Direct Democracy and the Health Sector:Umushyikirano 2011

During the holiday season, I took time to reflect on the highs and lows of the past year. Without a doubt, one of the events that made me most proud to be a public servant for the people of Rwanda in 2011 was our National Dialogue Day, or Umushyikirano. As written in Rwanda’s 2003 Constitution, the country hosts a two-day exchange of ideas, comments, and questions hosted by the President of the Republic at Parliament each December. On December 8 to 9, 2011, officials from the health sector joined representatives of the people as well as leaders from the central government to the village level for the Ninth National Dialogue at Parliament in Kigali. The Dialogue draws on Rwanda’s principles of transparency and participation, allowing Rwandans from across the country and around the world to join and follow the conversation through free (reverse-billed) SMS messages, phone calls, Twitter, Facebook, live radio, and television broadcasts. Phone calls and SMS have been the foundation of Umushyikirano in past years, but 2011 saw the first incorporation of Twitter and Facebook messages. The addition of social media, a powerful tool for new kinds of interaction across traditional boundaries, made this the most inclusive and intense Umushyikirano yet. Umushyikirano is a home-grown communications platform that facilitates open and deep dialogue. Over the close to eighteen years since the 1994 Genocide against the Tutsi, Rwanda has created many original innovations to ensure good governance and continual progress in the country. As one of the most empowering innovations, Umushyikirano is enshrined in the Constitution, guaranteeing that the people of Rwanda retain their right to participate in all decisions that guide their life and always have this forum (among many others) for expressing their proposals for improved policies as well as their judgments on the work of their elected leaders. In reflecting on the central role of Umushyikirano in the Government’s decision-making process, I do find myself wondering how anyone who takes the time to learn the fundamentals of Rwanda’s political process could feel justified in saying that this country lacks political space or the freedom of speech. I grew up in Belgium and have spent years in other European countries and spent time in the United States, but I have never seen anything else quite like Umushyikirano – direct democracy on such a scale that harnesses the power of the telephone and internet; this exists only in my motherland, Rwanda. Thanks to the rapidly expanding penetration of the mobile phone in Rwanda today, citizens from each and every corner of the country’s 15,000 imidugudu villages and countless diaspora communities can offer their views on every subject – whether the topic they wish to address is on the day’s agenda or not. Together, leaders and citizens reflect on potential solutions to the biggest challenges to our national development and the welfare of all Rwandans. This is true and direct democracy, where the officials entrusted with implementing national policy can be held accountable for their actions by each and every citizen. I have attended each Umushyikirano since 2003, but this year was my first as Minister. The main themes for the 2011 discussion were governance, social welfare, justice, and the pursuit of economic development. All Ministers and directors of central government institutions directly concerned, were organized into panels that discussed each of the four topics with the live assembly of approximately 1,000 at Parliament and the rest of the nation through phone and computer. The health sector presented on recent developments in Rwanda’s community-based health insurance program,Mutuelles de Santé, describing progress towards universal enrollment and the implementation of the new policy dividing premiums into three tiers based on families’ socioeconomic status. All Directors of specificHealth programmes and departments and other key staff from the Ministry of Health participated remotely throughout the entirety of Umushyikirano; some watched the live video feed in the main meeting room, others listened through the radio and read SMS messages, while several others joined through Twitter and Facebook. All together, we responded to each and every question regarding the health sector. As always in Rwanda, we presented not only the Ministry of Health’s achievements but also our greatest challenges so that we might collectively reflect on ways to overcome them and to perform better for the population. This year, we have delayed the collection of insurance premiums for the 75% of the population who pay their own premiums and also the transfer to districts and communities the funding to cover premiums for the 25% who are fully supported by the Government after being identified as indigent through Ubudehe-- Rwanda’s community-based system for establishing each household’s level of insurance premiums (and other socioeconomic indicators). One major challenge facing the health sector that was closely examined during Umushyikirano is malnutrition. An