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Community Classrooms- lessons from Rwanda!

By Dr Shubha Nagesh
on July 16, 2019

I never knew of a morning in Africa when I woke up and was not happy- Ernest Hemingway

 

Rwanda- a gem in East Africa, is also called the Land of a Thousand hills. Rwanda’s experience is one of the best examples in history to show the power of hope in the face of despondence. Twenty five years after the genocide, Rwanda is a success story the world wants to learn from. Stable leadership (unfortunately, also authoritarian, though) transparency, accountability, strong representation of women in leadership positions, decentralization, public-private partnerships, equitable program frameworks and strong community structures are considered some of the building blocks of the Rwandan comeback.

Recently, as part of the Atlantic Fellowship for Health Equity (hosted by the George Washington University), I visited the University of Global Health Equity (UGHE) in Butaro, Rwanda. Located about eighty miles away from the capital city, Kigali, UGHE is a ground breaking initiative from Partners in Health, and is all set to build the next generation of global leaders for the delivery of equitable healthcare. The campus location was deliberately chosen for it to be based in a context where disparities are most experienced; in remote and far flung areas.

As our bus drove past the green mountains, the endless eucalyptus trees and the potato farms, on a deep red, muddy road, for almost three hours from Kigali, my group and I wondered if we would reach Uganda soon! Finally, as we drove into the campus of UGHE, the architectural marvel before us, that won accolades for its design, had all the fellows, including me, spellbound. Laid down immaculately against the pristine mountains overflowing with trees, and a volcano as the backdrop, the buildings had a deliberate openness to encourage communication and collaboration. As we walked around the campus, full of admiration for the vision of the founders, I was reminded of my alma mater, Bangalore Medical College, which was once an artistic maze of Victorian buildings amid lush gardens (it has now been reduced to a concrete block in the midst of busy, noisy flyovers).

UGHE has a mission to radically change the way healthcare is delivered- they hope to initiate and sustain equitable and quality health services for all. They also aim to lead the way for health equity education and hope to hone the next generation of global health professionals into leaders and change makers. The University is creating a new healthcare paradigm—one where doctors are culturally sensitive and take a holistic view of a patient’s environment and the social determinants of health. With the community as the classroom and its people as the teachers, the university hopes to equip students to experience and solve complex health challenges in the field versus a classroom.

The university has just enrolled their first class of medical graduates and is very proud of each one of them. They also have a Masters program in Global Health delivery and executive programs, with a diverse, global student population from Rwanda, other African countries and also a few from Asia. In future, the university hopes to expand to add other hospitals to a nationwide network of learning centers to increase the scale and diversity of clinical knowledge for their students.

As a Fellow of Global Health Equity, I felt gratitude for being in a sacred global health space- UGHE seemed the perfect place to study global health and equity. My happiness grew when we had the opportunity to be taught by Dr Agnes Binagwaho, the vice chancellor of UGHE and the ex health minister of Rwanda. Called the doctor with sassitude, the pediatrician was instrumental in Rwanda’s healing through the difficult years. She believes that healthcare is a basic human right, no matter where that human may live. Dr Binagwaho, says: “If you give Rwanda money to save the life of the oldest person in Rwanda today, we will make sure that the infant born tonight benefits too.“ She encapsulates my favorite quote by Nora Ephron, “Above all, be the heroine of your life, never the victim”.

Five days on the campus allowed me access to one of the finest Rwandan kitchens, where I experienced one of the best vegetarian food fares in East Africa. The accommodation on campus was luxurious and had every possible amenity a student could possibly need. The staff was friendly and mingled easily with the staff, students and visitors; a few even spoke Hindi! And laundry was free.

UNESCO has named Rwanda as one of the top three countries globally for improving access to education. Health indicators have improved tremendously in the last two decades, with the under 5-mortality rate falling by 70.4% between 2000 and 2011, a fall in TB related mortality by 77.1% (the greatest decline in Africa), while mortality associated with HIV fell by 70.4% (the greatest reduction in the world around that time). There were other significant trends including a rise in institutional births, use of contraception, a 90% success rate for community-based tuberculosis treatment, etc. Rwanda’s shining accomplishment of 93.2% coverage for all three doses of HPV vaccine among eligible girls is inspiring and draws to attention the success that inter sectoral collaboration between ministries, strong health systems and robust partnerships can achieve.

Mutuelles de Santé, the mutual health insurance scheme has almost 96% of the population covered. Rwanda has included wrap-around social support for many of their programs and provides food, shelter, schooling help, and so much more for patients in the low socio-economic strata, so chronic conditions and the associated debility do not throw a family into a life crisis. Initiatives like Umuganda, the Saturday community-cleaning day once a month, where the whole community comes together to participate in community improvement programs, make Rwanda the cleanest country in East Africa. Regulations for helmet use and traffic rules are rigorous and road safety is a huge priority.

Prior to the hospital and community visits, the Fellows were oriented deeply and thoroughly on Rwandan culture, language and traditions, including the official language, Kinyarwanda. Community Health Workers form the backbone of the Rwandan health care system and most volunteer their time, with a united focus to better the health and well being of their communities. Most of the peripheral hospitals are nurse-driven; I was reminded of the commitment by the World Health Organization (WHO) to designate 2020 as the Year of the Nurse and Midwife. Community engagement is a key priority and the health department focuses on peripheral health workers as the crucial drivers of health care in the community- apart from service delivery in the health centers, there is significant commitment to educate families, especially women about basic health needs, maternal and child care. Community mental health is a huge priority in Rwanda and there is a comprehensive network of health workers who connect the community to the hospitals, making the system very efficient with equity being a significant driver.

Two decades of grit, determination and focus, helped Rwanda heal; despite this progress, the Rwandans themselves will tell us how they still have a long way to go. As Paul Farmer summarizes, Rwanda now needs economic growth to sustain the public sector investments in healthcare and infrastructure.  Mental health continues to be Rwanda’s biggest challenge, with depression, anxiety and post- traumatic stress disorder being very common.

The UGHE premises are a must-visit for anyone in global health as the university promises an experience of how health education should be delivered and how future health professionals must be trained. The passion and commitment of health workers in Rwanda is a benchmark in itself, and a firm lesson for all of us. ‘Health For All’ has fared very well in Rwanda. Universal Health Coverage is achieved for the poorest citizen, making Rwanda one of global health’s biggest success stories.  The country is all set to host the next Women Leaders in Global Health Conference (in November 2019), and I sure hope to be there.

Murakoze Rwanda!

 

The UGHE premises (credit: Ifeanyi Nsofor )
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