Rwanda's Quest for Universal Health Coverage

The following essay on Rwanda's Quest for Universal Health Coverage was featured in the Commonwealth Health Partnerships annual booklet, which is now available online: http://www.commonwealthofnations.org/wp-content/ebooks/CHP15/#/102/

I encourage you to look over the various essays on topics related to UHC, ageing, governance, NCDs, and much more throughout this publication.

Securing Health For the Next Generation

An Op-Ed that I recently wrote on ways to improve healthcare for the next generation was featured in Uganda's newspaper New Vision on 12 December. The full article is available at this website: http://www.newvision.co.ug/news/662800-securing-health-for-the-next-generation.html#.VIq-RCh3aVU.gmail and provided below:

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"When I served as a pediatrician in Rwanda’s public hospitals, I devoted myself to building a future where children could reach their full potential without fear of disease.

Today, as Rwanda’s Minister of Health, I can attest to the great progress our country has made to improve the health of everyone living in the “land of a thousand hills.” But I also recognize how critical it is to keep pressing onward, not only as a country, but also as a continent.

Africa is home to some of the fastest growing economies in the world, but the benefits of this progress have not been felt equally.  For far too many, basic health care remains out of grasp. Millions of Africans simply do not have access to health facilities staffed with trained workers, or even to experienced community health workers. Even for those fortunate enough to live in close proximity to a health facility, many cannot afford to pay for basic healthcare services.

The time has come to commit to making affordable, quality health care the cornerstone of Africa’s development. Several African countries have taken a stand on providing health services  

    to all their citizens, and their efforts are already paying off through healthier communities.

Twenty years ago, Rwanda was a nation devastated by genocide and war: Nearly eight in ten people lived in poverty, our health system was all but destroyed, and one in four infants didn’t make it to his or her fifth birthday.

Today, even though we still have a long way to go, Rwanda is flourishing. This is due to many factors, including a collaborative governance structure that aims to extract the most value for our people from the money spent.

Rwanda’s visionary approach to prioritizing the nation’s health has also been instrumental in achieving this progress.

Combining national resources with international donor support, we have developed a system to improve both geographic and financial access to quality basic care for all Rwandans. 

Through our community-based health insurance scheme, called Mutuelles de Sante, approximately 90 percent of the population has health insurance, with another 7 percent reached through civil, military, or private insurance.

Even in the most remote villages, Rwandans can rely on local community health workers to deliver 80 percent of the preventive and primary care services and connect them to advanced care when needed. Under this system, Rwandans can access care without fear of financial ruin.   

The results of this approach, driven by a deep commitment to health equity, have been striking: Since 2000, infant mortality has decreased by 66 percent, child mortality has decreased by more than 70 percent, and deaths from HIV, malaria, and TB have fallen by nearly 60 percent.  Rwanda’s children were the first in sub-Saharan Africa to receive the vaccines for pneumonia and the human papilloma virus (HPV).

Other African nations are also making important strides towards universal health coverage. Each country is developing its own model to provide coverage for its people—informed and influenced by our distinct cultures, histories, populations and settings.  For example, in Uganda, the government has committed to establishing mandatory health insurance for all citizens by 2025. Going forward, it is necessary that each country feel ownership of both the successes and failures of the approach they opt to take.

Whatever the approach, health systems should be participatory in nature, ensuring that communities provide “buy in” to the value of having health insurance, as well as a sustained political commitment to scale up these efforts.  This will help ensure that no one remains beyond the reach of efforts to provide affordable, quality care.

The need for universal health care has never been greater throughout the world, and especially in Africa. Despite commendable progress in health over the past decades, Africa still faces the highest burden of disease, and continues to have far too many weak health systems. The recent Ebola epidemic has highlighted what is at stake for all of us if we fail to invest in both strong health systems alongside good governance. 

Health coverage is also a major financial challenge. Millions of Africans suffer financial hardship due to catastrophic expenditure whenever they are sick. According to the World Health Organization, about half of health care expenses in our region are paid out-of-pocket, and a 2009 study in Health Affairs found that one in every three households in Africa must borrow money or sell their possessions just to pay these fees.  

No family should have to choose between getting well and going bankrupt, especially when we’ve witnessed what a powerful force national health care can be for stability and economic growth. When governments invest in affordable health care, the whole population is healthier.  There are real economic benefits: there is less absenteeism at work, and the money saved by avoiding these consequences of poor health can be invested in building stronger futures for families and communities. School fees can be paid, new business can be started, and households can build savings.

Politically, there has never been a better time for us to invest in universal health coverage. Two years ago today, the United Nations unanimously endorsed universal health coverage. Global institutions such as The Rockefeller Foundation and, more recently, The World Bank, have elevated the benefits of UHC globally, and to date more than 80 countries have asked the World Health Organization for assistance in implementing universal health coverage.

Today, we mark the anniversary of this landmark decision with the first-ever Universal Health Coverage (UHC) Day, a global call-to-action that has garnered unprecedented support from more than 500 organizations.

