Building on Trust
In 1994 Rwanda suffered one of the worst genocides in recent history. Today it has one of the best health systems in Africa. Former Rwandan health minister Agnes Binagwaho explains how this was achieved.
Impact: You returned to Rwanda from France after the genocide in 1994. What have you witnessed in terms of change since then?
Agnes Binagwaho: The biggest change is around the rebuilding of the social fabric. We had one million dead. Neighbors killed neighbors with machetes. There were also heroic people who saved others, but when I came back in 1994 the distrust was so high you could not leave your drink for fear it would be poisoned. So it was critical to rebuild trust and create a strong avenue for peace and reconciliation with a recognition of the victims. The message was that people are not in essence bad; they turned bad through bad leadership.
How has the healthcare system evolved since 1994?
When you are sick and vulnerable, you will not seek healthcare from people you do not trust. By building trust, we have achieved the best rate of child vaccination on Earth. To vaccinate your child is an act of trust by the parent because that infant is not sick and yet you are going to make it cry and give it a fever when you give it an injection. The parents have to believe the vaccination will help that baby. In 2018, the Welcome Trust surveyed people from 104 countries on trust in their national healthcare systems. Rwanda came out top. Rwanda is a poor country and yet we have better survival rates than countries with three times our GDP. This is not by chance. This is because we have managed to create the demand for healthcare, and that demand is based on trust.
How have you embedded the principle of trust in your local healthcare systems?
I think you should look at it the other way around. We gave people the right to control their destiny and then they created the trust. One of the first policies I passed when I was health minister was to make it a legal obligation to make communities participate in healthcare. At a community level, people are requested by law to elect health workers they trust. After that, it is up to the ministry to train them. Four health workers are elected for each village. They are responsible for women’s and infant health, common diseases, child development and malnutrition. Community members select people to be members of the board of their health center to make sure that they are happy with the care received. This basic participation process is key to Rwanda’s health policies.
By building trust, we have achieved the best rate of child vaccination on Earth.
How has Rwanda dealt with mental health issues following 1994?
Let’s start with the trauma of the people who survived. They received no specialist health attention as there was no mental health policy before 1994. We had one mental health hospital with 100 beds and one psychiatrist. So, we decided to rely on the community to alleviate the pain and we changed attitudes when it came to the expression of trauma. We said, “Don’t try to hide this or pretend it does not exist.” It was about the whole community coming together. Then, two years ago we discovered there was trans-generational trauma. Children were turning to risky behavior like drug usage because of the actions of their veteran parents. We reacted in the same way, asking people to talk about it openly and not deny it. We launched programs to teach clinical psychologists to detect trans-generational trauma. We are also working through schools to catch children who have problems. We needed to find a homegrown solution to our national trauma, which makes every Rwandan an actor in the solution.
Professor Agnes Binagwaho
Africa suffers from a shortage of health skills. How is Rwanda addressing this problem with regard to mental health?
After 2000 we started to train psychiatric nurses, placing them in every hospital and then in every health center. We trained community health workers to recognize dangerous signs and to understand who needs to be transferred to someone more qualified. There are doctors in each hospital with mental health training who know when to transfer a patient to a psychiatrist or back down to the health center. We have also just created a rapid screening tool to detect children at risk of depression. We are creating an architecture based on the country’s ability. We are not undermining specialist skills, we are just demystifying them by task sharing. Rwanda has also created a program called Human Resources for Health in partnership with 23 American higher education institutions to create residencies and start specializations to train Rwandan faculties to train psychiatrists.
There is talk of Africa having the opportunity to leapfrog or bypass traditional healthcare solutions with new technology. To what extent is that happening in Rwanda?
If we see an opportunity to leapfrog, we go for it. We have done it with HIV treatment and our vaccination program. Let’s take Covid-19. If health workers take temperatures while treating patients, they risk infection. So, we are using robots to take temperatures. We found a company that produces them, we tested them and now we use them to decrease the risk to health workers. The other area is in the organization of the health sector. We are very proud of our health information system. For example, if a community worker gives a treatment for malaria, the data is updated on a server using their phone, the information is collected at district level and the health minister can see each month how many treatments there have been. Drones are another example. We use them to send life-saving drugs or equipment to cut a four-hour road trip down to 25 minutes.
If we see an opportunity to leapfrog, we go for it. We have done it with HIV treatment and our vaccination program.
The WHO fears that Covid-19 is impacting immunization programs. How is Rwanda dealing with this risk?
In other countries, people don’t want to go to hospital for fear of catching Covid-19. In Rwanda, if you suspect someone has Covid-19 you call a number and an ambulance takes them to a special center. To make sure we protect the health system, you are not allowed to go to hospital with Covid-19. You don’t have to leave your district to get a vaccination because every district has many health centers. We have also been able to maintain our supply of vaccines throughout the outbreak. By comparing vaccine numbers with the number of children born, we believe we have been able to deal with the problem.
Non communicable diseases are on the rise in Africa. What are you doing in terms of public health measures to prevent disease?
We have been very attentive to this issue after seeing how China went from problems with malnutrition to problems with obesity. We have done a number of studies and we have unexpected levels of obesity. It is not high, but it is unexpected. Exercise has been made a state issue. Before Covid-19, every Friday all public institutions closed for people to do exercise. Every month in Kigali there is a car-free day where everybody is encouraged to walk in the city. You see ministers, you see your neighbors, you meet the president walking. It’s fun and you do a lot of exercise. This has now spread to districts. Every week people have to exercise, football matches are arranged between parliament and the ministries. Our message is to exercise to avoid non-communicable diseases. More than a message: we walk the talk.
One of the Sustainable Development Goals is about affordability for all. How are you achieving this in Rwanda?
The country cannot provide free healthcare and the people cannot afford to pay. The only thing to do is to adapt health insurance to our culture. We also have an efficient system with the highest level of affiliation. There is health insurance for the military and police, we have insurance for civil servants, we have private insurance and we have community health insurance, which is mandatory and costs $5 per person per year. The poorest 25 percent of the population pay nothing – the government pays their premium. At the point of care, you only have to pay 10 percent of the cost, because we don’t want the population to believe that care has no cost. We now have an aging population, so we have to find a way to add a little more to deal with chronic diseases – we are having to adapt as we go.
Rwanda is a poor country and yet we have better survival rates than countries with three times our GDP. This is not by chance.
Where do you hope to see Rwanda in terms of healthcare in 20 years?
We have a long way to go to get where we want to be. We are missing advanced care like cardiac surgery. You save people from TB and HIV and then they die of a heart attack. I want to continue to develop access to more sophisticated care. I want to continue to make care accessible, to grow communities and make every person contribute to this development. I want healthcare even more embedded in the community. This is why we created the University of Global Health Equity, to advocate for community-centered development with health at its center, providing for each and every person, especially the vulnerable.