Lessons in Resilience: Creating Stability and Universal Access to Care in Rwanda’s Health System

 {Photo credit: Todd Shapera.}Community health workers and children, Rwanda.Photo credit: Todd Shapera.

It has been 20 years since the genocide that killed over a million citizens and devastated the Rwandan health system and economy. In some respects, it feels more recent. Our memories of both the violence and our collective inadequacies in the international response are still raw. But the progress Rwanda has made toward economic and social stability in just two decades is astonishing and a cause for celebration.   

In 1998, just four years after the genocide, the new Rwandan government launched an ambitious plan to move the nation from a state ravaged by war to a middle-income country by 2020.  Central to this plan was health equality—equal access and equal quality of care for all Rwandans—not a simple goal for the most developed countries, let alone one emerging from conflict. But the Rwandan government met its challenges head-on and addressed both access and quality of care from multiple angles.

Improving Access with Community Health Workers and Community-Based Health Insurance Scheme

[Community health workers are the frontline of health care in Rwanda.] {Photo credit: Mary Burket/MSH.}Community health workers are the frontline of health care in Rwanda.Photo credit: Mary Burket/MSH.In the early 2000s, two key government initiatives worked to eliminate geographic and financial barriers to health care: 1) the deployment of three community health workers in each Rwandan village to bring health care closer to the communities, and 2) the implementation of a nationwide community-based health insurance (CBHI) scheme to mitigate the cost of facility-based care.

Both systems grew quickly, with notable success. From 2003 to 2012, the rate of enrollment in the insurance system increased from 7 to 91 percent and the annual utilization of health services increased from 0.3 to 1.7 services per citizen. Community health workers provided first-line treatments in the community and referred clients to health centers for more advanced care, thus increasing both supply and demand of health care.

However, for the poorest Rwandans, the cost of facility-based services was still prohibitive. In 2009, the Ministry of Health tasked the US Agency for International Development (USAID) Integrated Health Systems Strengthening Project (IHSSP), led by Management Sciences for Health (MSH), with revising the system to lessen the financial burden of health care for the poorest Rwandans.

IHSSP developed a national database that holds information on every Rwandan household’s assets, allowing the government to stratify citizens into three economic categories, and helped the government revise the payment system. Under the new system, Rwandans pay for their health insurance on a sliding scale according to their economic category. The poorest residents pay nothing, and their contributions are covered by the government and its partners.

Improving Quality

Access to health care means nothing if services aren’t well performed.

Many international partners focus on improving quality by providing training on medical techniques (e.g., no-touch IUD insertion; prevention of postpartum hemorrhage using uterotonics; or safe medical male circumcision) or improving a broad area of care, such as emergency or antenatal. While these interventions are beneficial, a stove-piped approach can leave patients open to harm.

What happens when a patient has been well cared for in the emergency department but receives the wrong medicine once admitted to the inpatient ward?

What about the mother saved from shock by an attentive midwife and a shot of oxytocin, whose baby then dies from neonatal infection?


Creating Measurable Standards for Care through Accreditation

[An accreditation visit with a lab technician at Kibungo District Hospital, Rwanda.] {Photo credit: Mary Burket/MSH.}An accreditation visit with a lab technician at Kibungo District Hospital, Rwanda.Photo credit: Mary Burket/MSH.

In recognition of the interconnectedness of all health care, the Rwandan Ministry of Health and IHSSP took a holistic approach to improving quality of care in Rwandan hospitals, and in 2009 began laying the groundwork to accredit Rwanda’s facilities according to international standards.

IHSSP worked with Joint Commission International (JCI), an organization that facilitates accreditation of hospitals throughout the world, to develop a set of 69 standards that govern all aspects of Rwandan hospitals’ administration and service delivery. The ministry selected five hospitals in which to implement the process first, and in 2012 IHSSP began working with these hospitals to develop the internal structures, policies, and competencies necessary to work toward accreditation.

