“ Every day I dream . . . ” An interview with the Rwandan Health Minister

The Honourable Agnes Binagwaho MD PhD has been the Minister for Health of the Republic of Rwanda since 2011. With extensive professional clinical experience as a paediatrician, she seems to be the ideal Minister of Health and her achievements thus far have proved this. Just recently in 2015, the Honourable Minister was awarded the Institute of Health Metrics and Evaluation’s Roux Prize, the largest international award for evidence-based public health achievements. In the weeks after 6 April 1994, Rwanda’s development status was crippled by the shattering effects of the Geno-

cide.During the Genocide of the Tutsi, close to one million people were killed and the country's infrastructure and manpower -especially professionals within the health sector -were destroyed.The country was left in chaos and the capacity of its health sector was depleted.Since then, Rwanda, called the "Land of a Thousand Hills" and known to some as "tropical Switzerland", has unified and made a brilliant recovery.A little more than half the size of Switzerland and with close to 13 million people today, Rwanda is prospering and has become a surprising, positive outlier in many sectors including health.Globally, the socioeconomic developments and health improvements in Rwanda represent one of the most dynamic paths of development for a nation.Many reasons have led to these positive transformations and improvements.In the health sector, one innovative programme in particular has led to dramatic improvements in public health: Rwanda's universal health insurance system -locally known as "Mutuelle de Santé" -which began in 2004.Presently, thanks to this inclusive and comprehensive programme, more than 80% of the population is protected by health insurance.The Mutuelle de Santé has set premiums based on the level of income, allowing health insurance to be free for the poorest 25% of the population.Mutuelle is not only nearly universal throughout the country, but it is also financially sustainable.This affordable health insurance is development driven by Rwanda's belief in health as a human right.It has led to significant changes in availability of basic healthcare facilities, and diagnostic and therapeutic services, and in access to trained healthcare personnel.Rwanda has also developed a safety net of community health workers across the country.As the country continues its efforts to develop, diseases linked with poverty are still the leading causes of death.However, deaths due to infectious disease have been reduced by more than 75% due to preventative, treatment-oriented and supportive measures.There is now an epidemiological shift with an increase in prevalence of non-communicable disease.This shift in the distribution of disease is also attributed, in part, to economic improvements that have brought new "westernised" lifestyles to Rwanda, provoking the rise in prevalence of chronic diseases such as diabetes and cancers.To tackle this, Rwanda is now developing chronic illness health prevention strategies.The health sector's positive developments can be best illustrated through the numbers (table 1).Human rights activist Martin Luther King, a revolutionary leader who started a movement to end racial inequality in the USA, is known for his famous words, "I have a dream…" Martin Luther King was dedicated to driving out inequalities and providing dignity and equity for all people, within Rwanda and around the world.His words live on in the efforts of the Ministry of Health led by Dr Binagwaho.Twenty-two years after the Genocide, the Honourable Minister and her colleagues from the other social sectors continue to push for better health and a better quality of life for the people of Rwanda; and this dream is becoming a reality.The future will prove whether Rwanda's health system might become a model for other regions in the world -in certain aspects even for Switzerland.Excerpts from a face-to-face interview with the Honourable Minister Dr Agnes Binagwaho in Kigali on June 4, 2015 follow: Rwanda's health care data and statistics are better than the World Health Organization (WHO) regional averages.

What is the secret of this success?
As with all the other sectors of human development, we have to follow the basic principles: Firstly, our actions have to be evidence based.Secondly, we have to put all the people involved in implementation around the table; nobody is left out of the discussion.And when the plan is made and when instruction comes, for instance in the form of a law or a policy, everybody has participated and so complies easily because everybody has contributed.

