Intended for healthcare professionals

Feature Covid-19

Rwanda’s secret weapon against covid-19: trust

BMJ 2020; 371 doi: https://doi.org/10.1136/bmj.m4720 (Published 11 December 2020) Cite this as: BMJ 2020;371:m4720

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  1. Eli M Cahan
  1. New York
  1. emcahan{at}stanford.edu

Surrounded by neighbours with heavy caseloads and lacking the resources of richer countries, Rwanda has nonetheless tamped down the virus so far. Agnes Binagwaho, an architect of the country’s health system, tells Eli M Cahan how

On 6 April 1994, Kigali descended into violence. A plane carrying Rwandan President Juvénal Habyarimana had been shot out of the sky. The ensuing months left around a million dead; 250 000 victims of sexual violence; and countless others displaced, bruised, and shaken.

In the quarter century since, the Rwandan capital has evolved from the symbol of the genocide to a buzzing centre of commerce, technology, and tourism, while the country has emerged as a beacon of political and social progressiveness on the continent. A major contributor to this is the country’s healthcare system, which emphasises equitable access for all through universal coverage that is free for the poorest.

During the covid-19 pandemic, Rwanda’s health system has become an exemplar for its success in controlling the virus. As neighbouring countries recorded between 10 000 and 90 000 cases, Rwanda, as of 9 December, had around 6000 cases and 51 deaths.

Agnes Binagwaho was a key architect of this health system, established in its modern form in 2008. She served as health minister between 2011 and 2016 and is today vice chancellor at the University of Global Health Equity, an academic institution founded in 2015 which provides tertiary education for health professionals.

This interview has been edited for brevity and clarity.

You spent many of your formative years abroad. How did those experiences shape you?

I grew up in Belgium, which was, at the time, post-colonial in many ways. From a young age, I experienced racism, white supremacy, and injustice. I was always learning the sociology of medicine, through my own experience.

By the time I was in [residency] training (in the late 1980s), I found myself learning the social determinants of health by fact, providing to France’s poor. To treat them medically, I had to stand up and fight for the families in the social arena. This was all years before anyone put together a formal framework for the social determinants of health. But even then, they were screaming for attention.

There was one case, a child to be removed from a single mother. The system believed she was not caring properly [for her child], but that wasn’t the case—she just didn’t have enough means to provide what the child needed. Yet there were few social resources available to support her. So, in that case, what was blocking her from caring for the child in the best possible way—and worsening the child’s health—was not her, or her capabilities. It was the system.

How did you integrate these learnings into the Rwandan health system?

The Rwandan health sector is quite bold, with respect to equity. When I returned to the country [in 1996], structural violence against the vulnerable was widespread. Distrust [of the government] remained, even after the genocide had ended. And the poorest were left to fend for themselves. I saw those as injustices, beyond simply risk factors for disease. When you construct a system, you are deciding whether or not you pit them against these structural biases—depending on whether you design it in a way that intentionally alleviates these risk factors. So, sure, universal coverage helps, extensive primary care helps, intense attention to health access helps, but they’re not enough. The human bits matter too.

How exactly did you design the health system for equity?

From early on, we sought to build a system that was designed for the people, with the people. Whether it was fighting HIV, malaria, or medical misinformation, I spent weeks on the road, working up close and in person with urban, rural, and local communities. We made a very deliberate effort to partner with local influencers: community leaders, religious organisations, and so on. All of these people also have an active interest and role in the wellbeing of society. So instead of avoiding them, we made sure we established a close interface between them and the health system.

It was a lot of hard work, a lot of sweaty days. But the success speaks for itself. Life expectancy has risen at unprecedented rates (from 28 years in 1994 to 68 in 2017, according to the World Bank). Maternal mortality is down, infant mortality is down. So we’ve achieved some of the most important goals related to vital statistics. But then there’s trust—and that’s a success I think is particularly unique to us.

A 2019 study from the Wellcome Trust found that 97% of Rwandans have confidence in the health authority.1 Why does trust matter for healthcare systems?

At a basic level, people know that the system is not against them. They know they can get care when they need it, and that getting care will not lead them to suffer in other ways [such as financially or in terms of employability]. And, they know that the public health guidance is not politically motivated. It’s motivated out of human interest for the wellbeing of the people. Our vaccine rates [of over 95%] speak clearly towards this trust, I think.

How has this contributed to Rwanda’s response to covid-19?

The first thing is—like during the Ebola crisis—people need not to be scared to say, “I have it.” They need to know that, by having it, they will not be villainised or exiled; they will not be slapped with a huge bill. Health systems must not worsen structural violence. Any crisis has a tendency to worsen inequity, unless we intervene. I think we’ve done that.

The people must know that the public health measures being taken are in their interest. So, when the government closes the borders and sends everyone home—when it deploys health workers to people’s homes, robots to their treatment centres, and drones to their skies (as it has done)2—the people must know these actions are not against them, but for them. That’s the only way they’ll comply with the guidance—enforcement gets you only so far. And we aren’t even talking about the trust needed to deliver a vaccine.

What can other health systems learn from Rwanda?

Covid-19 has shown that the Western world and the global north are not the best at doing everything. It’s time to revisit why they’re doing what they’re doing. The culture of individualism, the lack of solidarity—it’s losing trust with the people. And it’s making people sick.

Footnotes

  • Commissioned; not peer reviewed.

  • Competing interests: I have read and understood the BMJ policy on declaration of interests and have no relevant interests to declare.

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