In a previous version of the article, we identified Dr. Agnes Binagwaho as the former Minister of Health of Rwanda. She is actually the current Rwandan Minister of Health; she was formerly the Permanent Secretary of Health. Dr. Binagwaho’s name was also misspelled. We regret the errors.
Nearly 19 years ago, Rwanda was torn apart by a brutal genocide that killed more than one million people. Today, Rwanda is a peaceful country full of promise and hope. Along with efforts to rebuild the economic ruins of this once-failed state, government and health officials are tenaciously confronting nationwide health issues by implementing revolutionary strategies to provide sustainable health care to their citizens.
The progress is astounding. Life expectancy at birth was at only 25 years at the end of 1994, but had recovered to 50 in 2008. Meanwhile, infant mortality decreased from 129 to 62 deaths per 1,000 live births per year, and under-five mortality decreased from 219 to 103 between 1994 and 2007.
The Honorable Dr. Agnes Binagwaho, Minister of Health in Rwanda, has been a prominent presence in these amazing developments. Prior to this role, she was the Permanent Secretary of Health in the Ministry of Health, the Executive Secretary of the National AIDS Control Commission, a member of the Expert Panel of the Country Coordinating Mechanism in Rwanda for the Global Fund, and a pediatrician by training.
[DC]: How has Rwanda implemented the Millennium Development Goals to help rebuild their health care system?
[AB]: First you need to understand how we rebuilt our country at all levels. We have what we call our own Vision 20/20 that coincides with the Millennium Development Goals, and it was not a top-down vision determination—it was really bottom-up in two ways. We ask the people: “how do we dream our Rwanda in the year 2020?” And people put [forward] their vision, and we did that. It is more ambitious than the typical MDGs.
We translated this vision, when it came to the top, into strategies, policies, rules, ministerial orders, etc. Then we bring those documents back to the population to see if it fits. So it was a new process that took a long time, but when it is implemented, it is the tool of each and every citizen. We need to go fast, and go in harmony and cooperation—and that is how we have rebuilt the country.
We come from a disaster, a humanitarian disaster, led by criminals and their crimes against humanity. We don’t have to forget; we have to find a national solution because we cannot just implement what the law says. It will take us 200 years—and all our energy— just to put people on track, so let’s find something now, in our culture, in who we are, to find a solution that brings justice, that brings more reparations and more reconciliation. If we don’t bring everyone together, we are going to lose time fighting each other. Let’s use our time and energy for development.
That’s how our Vision 20/20, our MDGs, even other endeavors such as the Malaria Commitment, etc., were implemented—by putting all the energy into [preparation].
[DC]: Would you say that the same principles that were used in rebuilding the country are being implemented in developing the health care sector?
[AB]: Absolutely. First, integration. Second, citizen participation. Third, evidence based. And fourth, thinking outside the box. We don’t have the capacity to implement the exact same systems as completely developed countries, but we have the moral obligation to build the same quality. Since we started an intensive population participation program, we have three times more public participation. It is a simpler way; it’s cheaper and also owned by the people.
We also have a community-enhanced policy. We say that 80 percent of the burden of disease needs to be solved at the community level. That means we need to create awareness, and we need to make the people know what the problem is and own the solution so they are a part of the implementation.
[DC]: You mentioned in one of your blog posts that the trust between the people and health care officials has been greatly wounded due to the “humanitarian disaster.” What efforts are being put into place to rebuild that trust?
[AB]: It all comes down to leadership by example. There are many ways to be a leader. First of all, a good leader brings the people with him or her to a shared vision. Second, a good leader stands by example. Also, be truthful.
I remember President Kagame saying in 1997, “We don’t have a solution now. I don’t have it. I just know that this is the way the country needs to go. We will work together and find a solution together. Now I don’t want people to make their own justice. We don’t have the capacity to use the costly resources, but we will find a solution together.” And this has helped build trust. Because, you know, the people are a part of the solution. We are all working together to seek it out, to find it. And if the leadership has secured that trust, now you can use that time in a constructive manner for the country.
What is good about President Kagame is that he has convinced the people that there is good in the hearts of each and every one of us—even the people who have just followed the bad leaders. He has explained to the people that even though some individuals were involved in the killing of 800,000 people in one way or another, let’s just see if we can turn the bad into good. And we can serve this country. That is what is unique to Rwanda and its leadership.
[DC]: In 1994, during the genocide, along with the physical violence experienced, women’s rights were also profoundly denied. How have women been affected by these changes? How has the focus on protecting women and their rights impacted your work?
[AB]: In Rwanda we don’t like to talk about women rights. Let me tell you—we have a profound sense that those people who are screaming for women rights… it’s not enough. We just do it. Whatever we do we always think about how it will benefit the population, especially those that are vulnerable. And women are always ones we consider vulnerable. That’s how [it is done] for each and every policy.
If I bring to a policy to President Kagame, the first question is what will be the impact on the people? Actually the first is, “What evidence do you base this policy on? What is the proof that this doesn’t just come from your own head?” Evidence based. Then the question is how will it serve the most vulnerable first? It is citizen-centric governance. And this is my work. If you tackle the problem lying with the most vulnerable, you tackle the problems for the whole population.
[DC]: The UN Security Council Resolution 1325 “Women, Peace, and Security” urges countries to involve more women in participating in peace and security, and even in promoting the quality of health. Do you feel that Rwanda is following this resolution by involving more women in the process of rebuilding the country and the health care system?
[AB]: I really think so, because we have increased the number of women in the government sector. We have more women in the police force and also in the education sector. Women have been involved in plans such as the Malaria Commitment. We have also implemented a system of positive discrimination to help more women become involved. Women in Rwanda have experienced a social handicap, an economic handicap, an education handicap, and the use of positive discrimination helps counter that.
[DC]: Just to clarify, would you compare “Positive Discrimination” to Affirmative Action?
[DC]: Finally, I understand that on Twitter, you have what is called “Ministry Mondays” where you answer questions posted on social media. What inspired this idea?
[AB]: You know, the best way to assure the accuracy of your actions is to confront the beneficiaries in an indirect manner, and the best way to do that is to have a non- filtered way to communicate with everybody. Those who have the Internet, we use Twitter with a question-answer-question-answer process. I am very proud to say there is no Twitter question unanswered, even if it takes two days. You know, if I’m in a plane a tweet comes, when I land, I answer it. No tweet goes unanswered.
For people who do not have Internet I have a platform that you can join the conversation through SMS. We have put 3 phones in each village in the health sector, and if someone has a question, they can use the phone to send me a question. Every two weeks I have two hours to answer those specific questions. So social media is a great tool to bring people together, and to contact people directly. All part of our endeavor to involve the people.