It was a typical school afternoon when my 4-year-old cousin Keza* (not her real name) returned home with bloody underwear, sparking fears of a possible sexual assault. Despite the doctor's reassurance that there were no signs of assault at the first hospital they visited, the persistent bleeding led her parents to seek a second opinion at another hospital. This time, a gynecologist discovered a small mass on Keza's urethra, leading to a biopsy with heartbreaking results - high-grade invasive urothelial cancer. She was referred to a specialist, who was skeptical of the diagnosis, arguing that, based on the biopsy results, Keza’s physical condition should have been worse. Nevertheless, she appeared healthy. After a second opinion from another expert pediatric urologist and another biopsy, it was finally determined that Keza had been misdiagnosed; what she had was a non-cancerous polyp. Misdiagnosis in healthcare poses significant challenges to healthcare systems of countries. In 2013, the World Health Organization exposed a glaring issue within our healthcare systems: medical diagnostic errors, a silent but deadly problem that threatens patient safety and contributes significantly to morbidity and mortality. Shockingly, a research study conducted in the United States indicated that 11% of medical diagnoses resulted in errors, a distressingly similar figure in low- and middle-income countries, as evidenced by a study in Uganda revealing a 9.2% misdiagnosis rate among inpatients. Over the past two decades, diagnostic errors have been linked to an estimated 94,000 to 142,000 global deaths. In less affluent nations, the crisis is exacerbated by a scarcity of healthcare infrastructure and qualified professionals, along with inadequate diagnostic testing capabilities. Moreover, the economic fallout from diagnostic errors range from out-of-pocket expenses to lost productivity and catastrophic health expenditures. Even though in Rwanda we lack data about the burden of misdiagnosis, Keza’s case highlights that there might be similar cases but that are unreported. This underscores the urgent need for systemic reform for increased research and reporting on misdiagnosis rates within Rwanda, to fully grasp the extent of this issue as well as potential causes so that appropriate and informed solutions can be developed. Additionally, a misdiagnosis that fails to address the condition can plunge patients into uncertainty, leading them to explore alternative options such as traditional medicine, which in some cases can have serious adverse effects, particularly due to the limited scientific evidence of their safety and efficacy. Keza was fortunate to have educated parents with healthcare connections, including myself, guiding them in seeking appropriate care for their child. Imagine if Keza had started treatment based on a misdiagnosis of cancer, or if her parents, driven by desperation, had turned to traditional healers. The consequences could have been dire, potentially even fatal. Keza’s incident prompts a crucial reflection on our healthcare system's limitations. It also brings to light the psychological impact of medical crises on children and their families. Further, it raises questions of equity: What happens to those without the means or knowledge to seek further consultation? How many suffer, or even perish, under the weight of misdiagnosis? Evidently, the less privileged bear a disproportionate brunt of misdiagnosis, which calls for action toward equitable healthcare solutions. Health is a top priority for the Rwandan government. In fact, Rwanda was among the first countries in Africa to adopt the Community-Based Health Insurance (CBHI) scheme, to achieve universal health coverage with impressive results about 85.6% of the population was insured under CBHI as of 2020. Additionally, through its Ministry of Health (MoH), the government of Rwanda has introduced a visionary strategy known as the four-by-four (4x4) reform. This strategy aims to quadruple the healthcare workforce within four years, meeting the World Health Organization's target of four healthcare workers per 1000 population density. This welcome step should ideally reduce healthcare disparities. However, there is still room for improvement. In light of the misdiagnosis case of Keza’s story and other similar cases in the Rwandan healthcare system, a joint effort from the Rwandan government, the MoH, healthcare facilities, and individuals is crucial. The Rwandan government and the Ministry of Health should enhance the diagnostic capacity of hospitals. This can be achieved by training hospital staff in the proper use of existing diagnostic tools and technologies, investing in advanced diagnostic equipment, and accelerating efforts under the 4x4 reform to increase the number of qualified healthcare workers. Additionally, the MoH and researchers should collect and analyze data on the burden of diagnostic error in the Rwandan healthcare system, the potential risk factors, and their impact on individuals and the Rwandan community. Further, the MoH and Rwandan healthcare facilities should promote the collaboration between healthcare providers, local hospitals, international hospitals or health organizations, and research institutions to share knowledge, second opinions, and best practices. Lastly, individuals and families should advocate for their health rights, seek comprehensive information from health experts, and consider second opinions, especially for serious conditions. As the world marked World Health Day this month with the theme 'my health, my right', it is a fitting time to reflect on opportunities to strengthen our systems as we champion the right of everyone, everywhere to have access to quality health services. Embracing these changes offers a brighter future: enhanced diagnostic accuracy, better patient outcomes through training and advanced tools, reduced errors from alleviated workloads via the 4x4 reform, and insightful data analysis for continuous improvement. Collaboration and a patient-centered approach would not only uplift the quality of care but could also establish Rwanda as a benchmark in healthcare excellence globally, ensuring universal health coverage and setting a shining example for others to follow. Dr. Pierrette Ngutete Mukundwa is a medical doctor and a lecturer at the University of Global Health Equity. She is a Global Surgery Advocacy Fellow 2024.
