AROUND the world, it is well understood that catastrophic medical expenditures are a leading cause of destitution, driving some families from stability into poverty and preventing others from pulling themselves up.

One of the most common causes of hospitalization and mortality for young children in Rwanda is diarrhea and associated digestive diseases, causing tremendous suffering among the most vulnerable and hindering national development. Many of all of these cases are the result of poor hygiene and inadequate sanitation, a set of issues that we have all the tools and knowledge to solve. Vision 2020 and the Millennium Development Goals, toward which Rwanda has made strong progress in recent years, identify improved hygiene as a top priority for very good reason.Digestive diseases pose both immediate and long-term health risks to children and families in Rwanda. Not only do the acute symptoms of diarrhea and dehydration threaten the child’s health, but these can lead to malnutrition before long when the child is unable to eat. Acute malnutrition is compounded by severe diarrhea, and chronic malnutrition exacerbated by recurrent diarrhea can lead to developmental delays.Diarrhea leads to more hospitalizations among children than any other individual cause, and is responsible for a significant portion of out-of-pocket expenditure by families in both rural and urban areas. While mutuelle de santé covers 90% of all medical costs for enrolled families, even the 10% contribution can add up very quickly with lengthy or repeated hospitalizations. Families have had to borrow and draw on help from neighbors in order to manage these expenses due to diarrhea, but sometimes this is not enough.Through the payment of 100% of medical bills when families in Ubudehe category 1 and 2 are unable to pay, the government spends a significant amount of both the domestic and development budget to provide care for multiple hospitalizations for children with digestive diseases. This money should be used for the economic development of the nation – to build more hospitals in remote areas, to construct high quality schools to educate our youth, and to provide families with greater opportunities to build better lives for themselves and for the next generation.Furthermore, the opportunity costs of having a parent accompany and remain with a child to the hospital are enormous. Other children who stay at home are often neglected (not by parental irresponsibility but because they must give their full attention to the sick child), placing them at risk for poor school attendance, malnutrition, and depression. Additionally, that parent cannot perform their usual income-generating activity, rendering their family more vulnerable to catastrophic medical expenditure and making it less likely they will have the resources to continue improving hygiene and sanitation at home, so all of their children are at even higher risk for future digestive diseases. A vicious cycle of poverty and disease is perpetuated, undermining development and trapping families in a state of constantly trying to respond to the next health or financial crisis.Our most powerful tool in the struggle against digestive diseases among children in Rwanda would be a widespread change in mindset around the importance of better hygiene. The hygiene committees that already exist at the district and umudugudu levels should be sensitized around the threat poor hygiene poses to local and national development. Communities should be supervised by local leaders for the construction of adequate toilets that follow sanitation guidelines from the Ministry of Health. Families across the country must be remind by all of us at all occasions about the importance of washing hands after using the toilet and before cooking or eating. Each man, woman, and child must use potable water – whether from an improved water source or through boiling or filtering or using pharmaceutical. Every household should take pride in maintaining a clean home, with separate safe places for clothing, cooking, and eating. Finally, families must serve children food that is well prepared – not cooked too little so that dangerous bacteria remain, but not so much as to remove important vitamins.These actions are simple and urgent. The Ministry of Health and our colleagues across the Government Institutions are availing resources for continued scale up of behaviour change communication, improved water and sanitation infrastructure, and prevention and treatment of diarrhea (including the new rotavirus vaccine), but these will mean nothing if not accompanied by a major shift in day-to-day hygiene practices by the population. As a nation, we must stand together ready to confront poor hygiene as a serious but solvable threat to our development.The author is the Minister of Health.