Lecture given to Dartmouth University students 'building a health sector alongside a nation"

I gave this lecture given to Dartmouth University students to share how we built a health sector alongside a nation. It is the health sector contribution to Rwandan rebirth the past 20 years
the story of the Rwanda health sector after the 1994 genocide against the Tutsi. a story of ownership accountability participation equity sciences and fight for sustainable development.

Follow the live lecture using the following link: https://www.youtube.com/watch?v=_PfKMAb1I-g

PBS Television Covers Rwanda's Health Sector

On May 29, 2014, PBS Television aired a segment on Rwanda's health sector. Click here to watch the video.

URL: http://www.pbs.org/newshour/bb/rwanda-rebuilds-genocide-focus-community-health-care/

Towards Sustainable Health Care: From Community To Medical Tourism

Towards Sustainable Health Care: From Community To Medical Tourism

By Dr. Agnes BINAGWAHO

Published in  Ubuzima Magazine, of the Rwanda Health Communications Center and the Rwanda Biomedical Center. I recommend you to read the full magazine! Lots of great updates on our health sector from the MOH and RBC. issue No4 2013

Ultimately, our strategy is to tap into medical tourism but this can only happen if we first secure the health of our own people and build the soft and hard infra- structure – people, facilities and a quality regime assurance to provide a world class health product.

Rwanda has the ambitious but achievable vision of building a self-sustaining state. To achieve this, the country must accelerate and sustain economic growth at 11.5 percent annually for the next two decades.

Every sector must play its part in contributing towards the realisation of that vision. The health sector is an integral part of the journey to economic self-sustainability and our contribution will be measured by the extent to which we are able to provide the preventive, palliative and curative care, using the best quality state of science to each and every Rwandan at an affordable price with the idea of equity in mind. That would mean that wherever one happens to be in the country, they will have the same rights and enjoy access to what we can offer to each and every Rwandan.

Ultimately, our strategy is to tap into medical tourism but this can only happen if we first secure the health of our own people and build the soft and hard infrastructure – people, facilities and a quality regime assurance to provide a world class health product.

Over the past five years, we have been putting in place the building blocks to a sustainable healthcare delivery system. We have already made good progress towards making the first point of contact with the health system, the Community Health Worker (CHW) self-sustaining. We have three CHW’s per village. These are people that are elected by the community members and the Ministry of Health gives them six weeks training and an annual refresher course which equips them with skills to provide quality care with a community-centric approach. They are supervised by the health centers and the doctors at district level.

They provide care at village level diagnosing and treating pneumonia, bronchitis, and malaria. With the exception
of implants and IUD, they provide the full range of family planning services from condom, pills, and injections. They also treat diarrhea and they provide counseling for HIV. One of the CHW’s is a maternal health assistant who fol- lows up pregnancies in the community and children under one year. They follow up children ensuring that everyone is vaccinated.

CHW’s now take care of around 80 per cent of the disease burden and the cost of this care will soon be covered
by cooperatives with money mobilised by the Ministry
of Health for this purpose. We now have more than 470 cooperatives and our target is to reach 500.

The profits generated by the cooperatives are used to grow businesses for the Community Health Workers and to sustain them. The business opportunities are identified by the CHW’s in their own communities and some have started hostels, shops, farms while others have gone into agribusiness. The profits from those cooperatives have created a pool of funds from which care at the community level can be paid for through performance based financing. A percentage of the profits from the cooperative belong to the health sector and are used to pay for the services of community care. This means nothing is free, everything has a cost and no one works for free in Rwanda even though we have to generate the money to pay for healthcare.
We have been paying CHW’s since 2008 but the difference now is that instead of the resources coming from outside the community, they will be paid from revenue generated within the community with clear management and financial guidelines.

The percentage that is not secured for the health sector will go directly to CHW’s. Weighed against the diseases burden, that means that 100 percent of the cost of care at village level will be paid for by the com- munity itself so we provide sustainable health care. This approach will be scaled up to cover the different levels of the health system.

Above the village we have the cell. A cell is made up of about ten villages and we plan to have a health post in each cell. The community will provide the space – 4 rooms – one for examination, a reception area, observation room as well as a storage room and pharmacy. From here patients can either be referred for hospitalization at a health center or district hospital or get discharged to return home after treatment.

Those posts will be headed by nurses trained to A2 level. They will provide services that will be reimbursed by Mutuelle de Sante. They will have no salary and will be paid directly in return for the services they provide, just like any private practitioner. They will also operate a drug shop. That means they will be offering services under a frame- work dubbed public-private –community partnership.

We are also going to create a national cooperative for these A2 nurses and in a couple of years, the proceeds from that cooperative combined with Mutuelle de Sante and the proceeds from selling drugs at the drug shop will pay for the care at cell level. They will also be supervised by the health center and the leadership at the sector level. Once we are through with this arrangement, we should have completed the loop of providing health care at the community level in a sustainable manner. We are close to our target of having one health center in each sector.

Less than 50 health centers remain to be built.
Under this arrangement, the sector will be the first point of interface between a patient and a public sector health facility. The system starts with a CHW at village level on to the public-private-community partnership at cell level and then the public health facility at sector level. Next are the district hospitals and then referral hospitals.

