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 New Times: "Rwandans Among Top Users of Twitter in Africa"

Rwanda's New Times published an interesting article today about citizens' usage of Twitter, and discussed His Excellency's encouragement to all Rwandas to harness the power of social media. 

Rwandans Among Top Users of Twitter in Africa

By Edwin Musoni

A new report places Rwandans as the seventh top users of Twitter in Africa with close to 10,000 tweets in the last three months of 2011, according to a study.

The study was released yesterday by Portland Communications, a political consultancy and public relations agency that provides communications and public affairs advice to top brands and high-profile individuals.

The survey dubbed “How Africa Tweets” indicates that, in the last quarter of 2011, Portland Communications and Tweetminster conducted a unique study into the use of Twitter in Africa.

Analysis of over 11.5 million geo-located tweets originating on the continent and a survey of 500 of Africa’s most active tweeters showed that the seventh most active country was Rwanda with 92,880.

“The first survey of its kind in this region, How Africa Tweets, will serve as a benchmark for measuring the evolution of Twitter on the continent,” reads part of Portland Communications’ report.

South Africa led the table with 5,030,226 tweets, followed by Kenya (2,476,800). Nigeria (1,646,212), Egypt (1,214,062) and Morocco (745,620), while Algeria emerged sixth with 103,200 tweets.

The study also found that 57 percent of tweets from Africa were sent from mobile devices, 60 percent of Africa’s most active tweeters are between 20 to 29 years old and that 81 percent of those polled mainly used it for communicating with friends.

“Sixty eight percent said they use Twitter to monitor news and 22 percent to search for job opportunities,” reads the survey.

President Paul Kagame is among the Heads of State who have taken the microblogging site to directly engage or respond to people inside and outside Rwanda.

The Head of State has previously said he finds time in between his busy schedule to attend to his Twitter account @PaulKagame and answer questions, if any, or comment on current issues around the world.

Commenting on the ranking, Lucy Mbabazi, a public policy and IT specialist, who is also an ardent Tweep (moniker for people who tweet), said that Twitter had managed to contribute highly in the social affairs sector in Rwanda.

“If I can tweet police and ask them to ensure more safety at some junctions and they do it, I think the potential is massive. … Also, the Minister of Health, Dr Agnes Binagwaho’s Monday sessions on twitter are interactive and informative, this has made the ministry very responsive to feedback,” Mbabazi wrote in her tweets.

Jacqueline Ndinda, a Kenyan Freelance journalist, said that Rwanda deserved to come among the best countries in Africa considering the fact that President Kagame has taken the lead in motivating his citizens to use the social media platform.

“Rwandan President gives all other African countries a run. He engages in conversation. Which other African President does that? But I don’t see a big number of tweeps from Rwanda engaging him, it’s an opportunity Rwandans should exploit,” said Ndinda

A hash-tag of #Africatweets was suggested for debate on the findings. Twitters offers 140 characters to microblog and paste links from websites.

Mondays with the Minister: Vaccines and Immunization

On Monday, 9 January, I held the first Mondays with the Minister of 2012. It was a great start to the New Year. The topic of yesterday’s discussion was “Vaccines and Immunization in Rwanda.” We hosted the discussion on Twitter, and, through my new partnership with the Rwandan company Nyaruka, we were also able to integrate SMS into the discussion and received messages on that platform as well. Anyone who wishes to view either the Twitter or SMS discussions can do so here:

Twitter #MinisterMondays

and

Nyaruka #MinisterMondays

During #MinisterMondays yesterday, I received many questions, including:

• What has been most important achievement in the past few years regarding the immunizations? 
• Can you describe Rwanda’s involvement in efforts to find an HIV/AIDS vaccine?
• What are Rwanda’s experiences with the pneumococcal conjugate vaccine and treatment for pneumonia and are these two complimentary?

I posed a few questions for all participants as well, including:

• What do all you think is financial/human/moral cost of failing to implement 100% of possibilities provided by vaccines?
• Question for all: Developing an HIV vaccine is only longterm gender-equitable solution to pandemic. What do you think? 

It was a fantastic discussion and I learned from participants what some of their concerns are concerning vaccines and immunization. I can see that the reach of this forum is expanding and more and more people are beginning to communicate through these platforms. One thing I remarked during this last discussion was that several complaints were voiced (that were unrelated to the topic of this session). From this experience, I realized that the Ministry of Health must improve its sensitization of the population and empower people to use local outlets for complaints and concerns when their rights are not respected. There are faster ways to have your complaint heard in Rwanda, and to make individual and collective rights fulfilled!

Thank you all again for a great discussion yesterday. I look forward to connecting with you all – and more participants – again on 23 January. The next #MinisterMondays topic will be “Gender and Health.”

Follow along on Twitter or by SMS on Nyaruka

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: Vaccines and Immunizations

On Monday, 9 January, I will host my first Mondays with the Minister of 2012. The session will run from 5:00-7:00PM Rwanda time (3:00-5:00PM GMT). The topic for this coming session is Vaccines and Immunizations in Rwanda.

You can tweet questions or comments to me at @agnesbinagwaho, you can follow the discussion by searching #MinisterMondays, and you can send an SMS with your questions or comments at 0788 38 66 55. (If dialing from outside of Rwanda, please dial: +250 788 38 66 55). You can also follow the SMS discussion by visiting http://listen.nyaruka.com/ 

I welcome all of your questions and comments and look forward to another great #MinisterMondays conversation.

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