Rwanda and Universal Coverage: focusing on quality and equity

Lisa Hirschhorn, MD MPHHarvard Medical School

Partners in HealthJSI Research and Training Inst.

April 2013

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

The 5th area of quality

3

Structural Quality

(systems)

Process Quality

(activities)

Outcomes Quality

(results)

Customer defined quality

EQUITY

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

4

Adapted in part from A Binagwaho

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: Pilot2006: Fully implemented2008: Further regulation and strengthening

What is the impact?

• Child and maternal care coverage (2000-2008)

• Household catastrophic health payments (2000 to 2006)

• Enrollees’ medical care utilization

Improved medical care utilization

Protected households from

catastrophic health spending

8

Maternal and Child Health Intervention Uptake in Rwanda, 2000 – 2010

5.7%10.3%

27.4%

45.1%

26.5%28.2%

45.2%

68.9%

4.0%

15.8%

60.2%

70.3%

76.0%75.2%

80.4%

90.1%

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

What about equity?

• Lowest expenditure quintile: significantly lower rate of utilization and higher rate of catastrophic health spending.

Annual Rates of Decline in Child Mortality by Wealth Quintile and Residence, DHS 2008 and 2010

11National 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

(measures 10 years preceding survey)

So……• Rwanda’s 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.

Building a Health System

13

Referral Hospital

(5)

District Hospital(42)

Health Center(469)

Community Level(14,837)

~80% of burden of disease addressed here

Physician Specialist(150)

Physician Generalist(475)

Nurse Generalist(8,273)

Community HealthWorkers(~45,000)

Com

plex

ity o

f car

e

WHO-recommended health worker density:

2.3 per 1,000 pop.

Rwanda’s health worker density:

0.84 per 1,000 pop.

Courtesy of Dr Binagwaho. MOH, Rwanda

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

What are the responses?

• Increase training– HRH

• Task sharing

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

Can task shifting care expand universal access and

ensure/sustain/ improve quality?

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 ?

Task shifting, quality and HIV in RLSCountry Cadre Tasks outcomes

Kenya (Selke) Nurse to trained PLWHA

Monitoring (clinic to home-based)

Shift vs Standard of careViral 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 RxOutcomes:90% 1 year survival92% 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 0.15–0.49) and lower

Selke HM et al. JAIDS 2010: 55;483-490, Shumbusho, F. PLoS Med 2009 6: e1000163, Long L, PLoS Med 2011 8(7): e1001055; Bretlinger HRH 2010,8:23; Zachariah R, Trans R Soc Trop Med Hyg 2008;

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 6:e1000078; 2. Ooms G. Global Health 2008 4:61; 3. Price and Binagwaho. Dev World Bioeth. 2010 ;10:99-103.

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