Thursday, October 20, 2011

Rwanda, The Entrepreneurial Nation

I published the following Commentary piece in the New Times on Tuesday 18 October 2011. The original publication can be accessed HERE


Rwanda, The Entrepreneurial Nation

We define entrepreneurship as thinking out of the box, transforming one’s innovation into goods and products, and creating demand by marketing them. Rwanda is a country that lives by many characteristics of an entrepreneur; we are an entrepreneurial nation.

First, entrepreneurs must have the willingness to take risks. Rwanda has taken many risks in the post 1994 genocide period. For example, it was a risk to abolish the death penalty at a time when there was a massive call for justice. This decision was made after much reflection and a review of the global evidence that the legal taking of life has never changed any crime level or improved Human Rights. As our President Paul Kagame said, mass execution could not have been the right answer to the mass murders of the 1994 genocide in Rwanda. As a result of this courageous abolition of the ultimate punishment, Rwandans have a sense of satisfaction, welfare, and the value of life.

Another major risk taken by Rwanda was to strive for unity and reconciliation by believing that the example of good leadership can change the minds of even the worst. This risk has helped Rwanda to turn thousands of former genocidaires into peaceful, progressive, and active builders of the new Rwanda. The abolition of the death penalty and the promotion of national unity and reconciliation have contributed greatly to the healing process and the reduction of crime in our country, and this has encouraged Rwandans to invest their energy in development.

Rwanda thinks out of the box and is a home to innovation. When the traditional European justice system failed to meet our desire for justice in our timeframe during the life of Rwandans (as it would have taken more than 100 years to sort out all of the cases), we modernized the gaccaca courts. In a participatory manner, we discussed this innovation and found a way to implement it. Communities received justice, and We transformed this innovative legal idea into human good, and there was massive demand for it in Rwandan communities who then received justice.

A second quality of a true entrepreneur is knowing oneself – knowing who you are and where you stand without complacency. We know and we are proud of who we are in Rwanda. We have the ambition to be better everyday and have a clear vision of it: our Vision2020. We define ourselves by strong national principles, such as not leaving out of benefits the most vulnerable among us. This applies to our economic progress, access to education, access to health services, and many other public goods. Rwanda’s economic development strategy consists of many pillars that promote a strong private sector for our country, producing taxes that support education and health for all Rwandans by building schools, hospitals, buying drugs, and paying health professionals.

In the education sector, all the nation benefits from our nine year basic education program which keeps girls at school through the age of fifteen. Soon, our twelve year basic education program will keep all students in school through the age of eighteen. It will be coupled with the TVET program that aims to give employment to all.

We all know that educating women increases the health and wealth of families. Thus, Rwanda prioritizes education for all and access to health services for all. Again, these goals are set through a participatory process; if we don’t want to leave people out of the benefits of our progress, we must not leave them out of the decision-making process.

The third quality of an entrepreneur is passion for a purpose and a burning desire to achieve their goals. Rwanda has the passion – just listen to the speeches of our leaders. You will see that under the lines of their words lies all of the vibrant passion of this nation. We have the burning desire to be a middle-income country, and make no mistake that we will get there as each of us puts all our energy to the effort.

The fourth characteristic of an entrepreneur is the tenacity to succeed in the face of obstacles, and Rwanda has it. Tenacity is what our leadership has shown since 1994, when our vision of security and our plans for development were attacked. Rwanda chooses our own way for development, as so many solutions offered by the international community were not sustainable, were too slow, or lacked possibility to bring progress to Africa. So many commentators at that time and through today made their own prescriptions for peace, education and health as if they believe that it is normal for Africa to remain dirty, sick, and begging.

This is linked to another entrepreneur quality demonstrated by Rwanda, that of being a solution-maker herself. Our nation is one of home-grown solutions. This is what we discussed with youth convened in Rwanda on many occasions by His Excellency and First Lady Jeannette Kagame through the Imbuto Foundation for enlightening forums. The most recent of these forums was in August 2011, when youth from across the East African region discussed their goal to be ambassadors of change.

I could describe additional entrepreneurial traits that Rwanda has as a country, but I prefer to take examples from the health sector, the area that I know best. All of these qualities of entrepreneurship are evidenced through visible innovations, taking the risk to implement these innovations, maintaining the tenacity to sustain them, and creating the demand for our sector’s public goods in Rwanda and around the world. We reviewed the concept of universal access to care and devised a uniquely Rwandan way to provide it through community health insurance. We thought out of the box and created the “Mutuelle de Santé” system for access to care, inventing a national means of implementing a system of performance-based financing for heath workers to expand access while emphasizing quality. We have transformed health care into a public good in Rwanda, and other countries from around the world now demand our model. These are good politics that translate into good politics.