The accreditation process and training are long and complex; it will likely be several years before the first hospitals in Rwanda are accredited, and many more years until all 430 health facilities meet minimum standards. But the process itself has nurtured a nascent culture of quality within the facilities.

In just six months since the baseline assessment, the changes implemented by the staff of Kibungo District Hospital in the Eastern Province have made tangible improvements in patient outcomes.

Jean Marie Vianey Ukizentaburuwe, the hospital’s Quality Improvement Focal Person, explains:

Before, we didn’t have the habit of analyzing data. We didn’t know the rates of neonatal infection, neonatal asphyxia, or the infection rate from C-sections. But now we know these rates and have a plan to improve them.

In the first six months of implementing their plans to improve maternal and neonatal outcomes, the percentage of deaths due to neonatal infection dropped from 24 to 18 percent in Kibungo Hospital. The hospital has set a goal of reducing this to 9 percent over the next six months.

Similarly, the staff is monitoring the rate of post-C-section infections. To decrease incidence, the infection prevention committee is reviewing the charts of every C-section infection case to see if commonalities arise that may lead to corrective actions. Their goal is to decrease the rate of C-section infections from a baseline of 3 to 1.5 percent over the next six months.

[Rwanda.] {Photo credit: Todd Shapera.}Rwanda.Photo credit: Todd Shapera.

Supporting the Health Workforce through Professional Councils

Standardizing hospital procedures is one way to improve the quality of care, but equally important is supporting the professional growth of the health workforce. To do this, IHSSP helped establish three professional councils (the Rwandan Nurse’s Council, the Allied Medical Professionals Council, and the Pharmacist’s Council) and strengthened the Rwandan Medical Council to serve as governing bodies for their respective professional cadres.

The councils define the licensing standards and track the licensing status of all health professionals in Rwanda, thus reducing the number of unqualified people practicing.

The professional councils also conduct supervisory visits to health facilities—both public and private—either at random or in response to a reported incident of malpractice. In response to negligence, they can take disciplinary action up to and including revoking the provider’s license.

More than just governing bodies, these councils provide opportunities for members to keep abreast of international best practices and cutting-edge discoveries. With IHSSP’s support, all four councils developed a uniform continuing professional development policy to promote learning, inform their members about new developments in their field, and ensure that providers’ skills remain current. The educational opportunities are a benefit for professionals but also a requirement for licensing and a way to ensure quality of care.

Working toward Universal Health Coverage

By broadening access to quality services, Rwanda is truly working toward universal health coverage (UHC) for its citizens. In 20 years, the country has made astounding and measurable improvements to its health system. In 1994, Rwanda’s under-five mortality rate was the highest in the world, and their life expectancy was the lowest. In 2012, their under-five mortality had been cut by nearly two-thirds, to 55 deaths per 1,000 live births, significantly lower than the regional average of 95 per 1,000 births. Rwandan’s life expectancy is now 63 years, 7 years longer than the regional average.

Rwanda is one of the few countries on track to meet or exceed all five health-related Millennium Development Goals. By all measures, its health is improving at unprecedented rates.

But there is more work to be done. Though the health sector’s human resources are stronger than they were five years ago, and structures and policies are in place to further support their professional growth, there are still simply too few doctors and nurses to support the population and their distribution is uneven. And though the accreditation process is well underway in five hospitals, those five have not yet met international standards in many areas, and the remaining facilities have not yet begun the process.

The Rwandan government is not deterred. In the final months of the project, the Ministry of Health asked IHSSP to draft a sustainability plan to guide the health sector’s priorities, growth, and financing over the next ten years in the face of declining donor contributions. The plan touches on every aspect of the health system, from pre- and in-service training to infrastructure and maintenance.

With the systems IHSSP helped put in place, the tools it left behind, and a comprehensive plan for the future, Rwanda’s health system will continue to thrive, providing every Rwandan the opportunity to live a healthy life.