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Rwanda makes health-facility deliveries more feasible
World Report
Rwanda makes health-facility deliveries more feasible Rwanda, one of the poorest countries in the world, where a genocide in 1994 destroyed health infrastructure and drove hundreds of medical workers into exile, is emerging as one of the nations with the best maternal health-care systems in Africa. Wairagala Wakabi reports. Rwanda has seen a substanitial improvement in maternal health recently. This success has partly hinged on a medical insurance scheme known as Mutuelles de Santé, through which women can access medical facilities at nominal costs, and a government policy under which women deliver at no cost if they have completed four standard antenatal visits. The results have been impressive, say donor bodies and humanitarian agencies, which are actively supporting initiatives to improve maternal health in this small central African country. Nevertheless, the country has one of the worst maternal mortality rates in the world at 750 per 100 000 livebirths— down from 1071 early this decade. Female adult mortality rates shot up dramatically in the aftermath of the 1994 genocide, which killed an estimated 80 000 people. Solange Hakiba, head of maternal health at the Ministry of Health, says even during 1995–2000, it was 1·8 times higher than pregenocide levels. Mutuelles—a prepayment health insurance scheme—is run by community representatives and local health-
Panos Pictures
The printed journal includes an image merely for illustration
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care providers. A subscriber receives a membership card, which they produce at a health centre and receive treatment. Promoted by the health ministry and supported by international non-governmental organisations and donor agencies, Mutuelles is designed to enhance the performance of primary health-care providers while reversing the low usage of services, especially family planning and reproductive health care, a trend largely attributed to widespread poverty. With a gross domestic product per head of US$230, few can afford to pay for medical services in Rwanda. Before the advent of Mutuelles, hospitals routinely detained women who failed to clear delivery-related bills. Some were forced to sell property such as land to leave hospital. The Mutuelles adherence fee per person per year is about $1·83, whereas the cost of a delivery for a nonadherent woman averages $3·70. With membership, women receive maternity care at 10% of the usual cost. At Muhima Hospital in the capital Kigali, children born before term spend on average 45 days in the hospital. Clarisse Utamuliza, neonatology head at Muhima, says the medical bill can reach $370, which Mutuelles members do not need to pay. Currently, between 100 and 150 of the 200 patients Muhima cares for daily are members. Last year, skilled birth attendance in Rwanda increased to 49·5% from 31% 6 years earlier. This, Hakiba says, is due to increasing adherence to Mutuelles by the population and to an increase in funding for maternal health. Rwanda has set up health centres in remote areas to deliver insecticidetreated mosquito nets, contraceptives, condoms, and immunisation. Agencies such as USAID are also supporting
Mutuelles in part because they have realised a Mutuelle member is five times more likely to seek modern health care than is a non-member. Although experts say Mutuelles is an essential innovation, they believe that it must be supported by other measures if it is going to succeed. Melissa Gillooly, a country manager for non-governmental organisation Partners In Health (PIH), says removing user fees for pregnant women attending prenatal clinics is not enough on its own. “Hence, working in six sites in the Eastern Province, PIH sought to improve delivery of maternal health care by improving the capacity of health facilities and staff to handle obstetrical complications and by training community health workers in maternal health.” Being able to provide obstetric surgery could save hundreds of lives in an area where maternal mortality rates are high and transportation to hospitals in other districts is not readily available. The 2005 Maternal, Neonatal and Child Health Assessment in Rwanda, showed that just 7·2% of births in Rwanda took place in facilities capable of emergency obstetrical care. At Rwinkwavu Hospital, PIH has worked with the health ministry to renovate an abandoned district hospital including a surgical suite. Before the opening of this operating room, women arriving with life-threatening complications, such as obstructed labour or haemorrhaging, had to be transferred to the closest district hospital, a 40 minute ambulance ride. Since opening its delivery room and operating suite, the hospital now has over 100 deliveries a month, compared with less than five a month in 2005.
