Setting course for 2012

Posted in Ubuzima Journal 

first quarter 2012

By Dr. Agnes Binagwaho

As we embark on yet another year, it is time to check our bearings and determine the direction we want events in the health sector to take during 2012.

While there is no fault in celebrating our achievements in the past year, maintaining those gains should be the overarching priority for 2012. The gains in the health sector are always fragile and could easily be lost if we are not focused. Ten years ago, infectious diseases were killing us. Now those are contained but because they are still there we should not relax our vigilance. The gains made against HIV can be lost in as short a time as one year if we relax our guard.

We shall continue to see progress in the areas where we have done well and this is translating into reductions in the incidence of malaria, HIV/AIDs and TB. For children we are introducing the rotavirus vaccine this year. Two and half years ago we introduced the vaccine for pneumonia and as a result pneumonia has decreased. 

 Aging population

We have made good progress across all the infectious disease profile and people are living healthier and longer.  According to the National Institute of Statistics, the average Rwandan can now expect to live as long as 55 years.

It is a modest number that is at the same time significant in our setting. This year we need to begin focusing on the long term by anticipating health problems that are likely to arise in the not too distant future and preparing solutions now. As the health of our population gets better, they will start to experience health problems related to longevity. So we shall need to focus on those new problems that are changing our epidemiology. Simply by people beginning to live longer we are starting to see cancer and other non-communicable diseases emerge as public health issues.

This means that we have to be prepared to tackle the new diseases that are beginning to emerge in the population such as hypertension, heart disease, metabolic diseases etc. We are also beginning to see that deaths from motor accidents or other injury are beginning to overtake other causes. This is not necessarily because there has been an increase in the rate of accidents but there has been a reduction in other causes of mortality and morbidity.

The simple message from this trend is that we need to focus on non-communicable diseases since communicable diseases are now under control.

There are many areas where we can act on non-communicable diseases and others where we cannot act immediately. An area where we can act immediately and where we have already started is cancer. And even in cancer, it is not all cancer as the initial focus is on women and children. It is not that we are neglecting men but because affordable solutions targeting these cancers happen to be available on the market at this material time. On the other hand we cannot work on everything at the same time. 

For women we are taking action against cervical and breast cancer by detection and early treatment. A vaccine against cervical cancer is also available providing an affordable and sustainable solution. 

We are also going to act on a series of cancers affecting children. We are finalizing the protocols, the guidelines and policies.

We are taking on those cancers against which we can act immediately and which are also the most frequent. For example Lymphoma affects mainly children and there is something that can be done about it. We are not going to wait for big infrastructure but handle whatever we can within the present means. We shall then create facilities for cancer care knowledge. For those for whom it may be too late to offer successful treatment, we shall opt for palliative care.

The guiding philosophy is that Rwanda will always prioritize the most acute problem. So we can now focus on the next major killers and go on like that until such a time as we reach the level of the developed world.

Quality and value for money

The other area of focus this year will be improved management of the health sector to achieve more value with fewer resources as global fund resources are decreasing. Quality of care will come under increased scrutiny as we seek to maximize value from our resources.

Quality care has two sides – the science and the way to implement that science. After that you have the human dimension, the customer care. Already there is progress. When a population is healthy and when you empower them on their rights, they are more demanding. Before, expectations were low because it was the time when you had just two doctors per district hospital. But now we expect quality because the numbers have started to be significant and on the other hand we have pushed the people to demand quality care. 

At one time, many people who were visiting our health facilities would find a good doctor with skills who was critically short on customer care. Today people are legitimately complaining because they expect both quality care and customer care. I may be a good and highly skilled doctor but if am rude that undermines the quality of my overall output. 

On the other extreme you could have someone who may not be even be qualified but has great customer care and people actually prefer to consult him or her just because of that. This happens a lot in our country and potentially creates dangerous gaps in our health system if people choose to seek care from non-professionals. So doctors in the formal sector need to provide the full package of knowledge, science and customer care.