unacceptable 44% of children under the age of five remain chronically malnourished or “stunted” (to be distinguished from acute malnutrition or “wasting”), and 38% of children under the age of five suffer from some form of anemia. During Umushyikirano, we collectively determined that the way forward in combating malnutrition must be a multi-sectorial approach driven by a cultural revolution aimed at sustainably changing the ways we teach families about growing, cooking, and serving the foods that end up on the plates of pregnant women and young children. Rwanda does not lack the agricultural resources to properly nourish all our people, but we have been inadequately educating families about proper nutrition for too long. It is time to accompany the population in working together as one, for improved maternal and child health through nutritious diets. At Umushyikirano, the people of Rwanda set a deadline for the Government and its partners to eliminate the root causes of malnutrition within just six months. This approach is similar to that pf tackling one of the greatest challenges of poor living conditions by guaranteeing all households with iron sheet roofing in order to eradicate thatched roofing through the Bye-bye Nyakatsi programme. A third issue concerning the Health sector, discussed during Umushyikirano is the fact that Rwanda still depends on external financing for more than 45% of the health sector annual budget. As our Government and people know well, self-reliance can only be achieved through economic growth. Rwanda’s path away from dependency will be driven by sustainable development, and will involve generation of revenues through the health sector in the near future. The Ministry of Health will continue to do its part to reduce the importation of expensive drugs and consumables by relying on high-quality locally manufactured generics when possible as well as promoting private health facilities and providers. By encouraging the growth of the private sector, we can increase domestic tax revenues without raising taxes – this revenue will then be used to help increase the availability and quality of public sector services for all including the poor, as well as to invest in the education of more highly trained medical specialists for the benefit of all Rwandans. In addition to debating major challenges facing the health sector, participants in Umushyikirano raised questions about the organization and quality of health care in Rwanda. Several Facebook users asked why some health professionals with diplomas remain unemployed by the public health sector, and the Ministry of Health responded by observing that the employment in the health sector depends on mindset – professionals should stop waiting for the government to automatically employ them and instead create their own opportunities or explore jobs in the private sector to serve the population across the country. We also received questions from some patients via SMS asking why they were not transferred outside of the country for certain kinds of care. We answered that the national referral system is organized to provide decisions that are based on cost-effectiveness depending on available scientific evidence about when and where to send patients in the case that treatment cannot be offered in Rwanda. In some cases, medicine cannot do much for diseases at advanced stages (or for some diseases at any stage), and this is why we invest much more in preventive services and quality improvement in Rwanda’s health system. I wholeheartedly congratulate each of my colleagues in the Ministry of Health for their responsiveness to participants through SMS, Facebook, and Twitter, and I am proud to serve as their Minister. At this year’s Umushyikirano, there were no major criticisms targeted by the population at any sector, and the health sector has achieved a high satisfaction rate at 75%. Of course, we will not be satisfied until this figure reaches 100%; we know that the remaining 25% represents our weakness in customer care and the way that patients are handled – we commit to strive for improvements in these areas at all levels. At this year’s Umushyikirano, multiple home-grown solutions were presented and still others developed through dialogue between citizens and their elected leaders. Economic development and self-sufficiency were at the heart of the debate throughout the sessions; this gave me a strong sense of pride in my Rwanda. Our nation’s constant emphasis on accountability and access to information as a human right gives me great hope for our future. At the Tenth National Dialogue in December 2012, I look forward to being able to say that we at the Ministry of Health have done our very best to live up to the expectations of the Rwandan population, for they deserve nothing less. Honorable Minister Agnes Binagwaho will be hosting a discussion on vaccines in Rwanda through Twitter and SMS on Monday, 9 January 2012 from 5:00 – 7:00 p.m. You can join her “Mondays with the Minister” chats twice each month by following her on Twitter at@agnesbinagwaho or by sending comments by SMS to0788 38 66 55 during the specified time.