Wednesday, November 23, 2011

Entrenching a Service Culture in Rwanda’s Health Care System

Below is my contribution to the first issue of Ubuzima Magazine, published by the Rwanda Health Communications Center and the Rwanda Biomedical Center. You can click here to download the full magazine, I recommend you do! Lots of great updates on our health sector from the MOH and RBC.

Ubuzima, the quarterly magazine of the Rwandan health sector published by RHCC/RBC
Entrenching a Service Culture in Rwanda’s Health Care System
By Dr. Agnes Binagwaho

By just getting consumers to play their civic role of opposing wrong practices, we can take the quality of health care to the next level within the same resource envelop; without adding a single coin to our budget. This should help us on our journey to improvement.

Over the past decade, Rwanda’s health sector has made some laudable strides. 98 percent of the population has access to health insurance, mainly as a result of Mutuelle de Sante; maternal deaths are down to 70 percent and the incidence of malaria has been reduced by the same margin. More than 80,000 people that need treatment for HIV are receiving medication while pediatric HIV has been brought down to 2 percent.

The primary health care system is working. Health units are stocked, equipped are manned by appropriately trained care givers. As we acknowledge these achievements however, we are reminded that the higher you go the more difficult it becomes to achieve incremental progress.

Yet much as they are more challenging, those next few steps are all the more important in terms of the impact they are likely to have on performance of the sector. We have diversified services and spread them across the country and the population will have better health if they maximize use of those services.

They also need to be part of the process, highlighting any shortfalls we may have in the health sector such as hygiene and customer care. If they can understand that those services are meant for them and they insist on those simple rights, then the quality of care should improve. We have adopted a participatory approach in the health sector and the major goal right now is to bring the consumer of health services on board, to learn to demand services and help ensure that we provide services that are appropriate and relevant to their needs.

Even though the consumers of our services are not technical and we may sometimes disagree, involving them will help understand what we are doing and trying to achieve.

By just getting consumers to play their civic role of opposing wrong practices, we can take the quality of health care to the next level within the same resource envelop; without adding a single coin to our budget. This should help us on our journey to improvement. We have had a problem of lack of compliance with quality guidelines and lack of acceptance by consumers that they are paying for this service and are therefore entitled to quality care.

People need to know that they can complain and we shall listen to them; it is a right to be attended to in a clean healthy facility, to have a health professional wash hands before touching a patient, have a clean bed and to be attended to and receive medication in time. There are so many small things that can improve the quality of service- care and speed all comings at low costs.

We need to make the public aware of these goals through sensitization and demonstrating that we have no tolerance for those malpractices. This will be achieved by making them know that if they bring a complaint about a person who does not give them the expected quality of care, we shall listen to them and if their complaints are valid, we shall act.


Manpower is still a problem in the sense that we need more doctors, specialists, nurses and professionals in allied sciences to improve the quality of care. We have a seven- year plan for which we are mobilizing resources.

We want to introduce provincial hospitals that will act as an intermediate level between the district and referral hospitals. Those provincial hospitals have to be equipped with diagnostic and treatment tools and specialists to provide specialized care that is now only available at referral hospitals.

Even as we work towards providing specialized care, we must be careful not to compromise basic care. Our population is aging and the healthcare system needs to be prepared to adapt proactively to this mutation of the population.

With life expectancy now above 50 years, we are beginning to see heart diseases, hypertension, cancer etc emerge as public health issues. In the first place, the population has reached that age because of the improvement in basic care. If we don’t plan ahead to create requisite services and specialists, we shall be caught napping because developing these capacities takes time.

And some of these capacities are not just about unique disease conditions. For instance pregnancy is not a disease but if you have a pregnancy complication and you don’t have a gynecologist, you die. So we need specialists even for basic care.