It is a challenge to convince the people on all levels. Do you have a specific approach?
No, because it is about showing everyone the evidence for why changes are needed.You provide the data and the explanation.We let the data speak for itself.We have our own survey so that we know where we stand and, because we know collectively what is the best for the population after consulting them, we see clearly the reasons behind why changes should be made and we are able to explain them to everyone.This approach, through wide consultation brings everybody on board.I don't know any politician who doesn't want to look good.I don't know any scientist who doesn't want to learn and I don't know any doctor or nurse who doesn't want to do better for the patient.I don't know any university that doesn't want to provide better teaching.Everybody is on the same page.Here in Rwanda, we don't fight -we come together.If we can only agree on half of the package for a health service, we just go with half of the package and we move together.When we reach that objective, we come again together for the next steps.Unity must be at the heart of the approach.
"Unity must be at the heart of the approach."

Consensus and communication at all levels is apparently a key strategy?
The word "consensus" is even in our Rwandan constitution.We approach everything through consensus.Because, for example, if we were to start to fight with one another about imposing a full package of services, we would lose the time to advance the other half of the package.We would end up with nothing achieved.It is always better to come together in consensus and move forward in mutual agreement.

"It is always better to come together in consensus"
So you have a universal, transparent and consensual approach.
Yes.And beyond this, we are deeply committed to promoting transparency and accountability.This is how we fight corruption.We have what we call "imihigo".Imihigo is a performance contract that all Rwandans sign with their supervisors.Everyone signs imihigo; even Ministers sign them with His Excellency the President of the Republic of Rwanda.At the end of the year, our work is evaluated according to our commitments and plans and we are each compared with other institutions and ministries.There is absolute transparency -we have to explain everything we do.We are all on the same page and we all must be accountable for our part of the work we have to do.

How do you fight corruption?
We make it very costly for those who try….. (laughs).
… please tell us more.
The law is there but there are many issues in corruption.
Corruption is not always about money -it is much more complex than that.It can be about influence or about imposing; it is about using your authority to divert something.
As a disincentive, we use strict regulations.
Our legal system is structured in a way that tries to always give the right to the most vulnerable in the question.Because, even if the misunderstanding is on both sides, the more influential people will be guiltier because they have more opportunities to be informed to act well.People who cause institutions to lose public money due to their personal negligence, poor decision-making or bad intentions are held accountable and must reimburse any losses.You have to protect public money and public goods.
Negligence is not acceptable.Public good is and must always be at the forefront.

"You have to protect public money and public goods."
So the social control and transparency is at all levels -always the population in mind seems to be a driver for the success, right?Yes, and this is successful because human development is always the pillar of all our policies and laws.Rwanda is not a very rich country, so we allow zero tolerance for lack of transparency.Because zero tolerance means that we each cannot have a single behaviour that seems corrupt.I have to be fully transparent so that people trust me.If the people I work with believe that I am corrupt, it is an incentive for them to be tempted by corruption.So I have a moral and ethical obligation to be fully transparent.Additionally, we have something called the Citizen Card.The Rwanda Governance Board goes across the country to interview people about their perception of all institutions (i.e.Ministry of Health), asking questions such as "Are you satisfied with the service they offer?If not, why?"With this Citizen Card, which gives the honest voice and feedback of the citizens, I am held accountable and can fully understand how to best respond to the needs of the people of Rwanda in healthcare.

What comes out of this Citizen Card?
From this Citizen Card, we can understand that it is not enough to do the right thing, we also need the right thing to be understood by all participating parties.We need the people to understand why we, as the government, make specific decisions on their behalf.
In terms of fighting corruption, there is another important action we take: "umushyikirano", the "national dialogue days".During these three days, all ministers, parliamentarians, ambassadors, governors, executives, etc. come together in Parliament, where they are individually contacted directly by phone, e-mail, Facebook, Twitter and special blogs.We all report our work to the population and they themselves can call in and say anything they wish.They can say "Oh, a certain Minister has done this and that to me" and immediately the corresponding minister has to answer to that."Is it true?When was it?And why?"Because of this transparency, accountability and access for the community members to dialogue with leaders, there is a strong incentive to behave ethically because a simple SMS or twitter post can be seen across the whole country and will put you on the hotspot.

