Lessons from Rwanda and Ghana

At the recent Namaf conference in Namibia, Minster of Health and Social Services, Dr Richard Nchabi Kamwi explained some lessons from the Rwandan and Ghanaian health systems. He very kindly shared his speech, and I quote from it below.


Rwanda has one of the highest population densities in Africa, and their health system is highly decentralised. Their journey towards Universal Health Coverage dates back to the late 1990’s when they introduced the community-based health insurance, called “mutuelles”. The “mutuelles” concept had an initial focus on rural and informal sector but has now expanded to cover large segments of the population. By 2008, coverage of ‘mutuelles” was about 85%.

The benefit package offered by the “mutuelles” was limited at the beginning, covering only primary health care services. It has been expanded by 2006, to cover secondary and tertiary care. But they do not cover services provided by private-for-profit providers. Unlike in Namibia, private-for-profit have a minor presence in Rwanda, accounting for only 3% of all health centres.

Unlike in Namibia, in Rwanda almost 91% of the population has some form of insurance coverage, according to the World Bank.

The financing of the “mutuelles” is derived from households, who contribute a standard 1000 Rwandan Francs, the equivalent of US$2 and a 10% fee paid at the point of service for each visit to a health centre or hospital. Households can access loans from micro-finance schemes, enabling them to pay premiums. Membership of poor households is subsidized. Further funding for the “mutuelles” is contributed by development partners and the Government of Rwanda.

There are other components of this risk-pooling mechanism such as the national Solidarity Fund and the District Solidarity Fund.

Rwanda has also adopted performance-based funding as a mechanism to improve the quality and utilization of health care services.

A lot more could be said about the Rwandan experience, and we may need to consider a field visit by a multidisciplinary and multi-level delegation from Namibia. There are many lessons we can learn, which will help us set up our own system, tailored to our needs and taking into consideration our own context and realities.


The scenario in Ghana, a country with a population of about 25 million people is characterized by a National Health Insurance Scheme which was established in 2003 and became operational by 2005. The Ghana National Insurance Scheme is financed by value-added tax of 2.5%, investment income of interest earned on National health Insurance Fund reserves; 2.5% of social security contributions from formal sector workers; insurance premiums from informal sector workers (it is important to mention that this segment of the workforce represent about 85 – 90% of the workforce in Ghana); and development partners funding.

In Ghana, the benefit package covers 95% of all diseases prevalent in the country; only costly interventions such as organ transplant, dialysis, brain and heart surgery and most cancer treatments are excluded.

However, there seem to be complaints regarding quality of services provided under the National Health Insurance Scheme, whereby insured patients are not satisfied due to long waiting times, drug shortages, etc.

Other challenges faced by Ghana National Health Insurance Scheme include the low rate of enrollment. Although the Scheme aims at being compulsory, by 2010 only 34% of the total population was actively enrolled. Due to administrative delays, only 75% of those enrolled have valid cardholders and are able to be reimbursed for their expenses.

Nevertheless, there are reports of increased access to and utilization of health care services in Ghana, since the introduction of the National Health Insurance Scheme. This is again another context and experience that is worth looking at more closely, so that we can draw lessons for Namibia.


Another example we may wish to draw experience from is that of China.

China has a population of 1.3 billion, yet the government has successfully covered 95% of the population with Universal Health Coverage. What I am trying to say is that it all depends on the Political Will working together with the private sector in terms of what we as a nation want to achieve.


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