Malnutrition

Malnutrition is another priority for this year. The government has committed itself to eradicating the causes of malnutrition before the next Umushyikirano. Looked at objectively, malnutrition is not insurmountable. We have malnutrition not because we cannot produce food but rather because we are using it wrongly. You find families that say they don’t have food but they can grow the food. Others say they don’t have land but the local government can provide collective land for people to grow food. Malnutrition should not occur in this country, eradicating it is just a matter of organization.

Two percent of children under five years suffer severe malnutrition but that malnutrition can not be linked to disease since hunger per se is almost non-existent. There are also cases where malnutrition is a result of mothers not knowing how to feed their children. In the same age bracket we also find 11% that are underweight and 44% that suffer chronic malnutrition.

We have learnt that the primary cause of malnutrition is related to what children and pregnant mothers eat. Most of those children are born malnourished because the mother did not take enough micro-nutrients, vitamins etc when pregnant. The solution lies in increasing the knowledge to fight the habit of not eating some sources of protein. It requires a revolution in the way we are feeding children.

Human Resource for Health 

Another frontier during this year will be developing the Human Resource for Health. Because we have made good progress with what we have now and have achieved reasonable levels of basic care, people are going to get diseases that are related to age. Yet we don’t have the specialists to care for them.

At the district level at a minimum we need one surgeon, a pediatrician, one anesthetist, one internal medicine specialist and an oncologist to deal with cancer and related complications. We also need to develop the capacity to treat or manage metabolic diseases.

It will take us decades to achieve desired staffing levels if we were to continue producing health professionals at the current rate. To mitigate this, we have partnered with 18 American universities that will bring here hundreds of experts to mentor Rwandans to be teachers, teach residents to be good specialists and teach graduates to be good medical directors. Over the next seven years, we shall have attained the capacity to produce our on workforce and we will produce the minimum we need that are capable of giving the care we need.

Infrastructure

We are planning to have radio-therapy facilities and oncologic wards at CHK, Kanombe and Butaro hospitals where we shall provide specialist care for cancer patients. We will have a facility for radiotherapy and places where we shall hospitalize people that need special care. 

We are also going to produce an accompanying complement of Medical Directors with specialist skills in oncology within two years. We plan to create full specialists who will train and supervise others so that we have someone with these skills in every district hospital. The missing gap in the training of our human resource has been mentorship and bedside training.

Mutuelle de Sante

Making progress against infectious diseases does not necessarily free us from spending money because the cost of prevention is also high and that is why the health budget has been increasing year after year in the national budget. On the other hand even as we have increased the national budget for health, the international contribution to that budget is uncertain so the future lies in what we shall be able to do under the national budget and health insurance. 

Fortunately even the out of pocket expenditure is increasing because of the improving economic welfare of Rwandans. We have one million Rwandans who have transitioned from poverty to a better income status. As a result, they have more money out of pocket and are capable of paying for their health insurance. Additional resources for health may come by way of savings made by individuals against future sickness through health insurance and Mutuelle de Sante.

However Mutuelle de Sante is a national institution that is still growing and maturing. If we are not strict in its management we are going to pull it down yet it is a good system.

We have so many sectors and to ensure that all are managing the system properly is a fight that requires day and night vigilance. Because you have money there for healthcare that may seemingly be lying idle, some leaders at the local level may want to use this money for other things. We need to sensitize and convince them that is not right to diverting that money to other priorities and that this constitutes a financial crime. We need to get that message down to the sectors.

Finally, we need to create regional; reflections on how to treat diseases. We have started by seeking to create high efficiency programs for controlling malaria with our neighbours. Half of our problem with malaria is around the border areas and 45% of that burden is in just three sectors of this country meaning we need to work with our neighbours. Rwanda cannot be an island of welfare in a region of desperation. We are proposing common procurement and harmonization of policies and fighting together against counterfeit medicines. We shall tackle these problems jointly by agreeing on the best policies based on the best science of the moment.

