The Atlantic magazine had an interesting article this month: “Rwanda’s Historic Health Recovery: What the US Might Learn” by Neal Emery. Given the appalling genocide in Rwanda in 1994, the statistics of the country’s turn-around in health are truly good news. Given that bad news is the traditional fare of newspapers, it is worth highlighting what has happened in this Third World country in sub-Saharan Africa.
Emery writes that in the wake of the genocide Rwanda seemed another failed state. One in four children died before their fifth birthday and life expectancy was aged 30. However, within the last ten years alone, Rwanda has seen huge improvements: deaths from HIV, TB and malaria have each dropped by roughly 80% and the maternal mortality ration has dropped by 60 per cent. Despite a population increase of 35 per cent since the years 2000, the number of annual child deaths has fallen by 63 per cent. The economy is growing rapidly and millions have lifted themselves out of poverty during the same period.
These dramatic developments did not happen because of an influx of Western aid following the genocide. Emery writes that many aid organisations “wrote off the country as a lost cause” and that Rwanda “achieves its superb improvement while spending only $55 per person on health care and public health per year”. Emery cites an article by Dr Paul Farmer in the BMJ which investigated the ways in which Rwanda has been able to achieve these results. It seems that they are due because of how money has been spent on healthcare rather than on how much has been spent.
Credit is largely due to the Rwandan government’s centralised planning of health care. In 2000, the Government created a plan called Vision 2020, with the aim of developing into a middle-income country within 20 years. Economic growth required a corresponding improvement in health. Thus all the government ministries had to coordinate plans to deal with HIV and later on, other non-infectious diseases such as cancer. Outside funding agencies and NGOs had to fit in with Vision 2020, rather than push their own agenda. Money given to Rwanda to combat HIV has been used to build a system of primary care because “HIV does not exist in a vacuum – if an HIV program does not address the associated problems such as tuberculosis and malnutrition it will fail.”
Rwanda’s Minister of Health, Dr Agnes Binagwaho, emphasises that as well as building hospitals and clinics, the country has trained 45,000 community health workers who provide in-home care and psychosocial support for HIV patients as well as basic primary care for local communities. Rwanda also has universal health insurance; Dr Binahwaho comments, “Whatever we do, we make sure that the poorest and most vulnerable have benefits too.”
The article makes the point that in the US, despite its wealth, the health system relies too heavily on doctors and hospitals to provide care; many poorer patients living in the community fall through the cracks. It struck me that the UK could also learn from the example of Rwanda. Listening to “Yesterday in Parliament” I heard Jeremy Hunt, the Health Secretary, yet again talk about the importance of “compassionate care” rather than a managerial, target-based model of the kind that led to the Mid Staffs NHS Trust scandal. But are they mutually exclusive? Rwanda’s Vision 2020 has the goal of a radically improved health system – but without failing the most vulnerable.
By far the biggest problem the UK has to face now and in the future is the growing numbers of the elderly needing some form of support and help at home. Much of this basic care could be provided in the community – but the present system is woeful: too few and untrained care workers struggling with a large list of housebound and vulnerable people for whom “compassionate care” doesn’t exist. The NHS has enormous sums of money at its disposal; perhaps this budget could be used more effectively in recruiting and training more and better-qualified community health workers? As Rwanda shows, it is not how much money is available that matters, but how effectively the money is spent.