Forty per cent of health facilities in sectors and district hospitals (we have 42 district hospitals) belong to Non- Governmental Organizations (NGOs), associations and Faith Based Organizations (FBOs). We have an agreement with FBOs and NGOs. In return they offer treatment to each and every Rwandan in need. This has allowed us to have the same number of health centers and district hospitals in each part of the country rather than wait until the public sector can build its own.

The government through its budget pays subvention to each health facility or hospital. Mutuelle de Sante reimburses 90 percent of the cost of care but also there is a
10 percent out of pocket which patients pay directly to
the health unit when getting care. We are creating an e-system for better administrative and financial management of the health sector because we have private health facilities that for now do not get this contribution from the government but may be able to benefit of the e-system. We are therefore going to make the financial management more rigorous and private sector oriented.

Each district hospital will also become a teaching site with a director in charge of education for doctors and a director in charge of education for nurses. They will report directly to the College of Medicine and Allied Sciences that the Government of Rwanda is creating under the single university system. The same approach to self-sustenance will be employed when it comes to referral. Because all referral hospitals are also teaching hospitals that means they will have income from both the health and education sectors.

If we come to the ministry of health and the role of the Rwanda Biomedical Center; this center has been created to generate income to help the health sector become self- sustainable. We are now going into a phase of intensive business creation through RBC. PPP’s to create factories for consumables and drugs and goods for sale to the health sector are some of the options we are considering to decrease importation of what we bye anyway. We already have Labophar which has a unit for manufacturing infusions. Its capacity will be expanded; and we are going to build on that. The proceeds generated by these businesses will be reinvested to make the health sector self-sustaining at health center and hospital level. Because the system
at community up to cell level will be self-financing, the money generated from these activities will pay for services at sector, district and central level.

TAKING ON NCD’s

With a 50 percent decrease in acute malnutrition, we have made progress but our goal is to eliminate malnutrition all together. There is hope after the Clinton Foundation and World Food Programme teamed up with the Ministry of agriculture and the Ministry of commerce to set up a factory for nutritious foods.

This will help the health sector fight malnutrition by providing children and pregnant women with all the nutrients that they need. Malnutrition starts during pregnancy with malnourished mothers giving birth to malnourished children.

Sensitization to improve the nutritional status of children and mothers continues and the one cow per family programme has helped increase the consumption of milk. We now envisage a situation where we can use all those health posts we are creating to facilitate distribution of milk. We are progressing in creating systems, sensitization and what it takes to deliver the service.
 As we make progress against infectious disease; non- communicable diseases are gaining prominence. It is
not because these are new diseases, it is just that we are not dying of infectious diseases as we used to. Due to improvements to the health system we have doubled life expectancy and reduced the mortality of children. Life expectancy in Rwanda is now around 63 years at birth
and the profile of disease is beginning to be different as
a result. So we are beginning to see more cases of heart disease and lung disease that are related to longevity because the population is aging. 
 We are now educating medical personnel to manage this new challenge and we have introduced a diploma course in emergency medicine. We need 42 graduates to cover the 42 district hospitals. We have also created a residence of emergency medicine in provincial and referral hospitals. The school of medicine has almost completed the curriculum for a bachelor’s in cardiology so that we can have at least one medical doctor with special skills in cardiology in each district hospital. This is intended to accelerate the diagnosis and referral of patients to a full specialist if need arises and also do the follow-up of the people who have been treated.

We have already conducted more than 300 successful cardiac surgeries in Rwanda and those people are living in the villages. It is therefore necessary to have a doctor with the relevant skills living near them to keep them in good health through follow-up and ensuring they take their medicine. That way, they will not need to come back to Kigali because it is far and sometimes they come when it is already too late. 
The diploma in emergency medicine has already started and we hope to commence admissions to the bachelor
of cardiology next academic year. With these incremental steps, in five years, we hope to have a good referral system and fully functioning center of excellence for cardiology. We are also working on creating a residency in oncology and a diploma in oncology that again will allow us
to have in each district, somebody with skills in oncology and who through specialists, can follow up, seek advice via telemedicine and be available to see the patient on regular basis since we are equipping all our districts with telemedicine capacity over the next 3 years.
 Routine specialised care will be offered at district level. So renal disease, cardiac disease, cancer and other complications will be taken covered by system we are creating now to serve all the population in an equitable manner. 

MEDICAL TOURISM

We see medical tourism as a spinoff of care that will first and foremost be available to our own people and this is how we shall provide care for Rwandans.
 We are working with 23 institutions of higher learning in the United States that every year second 100 high level faculty members from their ranks who come to mentor their Rwandan counterpart’s under a twinning program. The aim is to create highly qualified and skilled clinical staff for both medical and nursing as well as lab technicians.

We are reinforcing high education in the health sector through the coming school of medicine and allied sciences. There are 60 A0 nurses to be trained to be tutors in specialized areas such as nephrology, theatre, neonatology, emergency, ICU, pediatrics and mental health. So we shall have highly qualified teachers for both the nursing and medical school. Through this twinning programs we hope to create very good educative tutors with a university that will be one of the best in Africa and attractive to students from outside Rwanda.

Once we have those highly qualified tutors, the system should produce highly qualified service providers. We have are sending to India, 16 people – surgeons, cardiologists, anesthetists, nurses, and lab technicians to train in cardiac surgery to help create a center of excellence for cardiac surgery here.

