Rwanda's efforts to improve its nationwide health system are considered unprecedented for the entire African continent. Nearly 100% of Rwanda's population is covered by health insurance and therefore has access to basic health care. Rwanda is therefore one of the few countries that has already achieved the Millennium Development Goals for 2015 in the health sector.

The health care system is roughly divided into formal and informal health insurance. For people in the informal sector, the innovative "community-based compulsory health insurance", also known as "Mutuelle de Santé", applies. It is subordinated to the Ministry of Health and covers over 85% of the total population. Since 2011, the population living in the informal sector has been divided into groups for the purpose of staggering health insurance contributions. This should prevent poorer people from being disadvantaged to an extent that has not yet been possible. Until 2011, the rule was that each insured person paid a flat-rate contribution of around 2,000 RWF per year, which forced poorer population groups to invest a much higher proportion of their total earnings in health insurance than wealthier population groups.  The health insurance currently costs 5,000 RWF per year. The poorest group has to pay only 40%, the remaining 3,000 RWF, is paid by the state.

Who belongs to which group is decided by a combination of a self-assessment of the insured persons and an assessment of the community meeting. The community-based compulsory health insurance gives people the opportunity to visit the local health centres. In addition to the regular annual fee, a fee of approx. 300 RWF is charged for each visit to one of the health centres. If a patient cannot be treated in the local health scenes, he will be transferred to the nearest hospital. For the transport in an ambulance another 1000 RWF have to be paid. Despite the low basic fees for insurance, medical treatment remains a major financial challenge for poorer sections of the population.

Rwanda has a total of 525 health centres as well as 5 so-called reference hospitals and 42 district hospitals. However, doctors are not always present in the health centres. In addition, there is a network of so-called "mobile health helpers". These consist of about 60,000 people who offer additional counselling, vaccinations and help, for example before and after pregnancy, mainly in the rural areas of Rwanda and in the villages. The health workers are in direct contact with the households, creating a link between the health centres and the people themselves.

In view of the fact that regular visits to doctors and affordable medicines were by no means a matter of course in Rwanda a few years ago and that after the genocide there was a great shortage of qualified doctors, health personnel, hospitals and an adequate infrastructure, the development emerging today is quite positive. Today, almost 80% of health workers work in rural areas and benefit from targeted training programmes. The infrastructure has been significantly improved and investments have been made in the construction of hospitals and the financing of ambulances, which are now available in every district. Despite these improvements in rural infrastructure, many areas still lack sufficiently paved roads. Medical emergencies are very difficult under these conditions, as it is often not possible to drive patients from their homes to the health centres with the help of an ambulance. In these cases, family, friends or neighbours are forced to carry the patient on a stretcher to the nearest health centre. There are only 1-2 health centres per sector, which are responsible for the care of about 20,000 people. As a result of this shortage of qualified medical staff, an average of 15,000 patients are covered by one doctor and 1250 patients by one nurse. In Germany, for comparison, 211 patients fall on one doctor and 13 patients on one nurse in clinics.

Despite all this, Rwanda is already making progress in the fight against life-threatening diseases. Malaria, a disease that was still the main cause of death for children under the age of 5 in 2005, has been largely reduced. The number of infections today is 70% lower than a few years ago. Among other things, a preventive educational work on the routes of infection and possibilities of self-protection contributed significantly to this. In addition, houses in rural areas were impregnated and households equipped with mosquito nets. Malaria is now ranked as the cause of death behind diseases such as influenza, measles, respiratory or gastrointestinal diseases.

Notable progress has also been made in the fight against HIV/AIDS. While the infection rate among the population as a whole has been constant at 3% for years, great progress has been made in terms of therapy. Ten years ago, only about 800 patients had access to life-prolonging retroviral therapy; today it is almost 180,000 and thus 83% of all HIV-infected people.

Great importance is also attached to prevention work through comprehensive basic vaccinations of children. The importance of preventive vaccination for young girls is demonstrated, for example, by preventive vaccination against cervical cancer, a form of cancer that kills around 275,000 women every year. For this reason, over 90% of girls in Rwanda have already been vaccinated against the so-called HP virus, which is considered the most frequent cause of cancer. In most western countries the vaccination rate is only about 30%. In 2015, 98% of those under one year of age were vaccinated against tetanus, diphtheria and whooping cough with triple vaccination.

Nevertheless, in addition to the successes mentioned above, Rwanda is also confronted with a multitude of problems in the health sector. Particularly striking is the still very high proportion (37%) of under- and malnourished people, especially children. In addition, infant mortality (death before the 5th birthday) is ten times higher than in Germany with 38 deaths per 10000 births. These problems are directly related to the lack of clean drinking water for the population and the increasing scarcity of agricultural land, which contributes to a lack of food in the country. However, the population growth itself in Rwanda seems to be mainly due to the fact that contraception was a taboo topic until recently. The increase in the population and a current average of just under 4 children per woman have prompted the Rwandan government to consider a three-child policy. Whereas in 1990 only 10% of women used contraceptives, by 2015 this figure had risen to 53%. As a result of this development, the average number of children per woman, at least in the cities, has dropped to around 3-4.

A further problem worth mentioning with regard to the health system is its financing. The Rwandan health system only finances itself to a share of 20-40%, with the rest being covered by Western countries. Health care is therefore largely dependent on the financing of foreign sponsors.

In general, the positive developments in the health sector have resulted in Rwandans having an average life expectancy of 67 years at the time of birth. The life expectancy of women is 68 years, slightly above the average, and that of men 65 years, slightly below (2017).

However, one development that remains unchanged despite the improvement in the health sector mentioned above is the fact that people with disabilities still receive little attention and support from the Rwandan state.


Autorin: Hannah Posern und Lisa Kirmser