In tiny Rwanda, staggering health gains set new standard in Africa

When Agnes Binagwaho began her career as a doctor in the slums of Kigali, Rwanda, in 1996, she worked in one of the most precarious health environments in the world.

The rickety public hospitals that had not been destroyed in the genocide two years before were filled with AIDS patients. But drugs – and doctors – were scarce or nonexistent. Meanwhile, Rwandans were dying in massive numbers from malnutrition, malaria, and tuberculosis.

“We could do nothing for them,” she remembers. “We didn’t have drugs even for ordinary diseases.”

19 years later, however, Rwanda is on pace to become the only country in sub-Saharan Africa to meet all of its health-related Millennium Development Goals, and the tiny pocket of Central Africa has posted some of the world’s most staggering health gains in the past decade, outpacing nations that spend far more per capita on healthcare.

And Dr. Binagwaho, who once stuffed her suitcases full of basic medicinal supplies to take home to Kigali whenever she traveled abroad, is now leading that charge as minister of health.

In an article published earlier this year in the British Medical Journal (BMI), a team of doctors and researchers working in Rwanda laid out the country’s swift rise.

Between 1994 and 2012, they wrote, the country’s life expectancy climbed from 28 years to 56 and the percentage of the population living in poverty dropped from 77.8 percent to 44.9 percent.

In the past decade, deaths from HIV have fallen 78 percent – the single largest decline in the world during that time frame – while tuberculosis mortality has dropped 77 percent, the most significant decrease in Africa.

Of course, the starting point in Rwanda’s climb was a harrowing one: In 1994, between 500,000 and 1 million people — up to 20 percent of its total population — were killed in an ethnic genocide, and some 2 million more fled. Many doctors were among the dead and exiled, and the country, including its healthcare system, was left in tatters.

That year, less than a quarter of Rwandan children received immunizations and more than 1 in 4 children were dead by their fifth birthday.

But in the years that followed, Rwanda became the darling of the international development community, a case study for how a country could use a trans-formative post-conflict period to effectively rebuild its core institutions.

As aid poured in, Rwanda’s new government channeled it into a wide variety of social programs, including healthcare. It rolled out a system of universal health insurance, doled out vaccinations and mosquito nets, and put nearly every AIDS patient on antiretrovirals.

And it did all of this in a place that still faces what the BMI article called “one of the greatest shortages of human resources for health in the world.”

Indeed, the country of 11 million has only 625 doctors in its public hospitals nationwide. But there are also now more than 45,000 “community health workers,” trained to treat basic health issues and help ensure adherence to drug regimens in rural areas far from hospitals and clinics.

As a result of these efforts, the probability that a child will die before the age of five has fallen by 70 percent and is now half the regional average. Some 108,000 people now receive antiretroviral treatment for AIDS – a figure approaching universal access.

But as the healthcare system has lurched forward, it has also come under attack for its heavy reliance on foreign aid: Nearly half of the government’s health budget comes from external funders.

Unlike many other countries, however, Rwanda has used these cash infusions to build institutions, not merely fund programs, says Peter Drobac, the Rwanda director for Partners in Health, a public health nonprofit, and one of the authors of the BMI paper.

Indeed, Rwanda spends no more on health than many of its neighbors, ranking 22nd among 49 sub-Saharan African countries in per capita health spending. That comes to about $55.50 per person each year, which Drobac says is a “tremendous value for money.”

But Rwanda’s government has ambitiously called for the country to be aid-free by 2020, an undertaking that would require a massive pivot away from its current healthcare funding model. In reality, that goal may be decades off, but in the meantime, officials have built the scaffolding for a sturdy healthcare system, Drobac says.

“The lesson we have learned is that you cannot solve every [health] problem at once,” Binagwaho says. “So you do the best with what you have, and you don’t leave anyone out.”

Inyumba’s Reconciliation Legacy

I am deeply saddened by the news that Aloisea Inyumba has passed away. Only 48 years old, she was a visionary leader who held a series of important posts in Rwandan public life after 1994, serving nearly seven years as a senator.

Inyumba played an instrumental role in persuading the Aegis Trust to become established in Rwanda over ten years ago. She was then the first Executive Secretary of the National Commission for Unity and Reconciliation, a body charged with what appeared to be an impossible mission after her country’s identity and heart was torn apart by those who committed the Genocide against the Tutsi.

