Transforming Healthcare in Rwanda with Agnes Binagwaho, MD, PhD

• [00:01:39] Binagwaho, who was born in Rwanda but spent much of her childhood in Belgium, describes her upbringing. Her father was a physician and that inspired her to become one as well. She always knew she wanted to return to Africa, but after medical school was unable to, because Rwanda was not welcoming people from her family’s ethnic group.
• [00:03:46] She explains the Rwandan genocide in 1994, in which more than more than one million people were murdered. Binagwaho explains that while the genocide was meant to exterminate a group of people (the Tutsi) they didn't succeed. She says “since then this genocide spirit has been almost eliminated from the mentality of Rwandans.” Today  Rwanda is focused on its own development. “Knowing that it's better to put your energy into that than when you kill each other, you destroy, you roll back,” she says.
• [00:05:32] She was able to return to Rwanda in 1996 and since that time held many roles in government, including Minister of Health, a position that she held for five years.
• [00:08:35] Transforming healthcare in Rwanda is part of Binagwaho’s legacy. Over 90% of Rwandans now have health insurance, and that's up from 43% in 2005. She details the process the country went through to make this a reality which included building a system where there is geographic equity, age and gender equity, to make sure that the most vulnerable of the population have access to healthcare.
• [00:13:07] The people of Rwanda have been partners in the healthcare transformation throughout the entire process and Binagwaho says that is critical. “(In a) country where the population is contributing to building the system. They trust the system because they understand it.”
• [00:15:08] She is retired from government life and Binagwaho is now focused on education. She wants to try to improve the capacity of people who are on the ground in Rwanda to repair, create, and improve health sectors for better access to the vulnerable. She would also like to make keep more young people educated in Rwanda, with country tax dollars, in country or charge higher income countries who take talent away with higher paying job opportunities. 
• [00:18:12] Feinberg student Clayton Lyons, a MD, MPH candidate asks Binagwaho for advice for U. S. trainees and health professionals who want to engage in global health work, but may not understand the political and social complexities that exist where they go to work. She says “Whoever you are, whatever you do enhance, proactively go and search for the vulnerable you can support.” She says respecting th political the landscape of the country and the leaders of the country is important and to remember you are not there to change politics, but to provide health services.
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[00:00:00] Rob Murphy, MD: Welcome to the Explore Global Health Podcast. I'm Dr. Rob Murphy, Executive Director of the Havey Institute for Global Health here at Northwestern University Feinberg School of Medicine. At commencement ceremonies taking place at universities, a few visionaries receive honorary degrees with graduates as a sign of respect for their contributions to their fields. Five individuals received honorary degrees from Northwestern University this year, including today's guest, professor and doctor Agnes Binagwaho. A Rwandan pediatrician and former Minister of Health of Rwanda, she's being recognized and celebrated for her work in building an equitable health system in the years after the 1994 genocide in Rwanda. She is currently Professor of Pediatrics at the University of Global Health Equity Initiative in Rwanda, where she is also the retired Vice Chancellor. In addition, she's a senior lecturer in the Department of Global Health and Social Medicine at Harvard Medical School and an adjunct clinical professor of pediatrics at Dartmouth's Geisel School of Medicine. Dr. Binagwaho joins me today to talk about her career path as a leader in global health and what led her to this moment in her career. Agnes, welcome to Chicago, Northwestern University, and this podcast.

[00:01:21] Agnes Binagwaho, MD, PhD: Thank you for welcoming me, Rob. 

[00:01:23] Rob Murphy, MD:  Your contributions to the field of global health are just incredible. I want our listeners to get to know you and how you became the leader you are today. You were born in Rwanda. You currently reside in Kigali, the capital city, but you spent many of your formative years in Belgium. Can you tell me about your upbringing?

[00:01:39]Agnes Binagwaho, MD, PhD:So I went in Belgium because I was born during the colonial time and my father went to study medicine in Belgium when I was a very, very little girl. So we went all the family to accompany him and that's how I went in Belgium for the first time. It was in the year 50. And then later on I came back for my own education starting by the secondary school and continue up to the medical education and for the specialty, the residency, I did partially in France as well.

[00:02:18]  Rob Murphy, MD: Tell me, why did you decide to become a physician? What motivated you to become a doctor?  