Wairagala Wakabi www.thelancet.com Vol 370 October 13, 2007
Rwanda makes health-facility deliveries more feasible Rwanda, one of the poorest countries in the world, where a genocide in 1994 destroyed health infrastructure and drove hundreds of medical workers into exile, is emerging as one of the nations with the best maternal health-care systems in Africa. Wairagala Wakabi reports. Rwanda has seen a substanitial improvement in maternal health recently. This success has partly hinged on a medical insurance scheme known as Mutuelles de Santé, through which women can access medical facilities at nominal costs, and a government policy under which women deliver at no cost if they have completed four standard antenatal visits. The results have been impressive, say donor bodies and humanitarian agencies, which are actively supporting initiatives to improve maternal health in this small central African country. Nevertheless, the country has one of the worst maternal mortality rates in the world at 750 per 100 000 livebirths— down from 1071 early this decade. Female adult mortality rates shot up dramatically in the aftermath of the 1994 genocide, which killed an estimated 80 000 people. Solange Hakiba, head of maternal health at the Ministry of Health, says even during 1995–2000, it was 1·8 times higher than pregenocide levels. Mutuelles—a prepayment health insurance scheme—is run by community representatives and local health-
Panos Pictures
The printed journal includes an image merely for illustration
1300
care providers. A subscriber receives a membership card, which they produce at a health centre and receive treatment. Promoted by the health ministry and supported by international non-governmental organisations and donor agencies, Mutuelles is designed to enhance the performance of primary health-care providers while reversing the low usage of services, especially family planning and reproductive health care, a trend largely attributed to widespread poverty. With a gross domestic product per head of US$230, few can afford to pay for medical services in Rwanda. Before the advent of Mutuelles, hospitals routinely detained women who failed to clear delivery-related bills. Some were forced to sell property such as land to leave hospital. The Mutuelles adherence fee per person per year is about $1·83, whereas the cost of a delivery for a nonadherent woman averages $3·70. With membership, women receive maternity care at 10% of the usual cost. At Muhima Hospital in the capital Kigali, children born before term spend on average 45 days in the hospital. Clarisse Utamuliza, neonatology head at Muhima, says the medical bill can reach $370, which Mutuelles members do not need to pay. Currently, between 100 and 150 of the 200 patients Muhima cares for daily are members. Last year, skilled birth attendance in Rwanda increased to 49·5% from 31% 6 years earlier. This, Hakiba says, is due to increasing adherence to Mutuelles by the population and to an increase in funding for maternal health. Rwanda has set up health centres in remote areas to deliver insecticidetreated mosquito nets, contraceptives, condoms, and immunisation. Agencies such as USAID are also supporting
Mutuelles in part because they have realised a Mutuelle member is five times more likely to seek modern health care than is a non-member. Although experts say Mutuelles is an essential innovation, they believe that it must be supported by other measures if it is going to succeed. Melissa Gillooly, a country manager for non-governmental organisation Partners In Health (PIH), says removing user fees for pregnant women attending prenatal clinics is not enough on its own. “Hence, working in six sites in the Eastern Province, PIH sought to improve delivery of maternal health care by improving the capacity of health facilities and staff to handle obstetrical complications and by training community health workers in maternal health.” Being able to provide obstetric surgery could save hundreds of lives in an area where maternal mortality rates are high and transportation to hospitals in other districts is not readily available. The 2005 Maternal, Neonatal and Child Health Assessment in Rwanda, showed that just 7·2% of births in Rwanda took place in facilities capable of emergency obstetrical care. At Rwinkwavu Hospital, PIH has worked with the health ministry to renovate an abandoned district hospital including a surgical suite. Before the opening of this operating room, women arriving with life-threatening complications, such as obstructed labour or haemorrhaging, had to be transferred to the closest district hospital, a 40 minute ambulance ride. Since opening its delivery room and operating suite, the hospital now has over 100 deliveries a month, compared with less than five a month in 2005.
Wairagala Wakabi www.thelancet.com Vol 370 October 13, 2007