As we look beyond the 2015 Millennium Development Goals, African leaders face an incredible opportunity: If we invest in our health systems now—which we know yields an impressive return for the investment—we can build an Africa where individuals, families, and entire nations reach their full potential. 

Together, we can chart a course for a stronger, more resilient Africa and world."

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From Uganda's newspaper New Vision - web link: http://www.newvision.co.ug/news/662800-securing-health-for-the-next-generation.html#.VIq-RCh3aVU.gmail  

Universal Health Coverage

I was so pleased to have the chance to contribute some remarks regarding the importance of Universal Health Coverage (UHC) as a global coalition celebrated UHC Day 2014 on 12 December 2014.  You can view a video of my remarks that was presented at a launch day event in London, UK, at the London School of Hygiene and Tropical Medicine and learn about all of the great work of this coalition through their website: http://universalhealthcoverageday.org/welcome/ .  We should all continue to monitor and support this great #HEALTHFORALL campaign.

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Coverage of my remarks at LSHTM 

(Link)

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The Video of My Remarks

(Link)

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Here are a few additional stories regarding UHC Day

1) Press Release from Rockefeller Foundation -  https://twitter.com/RockefellerFdn/status/543517004947525633/photo/1

2) Rwanda New Times Article - http://www.newtimes.co.rw/section/article/2014-12-13/184004/ 

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UHC Campaign 

A Grand Convergence for Global Health 

I was very proud to be part of this Lancet Commission, which could help countries in these final miles of the 2015 Millennium Development Goals (MDGs) and to plan beyond...

The entire report overview in .pdf format can be found here: http://www.globalhealth2035.org/sites/default/files/policy-briefs/overview-english.pdf - text and figures are pasted below.

"REPORT OVERVIEW

the growth in full income in low- and middle-income countries between 2000 and 2011 resulted from health improvements. Figure 3 summarizes estimates of the contribution of health to growth in full income in 1990–2000 and in 2000–2011 for different regions of the world.

As the world approaches the 2015 deadline for achieving the Millennium Development Goals and the international community negotiates the next global framework, massive health disparities still exist across countries. The vast majority of people who die from preventable deaths caused by infectious diseases or maternal and child health conditions live in low- and lower-middle income countries.

Global Health 2035 is an ambitious new investment framework to begin closing this health gap within a generation. Written by The Lancet Commission on Investing in Health, a group of 25 renowned economists and global health experts, Global Health 2035 provides a roadmap to achieving dramatic gains in global health through a grand convergence around infectious, child and maternal mortality; major reductions in the incidence and consequences of non-communicable diseases (NCDs) and injuries; and the promise of “pro-poor” universal health coverage.

A “grand convergence” in health is achievable within our lifetimes

A unique characteristic of this generation is that we have the financial and ever-improving technical capacity to begin closing the global health gap. History shows that even poor countries can achieve rapid declines in death rates by investing in health. Global Health 2035 points to the “4C countries”—Chile, China, Costa Rica and Cuba—which started off at similar levels of income and mortality as today’s low-income countries, but sharply reduced their preventable deaths by 2011. The 4C countries are now among the best-performing middle-income countries.

Global Health 2035 outlines a path for today’s low- and lower-middle- income countries to achieve similar rates of dramatic progress, reaching levels of mortality seen today in the 4C countries and averting about 10 million deaths in 2035. The 2035 convergence goals are summarized as “16-8-4”—reducing under-5 mortality to 16 per 1,000 livebirths (see figure 1), reducing annual AIDS deaths to 8 per 100,000 population and reducing annual tuberculosis (TB) deaths to 4 per 100,000 population.

Global Health 2035 lays out a detailed investment framework for national governments to achieve the “16-8-4” convergence goals by:

·       aggressively scaling up new and existing tools to tackle HIV/AIDS, TB, malaria, neglected tropical diseases and maternal and child health conditions; and

·       strengthening their health systems using a so-called “diagonal approach”—that is, building systems that specifically improve these countries’ ability to tackle the highest burden health challenges

About two-thirds of child deaths, AIDS deaths and TB deaths now occur in middle-income rather than in low-income countries. Achieving convergence therefore demands action that goes beyond low-income countries to also focus on poor, rural sub-populations of middle- income countries.

The Commission estimates that the average incremental cost of convergence for 34 low-income countries will be about US $23 billion annually from 2016-2025, rising to around US $27 billion annually from 2026-2035. The incremental cost in lower-middle-income countries will be about US $38 billion annually from 2016-2025, rising to around US $53 billion annually from 2026-2035. The expected economic growth of middle- income countries will easily allow these countries to finance convergence entirely from domestic sources. While low-income countries will require some external assistance, they should be able to finance most of the incremental cost of achieving convergence themselves.

