KIGALI, Rwanda – When Marie Grace Pendo was nine years old, she flew from Rwanda to India with a group of other patients and her doctor to have a mechanical valve implanted in her heart.

Pendo had rheumatic heart disease, usually caused by an untreated bacterial infection. She had little energy and her life was in danger. With only one cardiologist in Rwanda at the time – 2016 – she had little chance of receiving the life-saving operation. The Rwandan government paid for her travel and operation in India.

Pendo, now aged 20, tells Health Policy Watch that she is on blood thinners for life but other than that, lives a normal life under the care of health workers at Masaka District Hospital.

If she needed the operation now, she could stay in the country as Rwanda is slowly producing more cardiologists. There are currently six, with four more due to graduate within months.

Dr Everiste Ntaganda, director of cardiovascular disease at the Masaka Hospital, says Pendo’s medication and monthly consultations are covered by the country’s compulsory Community-Based Health Insurance (CBHI), introduced in Rwanda in 2004 as part of the country’s rollout of universal access to healthcare (UHC).

In 2003, only 7% of people had health insurance but currently, over 80% of the country’s 14 million citizens are part of the  CBHI, the highest universal health coverage rate of any low-income country (LIC).

The CBHI is funded by members’ premiums, taxes, and donor funding. Premiums are based on people’s income with people divided into six categories, paying zero (Category 1) to around $6 a year. Most people pay around $2 annually in Rwanda, which derives its main income from agriculture. 

Not all treatments are covered by the CBHI but the country is adding to what is available each year and treatment for breast cancer has been included for the first time this year. Rwandans are expected to pay 10% of the cost for treatments and medicines that are not covered – but that lies way beyond the reach of most people. In the poorest cases, the government endeavours to shoulder the entire cost.

Reorganisation of health services

When Paul Kagame came to power in 1994 after the genocide in which approximately one million people were killed, he made health a key pillar of rebuilding the country.

From a highly centralised system, the country has decentralised its health services, including the management of non-communicable diseases (NCDs), to reach more people closer to their homes to minimise transport costs.

Masaka is in the midst of a huge Chinese-enabled revamp that will almost triple its beds and, once completed it will become a teaching hospital.

The hospital caters for half a million people and its focus is on NCDs, said Dr Jean Damascene Hanyurwimfura, the hospital’s Director-General, pointing to the 2023 statistics which show 46% of deaths in facilities and 61% in communities are NCD-related.

“We decentralised because we can’t keep treating everyone at the hospital,” explains Dr Francois Uwinkindi, manager of NCDs at the Rwanda Biomedical Centre, which is the implementation arm of the health ministry.

“Before this, people could also spend $20 on transport which was higher than the cost of their healthcare.”

Rwanda has focused on NCD prevention and succeeded in reducing tobacco consumption, almost halving its use from 13% of the population in 2012 to 7%, said Uwinkindi.

But it hasn’t been able to reduce alcohol consumption, which has increased from 41% in 2012 to 48%. Hypertension and obesity are also up, although these are still a modest 17% and 4% respectively as the vast majority of the agrarian population gets enough exercise through their work. 

Rwanda’s capital city, Kigali, holds monthly car-free Sundays that not only prohibit vehicles in certain areas but are designed to encourage physical activity. Screenings for NCDs include diabetes and hypertension are also offered at some of the car-free days.

Community health workers in every village

The base of the country’s decentralised health services rests squarely on the shoulders of over 58,000 community health workers (CHW). These CHW are elected by village and town meetings, positions that mostly appeal to older residents. 

Each village elects four CHW who are allocated around 60 households to interact with.

Like in most African countries, the CHW are volunteers – but when budget allows, they get a little performance-related stipend, says Emery Hezazira, who heads the country’s CHW programme.

They need to be over the age of 21 and have completed primary school with good literacy and numeracy skills, as well as holding the trust of their communities, according to a health ministry document.

The document lists the CHW’s 15 tasks including diagnosing and managing malaria and tuberculosis cases, providing basic maternal and child care, managing childhood illnesses and conducting awareness campaigns about mental health and behavioural disorders.

They encourage behaviour to prevent NCDs, promote nutrition and promote HIV awareness.

“There is no fixed remuneration, CHWs receive their community performance-based financing (CPBF) on quarterly basis. The CPBF depends on the performed priority indicator, available funds, weight and unit cost of each indicator,” according to the document.

The CHWs are supervised and managed by the health centres, essentially primary healthcare clinics. The health centres are managed by district hospitals.

About 1000 CHW are active around Masaka, and they help to drive prevention messages, according to Uwinkindi.

During the recent Marburg outbreak, they went door-to-door in affected communities encouraging anyone with a fever and symptoms to go to their closest health facility.

In future, the health authorities want ongoing community awareness and education about NCDs and CHW to do more NCD screening. But as demands on CHW grow, so too may pressure to pay them –  challenge faced by all African countries that have introduced CHW.