Furthermore, we have installed three elected community health workers in each of Rwanda’s 15,000 umudugudu villages, creating a cadre of 45,000 across the country. This is also an innovation. Each community health worker volunteers for the position and is then elected by her community. The Ministry of Health pays all based on the quality and quantity of their services rendered. Of the money we give them, 70% goes into a cooperative that will help them to create economic growth at community level. By transforming Rwanda’s capacity to harness the power of health to stimulate economic growth at the community level, our people can gain wealth and buy more health, creating a virtuous social cycle by producing economic opportunity through health problem-solving. The success evidenced by the health sector exists across all sectors of the Rwandan government, explaining our economic growth and improvement in the wellbeing of our population.

Rwanda is spreading widely a spirit of entrepreneurship at all levels, from the very top of the central government to the community. I remember reading a beautiful article in Fortune magazine describing His Excellency the President Paul Kagame as a CEO running his country like a private enterprise. I agree, we are an entrepreneurial and proud nation with a vision.

Saturday, October 15, 2011

My Message to Activists at Dartmouth Rallying for Global Health Funding

On Tuesday, October 11th, I spoke to one hundred students and people living with HIV who were rallying for increased global health funding. They were at Dartmouth College in New Hampshire, and I talked to them from Kigali via Skype. A transcript of my message is below.


Hello to all - I am so pleased to be able to speak to you from Kigali in Rwanda. Today you all gather in solidarity with people around the world in need of ARVs.

This issue concerns many people in Africa and elsewhere, and concerns vulnerable persons lacking education, employment meaning means to pay for themselves. Let me talk about the most vulnerable in these situations, who live in a context that can lead to HIV because some people don’t feel or don’t think they can ever become employed or find types of survival modes other than to prostitute themselves and to put themselves at risk of HIV; or because they are vulnerable or uneducated (and we know well the link that exists between education and HIV risk).

Now, in the past ten years, we had a great movement of global solidarity around treatment access. This  was extremely timely, because I remember the time when I was working in public hospitals and Rwandans were dying without any solution, for HIV treatment - antiretroviral therapy (ARVs) - were not available in Africa. The only solution for people living with HIV/AIDS (PLWHA) when they need ARVs is ARVs. 

At that time, the cost of generic ARVs came down from incredibly high prices around 1,000USD per month to today's price of less than 100USD a year. We also know how to follow PLWHA in a very good way in the respect of science, in the respect of the patient, and in the respect of clinical knowledge. We know how to conduct patient follow up in a very cheap way that also maintains quality. So this means that money should not be an obstacle to grant access to care to PLWHA around the world. 

In Rwanda, we are fortunate to have achieved universal access to care and treatment for PLWHA, for both adult and children. But make no mistake - we fought hard for that. And that's why I understand your fight; that’s why I am fully in solidarity with PLWHA who want access to care and treatment. I want this for the world and also for Rwanda, because if we have 100,000 people on treatment today we also know that we have almost 100,000 people out there who are already HIV-positive but not yet in the clinical stage to be put on ARVs. But soon these Rwandans will also need ARVs, and when that time will come I want them to have access to the necessary life-saving care and treatment. 

So your fight – your movement – is really encouraging for the world because I feel in my day-to-day work what the reality is. We cannot afford to lose the life of PLWHA whom we could save. We have to keep young people alive – those that have just finished education and who are ready and willing to be useful to their nation. We need to keep parents with young children alive – we know that when children are orphaned they have less access to all services including education, and that they are more vulnerable to risk of HIV infection. Orphans are also at higher risk to be trapped in a non-development process. 

So we need parents to be alive. We need PLWHA to stay alive. We need to ensure access to care and treatment for all of them. And we need to ensure best practices in follow up that are affordable. It’s just a matter to do things differently. It’s just a matter to manage the health sector differently. It’s just a matter to manage the global solidarity movement differently. 

So I know that we don't have time for questions today, but my message to you is about solidarity. I am calling in from a country where we have a well-managed health sector, where we have people alive and living with HIV as a chronic disease in a country where we now start to tackle cancer and other non communicable diseases that are outcomes or not of being HIV-positive – and we are with you. 

Monday, October 3, 2011

Male Circumcision, HIV, and the Media: My Perspective on Device Approval

On Monday, 26 September 2011, the New York Times' "Fixes Blog" published an article on male circumcision in Africa and regulatory barriers to its implementation in Africa. Below is my response to the article: 


Dear Editor,

Surprisingly, your article “Obstacles Slow an Easy Way to Prevent H.I.V. in Men” (Sept 26) about Africa offers no perspective from Africans.

You state that "devices are game changers”, yet the process for their approval by external authorities is impossibly slow and is handicapping Africa from saving lives. This is by far the biggest obstacle. African governments cannot responsibly buy-in to a surgical procedure that could collapse the national health system given the shortage of surgeons in our region.

We have tested the PrePex device in over 1,000 cases in national public clinical studies ( ID NCT01434628), with over 50% of procedures conducted by low-cadre nurses.  The procedure is safe, fast, bloodless, virtually painless, and requires no injected anesthesia. The demand is enormous and men leave smiling, without losing work days.

With innovation, we can achieve the goal of 20 million men circumcised in Africa by 2015. Rapid male circumcision is a reality today, if approval is granted.


Agnes Binagwaho, MD, PhD
Minister of Health of the Republic of Rwanda