Rwanda and Universal Coverage: focusing on quality and equity

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Rwanda and Universal Coverage focusing on
quality and equity

• Lisa Hirschhorn, MD MPH
• Harvard Medical School
• Partners in Health
• JSI Research and Training Inst.
• April 2013

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Universal Coverage

• Universal coverage is critical
• ensure access to care for those in need,
• Provide financial risk protection by lowering
  catastrophic out-of-pocket health spending
• BUT also need to ensure
• Access for all
• Quality
• Responsive system which meets the needs of the
  community

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The 5th area of quality
EQUITY
Structural Quality (systems)
Process Quality (activities)
Outcomes Quality (results)
Customer defined quality
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Rwanda 26,300 km2 10.6 million
people Massachusetts 27,300 km2 6.6 million
people Annual growth 2002-11 7.6 Life
expectancy 56 years (up from 28 years in
1994) Per capita health spending 55
Adapted in part from A Binagwaho
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Rwanda and Mutuelles

• Insuring underserved populations considered
  effective means of improving access to care
• Mutuelles de sante (Mutuelles)
• Community-based health insurance program
  established by the Government of Rwanda
• Key component of national health strategy to
  provide universal health care
• 2000 Pilot
• 2006 Fully implemented
• 2008 Further regulation and strengthening

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What is the impact?

• Child and maternal care coverage (2000-2008)
• Household catastrophic health payments (2000 to
  2006)
• Enrollees medical care utilization

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Improved medical care utilization
Protected households from catastrophic health
spending
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Maternal and Child Health Intervention Uptake in
Rwanda, 2000 2010
90.1
80.4
76.0
75.2
70.3
68.9
60.2
45.1
45.2
28.2
27.4
26.5
15.8
10.3
5.7
4.0
Farmer PE, Nutt CT, Wagner CM, Sekabaraga C,
Nuthulaganti T, et al. (2013). Reduced Premature
Mortality in Rwanda Lessons from Success.
British Medical Journal 346(f65) Courtesy of Dr
Binagwaho. MOH, Rwanda
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What about equity?
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• Lowest expenditure quintile significantly lower
  rate of utilization and higher rate of
  catastrophic health spending.

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Annual Rates of Decline in Child Mortality by
Wealth Quintile and Residence, DHS 2008 and 2010
(measures 10 years preceding survey)
National Institute of Statistics of Rwanda, Macro
International, Inc. (2012). Rwanda Demographic
and Health Survey 2010. Calverton, MD Macro
International, Inc. Courtesy of Dr Binagwaho.
MOH, Rwanda
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So

• Rwandas experience suggests community-based
  health insurance schemes can be effective to
  achieve universal health coverage even in the
  poorest settings.
• Challenge is to ensure that access and protection
  is equal for the poorest
• Financial assistance
• BUT..

Lu C, Chin B, Lewandowski JL, Basinga P,
Hirschhorn LR, et al. (2012) Towards Universal
Health Coverage An Evaluation of Rwanda
Mutuelles in Its First Eight Years. PLoS ONE
7(6) e39282.
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Building a Health System
WHO-recommended health worker density 2.3 per
1,000 pop.
Rwandas health worker density 0.84 per 1,000
pop.
Referral Hospital (5)
Physician Specialist (150)
District Hospital (42)
Physician Generalist (475)
Complexity of care
Health Center (469)
Nurse Generalist (8,273)
Community Health Workers (45,000)
Community Level (14,837) 80 of burden of
disease addressed here
Courtesy of Dr Binagwaho. MOH, Rwanda
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So if quality is similar, what about scope?

• Your choice is to staff a few health centers with
  higher level nurses and an MD able to provide
  more advanced care
• HIV, NCD management, other
• OR
• Do you ensure full district coverage for more
  basic care
• First line ART, basic screening and treatment for
  NCDs

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What are the responses?

• Increase training
• HRH
• Task sharing

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What is it

• WHO the rational redistribution of tasks among
  health workforce team
• Specific tasks moved when appropriate from
  qualified health workers to health workers with
  shorter training and fewer qualifications
• Existing cadres or new ones

Not just short term fix but approach to
strengthen the health system
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Can task shifting care expand universal access
and ensure/sustain/ improve quality?
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Task shifting, quality and ethics

• Multiple studies found increased access and
  uptake
• Botswana (nurses) Haiti (CHWs), Zambia (nurses)
• 1. What if quality is not as good and care is not
  as effective?
• 2. Is it right to provide basic care access but
  with providers not able to provide more advanced
  care or ensure access at another site ?

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Task shifting, quality and HIV in RLS
Country Cadre Tasks outcomes
Kenya (Selke) Nurse to trained PLWHA Monitoring (clinic to home-based) Shift vs Standard of care Viral suppression 93 vs 87 CD4 counts 404 vs 358) New OIs 13.6 versus 19.8/100 pys
Rwanda (Shumbosho) MD to nurse ART prescription Process adherence (89) and SEs (84) assessed, 100 correct Rx Outcomes 90 1 year survival 92 1 year retention
Mozambique (Bretlinger) tecnicos de medicinas HIV care and treatment Agreement with clinical observer WHO staging 38 cotrim 72, ART 76
Malawi (Zachariah) Nurse to CHW F/U home-based monitoring and referral for OIs Improved alive and on ART (95.6 vs 75.8)
South Africa (Long) MD to nurse Down referral of stable pts Lower death /LTFU (RR 0.27, 95 CI 0.150.49) and lower
Selke HM et al. JAIDS 2010 55483-490,
Shumbusho, F. PLoS Med 2009 6 e1000163, Long L,
PLoS Med 2011 8(7) e1001055 Bretlinger HRH
2010,823 Zachariah R, Trans R Soc Trop Med Hyg
2008
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Task shifting and ethics

• Medical ethics provide the best standard of care
  you can
• Public health ethics require health system to
  consider how to help patients who can not access
  care1
• Challenge focus on quality of care for few with
  access to surgeon versus the silent majority
  who do not
• islands of excellence in a sea of
  underprovision 2
• continued policy inaction amounts to unwarranted
  healthcare rationing and as such is ethically
  untenable 3

1. Chu K, PLOS 2009 6e1000078 2. Ooms G. Global
Health 2008 461 3. Price and Binagwaho. Dev
World Bioeth. 2010 1099-103.
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Conclusions

• Public Insurance are a key tool to ensuing
  increased access
• However focus must remain on ensuring BOTH equity
  and quality
• Need to measure
• Task shifting when done well can sustain or
  improve quality and increase access
• More work is needed to determine the most
  effective use and limits of task shifting and
  other innovative and scalable approaches to
  ensuring quality with limited resources