We are searching for the same opportunities for renal transplants. We have entered a partnership with the Chinese to transform Masaka hospital into a huge public teaching hospital and a separate partnership with the Japanese to have another high level public specialised hospital.

We are also promoting partnerships with anybody who may want to come do fair business in the health sector because we have a beautiful country where one can create set up a beautiful hospital for the discerning patient who may want to combine a medical checkup in a high quality facility space in serene and scenic surroundings to mix tourism and reinvigoration of their health.

And just as we are doing cardiac and renal surgery, we will do the same in neurosurgery so that we can attract here people who will, come to pay for quality care in Africa as
it is done in other other parts of the world. That is how we will come to medical tourism. But before serving in such a segment you need to have first secured the care for your own people.

Community care is already on track, and RBC has begun the next phase of its evolution or the first steps to turn this institution into a business oriented entity. For medical tourism, the paperwork is in progress at RDB and a project proposal is already with the African Development Bank and other development partners for analysis. We are off to a good start and all we need to do is pull in the same direction to get to our destination.
 Medical tourism results into regional centers of excellence and good medicine is generally a good business.

© RBC/Rwanda Health Communication Centre 2013

Uniting to uproot malnutrition in Rwanda

I published the following article in December 2012 in The New Times. The full text is available online, and you can also read it below.

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Uniting to uproot malnutrition in Rwanda

Dr. Agnes Binagwaho, Minister of Health of the Republic of Rwanda

While Rwanda has made dramatic progress in decreasing child mortality over the past ten years, reducing the rate of deaths from 183 per 1,000 live births in 2000 to 54 in 2011, chronic height-for-age malnutrition (or stunting) has remained too high among children under the age of five. Earlier this year, His Excellency President Paul Kagame challenged the nation to eliminate the root causes of stunting by working together through a multi-sectorial approach from the community to the central level and across sectors. 

The rate of stunting among children under the age of five years was found to be 51 per cent in 2005; by 2010, it was still far too high at 44 per cent. Over the same timeframe, the prevalence of underweight had declined by roughly 30 per cent, from 18 per cent to 11 per cent of children. Based on this and numerous studies by the Ministries of Health and Agriculture, it was clear that the driver of persistent malnutrition was not a lack of sufficient food, but a complex set of social, cultural, and economic factors interacting to prevent many children from accessing a healthy diet.

This challenge necessitated a multi-pronged approach to identify and combat the fundamental causes of malnutrition with significant emphasis on prevention. The most important strategies identified as priorities for action were the diversification of food sources, systematic growth monitoring of children at the community level, early detection of malnutrition,  access to clean drinking water, and, most importantly, widespread awareness about the kinds nutritious diets children need and how to prepare them.

Existing programmes to promote access to a balanced diet among the most vulnerable have been strengthened, and new initiatives have been launched to fill gaps. The Ministry of Agriculture has continued to provide leadership in the national Girinka (One-Cow-per-Family) programme, Akarima k’igikoni (kitchen gardens), and One Cup of Milk per Child programs, and the central government has supported these initiatives by doubling the agriculture budget between 2006 and 2011.

More than 200,000 cows have now been distributed to families categorized as ubudehe socioeconomic  1 and 2 (equivalent to the poorest households), and these animals have begun to bear offspring which recipient families then pass along to their neighbors who have yet to receive a cow. 

With the support of local communities through monthly umuganda communal work days, kitchen gardens consisting of nutritious vegetable and fruit plants have continued to be scaled up across the country among ubudehe 1 and 2 families. Schools in 14 of 30 districts now receive one liter of milk per 3 each week, and this programme will be expanded to cover every school in the nation in the near future.

To ensure that children who do become malnourished – whether through severe or moderate growth shortfalls, underweight, or stunting – are linked to the health system and provided with appropriate treatment (from Plumpy’nut Ready-to-Use-Therapeutic Food to multivitamin supplementation), the Ministry of Health has incorporated monthly growth monitoring into the national community health system. 

The country’s 45,000 community health workers (responsible for child health, reproductive health, and health promotion) now make regular household visits and can report children found to be malnourished to their local health centre, district hospital, and the central level via the cell phone-based RapidSMS system. Referrals of malnourished children have begun to occur much more rapidly than in years past, and preliminary data from the Ministry’s community health information system (SISCOM) show that moderate malnutrition has fallen by half between January and November 2012 – from 1.2 per cent to 0.6 per cent at the community level.

To contribute to improving the population’s access to potable drinking water, in addition to the work done by the Ministry of Infrastructure, the Ministry of Health has worked with partners to provide water filters to nearly 2,000 households in ubudehe1 and 2 across the country, with plans to scale up to the 600,000 poor households across the entire country

 In addition to existing forms of filtration and purification (such as chlorination tablets), these filters help to improve hygiene and hence minimise children’s exposure to pathogens that cause diarrheal disease. Furthermore, recent international data from the United Nations project Rwanda to be on track for Millennium Development Goal 7, which includes key indicators for access to water and sanitation. 

These developments are crucial to the fight against malnutrition, as persistent diarrheal disease prevents children from absorbing the nutrients they need and makes them feel sick so that they do not eat enough. This is another reason why the Ministry of Health worked with the GAVI Alliance to roll out the rotavirus vaccine for the prevention of one of the most dangerous causes of diarrhea this May, and preliminary data show nearly 95 per cent coverage among infants.

