Women and community ownership have made a difference, says Rwanda's health minister

Rwanda is one of the few countries, globally, that are on track to achieve the 90-90-90 UNAIDS targets. Visiting Indian media personality Shobha Shukla spoke with Health minister Dr Diane Gashumba on the margins of ICASA 2019 – the 20th International Conference on AIDS and sexually transmitted infections in Africa, which will come to an end on Saturday in Kigali.
  • What has been Rwanda’s response to HIV/AIDS?
Dr Diane Gashumba: The Government of Rwanda has opted for politics that is fully decentralised and fully focused on the people at the community level. This happened right after the Genocide, during which we lost everything.

Not only over a million of people were killed, but all the basic infrastructure, including hospitals and schools, were destroyed. Even the hope and desire to continue to live was lost.

But the new leadership made a radical change. The political vision to serve the people has translated into action at ground level. Every citizen of Rwanda contributes to make a difference and this has led to a very high level of community ownership.

The political leaders neither impose upon nor decide on behalf of the people. All our citizens take part in the discussions and in the assessment of issues within the communities where they live and it is they who propose solutions to the problems. The leaders are there to ensure that these are implemented.
Dr Diane Gashumba, Rwanda's Health Minister (right) and
Shobha Shukla, CNS Managing Editor (left)

Apart from this decentralisation, we have a very strong health system that starts from the community level. The Government has invested in having a very strong workforce of community health workers (CHWs).

These CWHs do not have a medical background, but they are trained to help in prevention of infectious diseases like malaria, diarrhoea, pneumonia, etc, and also for family planning. The CHWs are a very important component of Rwanda’s health system. They are the ones working at the grassroots level.

They have the trust of the community as they are elected from the community. Their active participation and commendable work has contributed in no small measure to the success story of Rwanda’s healthcare system.

They helped Rwanda to be one of the few countries that achieved the Millennium Development Goal 5 on time (MDG 5 had two targets; to reduce maternal mortality ratio by 75% and to achieve universal access to reproductive health)

Another important aspect is the easy accessibility to medical care for all. Under the country’s community based health insurance system every Rwandan contributes US$3-4 annually and the Government subsidises and covers all the medical costs for vulnerable people, which constitute 16% of the population.

This financial capability to pay for medical services has also contributed to the reduction of maternal mortality and stabilisation of HIV epidemic.

One more strategy that we’ve put in place is integration of HIV care and control services – like counselling, testing, treatment – within the existing healthcare system that was strengthened.

  • From where does the money come to finance such a robust health system?

Dr Diane Gashumba: The Government of Rwanda allocates 16.5% of its budget to the health sector. The political leadership of Rwanda understands that investing in health is critical for economic growth of the country that we are now witnessing in Rwanda.

When we invest in people’s health we have a healthy population that contributes to the development of the country.
  • Where does Rwanda stand in terms of the UNAIDS 90-90-90 targets? 
(By 2020- 90% of all people living with HIV will know their HIV status; 90% of those diagnosed with HIV will get antiretroviral therapy-; 90% of those receiving ART will have viral suppression) 

Dr Diane Gashumba: We have already over-achieved the two last 90s. 98% of our people diagnosed with HIV are on treatment; and 91% of those on ART have their viral loads suppressed. Regarding the first 90, we are currently at 83.8% and are working very hard around to achieve it through community awareness campaigns to ensure that every Rwandan goes for HIV testing to know their HIV status and get treatment.

We have also recently initiated self-testing for HIV and hope that this will help achieve the first 90 very soon.
  • What is the status of Prevention of Mother to Child Transmission (PMTCT) of HIV in Rwanda?
Dr Diane Gashumba: This is yet another area where Rwanda is doing great, with collaboration of civil society, especially the relentless efforts of our First Lady. She launched a huge PMTCT campaign more than 15 years ago which has led Rwanda to achieve 98.5% elimination of mother-to-child transmission (EMCT) of HIV and we will soon achieve 100% elimination.
  • How serious is the problem of TB co-infection in people living with HIV in Rwanda?
Dr Diane Gashumba: TB co-infection in people living with HIV (PLWH) is a global problem. As per our national guidelines in Rwanda we test and screen every PLWH for TB and vice versa.

We are also following WHO guidelines for treating latent TB infection in PLWH. Although we do not have too many cases of drug resistant TB, but we have to keep the momentum and not let go of the gains we have achieved.
  • What has been the impact of non-communicable diseases, like diabetes, on Rwanda?
Dr Diane Gashumba: The demographic trend of diseases is changing in many countries, including Rwanda. Life expectancy in Rwanda has increased from 28 years in 1994 to 67 years today, through efforts to control infectious diseases as well as to reduce neonatal and maternal mortality.

But at the same time, we see more cases of non-communicable diseases (NCDs). So now our focus is also for prevention and control of NCDs like diabetes, cancer, and cardio vascular diseases.

One of the innovative strategies we have put in place in Rwanda is the ‘Car free Day’, which is held in all districts of Rwanda two times a month when we park our cars.

Instead, we exercise and walk around in designated open areas / grounds. We, in the health sector, also take these days as an opportunity to provide messages and raise community awareness around NCDs, and encourage them to go for a complete health check-up at least once a year.

We also screen them with support of private sector and public sector clinics/hospitals. While our main focus is on prevention of NCDs, we are also putting much effort on treatment.

How is Rwanda dealing with tobacco use/smoking?
Dr Diane Gashumba: We have very strict regulations against tobacco use in Rwanda and there is strict follow-up. While smoking is not a big problem, Rwandans do smoke and we need to keep educating the people about health hazards of tobacco use.

Rwanda was one of the first countries to have banned the smoking of ‘sheesha’ one year ago. Use of e-cigarettes too is banned in Rwanda. I believe that all products containing nicotine are addictive and bad for health.
  • What is your message to ICASA 2019 delegates, especially women?
Dr Diane Gashumba: Rwanda is one of the few countries that are promoting and empowering women in a big way. Our President is very gender sensitive and believes in the capability of women to do things properly. This has translated into a lot of women being in the workforce.

Women constitute 52% of Cabinet. They also comprise 61% in the Lower House of Parliament. Similarly, most of our CHWs are women, accounting for 66%. But we do not look at the numbers only. We look at the high quality of work that they are doing.

Women have been an integral part of all the achievements we have made. My message to the women participants at ICASA 2019 is that women are capable and when we invest in women we invest in the whole family, we invest in the progress of the nation.

Let us acknowledge that women are great!