Fixes looks at solutions to social problems and why they work.
Last week’s Supreme Court decision upholding of the constitutionality of President Obama’s health care law moves the United States closer to the goal of health coverage for all. All other developed
Fixes looks at solutions to social problems and why they work.
Last week’s Supreme Court decision upholding of the constitutionality of President Obama’s health care law moves the United States closer to the goal of health coverage for all. All other developed countries have it. But so do some developing nations — Brazil, Thailand, Chile. These countries are mostly middle income. But one country on the list is among the poorest of the poor: Rwanda.
The point is not that Americans should envy Rwanda’s health system — far from it. But Rwanda’s experience illustrates the value of universal health insurance. “Its health gains in the last decade are among the most dramatic the world has seen in the last 50 years,” said Peter Drobac, the director in Rwanda for the Boston-based Partners in Health, which works extensively with the Rwandan health system.
It couldn’t have happened without health insurance.
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.
Its most impressive gains, however, have been in health. AIDS has been cutting life expectancies in Africa and is widespread in Rwanda. Yet life expectancy at birth in Rwanda has increased from 48 to 58 — in the last 10 years. Deaths of children under 5 have dropped by half in five years; malaria deaths have dropped by roughly two-thirds. “Of all countries in Africa Rwanda is probably getting the closest to having health for all, health access for all,” said Josh Ruxin, a longtime resident of Rwanda who is the founder of the Access Project, a Rwandan-run health program.
One key reason that Rwandans are so much healthier today is the spread of health insurance. In 1999, Rwanda’s health facilities sat unused, as the vast majority of people couldn’t afford them. In response, the Health Ministry began a pilot project of health insurance in three districts. In 2004, the program began to spread across the nation. Now health insurance — called Mutuelle de Santé — is nearly universal. Andrew Makaka, who manages the health financing unit at the Ministry of Health, said that only 4 percent of Rwandans are uninsured.
Mutuelle is a community system — premiums go into a local risk pool and are administered by communities. Until last year, Mutuelle’s premiums were about two dollars a year. This system turned out to be untenable — even two dollars a year was too much for a lot of people. (If you are a rural farmer with an income of some $150 a year, you have to spend every penny on food.)
Last year Mutuel