All of these interventions will be essential if Rwanda is to succeed in our goal of dramatically reducing the prevalence of all forms of malnutrition. With the bounty of agricultural resources our land provides and the wisdom of the Rwandan farmer, we have all the tools we need to keep every child healthy and growing. 

But ensuring that improved availability and diversity of food sources translates into better health outcomes for the most vulnerable children requires more than accelerating production – it necessitates a revolution in the way that families prepare their children’s food and understand the importance of their children receiving nutritious diets for a brighter future. 

For this reason, the government has started a massive educational campaign on “how to cook,” and pamphlets have been distributed across the country detailing the kinds of foods that children need, how to cook them, and the importance of proper hygiene and exclusive breastfeeding for children under the age of six months. 

Demonstration kitchens are being rolled out in districts across the country, to show families recipes that make use of local foods in such a way as to maximise their nutritional value to children using traditional cooking methods. 

Each umudugudu will hold a meeting to strategise on ending malnutrition on December 27 of this year, and these meetings will result in the publication of comprehensive local plans.

To conclude, Rwanda has made great progress this year towards the goals we have set as a people under the leadership of our President. But our job will not be finished until every single child is assured a healthy and balanced diet, until no mother worries about how to feed her baby, until no household goes without a clean water source or a hygienic and sustainable toilet. 

From scaling up drugs for HIV to reducing child mortality, our nation has proven that we have what it takes to achieve what some have called impossible, and I have absolute faith that together we will successfully apply this same sense of purpose to the fight against malnutrition. 

I can guarantee you that your public servants in the Ministries of Agriculture, Gender and Family Promotion, Local Government, Education and Health are spending sleepless nights working with our colleagues and partners to devise, scale, and monitor solutions to the root causes. 

If you have specific complaints about the response to malnutrition or suggestions on how to improve, I urge you to engage with us via Twitter through @RwandaMOH and my personal account @agnesbinagwaho. Be specific –name names, share exact locations, and we will explore every claim. Furthermore, the next #MinisterMondays Twitter and SMS (via 0788386655) discussion on Monday, December 17 will address the state of the malnutrition response, and I look forward to your participation.

The writer is the Minister of Health of the Republic of Rwanda.

The Future of Innovation in Rwanda's Health Sector: Equity, Participation, Science, Sustainability

I published the following article in October 2012 in Andrew Mwenda's East African journal The Independent. The full text is not available online, but you can read below.

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The Future of Innovation in Rwanda’s Health Sector:

Equity, Participation, Science, Sustainability

Dr. Agnes Binagwaho, Minister of Health of the Republic of Rwanda

The world has begun to pay increased attention to Rwanda’s rapid rate of progress in the health sector, particularly as we approach the 2015 deadline set for the health-related Millennium Development Goals. Our country has likely already achieved goals of reducing the 1990 child mortality figure by two thirds and halting the spread of HIV/AIDS, tuberculosis, and malaria; we are on track to achieve the goal of reducing maternal deaths by three quarters by 2015.

What Rwanda has managed to achieve has been the subject of much dialogue (and much debate); I do wish to repeat what has been covered better elsewhere or to make it seem as if our health sector is resting contentedly for even one second when more than 22,000 of our children will die this year. Instead, I want to focus on the why, and to reflect on what must come next for our country and our region if we are to sustain, exceed, and spread this progress.

I firmly believe that the secret ingredient to Rwanda’s recent successes is something very simple in principle that requires a very serious commitment to implement effectively: the absolute insistence that nobody is left out of benefitting from our collective progress. This understanding forms the core of our national development plan, and all from the central level to the community realize that when we tackle the needs of the most vulnerable first, we are sure to also reach all the rest. Moving equity from the realm of the political into the realm of practice and policy has been a true force multiplier for everything that we do.

Rwanda has learned from our long history of segregation and division – due to sources both external and internal – that the only way forward is through complete inclusion. Therefore, before any single policy is implemented in the health sector (or any other), all stakeholders are invited to participate in a process of true consultation. The often complex task of implementation and dissemination is rendered simple when all are engaged to participate from the beginning.

But even policies that are formulated in the most open and inclusive manner will not succeed if they are not based on the highest quality of scientific evidence. It is often said that “you cannot improve what you cannot measure,” and one of Rwanda’s most important innovations has been the establishment of robust systems of monitoring and evaluation focused primarily on actual health outcomes. By implementing a national maternal death audit program, whereby health workers and communities analyze all dimensions of every situation where a pregnant woman dies in childbirth, we have been able to chart a reduction in the number of deaths from 8 women per day in 2004 to less than 3 per week today. By giving a name and a face to every lost mother has sparked each person’s innately human determination to stop this tragedy all the way from the most rural health post to the highest levels of the central government.

Putting evidence into practice requires more than just good tracking tools, however. It means bringing science to bear on both the root causes and the immediate causes of preventable suffering and death. Rwanda has prioritized increasing access to both essential health services (such as safe deliveries through a community-based SMS notification system for ambulances) and to the fruits of medical progress (such as new vaccines against pneumonia, the virus that causes cervical cancer, and the virus that causes many cases of diarrhea in infants). We are particularly proud to see our Ugandan sisters and brothers also scaling up access to the human papillomavirus vaccine this year, which will prevent thousands of young women from developing cervical cancer in the future.

