Rwanda and Universal Coverage:
focusing on quality and equity
Lisa Hirschhorn, MD MPH
Harvard Medical School
Partners in Health
JSI Research and Training Inst.
April 2013
Universal Coverage
• Universal coverage is critical
– ensure access to care for those in need,
– Provide financial risk protection by lowering
catastrophic out-of-pocket health spending
• BUT also need to ensure
– Access for all
– Quality
– Responsive system which meets the needs of the
community
The 5th area of quality
EQUITY
Structural
Quality
Process
Quality
(systems)
(activities)
Outcomes
Quality
(results)
Customer
defined
quality
3
Rwanda: 26,300 km2
10.6 million people
Massachusetts: 27,300 km2
6.6 million people
Annual growth 2002-11: 7.6%
Life expectancy: 56 years
(up from 28 years in 1994)
Per capita health spending: $55
4
Rwanda and Mutuelles
• Insuring underserved populations considered
effective means of improving access to care
• Mutuelles de sante´ (Mutuelles)
– Community-based health insurance program
established by the Government of Rwanda
– Key component of national health strategy to
provide universal health care
2000: Pilot
2006: Fully implemented
2008: Further regulation and strengthening
What is the impact?
• Child and maternal care coverage (2000-2008)
• Household catastrophic health payments
(2000 to 2006)
• Enrollees’ medical care utilization
Improved medical
care utilization
Protected
households from
catastrophic
health spending
Maternal and Child Health Intervention Uptake in Rwanda, 2000 – 2010
2000
2005
2008
2010
90.1%
80.4%
76.0%75.2%
70.3%
68.9%
60.2%
45.1%
27.4%
45.2%
26.5%28.2%
15.8%
10.3%
5.7%
Married women (15-49
years) using modern
contraception
4.0%
Deliveries at health facility Children (0-5 years) sleeping Children (12-23 months)
under LLITNs
given all basic vaccinations
Farmer PE, Nutt CT, Wagner CM, Sekabaraga C, Nuthulaganti T, et al. (2013). “Reduced Premature Mortality in Rwanda: Lessons
8
from Success.” British Medical Journal 346(f65): Courtesy of Dr Binagwaho. MOH, Rwanda
What about equity?
• Lowest expenditure quintile: significantly
lower rate of utilization and higher rate of
catastrophic health spending.
Annual Rates of Decline in Child Mortality by
Wealth Quintile and Residence, DHS 2008 and 2010
(measures 10 years preceding survey)
18.5%
15.1%
15.2%
15.1%
11.9%
5.7%
3.6%
Lowest
Second
Middle
Fourth
Highest
Rural
Urban
National Institute of Statistics of Rwanda, Macro International, Inc. (2012). Rwanda Demographic and Health Survey 2010. Calverton,
11 MD:
Macro International, Inc. Courtesy of Dr Binagwaho. MOH, Rwanda
So……
• Rwanda’s experience suggests communitybased health insurance schemes can be
effective to achieve universal health coverage
even in the poorest settings.
• Challenge is to ensure that access and
protection is equal for the poorest
– Financial assistance
• BUT……..
Lu C, Chin B, Lewandowski JL, Basinga P, Hirschhorn LR, et al. (2012) Towards Universal Health Coverage: An
Evaluation of Rwanda Mutuelles in Its First Eight Years. PLoS ONE 7(6): e39282.
Building a Health System
WHO-recommended
health worker density:
2.3 per 1,000 pop.
Rwanda’s health worker
density:
0.84 per 1,000 pop.
Referral
Hospital
(5)
District Hospital
(42)
Physician Specialist
(150)
Physician Generalist
(475)
Nurse Generalist
(8,273)
Health Center
(469)
Community Level
(14,837)
~80% of burden of disease addressed here
Community Health
Workers
(~45,000)
13
Courtesy of Dr Binagwaho. MOH, Rwanda
So if quality is similar, what about
scope?
• Your choice is to staff a few health centers
with higher level nurses and an MD able to
provide more advanced care
– HIV, NCD management, other
OR
• Do you ensure full district coverage for more
basic care
– First line ART, basic screening and treatment for
NCDs
What are the responses?
• Increase training
– HRH
• Task sharing
What is it
• WHO: “the rational redistribution of tasks
among health workforce team”
– Specific tasks moved when appropriate from
qualified health workers to health workers with
shorter training and fewer qualifications”
• Existing cadres or new ones
Not just short term fix but
approach to strengthen the health
system
Can task shifting care expand
universal access and
ensure/sustain/ improve quality?
Task shifting, quality and ethics
• Multiple studies found increased access and
uptake
– Botswana (nurses); Haiti (CHWs), Zambia (nurses)
1. What if quality is not as good and care is not as
effective?
2. Is it right to provide basic care access but with
providers not able to provide more advanced care
or ensure access at another site ?
Task shifting, quality and HIV in RLS
Country
Cadre
Tasks
outcomes
Kenya (Selke)
Nurse to
Monitoring
trained PLWHA (clinic to homebased)
Shift vs Standard of care
Viral suppression : 93% vs 87%
CD4 counts : 404 vs 358)
New OIs : 13.6 versus 19.8/100 pys
Rwanda
(Shumbosho)
MD to nurse
ART prescription
Process: adherence (89%) and SEs
(84%) assessed, ~100% correct Rx
Outcomes:
90% 1 year survival
92% 1 year retention
Mozambique
(Bretlinger)
tecnicos de
medicinas
HIV care and
treatment
Agreement with clinical observer:
WHO staging: 38%; cotrim: 72%,
ART 76%
Malawi
(Zachariah)
Nurse to CHW
F/U; home-based Improved alive and on ART (95.6%
monitoring and
vs 75.8%)
referral for OIs
South Africa
(Long)
MD to nurse
Down referral of
stable pts
Lower death /LTFU (RR = 0.27, 95%
CI 0.15–0.49) and lower
Selke HM et al. JAIDS 2010: 55;483-490, Shumbusho, F. PLoS Med 2009 6: e1000163, Long L, PLoS Med
2011 8(7): e1001055; Bretlinger HRH 2010,8:23; Zachariah R, Trans R Soc Trop Med Hyg 2008;
Task shifting and ethics
• Medical ethics: provide the best standard of care
you can
• Public health ethics: require health system to
consider how to help patients who can not access
care1
• Challenge: focus on quality of care for few with
access to surgeon versus the “silent” majority
who do not
• “islands of excellence in a sea of underprovision” 2
• “continued policy inaction amounts to
unwarranted healthcare rationing and as such is
ethically untenable” 3
1. Chu K, PLOS 2009 6:e1000078; 2. Ooms G. Global Health 2008 4:61; 3. Price and
Binagwaho. Dev World Bioeth. 2010 ;10:99-103.
Conclusions
• Public Insurance are a key tool to ensuing
increased access
• However focus must remain on ensuring BOTH
equity and quality
– Need to measure
• Task shifting when done well can sustain or
improve quality and increase access
• More work is needed to determine the most
effective use and limits of task shifting and other
innovative and scalable approaches to ensuring
quality with limited resources