Almost all Rwandans have an insurance for primary healthcare. When they can not afford the costs, the government can step in and when they want something more than just the basic care private insurance often is possible as well. That does not mean that healthcare here is at a high level. As soon as it becomes a little complicated, you will need to go abroad and most foreigners prefer to use the few foreign doctors (including a Dutch and a Belgian) who have settled here. That has a reason. In my previous blog I described the tendency of many Rwandans to attach great value to the directives of authorities. I have personally found out that there are some drawbacks to this culture in healthcare.
Scene 1, a job interview for the position of nurse. The nurse will work in a setting where many people with a problematic background live and where the rest of the staff does not have any medical knowledge.
The selection committee asked a fairly simple question of the candidate: “What would you do in a medical emergency?”
“I would call my boss.” was the answer.
Huh? Why? Okay, maybe he has not fully understood the question. Another attempt: “Your patient is dying in your treatment room. What would you do?”
“I would call my boss.”
Now I am curious and ask why. The boss, after all, has no medical knowledge and therefore can not give any advice.
“To ask permission to do something.”
We didn’t hire this candidate.
In defense of the Rwandan nurses I must say that this boy just graduated from a Bachelor of Nursing and the other more experienced candidates did give a much better answer, but it does make you think about the education.
Scene 2, a doctor’s visit on Saturday. Unfortunately, the Western doctors do not work on weekends. So for emergency cases you depend on the various local private clinics. I went to one with 39 to 40 degrees fever, after a telephone conversation with the Dutch GP (luckily they are available for that on weekends) and a pretty good idea what was the problem. Just a small test, and some physical examination to confirm the diagnosis, a prescription for antibiotics and done, easy. But no, Rwandan doctors follow the protocol.
After I had told the doctor what the symptoms were and what I suspected to be the problem, he checked my temperature. “Still high,” he observed.
Yes, I can feel that, I do not need a doctor for that diagnosis.
“You say now that it is probably X, but X alone does not cause such high fever. High fever is here mostly caused by malaria. So we should test you for malaria. ”
Go ahead, doctor, that will do no harm.
He continued: “And since you have the symptoms of X, we do not need to test for that.”
Hold on, that’s what I came for! So I protest that I do want it. He made no objections, if I want it, that’s possible (you pay for every test that they do).
So back to the reception area of the clinic, pay, and go to the lab (in the hallway next to the doctor!) for the test. Their systems are advanced, the test results are available within 40 minutes and they send you a SMS when they are ready. So I went to the adjacent shopping center for a coffee (not that it really tastes nice with a fever, but you have to do something).
Back at the doctor, he noted: “You do not have malaria, you have X, so you need antibiotics.”
Okay, that’s going in the right direction, now only the prescription. He wrote it right away. When I got it, I was seized with alarm. Three different drugs and in quantities that made me feel sick in advance. One simply turns out to be a simple pain killer, the other two are antibiotics. Cautiously I try: “According to my Dutch doctor the medicine Y would work all right.” Surprised, he looks at me.
“That doesn’t work here.” Then a bit of doubt shows on his face. “But of course you are different. You did not grow up here.”
So? Will he draw a conclusion from that? Maybe another prescription? But no, that’s too much to ask. There still is a protocol that says it should be this prescription. Outside I called the Dutch GP again. She laughed when she heared the prescription: it is like shooting with a shotgun. Preferably don’t follow this and use the Dutch prescription.
Later I understand that Rwandans are resistant to many antibiotics because it is freely available (why would you need a prescription?) and it is frequently used badly, so that is why this combination of drugs was prescribed. We would expect some discussion between doctor and patient…