is fee-free, there is an expectation that parents should contribute to the cost of their children's education by providing them with materials, supporting teacher development and making a contribution to school construction. According to the government, these costs should not be a basis for the exclusion of children from education, however. There are many private schools across the country, some church-run, which follow the same syllabus but charge fees. From 1994 until 2009, secondary education was offered in either French or English; because of the country's increasing ties with the East African Community and the Commonwealth, only the English syllabi are now offered. The country has a number of institutions of tertiary education. In 2013, the public University of Rwanda (UR) was created out of a merger of the former National University of Rwanda and the country's other public higher education institutions. In 2013, the gross enrollment ratio for tertiary education in Rwanda was 7.9%, from 3.6% in 2006. The country's literacy rate, defined as those aged 15 or over who can read and write, was 71% in 2009, up from 38% in 1978 and 58% in 1991. Health The quality of healthcare in Rwanda has historically been very low, both before and immediately after the 1994 genocide. In 1998, more than one in five children died before their fifth birthday, often from malaria. President Kagame has made healthcare one of the priorities for the Vision 2020 development programme, boosting spending on health care to 6.5% of the country's gross domestic product in 2013, compared with 1.9% in 1996. The government has devolved the financing and management of healthcare to local communities, through a system of health insurance providers called mutuelles de santé. The mutuelles were piloted in 1999, and were made available nationwide by the mid-2000s, with the assistance of international development partners. Premiums under the scheme were initially US$2 per annum; since 2011 the rate has varied on a sliding scale, with the poorest paying nothing, and maximum premiums rising to US$8 per adult. , more than 90% of the population was covered by the scheme. The government has also set up training institutes including the Kigali Health Institute (KHI), which was established in 1997 and is now part of the University of Rwanda. In 2005, President Kagame also launched a program known as The Presidents' Malaria Initiative. This initiative aimed to help get the most necessary materials