The international community should unite around the vision of Global Health 2035 and support the innovation and technical assistance needed to achieve it

The international community can best support convergence by renewing its commitment to providing global public goods, particularly health research and development (R&D), and managing cross- border externalities, such as preparing for influenza pandemics. These core functions have been neglected in the last 20 years. Convergence cannot be achieved with today’s health tools, many of which are decades old. The international community should double its current R&D spending from US $3 billion (see figure 2) to US $6 billion annually by 2020, with half of this additional amount coming from middle- income countries.
Some low-income and lower-middle- income countries will continue to require external financial assistance to scale up tools for achieving convergence. Eliminating malaria and combating drug-resistant TB and the threat of drug-resistant malaria will in some cases require assistance to middle- income countries.

The returns to investing in health are even greater than originally estimated

The costs of convergence are substantial, but the payoffs—in both health and economic terms—are much greater. Global Health 2035 proposes a more comprehensive approach to measuring the returns to investing health.

The impact of health on economic productivity has been well documented in recent years. Improved health has contributed importantly to income growth in low-income and middle- income countries, as measured using traditional national income accounting (based on GDP).

But while GDP captures the benefits that result from improved economic productivity (the so-called instrumental value of better health), it fails to capture the intrinsic value of better health—the value of health in and of itself. Global Health 2035 reports a more comprehensive understanding of the returns to investing in health by estimating this intrinsic value using a “full income” approach. This approach combines growth in national income (GDP) with the value people place on increased life expectancy—that is, the value of their additional life years (VLYs). Global Health 2035 estimates that 24% of

Using the full income approach to estimate the economic benefits of convergence in low-income and lower-middle-income countries from 2015-2035, the benefits exceed costs by a factor of 9-20, making the case for action even stronger.

The full income approach provides finance ministries, donors and other decision-makers with a strong rationale for investing in health to put their countries on a path to rapid improvement in national welfare.

Fiscal policies can dramatically curb NCDs and injuries, as well as leverage significant new revenue for low-and middle-income countries

One paradox of success in global health is that when low- and middle-income countries successfully reduce deaths from infections and maternal and child conditions, they then accelerate the shift in their disease burden to NCDs and injuries in adults. Global Health 2035 lays out the steps that all low- and middle-income countries could take now to delay the onset of NCDs to as late as possible in life and thus reduce premature illness and death.

National governments can curb NCDs and raise significant revenue by heavily taxing tobacco and other harmful substances, such as alcohol. They can redirect finances toward NCD control by reducing subsidies on items such as fossil fuels, which produce air pollutants that cause NCDs.
A tobacco tax is the single most powerful lever for curbing NCDs. In the next 50 years, for example, a 50% tax on tobacco could prevent 20 million deaths in China and 4 million in India and generate US $20 billion and US $2 billion annually in each country, respectively.

Donors and UN agencies should focus on provision of technical assistance on tax and subsidy policies, regional cooperation on tobacco (e.g. to reduce smuggling), and funding of population, policy and implementation research on scaling-up of interventions for NCDs and injuries.

Progressive universalism, a pro-poor pathway toward universal health coverage (UHC), is an efficient way to achieve health and financial protection

In order to protect the poor from impoverishing health costs, and to ensure that they benefit the most from the investments laid out in Global Health 2035, countries should adopt “pro-poor” pathways to insuring their citizens.

The Commission endorses two pathways to achieving UHC within a generation, which commit to covering the poor from the outset (“progressive universalism”). In the first, publicly financed insurance would cover essential health-care interventions to achieve convergence and tackle NCDs and injuries (figure 4). This  pathway would directly benefit the poor, since they are disproportionately affected by these problems. The second pathway provides a larger benefit package, funded through a range of financing mechanisms (e.g. payroll taxes, insurance premiums, copayments), with poor people exempted from all payments. Governments should approach UHC through progressive universalism—a commitment to reach the poor at the outset—to yield high health gains per dollar spent and ensure the poor benefit from health and financial protection.

One immediate way that the international community can support countries in implementing progressive universal health coverage is by financing critical research, such as on the mechanics of designing and implementing evolutions in the benefits package as the resource envelope for public finance grows.

Global Health 2035: A Call to Action

Global Health 2035 offers a new vision for profoundly transforming the global health landscape within a generation. Meeting its ambitious goals will require scaled up investments and innovations in global health technology, health systems and policies.

As an immediate first step toward realising this vision, global leaders—including low- and middle-income countries, donor nations, international agencies and civil society organisations—should unite around the goal of convergence and incorporate it into the post-2015 framework that is currently being negotiated.

By harnessing the financial and ever-improving technical capacity of our generation, we can avert 10 million deaths in 2035 and ensure healthy, productive lives for millions more people—a remarkable step toward closing the massive gap that has defined global health for the past three decades.

Figures (all from the Report Overview document)

the full report was published in the Lancet on 3 December 2013 and can be found at www.lancet.com." 

The above text and figures are from http://www.globalhealth2035.org/sites/default/files/policy-briefs/overview-english.pdf

Video for Harvard's Universal Health Coverage Conference 2012

This video was recorded for Harvard's conference on "Universal Health Coverage: Challenges, Measurements, and Evaluation Strategies" on 13 September 2012. In this video, I present Rwanda's community-based health insurance program, Mutuelles de Santé, and describes the principles of policy-making and program implementation in Rwanda.

You can also watch this video by clicking here.