OK, let's back to the Swallows - I've got to write about them first, as several people reading this blog have asked me how they are getting on. Four weeks ago, the three baby swallows in the nest on my balcony fledged. ie they came out of the nest and flew - up onto the guttering, and then, after four days of shouting at their parents to feed them - they were gone. Just like human children, I expect; their departure left me feeling at little empty.
To add to that, I have been away from Kigali for a couple of weeks in the UK where a close relative passed away, which was very sad for me and my family. Most of us from the UK don't encounter death regularly; children are inoculated at birth against all sorts of diseases, everyone gets plenty of good food, and the health service is well equipped and can fix many problems. But things aren't the same in Rwanda. This morning I cycled past King Faisal Hospital - which is the main hospital in town, with the best facilities and some of the country's top medical specialists. But even with this available, some of the richest people in the country will still travel to Nairobi or South Africa if they have serious health problems.
That route is only available to very few, of course; everyone else uses what is available locally. In the rural areas (ie most of the country) there are small health centres with inpatient beds and outpatient clinics, staffed by nurses and sometimes a doctor, who can treat minor conditions. The health centre pharmacy should be stocked with the standard range of basic drugs, including ARVs. But still the current health numbers for Rwanda are shocking to me: 103 out of every thousand children die before their fifth birthday - that is one in every ten little kids you see on the street die before they are 5 years old (it is 6.5 per 1000 in the UK), and 750 women out of every 100,000 giving birth will die as a result of their pregnancy (that is one woman dying in childbirth every three hours ).
The big problem is resources: the Rwandan Government does not have enough money to go round all the needs: to put it in perspective, the British Government last had the same amount of money per head available as Rwanda has now to spend on its population, in 1709 - exactly 300 years ago. So choices are really tough, and the way the Government deals with it in the health sector is having a mutual contributory health insurance scheme, known as the ‘Mutuelles de Sante'. Membership costs £1.30 per person per year, and the poorest should get their contributions paid. About 70% of the population are members, and attendance at health centres has hugely increased as a result.
But because people have to make a co-payment of £0.20 for each visit and pay 10% of the cost of hospital treatment, some people still do not come, fearing bills which they have no way of paying. Take Lauent Rugero, the blind, disabled, ex-soldier I met in Kayonza; there is no way he could afford these payments; he only has a bed, some clothers and a few cooking implements in his 10 foot square mud built house. But other, richer people can afford them - and could make even larger contributions. Some argue that a completely free system would be best, but the Government fears unnecessary use of the system and creating a culture of dependency, so financial contributions continue.
Controversial stuff, certainly, (see this document, Towards universal health coverage in Rwanda, a 2007 briefing by Caroline Kayonga, Permanent Secretary, Ministry of Health, Rwanda) but vital to get it right. DFID is a major contributor to the health system, but in the long run it will be Rwandan people and their Government who will shoulder the full burden of paying the costs of health, and they need a system that will fit their circumstances.
The swallows were successful in bringing up their offspring - I don't think any died; luckier than many families living here. Now they have even come back to the nest to have another brood, and I won't be able to resist writing about their future progress.
5 comments
Comment by Katine Editor posted on
The expense of healthcare is a seemingly impossible barrier for the poorest across the African continent. It is for that reason that healthcare provision is one of the five components of the Guardian's joint rural development initiative in Katine, Uganda.
But even with donor funding, not all medical needs are being met.
Madeleine Bunting writes a blog evaluating progress in meeting the key indicators as the Katine Project reaches its midway point. The blog is also open to comment, especially suggestions of what other measures need to be set up and questions asked to ensure sustainability of outcomes.
http://www.guardian.co.uk/society/katineblog/2009/jun/22/health-amref-review
Comment by Rob Yates posted on
You are absolutely right Martin, health financing is controversial stuff just witness what is happening in the United States at the moment with President Obama trying to introduce universal health care. The problem facing all governments is how to raise sufficient funds for the health sector without excluding the people who need services most.
But after years of heated debate, a consensus does appear to be emerging that countries should try and move away from funding health care using out-of-pocket payments and instead they should rely more on pre-payment mechanisms. The impressive coverage of the mutuelles in Rwanda is therefore very encouraging but you are right to highlight that there may still be problems associated with co-payments. This is because research has shown that even the smallest user fee can inhibit access by vulnerable people See:
http://www.povertyactionlab.org/papers/Dupas%20Free_Distribution_vs__Cost-Sharing_10.15.07.pdf
If we are to achieve the health MDGs, it is particularly important that women and children should have priority access to effective health services. Therefore we should welcome the recent Global Campaign for the Health MDGs, luanched by the United Nations Secretary General in New York in early June. As part of a broad consensus on maternal, neo-natal and child health, this recommends that countries should provide “Free quality services for women and children at the point of use” See:
http://www.ausaid.gov.au/publications/pdf/lead_by_example.pdf
In my opinion this would be a sensible first-step towards removing financial barriers and achieving WHO’s goal of universal health care coverage.
Comment by Martin Leach posted on
Rob, thanks for your detailed comment. My response turned out
to be longer than I expected so it's become a whole new blog
post at http://blogs.dfid.gov.uk/2009/07/the-reality-of-rwandan-health-provision/. Martin
Comment by Karishmah posted on
I will be going to work in the Ministry of Health in Burundi later this year, so this was a very useful read, thanks.
Any insights you can give into the health debates (e.g. how far they have got with health financing) in Burundi?
It would be really good to learn more about DFID's work in health in Burundi and DFID's experience / challenges / lessons learnt so far - do you know who will be the Burundi representative after yourself, as it says that you will only be there until August. Many thanks in advance.
Comment by Martin Leach posted on
Hi and thanks for this comment: I will reply separately in the representation question.
Response on Burundi health system:
- A lot of thinking going on about health financing in Burundi at the moment.
- In 2006, the Government of Burundi took the decision to subsidise healthcare entirely for women giving birth and children under five. This made a real difference. Before, nearly 4 in 5 did not seek treatment when they needed to because they could not afford to pay. Data is unreliable in Burundi, but the little we've got shows that since services have become free, mothers take their children who fall ill to the clinics twice as much as before.
- However, Government is concerned that the system is not equitable enough. Some health centres have refused to abandon user fees, because they feared that they would not receive the subsidies promised by Government. Government also announced last year at the UN General Assembly that it would extend free health care to all pregnant women, but this has not yet happened. In principle, services are also free for the 'indigents' (the poorest), but in pratice this does not work well. In many parts of the country, the very poorest still cannot get access to the care they need. And there is also a system of health insurance introduced over 20 years ago, but it only covers a tiny proportion of the population...
- So Burundi is currently looking at what more it can do make sure that all citizens can afford access to basic health services. The Ministry of Health has set-up a working group on health financing. As Government starts preparing its new Health Sector plan for 2011-2015, health financing is bound to remain at the top of the agenda. There is however no wrong or right answer and no blueprint, and Development Partners are helping Government look at what's happening elsewhere (whether in terms of free health care, mutuelles or others) and the lessons learnt.