The 1994 Genocide against the Tutsi had devastating effects on the country’s health sector, which was already limping and grappling with poor infrastructure, few hospitals, limited equipment and medical supplies to deal with the pressing health emergencies at the time. Healthcare is one of the areas the new government led by the Rwanda Patriotic Front (RPF-Inkotanyi), which had taken over from the genocidal government, had to start from scratch to rebuild, given the immediate health crisis the country faced in the aftermath of the genocide. Understandably, the healthcare system, which was already weak, was overwhelmed by the demand of care services, with the few remaining hospitals not just ill-equipped, but there were no medical personnel, including doctors and nurses, to treat the wounded, the survivors and the returnees. Many of the few healthcare workers had been killed, while many others fled the country. There were thousands of people dealing with fresh trauma, including women who had been raped during the genocide. Mariane Muhawenimana, 48, who survived the genocide in Nyange area, in the current Ngororero District, says they had to walk for several miles to seek treatment in Kabgayi, Muhanga District, before 1994 and the aftermath. “Getting treatment at the time was a huge struggle. We had to move with machete cuts infected with gangrene for 30km, to get dressings and disinfectant,” she says. Most healthcare programmes such as emergency services, preventative care, vaccinations, prenatal and postnatal as well as mental and psychological care services such as counselling, were non-existent. To complicate things further, at the time, the country was also grappling with the HIV/AIDS scourge, which was sweeping across the region and continent – with no treatment, vaccines or antiretroviral drugs then. It was a double dilemma. The past 30 years, however, have seen Rwanda’s healthcare system transform tremendously, undergoing a shift which researchers at Harvard University have described as “among the most dramatic the world has seen in the last 50 years.” According to available data, in 1994, only 2.6 per cent of Rwandans had health insurance, but currently, 97.3 per cent of the population has health insurance coverage, with more than 91 per cent covered by ‘Mutuelle de Sante’ – a robust universal healthcare system that the current government championed. ALSO READ: Cancer, kidney transplant services to be covered under mutuelle de santé One of the biggest achievements attributed to RPF-Inkotanyi over the past 30 is turning around the country’s faltering healthcare system. When the RPF-Inkotanyi took over, the country’s healthcare system was not only dysfunctional, it also lacked the most basic of infrastructure, while the private hospitals and clinics that existed were out of reach and unaffordable for locals. The situation was compounded by lack of resources to invest, in terms of restoring facilities or building new ones, equipping them and training health workers. The new government gave priority to training doctors and nurses, and at the same time, in 1995, introduced the Community Health Workers (CHW) programme, to complement the already existing healthcare programmes. Witnessing transformation It is a journey only those who were in the health sector at the time can understand better than anyone else, especially if they have lived long enough to see the many home-grown solutions Rwanda has deployed to turn around things over the past three decades. One of those is Dr. Barbara Joy Mukamabano, who has been working in the country’s healthcare system since 1982, and has seen all these changes with her own eyes over the past 43 years. Born in 1945, in Gahini, in the current Kayonza, Mukamabano grew up with a desire to become a doctor, having lived near Gahini hospital, where her mother worked as a cleaner and often saw doctors wearing their white coats and admired them. She is among people who can tell the difference between the state of healthcare systems under the former and current governments, having lived and worked under both of them. “The changes have been many and transformative for the past 30 years I have been working in this sector. We grew up seeing hospitals and clinics being managed by ‘white’ people, but today we have Rwandans in charge, in all these hospitals,” Mukamabano says, reflecting on the period before 1994. She recalls that at the time, Rwandans merely played a supportive role, but to study and get to a level of managing a health facility was a far-fetched dream. “Those days we would ask ourselves, can a Rwandan study and become a doctor and treat people?” she says, recalling how the few operational facilities were under missionaries and churches. However, the most important change, according to Mukamabano, is the distance Rwandans used to travel to access healthcare services, which has dramatically declined to below 5k to reach the nearest health facility. “People used to travel very long distances, even without assurances that you will get the treatment you want. People would move long journeys to Kigali, or to a missionary facility somewhere, to get treatment,” she recalls further. As someone who lived through different governments, Mukamabano vividly recalls how people used to make long journeys but due to the limited number of doctors and nurses, chances of getting quick and efficient care were minimal. She recognises the efforts the government has put in training medics, even though she reckons that there is more work to do, but most importantly today, Rwandans can