05 July 2012

What Can the US Learn from Rwanda's Health System?

The US health system is often compared to the universal coverage experienced by the majority of the West. Tina Rosenberg tries out something a bit novel in the New York Times by pointing out that Rwanda has the pleasure of sitting aside much wealthier nations by providing universal health coverage.

A sliding pay scale means that the wealthiest in Rwanda pay about $8 a year with a $0.33 co-pay and the poorest quarter of Rwandans receive their care for free. Rosenberg highlights the success of the scheme:
A measure of Mutuelle’s success is a tremendous increase in the use of health care facilities. Drobac said that 80 percent of people in need of AIDS treatment are getting it — a figure in Africa rivaled only by Botswana, which is 20 times richer than Rwanda. Hospital utilization rates have tripled, said Makaka. Five years ago, when giving birth in a health center cost around $25, only 20 percent of women did so. Now that it is 33 cents, 70 percent do — a big reason that deaths of mothers and children have dropped so precipitously.
She then concludes by looking at the sticky issue of cost. Premiums only cover 45% of the the total cost, which means that Rwanda relies heavily on donors to fill the gap. The problems appear to be inconsequential to Rosenberg when she writes, "Rwanda, at least, has used donors’ money wisely, employing it to build a complete health system — and to extend that system to all its citizens. “You can bring on all the diagnostic services, new technologies and specialties,” said Drobac. “But if those things can’t reach people in need, what’s the point?”"

The causal dismissal of relying on aid aside, what stands out most is how Rosenberg characterizes Rwanda and its president.
Rwanda is known, of course, for the 1994 genocide that killed 800,000 Tutsi and moderate Hutu. Since 1994, the country has been ruled by Paul Kagame, at first as de facto leader and, since 2000, as president. Kagame runs a repressive regime that equates criticism with treason; opposition journalists or politicians in Rwanda have disappeared or died mysteriously.

But Kagame is also widely admired as the most effective leader in Africa. A country in ashes 18 years ago is now safe and clean. It is one of the least corrupt countries in Africa. Per capita income has tripled — although the fact that it is now only $550 a year tells you how destitute Rwanda was.
The recent UN Group of Experts report on the M23 rebellion in the DRC is the latest example of the veil that sits squarely in front of Kagame moving every so slightly upwards. The feelings on the Rwandan leader are growing to be more polarizing. Regardless of how one personally feels about him, the story of stability in the nation is not quite as rosy as was once believed.

It's important to point the problem of Kagame out because he needs to play nice with the international community. If the aid rug were to be pulled out from under Rwanda, there is no doubt that a health system that is significantly funded through donors will collapse. That reality does not appear to be happening any time soon, but it is quite possible.

Kagame should be lauded for spending aid money well. By most accounts the health coverage in Rwanda is impressive. Of all countries in Africa Rwanda is probably getting the closest to having health for all, health access for all,” said Josh Ruxin told Rosenberg. Rwanda is posting some stunning numbers, such as raising life expectancy by 10 years in the bast decade. The question is if it is something that other nations should emulate.

Rosenberg seems to be making the point that the US can do it if Rwanda is, but what about other countries in the global south? Will health systems survive when so reliant upon foreign aid? Are donors interested in funding health systems given the vertical approach undertaken by programs with the most money?