It was in that capacity that she attended the Stockholm International Forum early in 2002 where she met Stephen Smith, an advisor to the Forum and co-founder of Aegis. She changed her return travel plans from Europe to Rwanda to visit Aegis in the UK, then based at The Holocaust Centre near Newark. I had already visited Rwanda twice on the invitation of the Government of Rwanda and was becoming aware of the overwhelming challenges faced by that small nation and its young people. “Eight years on and we have not yet finished burying our dead.” Such a short sentence, but when Inyumba spoke it resonated with depth, meaning, sorrow and determination.

That was only one challenge. Gacaca, the traditional courts system had not yet started. How do you quantify the burden of justice after a million people have been murdered, often by their neighbours? How can you describe the fear and mistrust of a new generation when they grow up with brutal, horrific memories; when they have knowledge of what human beings may do if the rule of law and moral codes are made to collapse?

I asked whether she was not daunted by such responsibility, heading up Unity and Reconciliation in Rwanda. She sat quietly yet confidently, clearly having considered the significance of her task. Her voice was as authoritative as it was gentle. “We have no choice but to try. We must do our best.” When she said “we”, I probed who she meant, whether the Government of Rwanda, or the Rwandan Patriotic Front, whom she served loyally during its days fighting in the bush. To her, “we” meant Rwandans – any Rwandan who was willing and able to play a role in re-building their nation. “But we cannot do this alone,” she added in her effort to convince me of the merit of the Aegis Trust working in Rwanda. I told her that not everyone agreed that the approach she was taking was the best. “So challenge us then. Convince me how we can do it better and I will try a different way.” I never found a better way, but she was always open to hearing one.

I had been responsible for establishing The Holocaust Centre in 1995 in the UK. That was fifty years after the Holocaust and the survivors mostly did not need to live among the perpetrators. Genocide memory in Rwanda was very different; it was all so raw. Aegis was a small organisation, and there had to be others more qualified and with greater capacity to work alongside Rwandans on these immense issues of memory, education and prevention. I told Inyumba that I was cautious about Aegis becoming involved. While we were beginning to understand something about the implications of the Genocide, it was all too much to comprehend, and frankly, we had been fed all kinds of reports about the dangers of working in Rwanda.

“This is your mission. You must do this.” She took time to describe how working with survivors and preserving memory for future generations is of itself profoundly important, yet neglected. Beyond that, she saw that it would lay a foundation for preventing genocide. “Please,” she said in her small yet reassuring voice. “If you fear the scale, then do something small. Work with me, and then you can assess for yourself the value. If it does not become apparent to you, others will convince you how valuable this is, how essential it is for us.”

She soon became the Prefet, or Governor, of Rural Kigali and took Stephen and I to visit the Nyamata and Ntarama churches that had become memorials where Tutsi victims had been slain in 1994. She found land for Aegis to be based in Bugesera, in the province then known as Kigali Ngali or Rural Kigali. The funding did not work out and the project did not progress. Then, by chance, the Mayor of Kigali found us and Aegis became involved in working with the Kigali City Council. I was still uncertain. Inyumba was supportive. “You must do this James. Aegis must do this. For this country; for others, too, elsewhere, please, for the future, work with us.”

Some of our conversation was recorded in the UK, and later in Ntarama Genocide memorial. She can be seen speaking about the enormous post-Genocide challenges for Rwandan society in the second half of ‘100 Nights,’ (www.vimeo.com/28355907 ), a video made in 2003 to explain the Aegis Trust’s role in the development of the Kigali Genocide Memorial, then simply known as ‘Gisozi’.

For Inyumba politics was a vocation. Her politician’s cloak was transparent, revealing her humanity beneath. The concern she showed to widows and orphans was as if she had been through the experience herself. She saw their loss as her loss, and it was not only words of sympathy she expressed. As minister of gender, family and social affairs after the genocide, Inyumba oversaw the burial of victims, the resettlement of returnees, and led a national adoption campaign to place Genocide orphans in homes. She was also central in establishing the national women’s network, which helped settle family and property issues resulting from the genocide.