easily access healthcare services wherever they are. “Particularly as a paediatrician, I happy that today, when a woman walks into a health facility with a sick child on her back, that child will go back home alive,” she says, in reference to how Rwanda has been able to reduce infant mortality rates from as many as 181 deaths per 1,000 children born in 1995 to the current number of 21.6 deaths per 1000 live births according to recent figures. “Those days, a mother would come with a sick child and you wouldn’t find any medicine to give her or a laboratory to send her to do tests. A child would come with a simple respiratory condition but there were no machines to check that,” narrates Mukamabano. At the time, there were only a couple of private pharmacies which many ordinary Rwandans couldn't afford, says Mukamabano. Indeed, it is a journey that started from scratch, with the government improvising within limited resources to equip hospitals and health centres, and at the same time restock government pharmacies within these facilities. Mutuelle, the game-changer With Mutuelle, locals are able to get these medicines for free or at a very low cost -something Mukamabano says has been achieved over the past three decades. “There was no insurance for ordinary citizens. People would fall sick or get involved in an accident and they just go home and wait to either heal or die because they did not have money to seek treatment,” she reveals, reiterating how insurance cover has been a game-changer in improving access to care. For Mukamabano, the biggest achievement Rwanda scored over the past three decades is bringing services closer to the people, through the many health posts and health centres, as well as district and referral hospitals, all of which they have access to. According to the Rwanda Health Sector Report of 2023, the country currently has a total of 2,067 public and private health facilities, out of which 86 per cent, or 1,788 are public facilities. They include eight national referral hospitals, four provincial hospitals, 40 district hospitals, 510 health centres and 1,252 health posts across the country. The majority of these facilities, if not all, have been built over the past three decades. Even the existing health facilities such as King Faisal Hospital (KFH), have had to undergo a major overhaul, including expansion, to make them fit for purpose. Mukamabano, who currently works as paediatric doctor at Polyclinic La Medicale (Dr. Kanimba’s Clinic), but previously worked at KFH, says that all these different levels of healthcare, starting from the Community Health Worker, have helped to improve access to services. The fact that an ordinary citizen can be referred to different categories of health facilities, up to a national referral hospital, using Mutuelle de Sante, is something Mukamabano says cannot be taken for granted. Looking at the different education institutions training doctors and nurses today, Mukamabano is confident the country is on the right track given the many options available and admission rate. During her time, it was difficult for a female student to enroll to be a nurse or doctor. Women would be restricted to jobs such as cleaning and other low-paying positions, but today, girls and boys have equal opportunities to study. ALSO READ: Closing the gender gap in Rwanda’s health sector “When we enrolled into medical school, people mocked us. They would say ‘while others are going to get married or stay at home to do chores, you’re wasting time and resources studying,” says Mukamabano. Herself and a few other girls persisted until the current government, which gave an opportunity to all Rwandans regardless of their gender, came into power, and many of them were able to get opportunities to go back to school and upgrade their skills. Mukamabano, who is 79 and still going strong, says the young generations, especially girls, need to take advantage of the immense opportunities available to them, study and come back to contribute to the country’s vision, because there is more work to be done. Her two sons followed in her path, one taking on pharmacy and the other public in the health fields. Currently, Rwanda has slightly over 2,000 and 11,325 nurses, with the doctor-patient ratio at 1/6793 and midwife ratio at 1/2272, which means that many health professionals are required to fill the gap. From nothing to something Rwanda’s transformative journey in healthcare is one many people cannot believe. To some, it is a miracle, while to the haters ‘it is just PR’, but that is something you won’t tell a doctor who saw boxes and cartons serving as hospital wards. In the aftermath of the Genocide against the Tutsi, the demand for health facilities and services was so bad, that doctors would improvise by using cartons and boxes in which relief aid was brought as temporary hospital wards. Dr. Emmy Agabe Nkusi, a Chief consultant neurosurgeon at Rwanda Military Referral and Teaching Hospital, and King Faisal Hospital, is one of the first neurosurgeons in the country, is one of the man, who can testify about the progress the country has registered over the past 30 years. Nkusi, who is also an Associate professor of neurosurgery at the University of Rwanda, made a difficult choice to abandon joining the liberation struggle to take up his admission to medical school in Uganda, which came around the same time RPF-Inkotanyi had launched a war to return Rwandans in exile home. As a medical student, Nkusi would come to Rwanda during breaks and holidays, between 1995 and 1998 when he completed his studies