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The Future of Innovation in Rwanda’s
Health Sector:
Equity, Participation, Science,
Sustainability
Dr. Agnes Binagwaho, Minister of Health of the Republic of Rwanda
The
world has begun to pay increased attention to Rwanda’s rapid rate of progress
in the health sector, particularly as we approach the 2015 deadline set for the
health-related Millennium Development Goals. Our country has likely already
achieved goals of reducing the 1990 child mortality figure by two thirds and
halting the spread of HIV/AIDS, tuberculosis, and malaria; we are on track to
achieve the goal of reducing maternal deaths by three quarters by 2015.
What
Rwanda has managed to achieve has been the subject of much dialogue (and much
debate); I do wish to repeat what has been covered better elsewhere or to make
it seem as if our health sector is resting contentedly for even one second when
more than 22,000 of our children will die this year. Instead, I want to focus
on the why, and to reflect on what
must come next for our country and our region if we are to sustain, exceed, and
spread this progress.
I
firmly believe that the secret ingredient to Rwanda’s recent successes is something
very simple in principle that requires a very serious commitment to implement
effectively: the absolute insistence that nobody is left out of benefitting from
our collective progress. This understanding forms the core of our national
development plan, and all from the central level to the community realize that when
we tackle the needs of the most vulnerable first, we are sure to also reach all
the rest. Moving equity from the realm of the political into the realm of
practice and policy has been a true force multiplier for everything that we do.
Rwanda
has learned from our long history of segregation and division – due to sources
both external and internal – that the only way forward is through complete
inclusion. Therefore, before any single policy is implemented in the health
sector (or any other), all stakeholders are invited to participate in a process
of true consultation. The often complex task of implementation and
dissemination is rendered simple when all are engaged to participate from the
beginning.
But
even policies that are formulated in the most open and inclusive manner will
not succeed if they are not based on the highest quality of scientific
evidence. It is often said that “you cannot improve what you cannot measure,”
and one of Rwanda’s most important innovations has been the establishment of
robust systems of monitoring and evaluation focused primarily on actual health
outcomes. By implementing a national maternal death audit program, whereby health
workers and communities analyze all dimensions of every situation where a pregnant
woman dies in childbirth, we have been able to chart a reduction in the number
of deaths from 8 women per day in 2004 to less than 3 per week today. By giving
a name and a face to every lost mother has sparked each person’s innately human
determination to stop this tragedy all the way from the most rural health post
to the highest levels of the central government.
Putting
evidence into practice requires more than just good tracking tools, however. It
means bringing science to bear on both the root causes and the immediate causes
of preventable suffering and death. Rwanda has prioritized increasing access to
both essential health services (such as safe deliveries through a
community-based SMS notification system for ambulances) and to the fruits of medical
progress (such as new vaccines against pneumonia, the virus that causes
cervical cancer, and the virus that causes many cases of diarrhea in infants). We
are particularly proud to see our Ugandan sisters and brothers also scaling up
access to the human papillomavirus vaccine this year, which will prevent thousands
of young women from developing cervical cancer in the future.
The final
building block of success, in my experience, is the honest pursuit of
sustainability. I do not mean sustainability as a buzzword, in the way it is so
often tossed around and how it comes to fill up a third of the word count for bureaucratic
reports. Instead, I mean a sense of deep accountability and responsibility to
ensure that programs are built to last and designed with an eye towards
continual improvement.
We
have a saying in the Ministry of Health that pilot projects are not a solution
in Rwanda – the only pilots here are in the sky, working for RwandAir! When
negotiating about a new opportunity for our population, we insist that we go
national as soon as possible, or we go nowhere. This is not a reckless strategy
that makes the perfect and enemy of the good. We simply know that as policymakers
and citizens tasked with improving the health of the entire population (not a
catchment area or capital city), we must strive for the most robust and
long-lived programs possible.
When
we designed our new pediatric cancer center of excellence in Butaro near the Rwanda-Uganda
border, for instance, it was not only for that one district – it was as a
referral center for the nation. When we rolled out the national community-based
health insurance scheme, mutuelles de
santé, we began by subsidizing the annual contributions and copayments for
the poorest one million citizens; soon enough, the middle-class and others bought
in because they saw that the most vulnerable were indeed enjoying the best
access through this new program. If we had attempted to move from an
experimental mutuelles program in one
or two cities to nationwide rather than this phased strategy, we would
certainly not be able to count 92% of our population as enrollees today.
Underlying
all of these principles, and ensuring that they are collectively translated
into results, has been innovation in partnerships. To harness synergies and maximize
value, we mobilize each and every willing partner according to the framework
and timeline of our national plan. This has fostered national ownership of our programs
and our success, but it has also led to novel collaborations that simultaneously
encourage service delivery, teaching, and research. Rwanda’s Human Resources
for Health Program, launched this year with 13 American universities, is a
great example.
The
lesson for me, then, from Rwanda’s experiences in the health sector has been
that anything is possible when you apply the principles of equity,
participation, science, sustainability. To better do so, we require constant
out of the box thinking, and a commitment to solidarity and shared improvement.
My colleagues and I look forward to fruitful cross-border collaborations, and we
know that we can make it together.
