A Health Care Success Story In An Unlikely Place

When you think about countries that might be considered health care "success" stories, Rwanda probably isn't at the top of your list. But that's exactly how renowned doctor and humanitarian Paul Farmer describes the African nation (once among the poorest in the world) in a recent BMJ article covered in yesterday's New York Times.

Since the 1994 genocide in Rwanda, which claimed up to 1 million lives, "the country has become a spectacular public health success story and could provide a model for the rest of Africa," the Times' Don McNeil reports.

Consider these statistics cited in the news story:

In 1994, 78 percent of the population lived below the poverty line; now 45 percent do. The gross domestic product has more than trebled. Almost 99 percent of primary-school-age children go to school.
With help from Western donors, the number of people getting treatment for AIDS rose to 108,000 from near zero a decade earlier.

Many doctors fled Rwanda before the genocide, and many were killed. Even now, the country has only about 625 doctors in public hospitals for a population of almost 11 million. But it also has more than 8,000 nurses, and a new corps of 45,000 health care workers, elected by their own villages, to do primary care for malaria, pneumonia, diarrhea, family planning, prenatal care and childhood shots.

Largely because of these workers, the country has high rates of success in curing tuberculosis and keeping people with AIDS on antiretroviral drugs.

Nearly 98 percent of all Rwandans have health insurance.

Annual premiums are small and subsidized by donors, and subscribers pay 10 percent co-pays. But many aspects of preventive care, like mosquito nets and immunizations, are free. The country has a national system of computerized medical records and uses cellphone text messaging to get reports from village health workers.

Since 2000, the maternal mortality ratio has fallen by 60 percent; the likelihood that a child would die by age 5 has dropped by 70 percent.

What jumps out for me is the 45,000 community health workers delivering primary care. Perhaps some lessons here for the rest of us as well?