Rwanda is one of the nine countries in Africa and Asia making significant progress to make universal healthcare systems possible, a new study shows.The study is part of a series of articles on health reforms published in the US-based scientific journal, The Lancet. It shows progress made by nine developing countries in Africa and Asia in extending healthcare to ever-widening sections of society, including the poor. These are Ghana, Rwanda, Nigeria, Mali, India, Indonesia, the Philippines and Vietnam.According to the study entitled "Moving towards Universal Health Coverage: Health Reforms in Nine Developing Countries in Africa and Asia” more than three-quarters of the populations of Rwanda and the Philippines are now enrolled in health insurance programmes. About half are covered in Ghana, Vietnam and Indonesia.Countries in the early stages of reform, like Mali, Kenya, India and Nigeria, cover less than 20 per cent. The nine countries have each reached a national consensus on the need to extend health care, but their approaches vary.Managing director of the Washington-based group Results for Development, Gina Lagomarsino, observed that finding a stable source of funding is essential. Some of the funding especially from donors often targets specific programmes to fight malaria, tuberculosis and HIV/AIDS. The report says donor contribution makes up about half of all healthcare funding in Rwanda and about a third in Kenya, but much less in other countries.Majority of the funding in most countries is from state revenues.Some countries use incremental measures to reach the goal of universal health care. One way is to create risk pools, or programmes devoted to various groups.  This is the system that Rwanda has currently adopted to help cater for the poor who cannot afford Mutuelle de Sante, the universal healthpremium to which over 90 per cent of Rwandans subscribe.According to the Director of Health Financing in the Ministry of Health, Andrew Makaka, the current system that government adopted a year ago is one way to sustain funding."The first system of Rwf1,000 required per individual was not generating enough funds, so government adopted a new system of setting a premium. Currently, the public pays the premium according to one’s income” Makaka explained. The new premiums which were introduced last year, are Rwf3,000 and 7,000 depending on the subscribers’ financial capacity whereas the vulnerable are paid for by the government.He added that the premium was hiked three-fold but proved to be valuable after evaluation one year later. "We have so far managed to pay all bills to hospitals and health centres. So we are moving towards sustainability as a solid mechanism for health insurance,” he continued. Makaka, however, pointed out some challenges such as building capacity at the grassroots level, saying this ought to be addressed for the population to clearly understand the level of services. The programmes in some countries, such as Kenya and Nigeria, began by targeting specific groups, like civil servants and taxable wage earners. The two countries are now working to include women; children and the poor, according the study.Lagomarsino said the goal in many countries is to eventually replace fragmented coverage with one large pool covering everyone."It allows for cross-subsidies across populations such that wealthier people are paying into the same pool as poorer people,” she said. "It’s easier to graduate the payments so that the contribution from the wealthy are used to help subsidise the poor."Similarly, the contribution from the healthier can subsidise those of the sicker. So bigger pools mean it’s more efficient; everyone pays an average cost.”Many of the nine countries studied in Africa and Asia are also integrating the private sector into their plans to extend healthcare. Advocates say private service providers can improve choice and access to care."We have found that in the countries that we’ve examined in this study, pretty much all of them have set up an independent purchasing agency that allows them to purchase care from providers rather than just handing a budget over to a ministry of health facility,” said Lagomarsino."And in many of the countries, they have set up a mechanism for purchasing from private sector providers. It varies by country but, for example, they are doing this in Ghana [and] in Kenya. They also purchase from public providers.”