The final building block of success, in my experience, is the honest pursuit of sustainability. I do not mean sustainability as a buzzword, in the way it is so often tossed around and how it comes to fill up a third of the word count for bureaucratic reports. Instead, I mean a sense of deep accountability and responsibility to ensure that programs are built to last and designed with an eye towards continual improvement.

We have a saying in the Ministry of Health that pilot projects are not a solution in Rwanda – the only pilots here are in the sky, working for RwandAir! When negotiating about a new opportunity for our population, we insist that we go national as soon as possible, or we go nowhere. This is not a reckless strategy that makes the perfect and enemy of the good. We simply know that as policymakers and citizens tasked with improving the health of the entire population (not a catchment area or capital city), we must strive for the most robust and long-lived programs possible.

When we designed our new pediatric cancer center of excellence in Butaro near the Rwanda-Uganda border, for instance, it was not only for that one district – it was as a referral center for the nation. When we rolled out the national community-based health insurance scheme, mutuelles de santé, we began by subsidizing the annual contributions and copayments for the poorest one million citizens; soon enough, the middle-class and others bought in because they saw that the most vulnerable were indeed enjoying the best access through this new program. If we had attempted to move from an experimental mutuelles program in one or two cities to nationwide rather than this phased strategy, we would certainly not be able to count 92% of our population as enrollees today.

Underlying all of these principles, and ensuring that they are collectively translated into results, has been innovation in partnerships. To harness synergies and maximize value, we mobilize each and every willing partner according to the framework and timeline of our national plan. This has fostered national ownership of our programs and our success, but it has also led to novel collaborations that simultaneously encourage service delivery, teaching, and research. Rwanda’s Human Resources for Health Program, launched this year with 13 American universities, is a great example.

The lesson for me, then, from Rwanda’s experiences in the health sector has been that anything is possible when you apply the principles of equity, participation, science, sustainability. To better do so, we require constant out of the box thinking, and a commitment to solidarity and shared improvement. My colleagues and I look forward to fruitful cross-border collaborations, and we know that we can make it together.

Rebuilding Confidence in Rwanda's Future

My latest article in Rwanda's New Times is below. To visit the website where the article is printed, click here. 

On all levels of a health care system, it is critical that there is real trust. This is true for the patient-provider relationship on a case-by-case basis, and between colleagues but also true on a larger scale. The population of a country must be assured that they can trust their health sector to make choices that are in the best interest of the people, and to avail technologies and services equitably and safely. The only way to gain this trust is by actually providing the promised services and technologies guided by the principle of equity as is written in our constitution.

When I returned to Rwanda in the mid-1990s to work as a pediatrician in Centre Hospitalier Universitaire de Kigali (CHUK), alongside all the team of clinicians, we struggled day-to-day to keep children alive and healthy despite the lack of equipment and supplies to apply the best clinical practice. We saw so many unnecessary deaths during those years - we knew what it would take to save a life, but simply did not have the health professionals, the drugs, nor the technologies available to us to do so.

During my first week at CHUK, I saw more avoidable deaths than I had seen unavoidable deaths over the course of the five previous years when I was working in a pediatric ward in Europe. It is no wonder, then, that the population did not trust the health sector. To lose a child results in unbridled pain for the parents - and this is what was happening in Rwanda every day, unnecessarily, for so many parents.

At that time in Rwanda, the impact of the ethnic tensions - planted by the colonial enterprise and exacerbated by the bad governance based on divisionism during the first three decades of independence that ultimately resulted in the 1994 Genocide against the Tutsi - made it even more important that we start a new chapter in terms of providing services to our population in the framework of equity and rights.

When I started to work in CHUK, distrust in health professionals was not only due to the fact that clinicians had limited tools to save lives, but distrust was also due to those that used their position in heath facilities to shorten the lives of Tutsi patients during the 1994 Genocide against Tutsi. Immediately following the Genocide, some patients were afraid of being victims as were their relatives during the 1994 Genocide against Tutsi, and others were afraid of possible revenge. We knew it was absolutely necessary that the public sector's health system change drastically in the framework of development in order to provide good quality care and regain the trust in parents and the entire population.

This difficult working environment almost pushed me to return to Europe, but I decided to stay with my colleagues to be part of the movement to change the medical environment in Rwanda. This was the most important decision I've made thus far in my professional and social life.

The organised, peaceful return home of more than a million Rwandan refugees from the Democratic Republic of Congo had great impact to the peace, and the security process, and has affirmed for ever my trust in the future of my country, as did the Gacaca courts for justice and reconciliation. These decisions, among many others, have aided Rwanda in planning and creating a better world for our children so they can live in peace, security, prosperity, and good health.

Last week was the closing of the Gacaca courts - close to two million people were tried in this homegrown judicial system, compared with the 60 cases tried by the International Criminal Tribunal for Rwanda (ICTR), which shows that it would have taken at least two centuries to process all cases through ICTR.