We also need to equip the health facilities at sector level with health professionals at a grade that is higher than A1 that can attend to most of the problems that arise in the community without the need to transfer patients to the district hospital. While sometimes necessary, transfers are not always in the best interest of patients. They take them far from home, thus disrupting the flow of routine activities in their homes. Bringing specialists to their communities is the best as this will bring more comprehensive care to the surrounding population.

For now, Rwanda has 423 health centres. Five of these are at referral level and another 42 are district hospitals. Five of these district hospitals are going to be upgraded to provincial level to create a layer between the district and referral hospitals.

This is the current structure but the objective is to have one medical officer in all health centres at sector level and to have one specialist in each district hospital meaning an anesthetist, surgeon, gynecologist, internists and a pediatrician. In the provincial hospitals we shall have more specialized health care including the capacity to treat cancer and carry out more advanced operations. Above these will be the teaching and referral hospitals. This is the future plan.

To address manpower challenges in the sector in a sustainable manner, medical education will now be under the ministry of health. That will allow us to produce the health profession we need without passing through another sector. The law establishing the Rwanda University of Medicine and Health Sciences is in development.

We have also created four schools of nursing and we are now able to produce 100 A1 graduates a year. Some of these are new recruits while the others are upgrading from A2 to A1.

For doctors the plan is to liaise with foreign Universities to bring lecturers to Rwanda. Our biggest problem is lecturers. Even if we want to increase the number of doctors we need to have lecturers. So we are going to partner with foreign Universities to bring teachers that will mentor Rwandans to be good teachers that will over time produce doctors and specialists through academic training and mentorship. This is in progress and we are keeping our fingers crossed that we shall succeed.


We now have universal access to treatment. There is nobody who is HIV positive and needs treatment and cannot get it. We have more than 80,000 people on high quality treatment. A few of these are on second line treatment for resistance and there is also universal access to treatment for children.

We now have an ambitious program to eliminate pediatric HIV by preventing Mother to Child Transmission by giving tri-therapy at all health centres. Five years from now,
we hope to have reduced the risk of Mother to Child Transmission below the current 2 percent. That is almost elimination; not eradication, but that is about the closest one can get to the elimination of pediatric HIV as a public health issue.

Available statistics indicate that 200,000 people in Rwanda carry HIV and slowly by slowly they will progress towards AIDS and need treatment. That means the mobilization to put them on treatment must continue.

Thirdly, if we are to sustain that effort we need to succeed in prevention. If we have no new infections we can care for those already infected, but if we have new infections at one time we are going to face a situation where we shall not be able to put any more people on treatment.

That will not only roll back the gains so far made and lead to higher mortality rates among AIDS sufferers but also increase the velocity of new infections. Putting people on treatment is therefore a public health need because of its ability to slow down the rate of transmission.

Muteulle de Santé

Ninety two percent of Rwandans are now on public health insurance. Another 6 percent are on other health insurance schemes meaning 98 percent of Rwandans are covered under one form of health insurance or another. Beneficiaries were contributing 1000Rwfr to get care. In 2003, we discovered that the per capita cost of dispensing care was 3750Rwfr. That excluded the cost of doctors, nurses etc. That raises the question of who covers the funding gap. So we needed to find a way of making Mutuelle more sustainable.

We decided to get people to pay according to income since Mutuelle is a contributory scheme. We have arrived at a rate that is now being implemented. The new system does not lock out anybody; the people who can’t pay will still be entitled to care. They will be identified. Those who have little income and those with high income will pay according to their means.

Beneficiaries have been categorized into three classes. The extremely poor – will not pay anything, the government will pay for the care and premium.

So far there has been good accountability for resources in the health sector as part of the wider culture of accountability in Rwanda. Part of the fight against corruption revolves around zero tolerance for the vice.

This has created a culture and strong administrative guidelines that require signatures at every step. This is how we protect public money. And it is not about not stealing money but making money work.

These are values that have carried us this far and will continue to lead us on the road to progress as we tackle the pending challenges.

Dr. Agnes Binagwaho
Hon. Minister for Health