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.

The Role of King Faisal Hospital Today

I wrote the following blog post, "The Role of King Faisal Hospital Today," in 2007. I am sharing it on my new blog as it has not been previously published, but some of the information is out-of-date. It does accurately describe the vision of the Ministry of Health for King Faisal Hospital and its role in our health system. 

All sectors of the Rwandan Government are dedicating substantial efforts to achieving our national development objectives. Together with the support of partners from around the world, the Government has strived to endow the country with innovative tools and programs that aim to make the necessary changes in the health sector to enlarge the range of quality services given to the population.  The programs in question are complementary and have specific objectives. Through this support, Community-Based Health Insurance, RAMA, the decentralization of sanitary systems, the equipment of district hospitals, referral hospitals, and King Faisal Hospital in Kigali have become essential pillars of the development plan of the health sector.  

Among the health sector’s various achievements, one of the most impressive is that more than one million Rwandans now have community-based health insurance and all Rwandan civil servants are now covered by RAMA as of late 2007. Among other resources available to public programs, we now have substantial funds for the fight against HIV/AIDS that are being used to control the epidemic in a way that builds the national health sector, as well as funds for new equipment in district hospitals, referral hospitals, and health centers across the country. These achievements have benefited the whole population.

At the same time, thanks to the Government's advocacy in negotiating with partners across many continents, King Faisal Hospital has increased its capacity to provide services to the country’s sick. King Faisal Hospital can now offer very specialized abdominal surgery by laparoscopy as well as other state-of-the-art technology in orthopedics, orthodontic care, and ophthalmology services. More specialties will continue to join the array of services offered on a regular basis.

Beyond this immediate improvement in the spectrum of available services, King Faisal Hospital has a mission of training that aims to assure capacity building of Rwanda’s medical students, general practitioners, and specialists.  With the support of the Ministry of Health and the United Nations Development Program, the hospital now has a telemedicine center that allows exchanges and continuing education programs through linking King Faisal to teaching hospitals around the world. Our population, our medical students, and our physicians are increasingly benefiting from it. Other strong partnerships have been created to allow cardiac catheterization and open heart surgery, treatments usually outside of the financial means of most Rwandans. Now, thanks to solidarity on the part of Australian, American, and Belgian physicians who come on surgical and capacity-building trips, the average Rwandan can benefit from these services at King Faisal Hospital. 

Thanks to Community-Based Health Insurance, RAMA, and the Ministry of Health’s national referral system, patients referred through the normal process can receive specialized care offered King Faisal at costs comparable to care offered at CHUK. A patient is generally referred from a health center to a district hospital to a referral hospital if necessary. These referral hospitals can then refer to King Faisal Hospital for care that is not available elsewhere. In the case of severe medical emergencies, a patient can be referred directly to King Faisal Hospital without progressing through the standard tiered referral process. 

Referral to King Faisal Hospital is free for the poorest Rwanda if they have the requisite administrative documents from ubudehe. As a result of this social justice-based access policy, the more King Faisal Hospital has high-level quality and varied care, the better the Rwandan population will be taken care of. King Faisal Hospital also allows our tourists or our investors who spend time in Rwanda to be assured that they will have access to high-quality health care should the need arise. This is a great way to attract and retain investors.

We have a long way to go, but the Government along with its partners has put in place a system so that all can receive affordable and quality care, even for the poorest citizens because the Government pays for them.  Rwanda has a national goal of becoming a middle-income country within the coming decades. Therefore, it is essential to sustain efforts to assure access to high-quality health care to all.