By Dr. Agnes Binagwaho
Dr. Agnes Binagwaho
Success in Rwanda’s health sector is due to the fact that the Government works as one in pursuit of an integrated and community-driven development process. This past year, I have read and listened to many great newspaper articles and speeches about Rwanda’s social and economic progress since 1994 that highlight the country’s unprecedented achievements but conclude with a single sentence or two that intends to make the reader or listener doubt all of these achievements.
Listening to such reflections on my country has caused me to reflect on a number of trends since my return to Rwanda in 1996. Still much needs to be done and as a nation and as a people, we have pursued with fierce urgency the integration of participatory democratic principles and equitable social policy to ensure that all Rwandans benefit from the process of development. We promote and strengthen our democracy by always engaging our people – Rwanda’s true wealth – in the formulation and implementation of policies for health, education, gender, youth, decentralization, financing, infrastructure and other.
In order to do so, the Government must apply an integrated and collaborative approach across all sectors. His Excellency Paul Kagame, the President of Rwanda, makes this quite clear when responding to a new policy proposal from a member of his Cabinet, asking first without fail: “What will this mean for the people, and how does it link to our poverty reduction and economic development strategy?” The evidence and results of such an approach can be seen at all levels, exemplified by a number of uniquely Rwandan approaches to the empowerment of our citizens.
One fine example of communities working together for national development is the monthly day ofUmuganda, a voluntary work day on the final Saturday of each month. Community members in villages, towns, and cities across Rwanda collaborate on various service projects. Activities are identified and selected through a participatory process, and often include building schools or health centres, planting trees, or clearing areas for the construction of new homes for the community’s most vulnerable families. Umuganda creates momentum for the development of all sectors, as public sector agencies often choose to contribute resources to these projects (and Ministry officials often join in the work around the country). All of these initiatives serve the pursuit of health; even the construction of a school will facilitate increased uptake of health services in the next generation because a well-educated woman is a highly valued member of a family who is well taken care of.
Other national programs similarly fight poverty and promote economic growth in ways that amplify the work of the health sector. For instance, the Ubudehe process of village-level community decision-making that includes “poverty-mapping” (or communal categorization of households into socio-economic categories based on income and needs) allows for better targeting of social services and pro-poor subsidies for items such as our community-based health insurance program, Mutuelles de Santé. In the Ministry of Health, we use Ubudehe and district level data to proportionally allocate our malnutrition interventions (such as the One Cow per Family and kitchen garden programs) towards the most affected areas of the country.
In order to catalyze economic development at the community level, our Government undertakes massive sensitization campaigns around financial savings. Umurenge Savings and Credit Cooperatives (SACCO) were established across Rwanda to increase access to financial services among the rural poor. Today, all of the country’s sectors manage their own SACCO with technical assistance from the central government. These cooperatives are voluntary, and they allow each citizen to contribute what they want to the communal savings pool. With these savings, the community can provide loans (same amount as invested by the citizen) to individuals who agree to reimburse the cooperative for the amount. One district I visited two weeks ago, Burera, has a savings pool of over one billion Rwanda francs. Umurenge SACCO is a very successful program for economic empowerment through the creation of community-owned and directed capital.
The Ministry of Health also uses cooperative savings mechanisms to compensate our 45,000 clinical services providers the community health workers (CHWs) through performance-based financing. Each community elects the CHWs in a participatory and open manner, after which they are trained by the Ministry of Health in prevention, care, and referral of the most common causes of diseases and mortality among communities in Rwanda. As I have written about elsewhere, our massive team of CHWs has contribute to dramatic improvements in health outcomes over the past five years, including a 50% decline in child mortality, a 70% decline in malaria incidence, a 52% increase in the proportion of mothers delivering at health facilities, and a 450% increase in the uptake of modern family planning methods. They serve as the first line of defence against the biggest killers, addressing 80% of the burden of disease through home-based care, but also stand ready to link patients to health centres or district hospitals via ambulances
that they contact with their cell phone.
Economic development at the community level is crucial to Rwanda’s long-term vision for the health sector, because we want every Rwandan to be capable of contributing premiums to the Mutuelle de Santé program. When visiting officials from our partners in the United States or Europe ask how we plan to make this vision sustainable, I like to show them a graph of Rwanda’s recent economic growth – about 8% for the past several years, which has contributed to the expansion and flourishing of our poverty reduction programs.
Rwanda has the vision of becoming a middle-income country that is able to self-finance our pro-poor social interventions and guarantee equitable access to high-quality medical care. When I join in for Umuganda or visit a SACCO and see our people’s unwavering commitment to our nation’s vision, I have no doubts that we will make it. To empower Rwandan citizens economically, we promote a spirit of independence to make the best choices for themselves. This is the basis of democracy; when you are dependent and begging, you cannot direct your life.
Full civil and political rights are essential to human development and are highly valued in Rwanda, but we can never forget that these must be built upon a foundation of social and economic rights. If a woman fears that her child may die of malaria for want of a 500 Rwandan franc treatment, being able to vote will not serve her in the short term if it is not link with economic growth; if a man does not have enough money to feed his family or send his children to school, the ability to nonviolently express grievances will not fill stomachs or pay school fees. Civil and political rights and social and economic rights can and must be mutually reinforcing; neither is sufficient alone – we must assure them all. This understanding is woven into the very fabric of our nation’s Constitution and each of our major social sector policies; we must never forget it.
I am truly delighted that more and more high-level officials from the Governments of our long-time development partner countries are coming to see firsthand what we are doing in Rwanda. I have the feeling that we are all truly contributing to a revolution that will bring more health and wealth to our people. Our partners deserve to see how we are using the investment in the health and wealth of our population. In the global humanitarian market, the value of money invested in Rwanda is incredibly high due to lack of corruption, our dedication to participatory processes, and our reliance on integrated cross-sectorial approaches to tackling policy challenges. As a public servant, I am so proud to belong to Rwanda, a country that has pro-poor human-focused policies in practice, and to its population, who are the most valuable resource our country will ever have.
Agnes Binagwaho, MD, PhD hc
Minister of Health of the Republic of Rwanda