Gacaca's detractors who claim that there is nothing good in Gacaca offer polemic arguments unsupported by evidence. Gacaca has allowed Rwanda to harness its tradition to reach a grassroots solution to ensuring we can dissolve our fear of insecurity, recover from wounds and pain, collectively hold criminals accountable, give victims reparation, and build a foundation for truth and forgiveness. This has and will continue to allow us to design the roadmap for Rwanda's future together as one nation, and promote a cycle of peace, development, health and wealth, instead of poverty, revenge, crime and distrust.

As President Paul Kagame has said Gacaca is not perfect but no system would be perfect in such an extraordinary situation. Yet those who criticize propose no alternative to it. I have asked myself if those who criticize Gacaca prefer to see a poor and forever destroyed Rwanda without hope in its future instead of our vibrant nation which wants the best of peace and development for its population

In my primary and secondary schooling in Europe, teachers taught us a concept called "enemies hereditaires" and explained it during many history lessons - the concept denotes a relationship wherein you inherit enemies from birth only because you are born in one place. This mindset is dangerous and gives false rationale that enables persistent regional and social divisions. In our new Rwanda, we have gone for the opposite of this term - we have gone for justice, recovery, and development through reconciliation and the understanding that every human being deserves respect and has fundamental rights to be protected, healthy and the right to be educated.

All sectors of Rwanda continue working together in the promotion of this virtuous cycle. We, in the health sector, do so by providing services to our population that can be accessed anywhere in the country and that can be afforded by all. The number of health centres has risen drastically over the past 18 years, to now 438, and soon 476, distributed evenly across the country.

Our trained community health workers (45,000 in total, three per village) provide preventive, diagnostic and curative services for some of the biggest killers equally in each umudugudu (village).

Nearly 70 per cent of new mothers in Rwanda now deliver in health facilities - this also has been facilitated by the confidence in each other, in part rebuilt by the Gacaca justice system, and is proof of a solid foundation of a trusting relationship between patient and provider. If parents wish to choose the size of their families, they must be able to trust that the health system will provide the needed services to keep their children alive. Between 2000 and 2010, uptake of modern family planning methods has increased by over 450 per cent from 10 per cent to more than 45 per cent and we expect within a year to increase access by availing this service in each of our villages. We, in the health sector, would not be able to achieve this in a country struggling with distrust and not focused on development

There are multifaceted processes, systems, policies, and interventions that have enabled Rwanda to be an example to the world. Showing, for example, fast improvement in provision of health services in low-income countries we can also provide hundreds of other examples. I can cite our education sector with the primary and secondary school enrollment increased for both boys and girls, and completion rates that continue to improve. Our country has also been highlighted in newspapers and journals around the world illuminating the fact that the percentage of Rwandans living below the poverty line has decreased from 57 per cent to 45 per cent between 2006 and 2011 - accounting for one million Rwandans who have lifted themselves out of poverty. In this area, Rwanda is one of the world's best achievers.

All this dramatic progress in a country destroyed 18 years ago has been made possible only because of good leadership, good governance, zero tolerance to corruption, a vision focused on the wealth of our people and a spirit of accountability developed through processes including the Gacaca.

The Gacaca courts have directly and indirectly allowed Rwanda to advance as a nation toward prosperity, security, increased wealth and better health. Even though some in the world will criticize Gacaca, I know from being like the millions of us a witness and a part of Rwanda's development, how important reconciliation is to building a public sector that can be trusted to provide services in the best interest of the people. I see a bright future in front of us and I am proud of my country.

To Improve Quality of Health Services, We Must Build Trust

Below is my piece in the New Times published on 30 January 2012. You can click here to read the article on the New Times.

To Improve Quality of Health Services, We Must Build Trust

By Dr. Agnes Binagwaho

Three different but related forms of trust are required to undergird a strong health system. Patients must trust their care providers, providers must trust their patients, and providers must trust each other. Without these three interlocking relationships of trust, patients will not seek health services, and care providers will never sufficiently improve their efforts to increase the quality of the care they deliver. 

To encourage patients to trust the health sector in Rwanda, we must not only provide high quality services that are based on the latest science but also employ effective communication strategies to convince patients of this.

At King Faisal Hospital, an internationally accredited hospital in Kigali, we have well-trained and diligent health providers. Across the country, providers are working together with the share goal of improving access and quality of care, from the most highly trained specialist doctors and nurses in referral hospitals to community health workers at village level. Along with our international partners, we are making strides to provide highly specialized services. For example, Rwandan surgeons and their European, American, and Australian colleagues have performed more than 150 heart surgeries in King Faisal operating theaters, as well as two recent kidney transplants and many difficult neurosurgery procedures. 

Furthermore, the Ministry of Health has developed a Charter of Patients as well as new guidelines for the implementation of customer care. These include the posting of a phone number and the photo of responsible official at the entrance to each ward, the placement of a suggestion box in each hospital, and a toll-free call center for reporting problems and making requests. While taking these steps is a promising start, we will need to follow through in assuring proper implementation of these measures if they are to contribute to continued increases in the quality of care. 

Yet some patients continue to prefer to travel abroad for care, choosing to pay more for basic services, such as dental or antenatal services, that exist in their homeland. Why is it that some Rwandans go spend their money on health services in another country instead of remaining here where those funds could help to develop our health sector? The answer is two-fold: first, we cannot deny that there are some cases of unacceptable malpractices that threaten trust in the entire Rwandan health system. The Ministry of Health is working hard to increase accountability, and we investigate all complaints made through our publicly available channels, the Rwandan Medical Council, the Rwandan Nursing and Midwifery Council, and the Police. 