[00:02:23] Agnes Binagwaho, MD, PhD: So I was interested in healing. When I was a little girl, my father was a doctor, so, I was interested, by family connection. But when I grew up, I dedicate myself to clinical education nurses, doctors, et cetera. And I found what I liked the most was pediatrics, where there was the most need. The needs were in neonatology. It's the place where, especially in Africa, there was not so many people because the neonate is not like another baby. The baby needs special care that is different than other kids. And I was very interested by that age.

[00:03:05] Rob Murphy, MD:  As a young physician, did you expect that you would one day return to Rwanda? Was that the original plan or did you think you would stay in Europe or someplace in Africa? 

[00:03:14] Agnes Binagwaho, MD, PhD: Rwanda or somewhere else in Africa because, when I was a student, Rwanda was not welcoming people from my family and ethnic group. But working in Africa, yes. I worked in Gabon four years before going back to do my residency. And I was ready to work any place in sub-Saharan Africa. 

[00:03:35] Rob Murphy, MD:  Take us back to Rwanda in 1994 and remind the listeners, especially some of our younger students, what happened between April 7th, 1994 and July 15th, 1994. 

[00:03:46] Agnes Binagwaho, MD, PhD: So what happened is one of the most horrific genocide .It was really politically, stimulated and orchestrated,now the French have changed, but they had a very big role in helping training the perpetrators and helping them organizing the genocide, help them having the list of people, because all the people were supposed to be killed were listed per administrative area and the list distributed to 200 people who have been trained as master killers, meaning pushing the population to contribute to the killing and also to kill the people who didn't want to kill. So you had people who killed for staying alive, and it was a true genocide, meaning they wanted to exterminate a group of people. But they didn't succeed. And also what is good is that since then this genocide spirit has been almost eliminated from the mentality of Rwandans and, you have a country that now is focused on its own development, knowing that it's better to put your energy in that than when you kill each other, you destroy, you roll back.

[00:05:06] Rob Murphy, MD:  You returned to Rwanda in 1996 and in the many years that followed, you took aim at improving the Rwandan health system through high level government positions you've held across the Rwanda health sector. First, you were Executive Secretary of the Rwanda National AIDS Control Commission, then as permanent Secretary of the Ministry of Health, and then more recently as Minister of Health, a position that you held for five years. Can you tell me about this work? 

[00:05:32] Agnes Binagwaho, MD, PhD: When I came back, we had almost nothing. No medicine, no drugs, no structure, no infrastructure. There was no school of nursing, for example, in the entire country. And the country has educated very, very few doctors and also the education was really not so good, to not say not good at all. So everything has to be built in parallel, meaning you had to educate the people, young people, who start education, but also correct the education of people who are already at work. And this brought the need to create all the facets of healthcare delivery in parallel. Meaning education, quality education, upgrading those who are there with quality, dispatch the people across the country with quality. For the people to be cared of and also with the objective to avoid that everybody rushed to the cities. So that means you had to create a condition, or to contribute to create conditions, for people to accept to be deployed upcountry and not in cities, but also in remote and rural area. So it was a multifaceted approach. And the government of Rwanda did well in that because they work well centrally, but also with the local government to create the situation for people to go and work upcountry. Because also the country was based on segregation and division, that led to the genocide, the fact that the country, the new leadership, wanted to build a country based on equity. It was also an equity in access to health. Meaning same number of doctors per thousand of inhabitants, health center by 25,000 inhabitant, et cetera. And explaining to the people that this is the plan. We do the plan together. We cannot build all the health centers to go. But this is where they will be, and this is the agenda, how we will do that for having the same in the north, the south, the center per thousand of inhabitants. And it has allowed the population to understand the plan, to understand that they will be served one day, that everybody cannot be served. And also why we start there, probably it was because the concentration of people were higher, but also the concentration of diseases also. So all this, in the balance, in the participatory process, has helped the country to take off, despite the history.

[00:08:11] Rob Murphy, MD:  Well, Rwanda has certainly certainly been a model for good health system development. Statistics that I've seen recently: today, over 90% of Rwandans have health insurance, and that's up from 43% in 2005. Can you tell me how that happened? I mean, that's a phenomenal thing. Many countries don't have any real health, Insurance system. 