and internship to return to Rwanda to make his contribution in rebuilding Rwanda’s health system. “I finished and joined in 1998 and there were still no specialists. The government had already started sending people out to specialise,” he says, recalling that one time there was a conference where all medical doctors were invited and there were not more than 100. “All doctors had come, including General Practitioners and we were less than 100. Now we are talking about over two thousand doctors now, from less than 100,” he says, adding that the strides the country has made in healthcare are unimaginable. In terms of challenges, Nkusi says that the medical personnel who were there can testify that it was a 180-degree turnaround, much as there is still a lot to do but looking back at the post-genocide era, the progress is noteworthy. The period 1994-1995, Nkusi says Rwanda at the time was not thinking of specialists but just doctors to handle the cases at hand. In surgery, his area of specialisation, there were not more than five surgeons by 1998. Among those he remembers were Dr. Eugene Kayibanda, Dr. Emile Rwamasirabo and Dr. Charles Murego (deceased) and a handful of others while another group had been sent to South Africa to train by the Ministry of Defence. Nkusi was among the second batch sent abroad to specialise in neurosurgery in 1998 after he had returned to Rwanda. The Rwandan doctors in South Africa had intimated to their South African counterparts about the many injuries Rwandans had sustained during the genocide. Nkusi worked with a South African neurosurgeon, Dr. Martin Lewer-Allen, who had been coming to Rwanda to conduct surgeries and soon he spotted his abilities and he was recommended to go for further training. Having briefly interned in and did rotations in Uganda’s Mulago Hospital, went to South Africa in 2000, where he first studied two years of general surgery before specialising in neurosurgery-one of the most difficult disciplines in medicine. He completed the course in 2008 and the next day after graduating he returned home and immediately got to work but as a new discipline, he was required to compile a list of what was needed to kick-start a department of neuro-obstetric surgery. He returned well knowing that back home there was no modern equipment similar to the ones he was using during training in South Africa. While in South Africa, Nkusi recalls that while in theatre, conducting one of his last surgeries, he was asked to handover a one of the modern machines used in cranial surgeries to a professor whose machine had broken down. He was requested to use old rudimentary tools such as the Gigli Wire Saw, because, after all, those are the tools he would be using back home because the country doesn’t have modern equipment used in neurosurgery. “They told me I have to learn how to use old equipment. I got offended but definitely they were telling the truth,” Nkusi says, adding that he was determined and he embarked on the use of old and rudimentary but very efficient tools. In fact, as he returned home, the professor said they would give him some of the old-style equipment to take back home, including the Gigli’s saw and other manual instruments used in neurosurgery. He was reluctant to use them but after submitting a pending list of basic equipment needed to establish a neurosurgical centre, he began improvising with the rudimentary tools which despite being labour intensive are efficient in doing the job. Now back home, Nkusi started mobilising like minds, having learnt about an existing neurosurgeon at the University Teaching Hospitals in Kigali (CHUK) and another in Huye (CHUB), who he mobilised to come together and set up a neurosurgical department, given the urgency. Starting out Nkusi was invited by the then Minister of Health, who asked him what was needed to set up a neurosurgery centre but it also proved difficult as it would be overwhelmed. There was also a need for quick and effective coordination and communication. There was a Cuban doctor who was working in Butare, but performed scans in Kigali and the hours lost in between endangered many lives. “Time brain and brain is time. You cannot afford to waste time with the brain. Once you have seen a problem, send a patient for treatment,” “Once you see something, take it out immediately. This person will do well,” he said, adding that the proverbial “golden hour” in neurosurgery would often be lost and so would be lives. “The Minister accepted immediately, and when we told him about developing a centre where we can welcome everyone, he had actually thought about having a hospital specifically for that but then when I talked to the CEO, he said that would be filled immediately, unless we make it a trauma or neurosurgical hospital. “So, we agreed that we set up a satellite centre at CHUK and the main centre here at King Faisal,” Talking about home-grown solutions, Nkusi says they developed a plan to train young aspiring neurosurgeons and nurses who would be supporting them on duty, by setting up a library where they can learn most of the things in theory. “We thought you cannot train people when you are very busy. Where are they going to get the time to teach the theory?” he says, adding that when he floated the idea, some thought he was crazy. “I told them no, it's simple. Give me an empty space in King Faisal that you are not using,” he said, having identified an ample space where the library can go. The next question he was asked is where the money to stock the library would come from. Nkusi wrote funding proposals to