Second, there has historically been a general lack of customer care, with providers not making the effort to smile, to welcome the patient, to carefully explain the causes of suffering to patients and their families. Sometimes it seems to patients that we do not like our work! This is a general problem in Rwanda, as we can also find the same attitude in restaurants, hotels, and administrative areas of the services sector.

Such individual experiences undermine our collective efforts to increase confidence in and utilization of the public health sector. This is why health professionals must have zero tolerance for medical malpractice of any kind, nor for any lack of respect or compassion for patients. We should not expect of ourselves anything less than the highest standard of customer care. Declining trust places a massive cost on all aspects of the health system, for if our own people do not trust the services provided, foreigners paying full prices certainly will not. As a result, potential tourists and investors who would need care during their stay in Rwanda may not wish to seek care here, and we lose money that could have served our development.

The second, and equally important, form of trust needed for a strong health system is that of providers trusting patients. In some critical care situations, health professionals may take risks for themselves to act quickly in order to save a life. If they do not trust the patient, they may take time at first to reflect on the risk they are putting themselves at and be unnecessarily cautious if they believe that the patient may later turn against them. 

What are the reasons a provider may not trust their patient? One example occurred just this month, when a patient and family alleged that a doctor had forgotten to remove materials from her womb fully four years ago. A team of multiple Rwandan clinicians, an international expert, and several Rwandan Police are still working to fully resolve the case, having spent significant amounts of time and energy investigating and uncovering the truth. This time could have been used to serve other patients.

The final form of trust essential for the health sector is related to team building and professional development. All members of a team engaged in the provision of medical care must be confident in each other’s ability to act quickly and to act as one for the benefit of their patients. If one provider lacks trust in their colleague, she or he will spend time to re-check everything their colleague has done before proceeding to the next step. Again, the time and energy lost constitutes a missed opportunity to serve additional patients.

So let’s all work together to inspire people and to build an enabling environment for trust to flourish and create positive changes. Trust is needed for the population to feel confident in seeking services, and for the health professionals to effectively deliver them. To advance this work, we will combat false perceptions and work to provide higher quality services and better customer care at all levels of the health system. This is our duty – not a favor that we give to our population. 

It is in this spirit of trust that I encourage all in the Rwandan health sector to enter into the year 2012 with inspired standards of care, proper customer care, and overall trust in one another. I wish the entire nation a fruitful and successful year full of progress. We all have been or will one day be clients of the health sector, so let us all commit to working together to build the trust needed to achieve our collective goals. Happy 2012.

Direct Democracy and the Health Sector: Umushyikirano 2011

Below is my piece in the New Times published on 9 January 2012. You can click here to read the article on the New Times website.

Direct Democracy and the Health Sector: Umushyikirano 2011

By Dr. Agnes Binagwaho

During the holiday season, I took time to reflect on the highs and lows of the past year. Without a doubt, one of the events that made me most proud to be a public servant for the people of Rwanda in 2011 was our National Dialogue Day, or Umushyikirano.

As written in Rwanda’s 2003 Constitution, the country hosts a two-day exchange of ideas, comments, and questions hosted by the President of the Republic at Parliament each December. On December 8 to 9, 2011, officials from the health sector joined representatives of the people as well as leaders from the central government to the village level for the Ninth National Dialogue at Parliament in Kigali.

The Dialogue draws on Rwanda’s principles of transparency and participation, allowing Rwandans from across the country and around the world to join and follow the conversation through free (reverse-billed) SMS messages, phone calls, Twitter, Facebook, live radio, and television broadcasts. Phone calls and SMS have been the foundation of Umushyikirano in past years, but 2011 saw the first incorporation of Twitter and Facebook messages. The addition of social media, a powerful tool for new kinds of interaction across traditional boundaries, made this the most inclusive and intense Umushyikirano yet.

Umushyikirano is a home-grown communications platform that facilitates open and deep dialogue. Over the close to eighteen years since the 1994 Genocide against the Tutsi, Rwanda has created many original innovations to ensure good governance and continual progress in the country. As one of the most empowering innovations, Umushyikirano is enshrined in the Constitution, guaranteeing that the people of Rwanda retain their right to participate in all decisions that guide their life and always have this forum (among many others) for expressing their proposals for improved policies as well as their judgments on the work of their elected leaders.

In reflecting on the central role of Umushyikirano in the Government’s decision-making process, I do find myself wondering how anyone who takes the time to learn the fundamentals of Rwanda’s political process could feel justified in saying that this country lacks political space or the freedom of speech. I grew up in Belgium and have spent years in other European countries and spent time in the United States, but I have never seen anything else quite like Umushyikirano – direct democracy on such a scale that harnesses the power of the telephone and internet; this exists only in my motherland, Rwanda.

Thanks to the rapidly expanding penetration of the mobile phone in Rwanda today, citizens from each and every corner of the country’s 15,000 imidugudu villages and countless diaspora communities can offer their views on every subject – whether the topic they wish to address is on the day’s agenda or not. Together, leaders and citizens reflect on potential solutions to the biggest challenges to our national development and the welfare of all Rwandans. This is true and direct democracy, where the officials entrusted with implementing national policy can be held accountable for their actions by each and every citizen.