You seem to talk openly and directly to each other on all levels.
After the 1994 Genocide against the Tutsi, we learned that it is absolutely necessary to recreate our social fabric.The trust between us was not there.Now, we have worked very hard to create an accountable society.And our actions also continue to be guided by two principles, which inspire dignity and self-direction: "do not do it for me, without me" and "do not believe that, because you have the science, you know better than me what I need.Ask me what I need".
"Do not do it for me, without me."

Is this kind of communication part of the old Rwandan culture?
Yes, it is embedded in our culture that was vehemently denied by the previous regime and the colonial powers that came into Rwanda.When we became independent, a big portion of Rwandans were denied basic human rights by the leaders of that time.There was no dialogue, nothing.So after the 1994 Genocide of the Tutsi, reinvigoration of and finding pride in our traditional values was of vital importance.

You try to solve problems quickly when they show up. This is different from other countries. (laughs)
We have no time.We have to fly for development -that is another guiding principle.You see, here people work very hard.We know where we have come from, where we are and where we want to, and can, go.The principle is "The process is done by the people, for the people".If the process is not good, people come together and review the process.But first, we all agree on the expected result and when it is done it is not negotiable.All these policies and strategic approaches described thus far are inspired by His Excellency, The President of the Republic of Rwanda.I remember when I was nominated Minister, the first words I heard from the President were, "I nominate you to achieve results, not to do politics" (laughs heartily).

For us, it is interesting to see that you recall your cultural values from the past and combine it with new technologies.
The first cultural value is the importance of a human being, and the second is our dignity.So we work, always, to inspire and empower the dignity of the people.We did it, with what we have.We do what we can for ourselves, by ourselves.For example, we are fighting to find money for cancer treatment but find it unacceptable to ask for funding for lung cancer medications and not creating proper legislation on tobacco regulation.

"…it is unacceptable to ask for medications for lung cancer and not create proper legislation on tobacco regulation."
In most parts of the world, non-communicable diseases are increasing and there is no good solution to it.How do you address these developments?
We promote sports.For instance, on each Friday afternoon, every civil servant practices exercise, which is an example for the rest of the population.Our health insurance offers a yearly check-up.Every woman aged 35 and man aged 40 can get a blood pressure reading on a voluntary basis and we analyse their blood sugar, etc.We mobilise people to do that.For the community we have the "community checkup".People can go and have their blood pressure measured and have an interview in which signs of diseases can be identified.In that case, they may go for further exams.For the members of Mutuelle de Santé, this can be done for the cost of less than a bottle of water.
And people take advantage of that?Not many.Because we still need to help them understand the benefits of going to see a doctor when they are not sick.
It is a new mind-set.
What about population growth?The WHO data show that Rwanda has a much higher coverage rate of oral contraceptive use than most other African countries.This is now my personal opinion.Firstly, we need to avail the service in the area where the people are living.In Rwanda, we know the missed opportunities for family planning.We discovered that, for many women, it takes nearly half a day to go and wait in line at a health centre.So, we decided to bring the service directly to where the women are living.The villages have community health workers, who give pills, condoms, and injections for long term contraception at the women's request.Secondly, in many parts of the world, the biggest reason why people want to have many children is because they do not trust the health system to keep their children alive.In Rwanda, we have solved this by reducing child mortality.The rest is about sensitisation of the population.

So you show them the interrelationships between health and disease?
You know, when I came back in Rwanda, I had only two girls.All of my family was saying, "Oh, only two girlsare you crazy, we need a boy".Now we have gender equality; boys and girls are equal.We have the highest level of women in Parliament and many women as Ministers and Heads of Institutions.Having only girls for children or to be a woman or a man -it's OK.Secondly, I have other family members who said, "You know, me I have eight children and I remain with two.You have only two, you will die alone".

