Saturday, December 10, 2011

Leadership and the fight against HIV/AIDS

Panel on leadership in Africa in the fight against HIV/AIDS, ICASA 2011. (Photo credit: UNAIDS/J. Ose)
Last Monday, December 5 - 2011, I had the great honor the speak on behalf of His Excellency, Paul Kagame, President of the Republic of Rwanda, at the International Conference on AIDS and STIs in Africa (ICASA 2011). I spoke on a panel with esteemed representatives of institutions and national health sectors, alongside Festus Gontebanye Mogae, Eric Goosby, Abune Paulos, Michel Sidibe, Oueld Zbel Yastahel Kadad, Madeleine Ba Diallo, and Bience Gawanas.

We were asked to speak about how African leaders can advance the agenda of addressing the burden of HIV/AIDS around the world. As we all now face financial challenges, such a question is vital as leadership will be the key to ensuring Africa does not backtrack on the progress made over the past decade.

When it was my turn to speak I stated that it is our duty to stand up for our people, as Africans are the most affected, especially in the Sub-Sahara region which accounts for more than 70% of all those living with HIV worldwide.

There is no doubt that a lot has been accomplished. The majority of African Governments have made the fight against HIV a top priority for the past 10 years since the Abuja declaration, leading to UNGASS 2001. Much more need to be doe as too many African are still dying due to AIDS.

Today the global economic crisis is a threat to the fight against HIV in Africa as it has impacted the global flow of foreign aid. The challenge we face today is the proof that overall national development (economic growth, self-sufficiency, etc.) is the key for sustainable success in the fight against HIV. I illustrated this point during the panel – taking my country, Rwanda as an example – and elaborated on our fight against HIV as a cross-cutting pillar of Rwanda’s Vision 2020, and our Economic Development and Poverty Reduction Strategy. From the outset, we made the multi-sectorial national HIV response a cross-cutting issue, which strengthened our health system as a whole and supported our national development. Our HIV response included prevention, treatment and the mitigation of the social burden mitigation of disease, as expressed in the National HIV&AIDS Strategic Plan.

Today the global fight against HIV does face constraints, but we also have many solutions that have not been explored widely in other countries. As such, even if many believe that nothing can be done without the money to make it happen, we do not believe this is totally true. There are many ways we can continue to advance.

For example we can use effective decentralization to break geographic barriers and scale-up HIV interventions at the district level. In addition, the Community Health Workers can sensitize Rwandans at the village level about issues of HIV/AIDS at almost no cost. This also goes for politicians, as well as community and administrative leaders who can take upon themselves the task of major sensitization campaigns on the radio, or newspaper, or internet. HIV sensitization could be included in every interaction with the population or in major speeches. It is not costly and it is effective and it creates a sense of national responsibility and solidarity.

We can improve the performance and quality of services as well as the retention of personnel in remote areas using a Performance Based Financing (PBF) framework.  This framework helps district health teams to ensure the availability of qualified health personnel, and to ensure that utilization in rural areas is commensurate with health needs by providing financial incentives to health workers. We can integrate HIV in all curricula in our formal education, aiming to break geographic barriers to access information about HIV/AIDS.

We can also shift the proportion of our national budget that is given to health financing, which would benefit the fight against HIV. Financial barriers can also been reduce by creating a health insurance program. This will enable people’s access to health services, and will prevent PLWHA from dying of common diseases. In Rwanda we developed the community-based health insurance (CBHI) scheme called Mutuelles de Santé. It is one of our key governmental programs, which addresses issues of equity, accessibility and utilization of services, including HIV.

If we use all of these strategies and continue to innovate to find new ones, we will make the money work, save lives, and increase equity in access to prevention, care, and treatment. In Rwanda we have implemented these strategies in order to leave no group out of the benefits of our health services and national development.

Our inclusion principle is largely based on age and gender equity. Children are a priority in service delivery; while we have improvements to make, we know that healthy and educated children are the path to a healthy, peaceful future for Rwanda. Women are equally prioritized, and we have more women on ARVs than men (more women are infected than men) and as a result we have now 80% of women accessing PMTCT, 94% of eligible HIV infected people on ARVs: children, women and men.

These gains are important as they allow us to provide better general services. In many hospitals, beds previously occupied by PLWHA are now free for people coming in with other diseases. This was certainly not the case 10 years ago, when many people were dying outside the hospital due to curable diseases because people with HIV/AIDS occupied many beds.

We are facing a global budget cut in different programs to fight HIV/AIDS and we know that if we don’t increase the proportion of PLWHA on treatment (who need treatment) the disease that is now largely under control will spread again and the world will lose its current gain. Some countries are facing that reality already.

We need to react by making our development partners fulfill their promises, but we need also to have smarter public health approaches as aforementioned. The integration of services is also key. HIV is a chronic disease and must be integrated into our service delivery for other chronic diseases and stop vertical programs. In Rwanda, integration is a policy we adhere to. We have started to tackle non-communicable diseases building on the success of our HIV program.

In this time of crisis, it is also imperative to be more innovative. We have created an Internet clinical based reporting system called TRAC-Net for all people on ARVs. It gives us monthly reports of the clinical, biological and immunological status of our patients and the status of drugs storage across the country. Building on our experience fighting HIV, we are now creating an Electronic Medical Record system for all Rwandan citizens, to be used in all health facilities, thus moving away from paper based medical recording.

In Rwanda, we have put in place an HIV evidence-based operational monitoring and evaluation system, and a Web-based resource-tracking mechanism for all finances in the health sector. It allows us to better plan and to align all actions of all stakeholders to our overall national development plan. But we still have a long way to go.

In 2011, Africa must have zero-tolerance for partners who do not respect the critical importance of country ownership. It is a matter of sustainability. We need better plans and to truly work hand in hand with our national partners and our development partners. But for sustainable success we need to reinforce the structure wth which we we coordinate everyone around our national plan. All of this will bring an economy of scale and will allow us to reach the imperative dictated by the diminution of aid: doing more with either the same or less investment.

We also need to center our fight against HIV in our development plan. We need to build pharmaceutical manufacturing companies on our continent, and continue to fight counterfeits to assure the quality of drugs. Building these companies here is necessary because although the cost of ARVs has declined dramatically, only 47% of all those eligible to receive ARVs in low- and middle-income countries are actually receiving it.

So, if we need to make our partners in the North, and in the West fulfill their promises in funding support, we may call upon them to reduce their overhead and inject that money into the fight against HIV. Let us all, together, commit to investing in a sustainable fight against HIV. We should commit ourselves to focus our fight against HIV on improved decentralization, better integration, more participation of our people and a stronger link between HIV/AIDS services and national development agendas.