Uniting to Combat Both Hunger and Undernourishment

Ahead of the G8-sponsored summit on Nutrition for Growth on 8 June, I published an op-ed in Project Syndicate entitled "Diet and Growth" on 31 May. You can read it on their webpage.

http://www.project-syndicate.org/commentary/stepping-up-the-fight-against-childhood-undernourishment-by-agnes-binagwaho

Same Old Problems, new approaches in 2013

Below is my contribution to issue 3 of Ubuzima Magazine, published by the Rwanda Health Communications Center and the Rwanda Biomedical Center.

I recommend you to read the full magazine! Lots of great information on our health sector from the MOH and RBC

Same Old Problems, new approaches in 2013

By Dr. Agnes BINAGWAHO

Despite lingering challenges, 2012 was another year of incremental performance in health delivery to the Rwandan population. One visible improvement was the 50 percent reduction in acute malnutrition. However we need to not only reduce acute malnutrition but reduce the incidence of malnutrition in general.

That can be achieved by focusing our efforts on prevention. We have changed the way malnutrition is monitored because we realized that the source of the problem does not reside with the health sector alone but cuts across other sectors like Agriculture and Minaloc ( the Local Government Ministry), which are responsible for kitchen gardens, tree planting, distribution of small livestock, such as poultry for producing eggs, goats for milk etc.

However, the population also needs to be educated on how to eat these nutrients properly when they are available and that falls under Migeprof (Gender Ministry) and the National Women’s Council. The National Women’s Council which is decentralized down to village level will be used to help in monitoring not just kitchen gardens but the plate of the child as well. This is the first time we are going to monitor not what is available to the village and the family but the nutrient value in what children are actually eating.

To fight malnutrition of under-fives, we have hatched a new plan to complement what we have been doing. Because many pregnant women are themselves malnourished, they give birth to malnourished children. So we are also going to monitor the plate of the pregnant woman and then monitor the plate of the child as well.

Volunteers from the National Women’s Council will meet with families to see what the children are eating. Before this, we were monitoring only the kitchen garden but the reality is that while the garden or cow may indeed be there, their products are not being given to the child. That is the next frontier in monitoring the fight against malnutrition.

HRH

Overall my impression of the Human Resources for Health program is that it is positive thus far. We need to increase the number of health professionals in order to assure quality care for Rwandans. By improving basic care, reducing child and maternal mortality, we have been able to increase life expectancy from around 30 years in 1994 to 55 today. This transition has its own dynamics and we are now staring at the emergence of new chronic diseases that are not the result of any new epidemic but because the population is aging. It is evidence of our success against infectious diseases.

All people who need HIV treatment are on treatment. We have managed to control malaria and Tuberculosis. But going forward we now need specialists to deal with the emerging health problems related to age and consumption. We need to deal with heart diseases and chronic diseases such as cancer. We also need to improve child mortality by improving neonatology because the rate of death of neonates is what pulled down our child mortality indicators.

So we decided to create a program that brings to Rwanda around 100 Americans from the best universities every year, to teach, to mentor, bedside and also transfer clinical skills to Rwandan professionals at the level of post-graduate. Through this we hope to produce 500 specialists and sub specialists. Through this program we are going to be able to staff every district hospital with one gynecologist one pediatrician, one internist, one anesthetist and one surgeon.  We shall also have the capacity to treat our population for cancer and other diseases that need specialized care. This is not going to be done overnight; it is a seven year program that brings together all the partners working in education around the program. We are stopping petty training and focusing on good sustainable academic training.

This program will reinforce our universities to provide teaching and at the end of the day we are going to have a very skilled workforce in the health sector.

Decentralization

We are making great progress in management of the sector. Management at the central level has been very good and certified by various audits. 