"…Oh, only two girls -are you crazy…"
So the point is to not die alone and have many children to take care of you?
We are changing that mind-set.Now we are creating a safety net so that elderly are not abandoned in the village.
We have started, first, with those left widowed or vulnerable after the 1994 Genocide against the Tutsi.We are creating places where they can live together at the village level.
Referring to a family that had eight children and only two remain because they were dying, I believe that a person was not only afraid to be alone as they aged but I think that every human being wants to contribute to the next generation through his or her children.Now we have reduced premature deaths by more than 70%.That means that this reason is no longer in the mind of people.We are creating a safety net at the community level.
In Switzerland, we encounter increasing problems with exploding healthcare costs.Do you take some precautions that the healthcare costs do not increase disproportionally?I would love to manage your problem, because this is a problem of people who have too much.We are still in the phase where people have too little.For the time being, we are far from having that problem.It will come but we are still creating the demand for health care.

"I would love to manage your problem, because this is a problem of people who have too much"
Can you then give a recommendation to us, to those who have really too much and who also abuse the health system?First of all, you should explain that there is nothing more toxic than the overdose of medicine, doctors, and nurses (laughs heartily).Secondly, doctors, nurses and the whole health system is not God.Health professionals are here to help each of us to have a good life.And every minute that you spent waiting for them, when you do not need them, is time lost -you'd better live your life.OK? Also, trying to keep people alive when it is their time to go, I find to be almost an [act of] aggression.We need to convince families that death is a natural part of life; there comes a point when any health sector cannot do more.Today, people in Europe deny the fact that they become old and that their lives will end.You must go back to your traditional values, two thousand years ago, and reconcile yourselves with the end of life.You will see medical bill will go down (laughs)."…there is nothing more toxic than the overdose of medicine, and doctors…" "…trying to keep people alive, when it is their time to go -I find it almost an aggression."

Op-ed
This is an important message, which we know from our work.
Yes, live your life when you are alive!Another important thing that we are addressing now: we want to avoid people dying unnecessarily in the hospital, because it is an inhuman death.We want to create a community system where people die in their beds, in their blankets at home with their loved ones.It is really a punishment to die in white blankets, with a smile but with somebody whom you do not know.

"….live your life when you are alive."
What do you do for that?
We have created a curriculum, which is called "Home Based Care Practitioner Programme."They [those who take the course] will be in charge of chronic care, palliative care, and end of life support at home.It is an education of 6 months.They have to know how to put up an infusion, how to give pain medicine, etc. ... The family wants the person to be safe and sure, as they already feel helpless in the face of death.We are all going to die.But we want people to die with dignity, in their environment, and we want the family to feel that everything has been done.And, when possible, people should die at home, if they wish.
It's good that we touched on this topic because we can learn a lot from your thinking and approach.
Global health starts where you have your two feet.That is my principle.There is no bad idea.There are people not supporting end of life care at home because they are scared.You can only do that, if you have a special social fabric where trust is there and when you accept the fact that being young, beautiful and alive has its time (laughs).

As a Minister of Health, what do you see as your biggest challenge for your country?
My biggest challenge is to really use each and every dollar in the frame of sustainable development and health.Furthermore, it is to nurture young people; to stimulate their imagination and thinking and to give them a good vision.For us, capturing each and every opportunity is the way to go.Money is not everything; ideas are everything.
"Money is not everything, ideas are everything." Thank you for your time.

Table 1 :
Data from health and related sectors in Rwanda.
*1 = high inequality AIDS = acquired immunodeficiency syndrome; HIV = human immunodeficiency virus; WHO = World Health Organization Op-ed Swiss Med Wkly.2016;146:w14316 Swiss Medical Weekly • PDF of the online version • www.smw.ch Disclosure statement:No financial support and no other potential conflict of interest relevant to this article was reported.
Figures (large format)The Honourable Agnes Binagwaho MD PhD, Minister for Health of the Republic of Rwanda.Op-edSwiss Med Wkly.2016;146:w14316 Swiss Medical Weekly • PDF of the online version • www.smw.ch