analysisBy Dr. Agnes Binagwaho
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.
The author is the Minister of Health.