We are now actively supporting the decentralized sector with the people we have trained and mentored. We are now going to move to the district level deploying people with skills in monitoring and evaluation of health programs. They also have skills in in-service training, supervision etc. Those people are now well trained and functional and we are going to base them in districts where they will be at the service of the districts. The Director of a hospital will report to the Director of health and to the Vice mayor. By decentralizing the audit function to the district and having these highly skilled people distributed equitably across the entire country, we are going to see even better management of the health sector.

This is a big move towards ownership of the sector by the districts. Because it is not fair to decentralize tasks without decentralizing the capacity to do that, we are confident they will transfer this knowledge and capacity since they have been doing it well at the central level.

2013 targets

Customer care and putting in practice the knowledge we have acquired through various programs such as HRH (Human Resources for Health) is our collective target for 2013. Our workforce is skilled and knowledgeable and what we need is to marry knowledge with practice. Health workers need to know that they need to care and apply their knowledge with customer care in mind.

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.

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.

Mondays with the Minister #3: Malnutrition in Rwanda

On Monday 12 December 2011, I hosted the third consecutive “Mondays with the Minister” Twitter chat on the topic of malnutrition in Rwanda. For the first time, SMS was used in addition to Twitter. I recently partnered with a local company, Nyaruka, to integrate SMS into the bi-weekly discussions. Nyaruka moved fast to design a superb web platform where I can receive, respond to, and publicly display SMS messages. During this first Twitter/SMS Mondays with the Minister, approximately 40 people participated on Twitter, asking questions from across Rwanda and other countries in the region. Students and researchers interested in global health also joined from Europe and North America. 

We will be improving the publicity on the SMS portion of the discussion in coming weeks. Radio announcements and a Ministry of Health press release will help to publicize it more widely for future chats, allowing Rwandans across the country to contribute questions or comments about the chosen topic in the language of their choice (Kinyarwanda, English, or French) during the time frame of the discussion. Five total questions were contributed by SMS in English and Kinyarwanda this past Monday, and I look forward to seeing many more in future weeks.

This week’s discussion on malnutrition in Rwanda touched on current chronic malnutrition and anemia statistics in Rwanda, which remain very high. We discussed the state of the Ministry of Health’s response to malnutrition, and many Rwandans were interested in behavioral change communication efforts underway to promote balanced diets in addition to structural anti-poverty interventions (such as One Cow per Family, kitchen gardens, milk for students at school, and ubudehe) that seek to combat food insecurity at the community level. Others were interested in institutional collaborations to address malnutrition, public-private partnerships in Government programs, the linkages between nutrition and care for chronic diseases such as HIV and tuberculosis, oversight of UNHCR refugee camps, and the prevention of obesity as Rwanda’s economic growth continues. I asked what participants thought was the weakest part of the Ministry of Health’s response, and this led to an exchange about meeting the needs of vulnerable youth – particularly “street kids.”

All in all, the discussion was very interesting and informative for me as Minister of Health. As is the case with Rwanda’s Umushyikirano (National Day of Dialogue), it is so important for Rwandans to be able to communicate with their Government. In the Ministry of Health and throughout the central Government, we strive for transparency, accountability, and accessibility.

I’d like to thank again Nyaruka’s staff, especially Nic, Eugene, and Eric, for their hard work on creating this new platform. I appreciate this partnership and highly recommend them for other ICT for health initiatives. For all those interested, you can visit their company’s website at http://nyaruka.com.

My next “Mondays with the Minister” discussion on Twitter and SMS will be held on 9 January 2012 (time TBD). The topic will be vaccinations, and we will discuss the impact, delivery, and sustainability of vaccines in Rwanda. As a reminder, you can follow the discussion through my Twitter account @agnesbinagwaho and by searching for #MinisterMondays. You can also send a question or comment in Kinyarwanda, English, or French by SMS to 0788 38 66 55. SMS questions and my answers can be viewed online at listen.nyaruka.com. I greatly look forward to our next discussion.