1. 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

2. 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

3. The 5 th area of quality 3 Structural Quality (systems) Process Quality (activities) Outcomes Quality (results) Customer defined quality EQUITY

4. Rwanda: 26,300 km 2 10.6 million people Massachusetts: 27,300 km 2 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

5. 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

6. What is the impact? Child and maternal care coverage (2000-2008) Household catastrophic health payments (2000 to 2006) Enrollees’ medical care utilization

7. Improved medical care utilization Protected households from catastrophic health spending

8. 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

9. What about equity?

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

11. Annual Rates of Decline in Child Mortality by Wealth Quintile and Residence, DHS 2008 and 2010 11 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 (measures 10 years preceding survey)

12. 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.

13. 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 Health Workers (~45,000) Complexity of care 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

14. 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

15. What are the responses? Increase training – HRH Task sharing

16. 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

17. Can task shifting care expand universal access and ensure/sustain/ improve quality?

18. 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 ?

19. Task shifting, quality and HIV in RLS CountryCadreTasksoutcomes 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 nurseART prescriptionProcess: 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 CHWF/U; home-based monitoring and referral for OIs Improved alive and on ART (95.6% vs 75.8%) South Africa (Long) MD to nurseDown 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;

20. 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 care 1 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.

21. 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