aid, the mutuelles program is also partially funded by foreign governments and NGOs (for example, The Global Fund to fight AIDS, Tuberculosis, and Malaria covers premiums for around 1.5 million Rwandans according to one figure I saw).

Despite the success of the CBHS in Rwanda, there remain challenges. The first among these is the cost of healthcare. Although the cost for insurance is low, some still cannot afford it, whether from large family size (the 1000 RWF is per person) or simply an inadequate income. Those without insurance often do not go to receive healthcare; one Peace Corps Volunteer who works in a health center told me that probably fewer than 5% of their patients do not have health insurance. I have also heard stories of people being turned away because they do not have a health insurance card. Besides the personal cost, there is some worry about the financial stability of the entire system, especially in light of the fact that so much foreign aid is needed to support it. Perhaps adding to the financial questions is the fact that payments are not based on a capacity to pay. That means that the farmer who lives next door and earns perhaps 15,000 RWF per month pays the same 1000 RWF each year as the mayor who earns 300,000 RWF each month.

Another challenge facing the healthcare system in Rwanda is a lack of adequate infrastructure and facilities. Poor roads make it difficult to transport sick people to hospitals, especially during the rainy season, and there is often a lack of sufficient laboratories and/or diagnostic equipment in the smaller hospitals and health centers.

Finally, a lack of education is the third challenge that Rwanda's healthcare system faces. There is still a lack of information on the services available in some instances, such as family planning, and there remain misconceptions about diseases such as HIV/AIDS and malaria and how they are spread.

To address these challenges, efforts are being made in many areas. First, there is a general push to raise the standard of living for all to make healthcare more affordable. To address the problem of lacking infrastructure, roads are constantly being improved, mostly by tigistes (accused génocidaires who live in camps and work on roads for their prison sentence), and more health centers are being equipped with a reliable supply of electricity instead of relying on solar panels, thus allowing them to have more modern equipment and laboratories. In order to educate people about health problems and what services are offered at the health centers, there are radio programs such as BBC's “Urunana,” which talks about health issues; billboards about malaria, HIV/AIDS, and tuberculosis; and even igitenge (colorful African cloth) proclaiming the need to protect against malaria. Finally, each village has three community health workers to help with education and local projects. They are involved in the areas of family planning, social affairs, and aiding pregnant women. One of them came to our house a few months ago to see how many mosquito nets we have in an effort to fight malaria.

Rwanda may face many challenges when it comes to healthcare, but they have in place a system that affords most people coverage (more, in fact than the U.S.). As one Volunteer who was finishing her service told me, “When things aren't going so well, I just have to remind myself that at least there's a system.” Continued improvement in infrastructure, financing of the system, and education of the general population should only lead to further improvements, a better system, and a higher quality of life for Rwandans.

Happy birthday this month: Chris
Next month's topic: Rwanda's Justice System