[00:08:35] Agnes Binagwaho, MD, PhD:First of all, between 40 and 50% of the population in Rwanda are poor. So that means, without a health insurance the families became more poor when somebody is sick and there is also not the cash to pay. So that means the rate of death is not necessary, because there is a treatment, but you cannot access it. So we needed to create a system where there is geographic equity, the people all over the country have the same type of access, but also age and gender equity, and make sure that the most vulnerable of the population have access as well. So it cannot be based on pay as you go. So create another system was to create a new model. It was a new model of community-based health insurance. Meaning, an insurance, where the major player were the community, but where the people who cannot pay-- don't pay. Where those who can pay a little-- pay a little, and those who can pay, really, pay even more to compensate for the others. And the government put the rest of the money for those who doesn't pay or for those who pay a little. However, whatever contribution you give, you have access to the same care. 'Cause the card you receive is not that you have paid this or not paid, it's that you are enrolled. Make sure also that the nurses and doctors and labs, etc. are equally distributed around the country. So it took time to have everything in place, but starting with this plan, I know where the next lab will be built. I know where the next nurses will be appointed. I know where the next doctor will be appointed. 

[00:10:21] Rob Murphy, MD:  That's a different model than many other countries have. What was the biggest influence you had on developing that model? 

[00:10:27] Agnes Binagwaho, MD, PhD: The population. The population. 

[00:10:30] Rob Murphy, MD:  Did you look at some other system and incorporate it into Rwanda or did you grow it organically? 

[00:10:35] Agnes Binagwaho, MD, PhD: Senegal has tried to have health insurance, but it was still in infancy. So we took a lesson of what was not working but having a lesson of what is working, we didn't have. So it was created to be a flexible system that can be changed overnight if we found something that doesn't work. And, in a very open manner, we knew that we were learning and doing at the same time. And it works well because having the feedback of the population, of the local leaders, national leaders, of the religious, of everybody, everybody was together building that. 

[00:11:16] Rob Murphy, MD:  You've held a lot of government positions and people that are interested in working in global health, that is definitely a pathway a lot of people take. Some go into clinical work, academic work, non-governmental work. What motivated you to get involved at the government level? 

[00:11:33] Agnes Binagwaho, MD, PhD: I didn't want to say "I want to serve," probably because by criticizing and by proposing other things they say, "Go and do it." And so, I didn't ask to have the position. But it happened that it was offered and because I was criticizing. When it's offered to you, I cannot say, "No, I don't take it," because that means after that I can no longer propose for improvement. Hmm?

[00:11:59] Rob Murphy, MD: : You've said that evidence-based research played a significant role in improving health in your country. Can you tell us a little bit more about research and making policy decisions?

[00:12:09] Agnes Binagwaho, MD, PhD:The path I have taken and also, the entire government by the way, is to find evidence to back up your decisions. Meaning, you are not there to say, mmhmm, I think we have to do that. No, no, no, no, no. You have to find evidence and accept also that when what you think is not the right thing to do, according to evidence, you just always privilege evidence. And when you do that, you avoid hours of discussions. You avoid frustration because everybody understand that what we do is what will work the best with fact. And in general, it has gone well that way. 

[00:12:53] Rob Murphy, MD: You've set up quite a model. I think you're very well respected and Rwanda is really looked at truly as a different model that's been quite successful. What can other countries learn from the Rwanda experience? 

[00:13:07] Agnes Binagwaho, MD, PhD: The participatory process, meaning people in decision making positions and experts who have the knowledge about how to provide clinical services, need to come with other partners all together and found together what is the best way to do it and make sure they do that with equity based on geography, meaning to avoid movement of population when people are sick, not to go in another place because you cannot have it near your home. Of course, we cannot have it everywhere in the beginning, but you can at least start by north, south, southwest and center so that people move near their home. And after that, education. And make sure that the services can be brought in health facilities where the people live. Make sure also that it should not depend on the reaches of a place to be served. Equity in administration, equity in geographic access, equity for gender access and age access. If you build a system based on that, it will work for everybody. And also involve the population in what you do so that you create trust. You have seen that in Europe with the vaccine. Population were not really involved and there was so distrust in vaccine, hm? In country where the population is contributing to building the system. They trust the system because they understand it.

