Over the years, the Government of Rwanda has been promoting a public-private partnership healthcare model, which allows players in the private sector to make their contribution towards developing the country’s health sector.

In a country where at least more than 30 per cent of the population requires some form of eye care service according to the World Health Organisation (WHO), the need for ophthalmological services remains ever present.

From a global perspective, at least 1 billion people are affected by vision impairment worldwide, including Rwandans, and the WHO estimates that 80 of most of the eye defects are treatable and, if tackled at an early stage, the majority of them are preventable.

What is even more concerning is that the prevalence of vision impairment is four times higher in developing countries, where lack of access to eye-related medical treatments can lead to different eye conditions, and later blindness.

In recent years, eye care in Rwanda has improved tremendously, with the number of eye hospitals and specialists increasing, feeding into the national vision of bolstering healthcare services across the board.

For instance, in 2011, Rwanda had just eight eye care specialists but that number has since grown more than five-fold today, thanks to different efforts to train more ophthalmologists and nurses who can provide eye care services.

Today, Rwanda boasts of different eye care hospitals, some of them delivering services including surgeries which Rwandans often traveled to acquire abroad. One such facility is the Nyarutarama-based Rwanda International Institute of Ophthalmology (RIIO).

Established in 2012 by Dr John Nkurikiye, a Rwandan and Prof. Wanjiku ‘Ciku’ Mathenge, from Kenya, to address the gaps in the provision of eye care services in Rwanda, the hospital has gone on to become one of the major ophthalmological facilities in Rwanda and the region.

For those who might not know him, Nkurikiye, was recently promoted from the rank of Colonel to Brigadier General and appointed the Deputy Chief of Staff of the newly established Medical Health Service under the Rwanda Defence Force (RDF).

Nkurikiye is one of the most experienced ophthalmologists Rwanda has, having started practicing in 2001 after completing his training in South Africa, between 1996 and 2000.

Like many active RDF medical personnel, he was deployed at Rwanda Military Hospital (RMH) in Kanombe before he joined King Faisal Hospital (KFH) in 2005, where he helped establish the department of Ophthalmology.

In 2012, he left the referral hospital to join hands with an Indian doctor, Agarwal, to establish Agarwal Eye Hospital and in December 2022 set out to partner with Mathenge to establish RIIO.

Today, the hospital has become one of the most advanced in the country and according to Nkurikiye, when they set out with Dr. Agarwal Hospital, their mission was not just to offer care service but also to train specialist doctors and nurses.

"That was our main purpose of partnering because we needed a very specialised facility with all the equipment but from 2022, we started to notice that we were not reaching the heights we wanted,”

"Therefore, together with my co-founder, we decided to start our own. RIIO is an institute because we do care and we also do education, research and we do community service,” He said.

Nkurikiye said that training of specialists is their main preoccupation because the number of ophthalmologists in Rwanda is still very low.

"We noticed that when we send people to go and train outside Rwanda, sometimes they don't come with the skills we want. Sometimes they decide to stay in those places they were trained

"Since 2006, we've lost four ophthalmologists who went to train and never came back. Then we have those who return but do not have the skills we wanted. You will find that you have to retrain them even after qualifying,” he observed.

Nkurikiye said their aim was to start a training institution which can offer the right skills and knowledge expected from specialists.

It was not an easy journey, having started the planning process in 2012 but they could only enroll the first class in 2018, training under the College of Ophthalmology of East, Central and Southern Africa (COECSA), which covers 12 countries in the said regions of the continent.

"Rwanda was the pioneer in starting this training program. The college has grown and has a lot of tools that we use to assess the quality of training,” he said, emphasizing how the training they offer is different from what one can offer at conventional universities.

"There is a difference between quality training and the normal university training because we focus more on skills. We wanted specialists who can deliver care. For us to reach there, the college has a lot of quality assessment tools which might not be applicable to universities,” he added.

Rather than focus on academic patterns to train and pass on knowledge and on research, at RIIO they focus more on the level of skills which are assessed based on certain milestones, to determine whether one has passed or not.

Their training is not time bound with some individuals getting all the aspects of training in four years while others can achieve the same in five or six years.

"We don't release you until we know you are safe to go and deliver care,” Nkurikiye, who is currently the president of COESCA, says.

In Prof. Ciiku Mathenge, Dr. Nkurikiye found a willing partner who has an excellent track record as an educationalist and researcher, who shared a similar vision.

"We complement each other in terms of our clinical skills, combined with training skills, education skills and research,” he says when asked about their partnership to set up the health facility.

The duo shares a long history, dating back to 2002, having crossed paths on their education journey and they started conceiving joint projects together, up to the point they decided to get married.

They both shared the same dream, of advancing medical education to desired levels.

Incidentally, they both happen to lead regional professional bodies. While he is the president of COECSA, Mathenge also serves as the head of the Africa Ophthalmology Council, which is even bigger.

While there is still a lot more ground to cover, Nkurikiye says today he feels they have achieved what they set out to do, with their training ranked by experts among the best in Africa, in terms of training specialists

"We are in a good place. We have trainees from as far as the Caribbeans. We have someone from the Bahamas, we have Kenyans who come to train here because they know the quality is good,”

In regard to treating patients and solving problems of visual impairment, Nkurikiye said their vision was to offer the best services because they consider eyesight the best gift that God gave mankind.

