Saturday, November 17, 2012

The Future of Innovation in Rwanda's Health Sector: Equity, Participation, Science, Sustainability

I published the following article in October 2012 in Andrew Mwenda's East African journal The Independent. The full text is not available online, but you can read below.


The Future of Innovation in Rwanda’s Health Sector:
Equity, Participation, Science, Sustainability

Dr. Agnes Binagwaho, Minister of Health of the Republic of Rwanda

The world has begun to pay increased attention to Rwanda’s rapid rate of progress in the health sector, particularly as we approach the 2015 deadline set for the health-related Millennium Development Goals. Our country has likely already achieved goals of reducing the 1990 child mortality figure by two thirds and halting the spread of HIV/AIDS, tuberculosis, and malaria; we are on track to achieve the goal of reducing maternal deaths by three quarters by 2015.

What Rwanda has managed to achieve has been the subject of much dialogue (and much debate); I do wish to repeat what has been covered better elsewhere or to make it seem as if our health sector is resting contentedly for even one second when more than 22,000 of our children will die this year. Instead, I want to focus on the why, and to reflect on what must come next for our country and our region if we are to sustain, exceed, and spread this progress.

I firmly believe that the secret ingredient to Rwanda’s recent successes is something very simple in principle that requires a very serious commitment to implement effectively: the absolute insistence that nobody is left out of benefitting from our collective progress. This understanding forms the core of our national development plan, and all from the central level to the community realize that when we tackle the needs of the most vulnerable first, we are sure to also reach all the rest. Moving equity from the realm of the political into the realm of practice and policy has been a true force multiplier for everything that we do.

Rwanda has learned from our long history of segregation and division – due to sources both external and internal – that the only way forward is through complete inclusion. Therefore, before any single policy is implemented in the health sector (or any other), all stakeholders are invited to participate in a process of true consultation. The often complex task of implementation and dissemination is rendered simple when all are engaged to participate from the beginning.

But even policies that are formulated in the most open and inclusive manner will not succeed if they are not based on the highest quality of scientific evidence. It is often said that “you cannot improve what you cannot measure,” and one of Rwanda’s most important innovations has been the establishment of robust systems of monitoring and evaluation focused primarily on actual health outcomes. By implementing a national maternal death audit program, whereby health workers and communities analyze all dimensions of every situation where a pregnant woman dies in childbirth, we have been able to chart a reduction in the number of deaths from 8 women per day in 2004 to less than 3 per week today. By giving a name and a face to every lost mother has sparked each person’s innately human determination to stop this tragedy all the way from the most rural health post to the highest levels of the central government.

Putting evidence into practice requires more than just good tracking tools, however. It means bringing science to bear on both the root causes and the immediate causes of preventable suffering and death. Rwanda has prioritized increasing access to both essential health services (such as safe deliveries through a community-based SMS notification system for ambulances) and to the fruits of medical progress (such as new vaccines against pneumonia, the virus that causes cervical cancer, and the virus that causes many cases of diarrhea in infants). We are particularly proud to see our Ugandan sisters and brothers also scaling up access to the human papillomavirus vaccine this year, which will prevent thousands of young women from developing cervical cancer in the future.

The final building block of success, in my experience, is the honest pursuit of sustainability. I do not mean sustainability as a buzzword, in the way it is so often tossed around and how it comes to fill up a third of the word count for bureaucratic reports. Instead, I mean a sense of deep accountability and responsibility to ensure that programs are built to last and designed with an eye towards continual improvement.

We have a saying in the Ministry of Health that pilot projects are not a solution in Rwanda – the only pilots here are in the sky, working for RwandAir! When negotiating about a new opportunity for our population, we insist that we go national as soon as possible, or we go nowhere. This is not a reckless strategy that makes the perfect and enemy of the good. We simply know that as policymakers and citizens tasked with improving the health of the entire population (not a catchment area or capital city), we must strive for the most robust and long-lived programs possible.

When we designed our new pediatric cancer center of excellence in Butaro near the Rwanda-Uganda border, for instance, it was not only for that one district Рit was as a referral center for the nation. When we rolled out the national community-based health insurance scheme, mutuelles de sant̩, we began by subsidizing the annual contributions and copayments for the poorest one million citizens; soon enough, the middle-class and others bought in because they saw that the most vulnerable were indeed enjoying the best access through this new program. If we had attempted to move from an experimental mutuelles program in one or two cities to nationwide rather than this phased strategy, we would certainly not be able to count 92% of our population as enrollees today.

Underlying all of these principles, and ensuring that they are collectively translated into results, has been innovation in partnerships. To harness synergies and maximize value, we mobilize each and every willing partner according to the framework and timeline of our national plan. This has fostered national ownership of our programs and our success, but it has also led to novel collaborations that simultaneously encourage service delivery, teaching, and research. Rwanda’s Human Resources for Health Program, launched this year with 13 American universities, is a great example.

The lesson for me, then, from Rwanda’s experiences in the health sector has been that anything is possible when you apply the principles of equity, participation, science, sustainability. To better do so, we require constant out of the box thinking, and a commitment to solidarity and shared improvement. My colleagues and I look forward to fruitful cross-border collaborations, and we know that we can make it together.