Lessons from Rwanda for COVID-19

Health, and COVID-19

Dr. Agnes Binagwaho, Rwanda’s former Minister of Health, shares her experience rebuilding the country’s health care system and her insights on an equitable response to a pandemic.

Dr. Agnes Binagwaho knows how to control an epidemic because she’s done it before.

Born in Rwanda, Dr. Binagwaho, an Emerson Collective Dial Fellow, grew up in Europe, where she earned her medical degree and a Master's in Pediatrics. In 2006, she returned home to Rwanda to serve in the aftermath of the genocide there.

Dr. Binagwaho is Rwanda's longest-serving Minister of Health. Credit: Barbara Kinney

From 2002 to 2016, as leader of Rwanda’s National AIDS Control Commission and then, as the country’s Minister of Health, Dr. Binagwaho was part of, and ultimately, led the effort to rebuild Rwanda’s health system from scratch, using an equity lens and a commitment to high-quality health care for all. The government of Rwanda and its partners successfully cut new HIV infections in half, dramatically reduced maternal and child mortality, and doubled life expectancy for Rwandans.

Now, as Vice Chancellor of the University of Global Health Equity, Dr. Binagwaho is training a new generation of health professionals from Africa and beyond to deliver equitable, effective health services—and build the systems that will sustain it.

UGHE courses are framed in the context of current health care delivery issues to make lessons relevant and practical.

Here, Emerson Collective’s Director of Global Health Equity, Cassia van der Hoof Holstein, talks with Dr. Binagwaho about her lessons for a world working to control the COVID-19 pandemic, and how we can deliver on the human right to health care.

Let's start with some background. How did you embark on your work as a clinician and as a leader in public health and global health?

I wanted to provide health care from the time I was a child. I did my nursing education, and after that, I did my medical education. Afterward, I thought about studying gynecology, but finally decided to do pediatrics because I wanted to interact more with newborns.

After my residency, I returned to Rwanda—not immediately after, because the year I was supposed to come back was the year of the 1994 genocide against the Tutsi. But I came back two years later, and when I came back the health sector was totally destroyed. I realized that I was not able to provide services to patients, because there were no equipment, no medicines and above all, no functioning systems in place. So, we had to create a system to provide care, which led me to work in the government—at the National AIDS Control Commission, and eventually, as Minister of Health.

I always wanted to be an educator, too. I had been deciding between clinician or educator and now, with my work at the University of Global Health Equity, I get to do both. I am a very lucky woman.

You mentioned your time as Minister of Health and your time with the National AIDS Control Commission before that. What lessons did you learn from the success of treating HIV in Rwanda, and the more recent experience controlling the Ebola outbreak there? What lessons could we bring to bear on the COVID-19 response?

I learned how important good policies are, but also how officials can never be the only ones involved in setting policies. I believe the participatory process has made our policies in Rwanda successful, because we have made our policies with the people that will benefit from or will be harmed by them. The participatory process can help you to frame policies in a way that serves the majority, and especially the most vulnerable.

How does this work? You put them or their representative at the table. Let me give an example. We put civil society in the heart of the decision process in the National AIDS Control Commission. Our policies ultimately served them well because they wrote them with us. When I became Permanent Secretary, I extended this approach throughout the health sector. To make that happen, we had to help the civil society to be independent and strong, knowledgeable, and capable of advocating for themselves. This meant providing them with the right resources to be autonomous, knowledge about their opportunities, the capacity to advocate, and a voice at the table.

Never do something for people without them. In this way, we also built trust with the population of our country, so that they listen to us when we have something to say, because we also listen to them. They trust us if we tell them we are in danger. People say, “Rwanda is a very disciplined population.” No, it's a population that trusts its leaders.

Cultivate solidarity, participatory process, transparency, and good trust. That's what I learned.

With the campus strategically built in a rural area, students are embedded to directly help communities with under-resourced health care systems.

Tell us more about what UGHE is doing. I imagine in some ways this experience is a learning lab for students preparing to help address outbreaks and epidemics in the future.

I am so proud of the UGHE family because the people from the university have stayed here in Rwanda during the COVID-19 pandemic. The students had the choice to go home, and the majority of them have stayed in Rwanda. We are teaching our students that the future of global health needs leaders who will care for the most vulnerable. They have seen that in action: the majority of the staff and teachers stayed on campus.

Let’s talk about our favorite subject: the human right to health. We spend a lot of time thinking about the human right to health and how we can fulfill it, defend it, deliver on its promise. But we’re seeing isolationist rhetoric, fear-based policies, the erosion of protections and rights. How can we protect these rights, which are more important now than ever—especially for the most vulnerable?

This is a challenge, especially with a disease like COVID-19, where there may not be enough equipment and supplies to treat everybody. The human right to health is not always respected even when there is no emergency. So it's not easy during a crisis like COVID-19 for people to decide they are going to suddenly value the human right to health for everyone. Leaders in many countries don’t do this even during ordinary times. That's my concern.

We have to create a system that values all lives equally, and that ensures that everyone has access to the fruits of modern medicine. This is the foundation we need every day, and especially in moments of crisis.

UGHE students not only learn how to effectively treat their patients, but also, gain skills to build more equitable health systems.

What is your guidance or encouragement to people working hard in the face of a pandemic to make sure that they keep equity uppermost in the response?

Repeat every day that the life which is in front of you has the same value as the next life that will be in front of you, and the next life in front of you. I think we need simple language like that. The world still has a long way to go. But I think we will make it. We will make it.