It is for that reason that they have invested, including the latest technology that does imaging and surgery used elsewhere in advanced hospitals in other parts of the world.

"We wanted to maintain the best eyesight as we can for everybody,” he says, adding that ophthalmology is one of the costliest fields of medicine, requiring a lot of investment, as technology keeps evolving.

A growing problem

Nkurikiye said today people are exposed to different eye conditions which are a result of lifestyle or are even work-related, for instance people being exposed to gadgets and screens more than ever as well as exposure to Non-Communicable Diseases (NCDs) such as diabetes and hypertension, which affect eyesight.

Conditions resulting from people not being able to do enough exercise as well as diet can equally result in vision problems, revealing that diabetic retinopathy is one of the main challenges they are dealing with.

"It is now getting more prevalent among young people and it's one of the conditions which we are treating on a regular basis here,” he says, adding that the availability of technology has eased how they diagnose some of these conditions.

Apart from costly equipment, Nkurikiye said they are still dealing with a number of challenges, including lack of capacity to maintain the said equipment due to lack of biomedical engineers who are specialised in maintaining eye equipment.

"Whenever you have a small problem with the machines, it becomes difficult to manage,” he says, adding that they have to ship someone from outside the country to fix the machines, which comes with its own cost.

The other challenge relates to having to import most of the materials and supplies they need, most of which cannot be sourced locally, and it becomes even more expensive, given the bureaucracy and the logistical delays.

Setting up such a facility and acquiring equipment at a high cost can make it pretty difficult for such investments to breakeven, given the marginal cost at which they have to offer the services. The balance is not easy according to Nkurikiye.

Nkurikiye noted that providers find these prices very low to even cover their costs.

RIIO is currently eyeing going into specialty training, to nurture the next generation of eye doctors, particularly the young and more exposed groups.

‘Avoidable blindness’ is a reality

Dr. Nkurikiye urges people to regularly test their eyes to know if they have a condition they need to deal with early or not, observing that most people have never checked their eyes at all, which exposes them to unknown conditions that could affect their vision in a short or long term.

"Once you reach the age of thirty, you should have your eyes checked at least every two years and above 60, once every year. If you are found with anything of our concern, then it will be given if a specific time table for your checks,”

"That is the only way we can prevent what we call avoidable blindness. Avoidable blindness in Rwanda is a reality,” Nkurikiye said, and this is something he has seen over the years in different corners of the country, through the RDF citizen Outreach program for eyes.

Every year, the army conducts citizens outreach exercises, taking services closer to the masses. This year, the military doctors are expected to operate on over 4,700 people to restore their sight.

Nkurikiye noted that a nationwide screening exercise found that there are 83,000 people with eye problems, who need some sort of help. Ahead of the 30th liberation celebrations, the medic says that "everybody should be given a chance to see what Rwanda has achieved in the last 30 years.”

Among other things, the ophthalmologist encourages Rwandans to desist from ‘self-medication’, where some people also put sorts of over-the-counter eye drops in their eyes, some of which can be dangerous if not prescribed by a doctor.

"That is one thing but the worst people are those who use traditional medicine. Those herbs are toxic to the eye and sometimes the damage can be irreversible,” he said, urging people to always seek medical help before inflicting damage on their eyes.

Some of the most popular eye conditions in Rwanda include cataracts, which is the leading cause of blindness yet treatable, followed by glaucoma — the second cause of blindness but it's irreversible.

RIIO offers specialised ophthalmology treatment like cataract, glaucoma, retina, lasik surgery, and oculoplastic surgery, among others.

Starting small

Dr. Mathenge, Chief Consultant Ophthalmologist and Programme Director at RIIO School of Ophthalmology, said the programme started with four Rwandan students who graduated in 2022 before they were deployed in different districts which didn’t have eye doctors.

"We train doctors to treat eye diseases by sitting in a clinic and performing surgery for diverse eye conditions. The training involves micro surgery and intensive care,” she said.

"Our trainees are in high demand. The six that graduated so far are operating in Rwamagana, Ruhengeri, Kibuye, Kibagabaga, and Kabgayi Hospitals.”

As part of the arrangement, RIIO helps to seek scholarships for the students so that the institute is able to meet their bills.

According to Mathenge, the course is a unique model since it offers competence, and a doctor graduates after acquiring expertise -an education model which many were not accustomed to.

When the school started, it only had four applicants. The number increased to 70 in 2023, which shows that the profession is becoming more popular.

After graduating their first four students, RIIO School of Ophthalmology increased the number of eye specialists in Rwanda by 30 per cent.

"Our desire is that this program will bloom and run as a private enterprise and taken up by a bigger body to afford paying our bills so as we only focus on training students,” Mathenge noted.

She envisions having the best talent at RIIO and deploying all graduates to make a difference.

One of the challenges that the school faces is lack of enough resources —their capacity is 14 students which is determined by access to clinics where doctors train.

Mathenge is grateful to the Kibagabaga District Hospital’s support to allow the school to create a good training eye clinic.