[00:14:43] Rob Murphy, MD: You've had an incredible experience and trajectory in your career development and the development of the health system in your country. What's your main focus today in 2023? 

[00:14:55] Agnes Binagwaho, MD, PhD: So, today I'm retired. 

[00:14:59] Rob Murphy, MD:  Yes, but, I think you're a very active person now. What's your main focus today? What are you doing today? What happens at this point in your career? 

[00:15:08] Agnes Binagwaho, MD, PhD: Education. Try to improve the capacity of people who are on the ground to repair, create, improve health sectors for better access to the vulnerable. So this is very different from a place to another place, but the principle behind are the same everywhere. Hmm? Putting the people at the center of your decision of how you are going to do business, knowing that what you're going to offer are the same everywhere, according some time there is not enough money to provide care like in Europe, etc. But if you look at the last pandemic we had where the solution was also at community level, there, those principle matters. The biggest challenge is, first of all, that a group will say, I know it all, and I have it right, because, it has to be adjusted to the life of the people, to their culture. And, to, what can be done. Not the quality of services, but the way you make sure those services are reaching the population have to be customized. So, this is one. Second, is that we take the excuse of money. Money is always an excuse because the cost of doing nothing is far higher than the cost to invest in organizing quality care. And education to make sure to have the right number of people to provide the needed quality services. We have this issue that many people educated by the low income countries are going to work in high income countries. I'm for the free movement of the population, but not for stealing people. Look in football when I educate a player and another club recruit this player, they pay me back. I think this should be the case for low income countries, educating health professionals. 

[00:17:07] Rob Murphy, MD:  Well, you're referring to brain drain is a common term used for that. 

[00:17:12] Agnes Binagwaho, MD, PhD: I refer to brain drain, but it's more than brain drain. It's really economic impoverishment due to that, it's more than brain drain. First of all brain drain, I don't like the word because it's really stealing capacities that a country have invested in creating at high cost. 

[00:17:32]  Rob Murphy, MD:  Right. They've educated that person, that person has experience. They're adults. It takes a long time to make a doctor, to make a neonatologist. And then for that person just to be gone, after all that training. 

[00:17:44] Agnes Binagwaho, MD, PhD: Absolutely. And also it is educating with taxes of poor people. So it's hypocrisy. 

[00:17:50]  Rob Murphy, MD:  Can I quote you with one of your comments just made? Is this fair? The cost of doing nothing is much higher. 

[00:17:56] Agnes Binagwaho, MD, PhD: Yeah. 

[00:17:57]  Rob Murphy, MD:  You're right, because otherwise people die young. Do you lose the impact of the training that went into that person or the skills? It's really very illuminating to look at things that way. and finally, Agnes, We have a question from one of our global health students

[00:18:12] Clayton Lyons: My name is Clayton Lyons, and I am an MD, MPH candidate here at Northwestern University Feinberg School of Medicine. My question is, what advice do you have for U. S. trainees and health professionals who want to engage in global health work, but may not understand the political and social complexities that exist where they go to work?

[00:18:30] Agnes Binagwaho, MD, PhD: So working in global health you always have to make sure you include the most vulnerable in the care you give. And also you need to never forgot that those who are the most vulnerable doesn't master the system, so they will not come to you. Whoever you are, whatever you do enhance, proactively go and search for the vulnerable you can support. I think that for young people from across the world who want to go in Africa they should just concentrate to the vulnerable who need their support. And respect the landscape of the country and the leaders of the country and don't mix everything. They're not there to change politics, they are there to provide health services and they can help to provide health services. Even the worst government are pleased when you help them to design health services that they can afford and that will make the people love them. 

[00:19:29]  Rob Murphy, MD:  I really thank you so much and congratulations on your honorary degree. 

[00:19:34] Agnes Binagwaho, MD, PhD: I am very honored to receive that, very pleased and thank you for having me.

[00:19:38] Rob Murphy, MD: Follow us on Apple Podcasts or wherever you listen to podcasts, to hear the latest episodes and join our community that is dedicated to making a lasting positive impact on global health.