Learning from Rwanda’s extraordinary health gains

As many of you will have seen from Twitter I’ve spent the last week or so in Rwanda visiting health clinics and hospitals around the capital Kigali to learn about the health system there - its successes and challenges. This is the first of two blogs I’ll share about some lessons from my time there. I’ll focus this first one on some amazing results the country has delivered and three insights to take from how they’ve done this. The next will give a couple of case studies that I think are of relevance for us to learn from in the UK.

I’m hugely grateful to Dr Gabin Mbanjumucyo, Emergency Medicine Consultant and President of the Rwanda Emergency Care Association for supporting my visit, and to Dr Stevan Brujins, Consultant in Emergency Medicine at Yeovil Hospital for suggesting I come to Rwanda in the first place.

With Dr Gabin Mbanjumucyo

Amazing results

Before I get into the detail of how Rwanda’s health system works, I want to share some of the extraordinary results the system there has delivered over the last 20 years. They have delivered:

• An 84% reduction in maternal mortality rates since 1992 
• A fall in infant mortality rates from 151/1000 in 1990 to 55/1000 in 2012 (Binagwaho et al, 2014)
• An increase in life expectancy from 33 in 1990 to 63 in 2012 (Dhillon and Phillips, 2015)

Infant mortality in Rwanda compared to world and sub-Saharan Africa (taken from Yamey et al, 2015)

These drastic improvements in outcomes have been driven by a number of specific process measures that have tackled the root cause of mortality. For example, the government has exceeded the Millenium Development Goal target of 80% of HIV patients on Anti-retroviral therapy. By combining this with transport and nutritional support for these patients the government has ensured they continue participating in treatment. Through these actions AIDS mortality fell by 82% between 2000 and 2012. 

Similarly, to reduce maternal and infant mortality, the government knew that what mattered was to increase the presence of a skilled health worker during delivery. Since making this a priority the percentage of mothers giving birth with a health worker present has tripled from 31% to 91% (Abbott et al, 2017) and the outcome in mortality rates has followed with it. 

There’s clearly much still to do: growth stunting due to nutrition is still a major issue, there aren’t enough health workers in Rwanda, and external funding is important to sustain these results while the economy grows. But the successes are truly awe-inspiring  for a country that in 1994 was all but destroyed by a genocide that saw almost one million of the population killed.

Learning from Rwanda: priorities, structure and incentives

I’d like to draw out three elements of Rwanda’s health system that particularly stuck out for me and that can prompt discussion for us in the UK .

1. Priorities and delivery

As I visited health professionals across a range of services I was struck by their clarity on current health priorities and everyone’s role in delivering them. For example, maternal mortality is a clear priority in Rwanda in which, as shown above, they have had considerable success. Everyone I met talked me through (unprompted) how much of a priority maternal mortality was and how their role contributed to it. For example:

• Community health workers told me how they could text a hospital to alert them if they had concerns about a mother’s health in order to get early support,
• Health centres talked about their need to quickly triage and transfer any mothers at risk to more specialist referral centres, 
• Ambulance teams discussed the relative priority of transferring an at-risk mother to hospital to ensure prompt intervention
• ED consultants talked me through how any maternal deaths were investigated in detail by the most senior healthcare staff to identify lessons to stop it recurring.

This clarity of objectives is cascaded effectively by a very clear structure that links the highest government levels to local communities as discussed next.

Rwandan ambulance teams prioritise at-risk mothers to reduce maternal deaths

2. Structure: connecting national to local

The structure of the health system in Rwanda provides a very clear way of linking the most local health interventions with the most specialised central ones. The diagram below summarises the key tiers within the health system. Generally to access the level above, patients must be referred by the preceding level. 

Health system structure in Rwanda

This structure provides a clear cascade from government down to the most local communities on key health messages. For example, through community meetings held monthly and through door-to-door visits conducted by Community Health Workers, key messages on malaria prevention, family planning or HIV reach almost everyone in the country. In addition, the system enables local teams to escalate issues they may face more locally. For example, the community health worker text system allows them to immediately alert more senior staff on mothers who may be at risk to ensure appropriate action is taken at an early stage. 

The link of the national to the local isn’t just structural, there is also a clear alignment of incentives throughout the health and care system. 

3. Incentives

In the UK we’re used to CQC inspections and I suspect many staff could talk through the key domains and priorities. The regulatory process for hospitals in Rwanda is similar with accreditation processes assessing hospitals’ maturity on a scale of one to three. Hospitals are assessed against five domains:

1. Leadership and accountability
2. Competent and capable workforce
3. Safe environment for staff and clients
4. Clinical care for patients
5. Quality improvement and safety

When I visited hospitals I was struck by how quickly staff would cite these five domains and their constituent priorities. However, of particular interest was that the pay of staff at hospitals is highly dependent on their quality outcomes through something called Performance Based Financing (PBF). Under this scheme, approximately 20% of the hospital’s income is dependent on peer-reviewed achievement of these quality standards. This in turn affects staff wages in the institution - based on informal feedback a doctor with one year’s post-graduate experience may earn the equivalent of £500 a month. Of this up to 25% is made up of their PBF payment contingent on the quality of the hospital they work in. 

This principle of quality-linked pay permeates throughout the system. Even Community Health Workers receive some small payments depending on key quality measures they are assigned such as the number of TB screenings undertaken. 

For a more detailed discussion and evaluation of Rwanda’s PBF scheme, this article is a great start. Clearly incentives must be used carefully but it is clear the PBF in Rwanda provides an incentive system that cascades across the health system and ensures everyone is aware of their part in delivering priorities. 

With Dr Marcel Uwizeye, a passionate leader of one of Rwanda’s newest District Hospitals which has achieved positive results in its accreditation

Final thought

The health system, government, and communities in Rwanda have clearly done amazing things since the horrendous experiences of the genocide 24 years ago. Their reduction in maternal and child mortality as well as the almost doubling of life expectancy contain lessons for developed as well as developing health systems. In my next blog, I’ll focus on two particularly interesting case studies there: the growth of emergency medicine as a specialty, and the role of the community health worker which I think has huge relevance for us in the UK.

Articles referenced

Abbott, P. et al (2017), Learning from success: how Rwanda achieved the Millenium Development Goals for Health, World Development, Vol 92, pp. 103-116

Binagwaho, A. et al (2014), Rwanda 20 years on: investing in life, Lancet, 384:371-75

Dhillon, R. S. and Phillips, J. (2015), state capability and Rwanda’s health gains, Lancet, vol 3 June 2015.