I have attended each Umushyikirano since 2003, but this year was my first as Minister. The main themes for the 2011 discussion were governance, social welfare, justice, and the pursuit of economic development. All Ministers and directors of central government institutions directly concerned, were organized into panels that discussed each of the four topics with the live assembly of approximately 1,000 at Parliament and the rest of the nation through phone and computer.

The health sector presented on recent developments in Rwanda’s community-based health insurance program, Mutuelles de Santé, describing progress towards universal enrollment and the implementation of the new policy dividing premiums into three tiers based on families’ socioeconomic status. All Directors of specific health programmes and departments and other key staff from the Ministry of Health participated remotely throughout the entirety of Umushyikirano; some watched the live video feed in the main meeting room, others listened through the radio and read SMS messages, while several others joined through Twitter and Facebook. All together, we responded to each and every question regarding the health sector.

As always in Rwanda, we presented not only the Ministry of Health’s achievements but also our greatest challenges so that we might collectively reflect on ways to overcome them and to perform better for the population. This year, we have delayed the collection of insurance premiums for the 75% of the population who pay their own premiums and also the transfer to districts and communities the funding to cover premiums for the 25% who are fully supported by the Government after being identified as indigent through Ubudehe - Rwanda’s community-based system for establishing each household’s level of insurance premiums (and other socioeconomic indicators).

One major challenge facing the health sector that was closely examined during Umushyikirano is malnutrition. An unacceptable 44% of children under the age of five remain chronically malnourished or “stunted” (to be distinguished from acute malnutrition or “wasting”), and 38% of children under the age of five suffer from some form of anemia. During Umushyikirano, we collectively determined that the way forward in combating malnutrition must be a multi-sectorial approach driven by a cultural revolution aimed at sustainably changing the ways we teach families about growing, cooking, and serving the foods that end up on the plates of pregnant women and young children.

Rwanda does not lack the agricultural resources to properly nourish all our people, but we have been inadequately educating families about proper nutrition for too long. It is time to accompany the population in working together as one, for improved maternal and child health through nutritious diets. At Umushyikirano, the people of Rwanda set a deadline for the Government and its partners to eliminate the root causes of malnutrition within just six months. This approach is similar to that of tackling one of the greatest challenges of poor living conditions by guaranteeing all households with iron sheet roofing in order to eradicate thatched roofing through the Bye-bye Nyakatsi programme.

A third issue concerning the Health sector, discussed during Umushyikirano is the fact that Rwanda still depends on external financing for more than 45% of the health sector annual budget. As our Government and people know well, self-reliance can only be achieved through economic growth. Rwanda’s path away from dependency will be driven by sustainable development, and will involve generation of revenues through the health sector in the near future. The Ministry of Health will continue to do its part to reduce the importation of expensive drugs and consumables by relying on high-quality locally manufactured generics when possible as well as promoting private health facilities and providers. By encouraging the growth of the private sector, we can increase domestic tax revenues without raising taxes – this revenue will then be used to help increase the availability and quality of public sector services for all including the poor, as well as to invest in the education of more highly trained medical specialists for the benefit of all Rwandans.

In addition to debating major challenges facing the health sector, participants in Umushyikirano raised questions about the organization and quality of health care in Rwanda. Several Facebook users asked why some health professionals with diplomas remain unemployed by the public health sector, and the Ministry of Health responded by observing that the employment in the health sector depends on mindset – professionals should stop waiting for the government to automatically employ them and instead create their own opportunities or explore jobs in the private sector to serve the population across the country. We also received questions from some patients via SMS asking why they were not transferred outside of the country for certain kinds of care. We answered that the national referral system is organized to provide decisions that are based on cost-effectiveness depending on available scientific evidence about when and where to send patients in the case that treatment cannot be offered in Rwanda. In some cases, medicine cannot do much for diseases at advanced stages (or for some diseases at any stage), and this is why we invest much more in preventive services and quality improvement in Rwanda’s health system.

I wholeheartedly congratulate each of my colleagues in the Ministry of Health for their responsiveness to participants through SMS, Facebook, and Twitter, and I am proud to serve as their Minister. At this year’s Umushyikirano, there were no major criticisms targeted by the population at any sector, and the health sector has achieved a high satisfaction rate at 75%. Of course, we will not be satisfied until this figure reaches 100%; we know that the remaining 25% represents our weakness in customer care and the way that patients are handled – we commit to strive for improvements in these areas at all levels.

At this year’s Umushyikirano, multiple home-grown solutions were presented and still others developed through dialogue between citizens and their elected leaders. Economic development and self-sufficiency were at the heart of the debate throughout the sessions; this gave me a strong sense of pride in my Rwanda. Our nation’s constant emphasis on accountability and access to information as a human right gives me great hope for our future. At the Tenth National Dialogue in December 2012, I look forward to being able to say that we at the Ministry of Health have done our very best to live up to the expectations of the Rwandan population, for they deserve nothing less.

Honorable Minister Agnes Binagwaho will be hosting a discussion on vaccines in Rwanda through Twitter and SMS on Monday, 9 January 2012 from 5:00 – 7:00 p.m. You can join her “Mondays with the Minister” chats twice each month by following her on Twitter at @agnesbinagwaho or by sending comments by SMS to 0788 38 66 55 during the specified time.