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.