What if we told you that the U.S.
should think about health care
the way Rwanda does?
Rwandans are the most likely in the world
to say they trust their health care system.
The UN calls it
But is that true?
Hey guys, it’s Dena,
and this is part one of our series,
“What the U.S. Can Learn”
from other countries.
Today we’re looking at
what one of the poorest
countries in the world
can teach America about health care.
It is the hard work of a lot of Rwandans.
[To] accept that it's a miracle
just gives an excuse
to lazy politicians,
lazy technicians to not try.
Rwanda had to pretty much
build up everything
after the 1994 Rwandan genocide.
More than 800,000 people were killed
in a Hutu Power-led massacre.
The main challenge
right after the genocide against the Tutsi
was putting everyone together.
National unity became the main goal
of the Rwandan Patriotic Front or the RPF.
They were the Tutsi-led party
that ended the genocide,
came to power in 1994
and are still the ruling power today.
The RPF was faced with a country
that had no infrastructure.
Hospitals were scarce.
And for 83% of Rwandans living in villages
dispersed in the country’s hilly terrain,
those hospitals were unreachable.
So how did the RPF
bridge the divisions that had destroyed
so many lives?
By bringing health care to rural areas.
That was the beginning
of Rwanda’s highly successful
community-based health care system.
In 1999, the Ministry of Health
picked three districts
with a total population of 1 million people.
There, it piloted its first
54 community-based
health insurance plans
through ongoing collaboration
with local residents.
And since 2008, it’s been
compulsory for Rwandans
to have some sort of insurance.
But right from the beginning,
people knew that health care
wouldn’t be free.
It's very important in Rwanda
to make the population
contribute to development
by paying some fees.
The richest pay about $7 a year
for health care.
But up to 25% of the population
can’t afford it,
There is really this ideology that, you know,
nothing should be free
 in post-genocide Rwanda,
that free things destroy mentality,
that it fosters a mentality of passivity
and of dependence.
And Rwanda wants to avoid that at any cost.
So how does this system work exactly?
Over the past two decades,
Rwanda has trained
over 58,000 community health workers
to serve the rural population.
Each village has four workers
who are elected by their community.
But they are not there
to perform medical procedures,
like deliver babies or administer vaccines.
Those procedures still happen
in health centers.
Community health workers are there
to prevent potential outbreaks
from spreading
and provide basic services families need.
Think of it this way:
They're kind of like
a quick Google search for households
only a knock on the door away.
This system is what led Rwanda
to exceed the 2020 global HIV targets
and educate 200,000 Rwandans
about the Ebola epidemic
in neighboring DRC.
It sounds impressive, right?
90% of Rwanda’s 12 million people
can access health care.
Meanwhile, in rural America,
there are only 30 specialists
per 100,000 people,
compared to 263 specialists
per 100,000 urban residents.
But some researchers are critical
of Rwanda’s top-down approach,
saying it only works
because the RPF
has all the power in its hands.
I would describe the regime
as quite authoritarian, in the sense that,
actually, political opposition
to the Rwandan Patriotic Front
is not obvious at all in the country.
While opposition parties
may technically exist in Rwanda,
rights groups say, real opposition
to the RPF
is not tolerated.
People who have dared
to challenge President Kagame’s rule
have found themselves
imprisoned or murdered.
So it may be no surprise that
that the opposition in Rwanda
is on the same page
about compulsory health care.
In Rwanda, often you will see that
all the political parties
will not necessarily challenge
the idea of the RPF
and will often actually
repeat and amplify its message.
But despite a politically
authoritarian environment,
Rwanda’s huge health care gains
are undeniable.
In fact, one community-based
effort in Rwanda
was so successful,
the world wondered
how Rwanda pulled it off.
Rwanda’s head-on fight against
cervical cancer showed that
women are at the heart
of the country’s thinking about health.
In 2011, it became the first
low-income country
to introduce the vaccine
against human papillomavirus, or HPV,
to adolescent girls.
It is because we have already
developed the trust with the population
that we can go to the population,
explain a disease they didn't know,
about a portion of the body
they didn't even know.
Women knew they had a uterus.
They didn't know they had a cervix.
Now, more than 93%
of Rwandan 12-year-old girls
have received the HPV vaccine
against cervical cancer.
The vaccine proved to be hugely effective.
But in America,
only 57% of 13- to 17-year-old girls
have been vaccinated against HPV.
People have the right to have the truth
and have the right to say “no,"
but a “no” that is fully informed.
Women’s health isn’t just
a one-off example.
Women’s empowerment
has been at the heart of
Rwanda’s governance and education.
Women make up 64% of
the country’s parliamentary seats.
Rwanda’s Constitution actually says that
women should hold at least 30% of posts
in decision-making bodies.
But neither Parliament or those
decision-making bodies
have any real power
to challenge the president
or change the country’s leadership.
And there are limits to the empowerment
of Rwanda's women.
Abortion is only legal 
in the most extreme cases.
50 women have recently been 
released from prison.
Their crime? Having abortions.
So despite Rwanda's tremendous
achievements in health care,
the country still has its own issues
 to work through.
Unfortunately, the kind of health care
you are accessing is not that good.
You will be often asked
to pay for medication or even
some surgical equipment yourself.
You have lots of hidden costs
that are still remaining,
partly because the state
simply doesn’t have money.
But what can the U.S. take away
in the meantime?
Rwanda is a success story
because the government convinced
the private sector and NGOs
to get on board with one health system.
If you are serious about health insurance,
donors need to put money in state budgets
rather than just, you know,
piecemeal activity.
Tuberculosis, HIV, malaria, Ebola.
Rwanda always had to be
ahead of the game
in preventative health care
to protect its population
from infectious diseases.
That’s why when COVID-19 arrived,
Rwanda was ready.
Pandemics, epidemics may continue,
but the best way to be prepared is to have
a resilient and strong health system.
Even though now Rwanda’s
community-based health care
looks more like a national health program,
it was created by and for Rwandans.
If America wants to make
its people healthier,
it needs to listen to
marginalized communities 
most affected by inequality.
Advocacy is a major piece of
giving people access to health.
Advocacy for the finance of it.
Advocacy for the science of it.
Advocacy for the good practice of it.
Advocacy for protection.
Advocacy for participation.
