NHI: SA can learn lessons from Rwanda

An aerial view, displayed on a cellphone, synchronised to a tele-guided drone camera in Kigali, Rwanda. The country has adopted drone technology for delivering medicines. Picture: AFP

An aerial view, displayed on a cellphone, synchronised to a tele-guided drone camera in Kigali, Rwanda. The country has adopted drone technology for delivering medicines. Picture: AFP

Published May 24, 2024


Many years ago I thought Rwanda was mad to go ahead with a census of civil registration, and I will explain why. However, in retrospect, it showed great vision, and there are lessons South Africa can take from Rwanda as it gears up to work towards implementing National Health Insurance (NHI).

It is akin to a tale of two twins separated at birth.

To put it in perspective, Statistics South Africa played a significant role in the making of the Institute of Statistics of Rwanda, and we enjoyed a mutually beneficial relationship. Twelve years after the bloody genocide that ripped through Rwanda, Rwanda hosted South Africa and other nations on the derivation of indicators of fragility.

We then flanked out into the Civil Registration and Vital Statistics (CRVS) as an output of the African Symposium for Statistical Development. The principles governing CRVS are well-known in the statistics community. We dragged home affairs and health departments on the continent into the discussion and methods as early as 2006. Championing the cause, I had a level of professional confidence and well-earned pomposity on the subject.

Yusuf Murangwa, the Director General of the National Institute of Statistics of Rwanda. Picture: YouTube

So, when I learned that Rwanda was coming up with a census of civil registration, I lost composure.

I subsequently travelled to Kigali, Rwanda, to meet Emmanuel Katera, who had now moved to the Department of Communications, and Yusuf Murangwa, the Director General of the National Institute of Statistics of Rwanda, to understand the blasphemy they were after.

They had just had a census of the population. I believed conducting a civil registration within two years was misguided. We held frank discussions where I made my misgivings known on the basis of cost, logistics and a waste of resources.

But Katera and Murangwa were not swayed from their path.

The method was not very different from the census, but embedded large-scale running computerisation of recording of people and their geographic locations. The use of technology made a big difference on the design parameters. The data was the backbone of generating IDs for Rwanda. The need for an individual record system was an overriding and massively urgent need for building a nation and securing territorial integrity after the massacre in April 1994.

When the exercise was completed, Murangwa called me to say, “Pali, we are done and we are now producing IDs for the nation.”

I could not believe it. I congratulated him, but not before I could have my last word, saying, “But your register is surely now very much outdated?”

He agreed with this but explained that this only applied to a smaller percentage of the population whose records they would immediately update. These were more generally deaths. We were very excited by this feat and unorthodox method in statistical operations. My misgivings were unfounded.

A few years later at the World Health Summit, in a heart-to-heart discussion with the then Minister of Health, Dr Aaron Motsoaledi, he said he needed 30,000 community health workers to prepare for the Universal National Health Access, which was an NHI of sorts.

Motsoaledi lost the battle and the war to implement this.

And now the NHI is back, but in a poorer format, without the infrastructure that Motsoaledi was strategically focused on building 10 years ago.

And this is where my comparison between South Africa and Rwanda sheds light on health care.

South Africa has a sophisticated population register built over years and improved continuously – fundamental for the NHI.

While Rwanda had to run a census twice within a very short space of time to build a civil registration system, it managed to rebuild the nation as well as a new and all-embracing health system. This is something South Africa has failed to do.

Save to say I ate humble pie when Rwanda proved me wrong and that Rome can be built in a day.

Today, health care in Rwanda is not only universal, but it is affordable. We need to recognise how Rwanda achieved this despite taking a roundabout statistical route.

It went through a similar strategy of community health workers that Motsoaledi had envisioned but went a step further employing 60,000 community health workers in a population a quarter the size of South Africa.

Its health system functions very well from primary health care to the tertiary system. By adopting drone technology for delivering medicines, they shortened the distance and removed dis-empowerment and the disadvantage in rural areas relative to urban areas. By equipping medical staff and community health workers with mobile communication devices, they have tripled knowledge sharing and absorptive capacity for knowledge.

But above all, they are milking the mad investment they made of a similar exercise like a census within a space of two years.

Rwanda's quest for a population register and its benefits far surpassed the bean counting of francs; they were pound-wise when we in South Africa became penny-wise, pound-foolish. For them, nation-building was the delivery of better and increasingly improving health outcomes through the use of data. Staying the course is central to this nation that almost exterminated itself in 1994.

South Africa argues that 30 years is too short a time to change the fortunes of a nation, unfortunately, the argument does not fly as Rwanda teaches us otherwise.

Let us heed Albert Einstein who said when you face an existential problem, and you have an hour to address it, the first 55 minutes are the most important. Spend them on understanding the problem and designing systems to fix the problem and then spend the next five minutes focused on execution. Then you can build Rome in a day, every day, rather than destroy it in a day, every day.

However, while Rwanda took brooms and swept itself of its trauma, South Africa for a while did too, but soon slid and, ultimately, jumped into the feeding trough and started eating the seeds of progress.

South Africa and Rwanda are akin to 30-year-old twins in democracy. The question is, what will the next 30 years look like for both countries?

Dr Pali Lehohla is a Professor of Practice at the University of Johannesburg, a Research Associate at Oxford University, a board member of the Institute for Economic Justice at Wits and a distinguished Alumni of the University of Ghana. He is the former Statistician-General of South Africa and former President of the African Symposium for Statistical Development.