Speaking in 2004 following the opening of the Kigali Genocide Memorial, she said, “Some people think ten years after it’s a long time, but when they visit this site, it brings the Genocide into memory again; it makes it real. It’s the message it gives, you know; that this bad act of genocide was committed in Rwanda, and what’s important today is to ensure that such a thing doesn’t happen in Rwanda or other places in Africa.”

Inyumba dreamed there could be a better future. But for dreams to become a reality, she knew they needed turning into a vision, and that vision needs to be turned into action. Now she rests in peace, but her legacy is left with the many she inspired and encouraged along her own journey. The Aegis Trust in Rwanda is just one of those she touched. I know we would not have had the foresight or courage if it were not for her. We may feel poorer now she’s gone, but many were made richer, beyond measure, by her life.

Dr James Smith is the Chief Executive of the Aegis Trust.

Kagame Pays Last Respects to Late Inyumba

President Paul Kagame has described Aloisea Inyumba, the late Minister of Gender and Family Promotion, as a selfless leader, who was ideologically clear.

“She was a very good cadre and ideologically clear, she was more than just a minister, governor, senator…those are positions that come and go; Inyumba was not just another leader, that’s the difference,” the President told mourners at the Parliamentary Building where the late minister’s body lay in state.

Kagame praised the deceased for her dedicated service during and after the liberation struggle, describing her as a “fearless cadre” of the Rwanda Patriotic Front (RPF), who put her life on the line for the good of the liberation movement and country.

The President, who said he first met Inyumba around 1985, eulogized the late minister as a trusted and patriotic cadre who had the ability to cultivate a good working relationship with anyone and bring rivals on the same table.

He said Inyumba’s character symbolized Rwanda’s own experience of perseverance and triumph, and urged the nation to uphold her legacy.

“Today we bid farewell to her body, but her values live on,” Kagame said.

Inyumba succumbed to cancer from her home in Kigali, last Thursday, two weeks after returning from a hospital in Germany.

After her first stint in Cabinet, Inyumba went on to serve as the Executive Secretary for the National Unity and Reconciliation Commission (1999-2001), during which time the country was going through a critical phase of truth-telling, reconciliation and healing – from the Genocide and its after-effects.

During that period, she actively spearheaded a national adoption campaign to place Genocide orphans in homes.

Later, she was appointed the governor of the Kigali Ngali province before joining the country’s inaugural Senate in 2004, and in May 2011 reappointed to Cabinet.

She spent her last days urging the public to adopt children from orphanages and to raise them as their own, with the view of phasing out orphanages.

The President talked of how he practically forced Inyumba to take medical leave after she had insisted on accomplishing certain official responsibilities.

Mourners formed a long line to view the body of the late minister in a casket draped in national colours, before they headed to Christian Life Assembly (CLA) church for funeral service ahead of burial at Rusororo cemetery in Gasabo District.

Earlier, Cabinet Affairs minister Protais Musoni eulogized Inyumba on behalf of those who had worked with the fallen minister over the years, as did the central bank vice governor and chairperson of Unity Club (association of current and former senior leaders and their spouses), Monique Nsanzabaganwa.

They both described her as a heroine, and exceptional and charismatic leader, who will be dearly missed.

Inyumba is survived by a husband (Richard Masozera, the head of the Civil Aviation Authority) and two children, aged 15 (girl) and 10 (boy).

Women commit to dev’t programmes

By Charles Kwizera


Minister Aloisea Inyumba

Members of the Kigali City National Council for Women (CNF) have resolved to actively promote government development programmes, especially at the grassroots.

The women made the promise last week at the closure of the group’s annual general assembly. The body is constituted of women committees from the cell level in the City of Kigali.

They agreed to spearhead campaigns to improve health in their homes, fight Gender Based Violence, promote justice, participate in good governance as well as improve their own economic status.

Speaking to The New Times, CNF Coordinator in Kigali City, Alice Ababo, said they agreed to increase the momentum in the fight against malnutrition.

“We want to focus on improving the health of children and women, right from the grassroots level,” said Ababo.

The Minister of Gender and Family Promotion, Aloysia Inyumba, urged the group to use their leadership positions to enhance the welfare of the fellow women. She further asked them to seize the opportunity of the country’s good leadership that values women and utilise it to develop themselves.