We are super-happy that Dr.Jim Sherry, global health leader, has joined CUNY SPH recently..Welcome!! I have been visiting Boston Global health series, Columbia and NYU! : now it was pleasure to travel from washington DC to New York to attend global health event in our own yard! Thanks Dean!!!

At one time, Rwanda had one of the weakest public health system in the world! Now it is example of good governance, economic growth, rationalized use of resources, equitable participation  of women in power and the effective use of outside financial assistance , which ultimately resulted in public health dividends  for once war torn country. In this article, I highlighted the achievement of Rwanda in light of public health, I also tried to find out the causes for its progress. And lastly, I mentioned the areas which need further improvement.. Rwanda emerged from the situation where security of life was first and foremost point on the agenda. Public health infrastructure was completely broken.

Even though Rwandas original inhabitants were Khosian speakers, their descendants now constitutes merely one percent of the total population of country. Hutu, Tutsi and Twa are the major ethnic groups. Hutu were traditionally concentrated in agriculture sector while Tutsi were cattle herder. Tutsi were powerful in military point of view. Rwanda had been witnessing ethnic conflict for almost 19th century, perhaps since the freedom from Belgium, but in 1994, it reached at zenith, which forced historian to term it as genocide. Rwanda genocide in which ten thousand people of Tutsi tribes were killed every day, and this massacre ran for 44 days., touching the number of deaths to one million. European medical staff were also executed who were treating victims. The most scary part of the killing was the people who participated in the massacre were between ages of 18 and 24 years, and from majority group of Hutu which left everlasting mark on all demographic, socioeconomic and health fabric Rwanda. Thousands became orphans and widows; and two million people became homeless. Even first woman Prime Minister  Madam Agathe and her husband  were not spared and were executed along with her Belgium security guards. One thing is sure, this carnage was the result of exclusion policies.

After genocide, Rwanda took eventful journey with optimism. Despite devastated completely by genocide, Rwanda did great comeback showing its resillience skills.  Its performance in public health is second best in Africa and only second to South Africa. It would be unfair to credit Rwandas success to just outside financial assistance. Nonetheless, it is worth to mention that of 49 Sub-Saharan countries, Rawanda is 22nd in getting financial assistance. Per capita income in getting financial assistance is little higher than other countries like Ethiopia and Uganda.  Almost 47% of budget of Ruwandian government comes from outside assistance.

Rwanda signed the declaration of achieving the Millennium Development Goals (MDGs) by 2015. It has scored high on at least two of  the eight goals. First, it achieved universal primary education, and second, it promoted equitable share of women in parliament. Child mortality rate has dramatically come down.  Even maternal heath has improved a lot. Infant mortality rate has come down from 92 in 1990 to 36 in 2012. Life expectancy at birth has also improved.  Rwanda is the country where number of women parliamentary members is higher than any other nation. This progress is credited to education, community health workers and governments insurance policies (muetelles de santé). 10percent of GDP is attributed to health sector.

It may be apparently debatable that Rwanda’s good result in light of public health is attributed to its business friendly environment policies and overall economic development.World Bank has ranked Rwanda at 28th in view of business friendly. According to Rwanda development Board (RDB), Rwanda is the most  competitive place for investment in the East Africa.Many of business initiatives were taken by present government since 2000. Construction permits, which used to takes years, are issued fast, perhaps in few days.  Foreign investment is encouraged. New business licenses are served in a day. Significant reduction in poverty by 11% was reported.   New Special Economiz Zones (SEZs) have been develed by the government. In addition. Labor in Rwanda is cheaper and efficient. According to Dr.Jim Sherry (CUNY SPH grand round lecture on 5/4/2015), success in public health goes hand in hand with economic prosperity and which seem largely applicable in case of Rwanda. Rwandas business and information technology initiatives are helping   to create job opportunities.

Malaria, HIV and tuberculosis yet account for estimated twenty percent of deaths. Rwanda has done well in view of fighting HIV/AIDS,  With funding from US presidents Emergecny Plan for the AIDS Relief , and Multisectoral AIDS program (mAP). Cancer as the cause of death is still far less than developing world, which stands at 3 percent. Since the life expectancy of Rwanda is less than 60 years, and large chuck of cause is attributed to infection and chronic diseases, low rate of cancer as cause of death is understandable.

One person who really deserves accolades for bringing Rwanda from death bed to the new hope of better life, for converting Rwanda from devastation to the new hope of edifice,  and for successfully meeting the herculean  challenge of changing Rwanda  from insecurity to the business friendly situation, is none other than sixth president of the nation, Dr.Paul Kagame . He has been head of Rwandan Government for last fifteen years. He once famously said that Rwanda is in hurry. What is the contribution of political part? Present government adopted inclusive growth, and tried not to widen the economic disparity across tribes. It also cancelled the identity of people on the basis of tribes. During our brief conversation, Dr.Jim Sherry, who did extensive public health work in Rwanda, also highlighted the enthusiasm and passion of President Kagame. The functioning of Rwanda government rely on 2020 vision-namely, human development, poverty reduction, economic growth, good governance. Population density of Rwanda is highest in the African continent.

Ethics and epidemiology were another pillars for the successful public health story in Rwanda. Performance was the criteria to provide benefits, allowances and rewards to health care workers. Data driven approach was taken into consideration before formulating policies. Evidence based public health practice as well as evidence based medical approach was emphasized while dealing with population and patients.

Good road network and market infrastructure helped to reduce food insecurity in some ways. Yet, according to 2012 report, 14% of Rwandan Households have to face hurdles to provide food to their families. Unequal distribution of food security is noted, especially in rural areas, Households with inadequate food consumption was especially high (42%). In addition, East and West of Congo Nile Crest also shows the seme results  because of soil erosions. Here, GIS can help in creating hotspots and assist in decision making process for policy makers.

No health is possible without mental health. Rwanda has been struggling to provide quality mental health care. Rwandan medical schools lack psychiatry clinical training. Its being almost 20 years passed, much of victims still suffers the effect of genocide. During hundred days genocide, HIV positive men were released from prison , and were asked to rape Tutsi women.  33% of genocide survivors experienced rape. Number of Psychiatrists per 1,00,000 population is 0.05 exact number in all country is 5. Nurses are the bulwark for the mental health care in Rwanda. . Rieder et al (2013) conducted mental health status study in conflict survivors. There are genocide survivors who were even raped and infected with HIV need extensive mental health therapy. Bolton et al 2002 reported that Bugesera had 15% prevalance of depression.   79% population was exposed to traumatic events. There is need of integration of mental health services. Mental health still carry stigma, it need cultural shift. It can be done through the channel of education and communication, where media can paly big role. Psychopharmacologic approach to deal with mental health patients, specially when drugs and quality mental health professionals are available, will work. In many condition, depression act as comorbidity. Though Rwanda is host to 0.13 percent population of world, it carries 5 percent burden of mental health illness. This magnitude speaks the quantum of the problem,

Though Rwanda has done dramatically well specially post-genocide, it has to go a long way to meet challenges such as unequal distribution of infrastructure between rural and urban areas, increasing population density, shortage of high-skilled physicians, shortage of tertiary centers, alarmingly high rates of chronic malnutrition for children under five, and high  burden of neuro-psychiatric disorder. Population control measures need to be in place. Rwanda had one the highest birth rates. If this issues is looked through the triad of environment, population and health,  it becomes obvious that increasing population will add burden on already limited resources. Despite, the journey of Rwanda is successful and can be labeled as template for other nations.