What makes Rwanda so unique?

By Leon Bijlmakers, Radboud University Medical Centre, Nijmegen, The Netherlands 20 July 2016

Just a few days ago, Paul Kagame, the President of Rwanda, relieved the Minister of Health from her duties. For many this came as a surprise. Rwanda is a country that has achieved great improvements in maternal health and several other key health indicators over the past decade or so. These achievements are often attributed to a combination of improved population coverage and improved health service quality. The proportion of deliveries that took place in health facilities, for example, has increased to more than 90%, while 98% of pregnant women attend antenatal clinics at least once during their pregnancies (1). Rwanda also achieves good progress in its national human Papillomavirus vaccination programme for the prevention of cervical cancer (2), the provision of antiretroviral therapy to pregnant and breastfeeding women who are HIV positive (3), and – until recently – the national malaria control programme.

Researchers involved in an NWO-WOTRO supported research project published the results of a web-based survey conducted among district health managers in Rwanda (4). These managers gave their personal opinions on the factors that drive performance in the health sector, in particular those that determine maternal health service coverage and outcomes. The questionnaire covered the six health systems building blocks that make up the WHO framework for health systems analysis, and two additional clusters of factors that are not directly covered by the framework: community health and determinants beyond the health sector.

Government leadership, health insurance and community health workers come out as factors that are considered to have contributed most to Rwanda’s remarkable achievements in the past decade. The results also indicate the importance of other health system features, such as managerial skills and the culture of continuous monitoring of key indicators. In addition, there are factors beyond the health sector per se, such as the widespread determination of people to increase performance and achieve targets. This determination appears multi-levelled and influenced by both intrinsic and extrinsic motivation.

It turns out to be the comprehensiveness and combination of interventions that drive performance in Rwanda, rather than a single health systems strengthening intervention, or a set of interventions that target a specific disease. There is need for policy makers and scholars to acknowledge the complexity of health systems, and the fact that they are dynamic and influenced by society’s fabric, including the overall culture of performance management in the public sector. Rwanda’s robust model is difficult to replicate. Introducing the model elsewhere in the world, or fast-tracking some of the interventions that form part of its success will require a holistic approach.

The dismissal of the Minister of Health, a few days ago, by President Paul Kagame, comes at a time of serious allegations of mismanagement of public resources (5,6). In his 2015 report, the Auditor General had singled out the health ministry, and its linked institution the Rwanda Biomedical Centre (RBC), as some of the government bodies with gross mismanagement of resources. The resurgence of malaria in particular has been blamed on the government procurement of three million ‘substandard’ mosquito nets in 2013, which allegedly cost the country more than US$ 15 million. Over the last couple of months, several key officials had already been arrested or sacked from government service in what has been alleged to be a multi-million corruption scandal. That for sure may be interpreted as a sign of vigilance on the side of the government. Whether it speaks to good governance is to be seen: we have not seen any proof, and journalists may have been too quick to link the dismissal of the Minister to the mismanagement that is still under investigation.

Meanwhile, we hope that the new Minister of Health, who is yet to be appointed, will express the same clarity in direction that characterised the previous one. That will then not undermine Rwanda’s uniqueness in the world of public health and human development.

References:

1. Ministry of Health. Rwanda annual health statistics booklet 2013. Government of Rwanda. 2014.
2. Binagwaho A, Wagner CM, Gatera M, Karema C, Nutt C, Ngabo F. Achieving high coverage in Rwanda’s national human papillomavirus vaccination programme. Bull World Health Org. 2012;90:623-28.
3. Nsanzimana S, Remera S, Kanters S, Chan K, Forrest JI, Ford N, et al. Life expectancy among HIV-positive patients in Rwanda : a retrospective observational cohort study. Lancet Global Health 2015;3:e169-77.
4. Sayinzoga F, and Bijlmakers L. Drivers of improved health sector performance in Rwanda: a qualitative view from within. Results from a Web-based survey among district health managers. BMC Health Services Research (2016) 16:123. DOI 10.1186/s12913-016-1351-4
5. www.africanews.com/2016/07/12/rwanda-s-president-fires-health-minister-over-mismanagement/
6. http://allafrica.com/stories/201607120700.html