Developing Countries

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.

Uli Knörzer

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

Vice Chancellor, University of Global Health Equity
MD, M(PED), PHD is a Rwandan pediatrician who returned to Rwanda from France in 1994, settling permanently in 1996. She has served as Executive Secretary of the National Aids Control Commission, Permanent Secretary of Health and as Minister of Health. Today she is Vice-Chancellor and co-founder of the Rwanda-based University of Global Health Equity, focused on changing healthcare delivery globally. She was named one of the 100 most influential African women for 2020.

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.

Key information about pregnant women is held in the RapidSMS database, enabling healthworkers to coordinate care with hospitals. Stephanie Aglietti/Getty Images

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.

1 Governments must build trust in healthcare systems by enabling communities to participate in healthcare delivery. 2 A focus must be placed on preventing non-communicable diseases – for example, by introducing more opportunity for exercise. 3 Every opportunity should be taken to bypass traditional healthcare solutions with new technologies.
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