Every day, Euphrasie opens her health post to the community she serves in the green hills outside of Kigali, Rwanda. Her post treats a wide range of diseases and conditions, provides consulting services and basic trauma care, and is open to all community members, but is not a public facility. Euphrasie is a self-employed nurse operating a franchised One Family Health health post under the private-public partnership model established between OFH and the government of Rwanda. While Euphrasie used to work within the governmental system, since she began working in 2012 with OFH she has become her own boss. The One Family Health model has proven successful in not only improving access for essential health services for the poor, but also in creating an entrepreneurial launching pad for the health workers of Rwanda’s future. Rwanda’s Vision 2020 roadmap plans for a health post in every sector in the next five years. While this ambitious goal still may be a long way off, the centers operated by One Family Health nurses are setting the example for other public facilities. The investments the nurses make into the facilities they own and operate demonstrate the effect of a personal stake in business, and the value of community support for small businesses.
After visiting Euphrasie and her health post in the hills, CHMI’s Lane Goodman sat down with One Family Health country director Maggie Chirwa to learn more about this innovative approach to improving health care access with an entrepreneurial bent.
Lane: Tell me about what makes One Family Health such a success in Rwanda, and why you operate in this unique franchise agreement with the government?
Maggie: Rwanda has successfully decentralized much of the management of public health to the district level, which operates on a semi-independent contract. The districts are accountable to the communities they serve, while also striving to meet the health targets that serve as their contract with the national government. These districts operate autonomously and set their own monitoring and evaluation processes for sub-district sectors, or cells. Our mission at One Family Health is to improve access and quality of health care at the lowest cell level. Our network consists of franchised cell health posts, owned and run by the nurses who staff them, and functioning in a public-private partnership with the Rwandan government. The government’s plan for a health post in every cell will require at least five hundred posts. One Family Health currently operates through a franchise of over 90 health posts, with plans to expand further.
Lane: Can you tell me more about how the nurses become the post owners, and how they are selected?
Maggie: We put out a call for trained nurses when we first started the franchise network in 2012, and had many more responses than we had posts. The nurses we hire are all A-2 level, and must undergo additional testing and weeks of initial training. We hire nurses as franchisees, and focus our attention on supporting these healthcare providers as business owners. One Family Health starts the nurses’ business with a five year loan to renovate the government-provided physical structure for the health center, and for initial purchases of medications and equipment. We provide business training and capacity building workshops for these nurses. Our franchisees are part of the larger OFH network, but are truly integrated and supported by the communities they serve.
Lane: What makes the OFH health posts distinct from public-run facilities?
Maggie: Our nurses are working for themselves, and so they’re really motivated to provide the best possible care and keep their communities healthy. Currently, our 83 health posts are all within a 30 minute walking distance for the catchment zones of their communities. The nurses use an Electronic Medical Record system on mobile phones to track patient data, pharmacy stocks, and prescription information. Our central staff monitors the “virtual dispensary” for each health post, while also checking for errors in stocking or prescription dosage. We focus on helping nurses run sustainable operations by ensuring proper collection and use of funds, and by ensuring the relationships between nurses and the community-based insurance boards that reimburse patient claims. One Family Health is one of the only private entry points into the public Mutuelle de Sante national health insurance plan. Our nurses have a much higher rate of claim reimbursement because they meet with the insurance boards in person, who then come to know the nurse as an individual.
The nurses that staff OFH post are also well-supported by the community. The district officials are often the ones to request a One Family Health post in the cells, and work with the nurse to create the infrastructure. Nurses speak with the community at monthly meetings, where they provide health education sessions and explain the service offerings of their post.
Lane: What are some of the lessons that you have learned over the past three years of operation?
Maggie: With the franchise model, our initial attempt was to mass produce health posts. We do a great job of using a lean strategy for our central operations; we have a small core of staff here in Kigali, and use IT systems to minimize the need to micro-manage. However, we realized early on that the needs of each post are unique – you cannot have a “one size fits all approach.” We have established a high level of cooperation and trust with all levels of government, which has allowed us to rapidly scale the health posts to multiple sites. As we approach our 100th post, we’re taking the opportunity to stop and reflect more on what we’ve learned before we push ahead. We recently conducted a satisfaction survey among our franchisees, and found that over 85% are more satisfied today, working as their own boss and creating the health post they work in, than they were as publically-employed nurses. We look forward to continuing on our success, and seeing the high rates of satisfaction among nurses and patients for years to come.