different institutions and also used the books he had to set up. Soon, support came through. The solution worked in the sense that rather than spend time teaching, the neurosurgeons focused on treating people while those interested in joining the profession started with the well-equipped neurosurgical library, which has online resources and many reference materials. “That was one of our survival methods,” he says, pointing out that this is how the Rwanda Neurosurgical Centre, which has the neurosurgical library, was born, in July 2010. The main objective was to improve patient care and ensure efficiency in service delivery as well as boost research and education -all of which have been achieved, much as there is more to do. At the time, there were no nurses trained or dedicated to supporting neurosurgeons, who spend hours and hours in the theatre conducting surgeries, because this was a whole new area. When the centre opened, the Minister allocated 16 nurses to specialise in neurosurgical patient care and management, which eases the work of neurosurgeons. It is a delicate field that requires specialisation and intensive care. As such, a ward at CHUK, which is near the ICU, was dedicated to neurosurgery while three general practitioners were also transferred to neurosurgery as support staff. There was still a need to train more neurosurgeons, considering that there were just two in Rwanda, yet training takes a minimum of six years, which means that even sending a doctor for further studies, one has to wait for at least six years for them to return. Nkusi says it was all possible because everybody was very supportive and there was political will to get things done. A good example is when they proposed to develop a curriculum to start teaching neurosurgery after establishing the centre but some people said ‘you are just two, not enough to treat all the people. How will you do it?’ When they approached Dr. Patrick Kyamanywa, at the time the dean of the College of Medicine at the National University of Rwanda (UNR), now University of Rwanda (UR), he was positive and forthcoming. The curriculum was developed, went through institution, cabinet and Parliamentary approvals and by 2013, Rwanda was training her own neurosurgeons. “We started training with two candidates. One was in third year because he was already in general surgery and another one in second year and they migrated to neurosurgery. The first two who completed the six-year programme were Dr. David Hakizimana, in 2017 and he is currently the head of the neurosurgery department at KFH, while Dr. Steven Nshuti, who is currently at CHUK. They both did their College of Surgeons of East, Central and Southern Africa (COSECSA) exams in 2018, to join a very limited list of neurosurgeons in Rwanda. After every two years, they admit two after thorough screening, given the demands of the course. The dropout rate is equally high. Today, there are about five locally trained neurosurgeons, 10 resident doctors in training and also opened the door to doctors and students from elsewhere. Today, there are 22 medical personnel doing neurosurgical work, from just two in 2009. Beyond neurosurgery, Nkusi says that similar efforts have taken place in other fields such as urology, orthopaedics and oncology, among other specialised fields where Rwanda was lagging behind. In fact, some of the said areas are doing way better, for example orthopaedics, where there are more than 20 surgeons, but it is much more than training. It also took years of confidence building in Rwanda and beyond. It started with bringing COSECSA on board in 2007 to vet and examine surgeons, with the first graduation taking place in 2009 while other disciplines equally picked up. Today, many people from neighbouring countries are coming to Rwanda to seek treatment yet just about a decade or so ago, Rwandans were going to countries such as Kenya, India and South Africa to get this treatment. The number of Rwandans travelling abroad to get treatment has declined dramatically due to these gains. However, the medic says this progress should not be a reason to become complacent. Among other things, he said there is a need to improve how systems work, to ensure that people spend less time and resources on healthcare and to ensure that Rwandans can get whatever treatment they want whenever, wherever. “The government has really invested in the healthcare sector a lot, look at Mutuelle de Sante, we put a lot of effort,” Nkusi says, adding that the government has done a lot in terms of dealing with emergencies and trauma. “Soon we will see a lot of centres coming out countrywide so that people can access advanced care in their own localities,” he said, adding that everything so far seems to be on track, regardless of a few remaining challenges such as equipment and limited personnel. Nkusi says that under the country’s 4X4 health reform initiative, the government is looking to establish more training centres with a mission of quadrupling the number of healthcare workers in the country within the next four years to meet the WHO recommendation of at least four healthcare professionals per 1,000 population. ALSO READ: Africa’s modern surgical training centre opens in Rwanda He highlighted the different initiatives to train and equip more people to provide quality healthcare to all Rwandans, that while the past three decades have been fruitful, there is a need to consolidate and reinforce what has been built to ensure that all Rwandans wherever they are have access to efficient and affordable healthcare services.
