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.

Thursday, November 15, 2012

Congratulations, Dr. Mark Dybul

I am delighted to share that US Ambassador Mark Dybul, former leader of the US President’s Emergency Plan for AIDS Relief (PEPFAR), has been announced as the next Executive Director of the Global Fund to Fight AIDS, Tuberculosis, and Malaria. Mark is an inspiring choice by the Global Fund’s Board of Directors. I have believed in his candidacy for this position since the outset, and have great faith in what he can bring to one of global health’s most vital institutions.

Mark has long understood that global health must fundamentally be about equity and the fulfillment of the human right to health – not simply about addressing infectious diseases in far-off places. During his work to launch and expand PEPFAR, he demonstrated time and again that he believes in a person-centered approach to health care delivery and that he knows how to build strong systems that do not leave any among the most vulnerable out of benefits. Mark’s leadership in the global HIV/AIDS response helped to set a new paradigm for global health partnership, transitioning the world towards a long-term approach to tackling the most deadly pandemic in centuries while strengthening systems that have increased access to primary and specialty care for a wide range of diseases.

I am hopeful that Mark’s appointment to lead the Global Fund will help to usher in a new era of results-oriented programming that builds on the legacy of his predecessors, Michel Kazatchkine and Gabriel Jaramillo, while ensuring that the Fund stays true to its roots as an instrument truly of the people. I look forward to fruitful future collaborations with Mark and the Global Fund, and believe that the time for an integrated, solidarity-driven, and country-owned response to global health challenges is within our grasp. There is much work ahead, but the future is bright. Congratulations, Mark!

Sunday, November 11, 2012

The Importance of Using Accurate Data: Case Study of Hunger in East Africa

On Saturday, 3 November, I published an op-ed in The East African responding to a recent article describing the findings of the "Global Hunger Index 2012," a European report analyzing the state of food insecurity around the world. The report's authors used extremely outdated data for Rwanda in their calculations, skewing their conclusions. My response attempts to call attention to the importance of using the latest and most accurate data in such global assessments.

Hunger Index Used Outdated Data for Rwanda
By Dr. Agnes Binagwaho

As with many international reports derived from complex and non-transparent methodologies to assess relatively straightforward challenges, the Global Hunger Index of 2012 represents an outdated and poorly designed approach to quantifying progress towards Millennium Development Goal 2. -As recently reported in The East African, the Index report ranks Rwanda behind only Burundi for food insecurity in the East African Community.

Based primarily on inputs of child mortality rates and chronic malnutrition or stunting among children under age five, the Hunger Index calculation could not possibly be using updated data for Rwanda, as the child mortality rate has declined by fully 50 per cent between 2005 and 2010 according to both our own internationally-validated Demographic and Health Surveys (DHS) and the World Health Organisation’s modelled estimates. The latest WHO figure shows that Rwanda’s child mortality rate is 54 deaths per 1,000 live births. Yet the Global Hunger Index report cites Rwanda’s child mortality as 91 deaths per 1,000 live births – using an old Unicef report from 2009 that is based on the 2008 DHS.

If child mortality has been falling so much but Rwanda’s Hunger Index has not, then malnutrition must be paradoxically skyrocketing despite increased access to all other child health interventions? But one look at DHS or WHO data shows otherwise: Chronic malnutrition among children under five years old decreased from 51 per cent to 44 per cent between 2005 and 2010. The proportion of children underweight plummeted from 18 per cent to 11 per cent over the same timeframe. But the Global Hunger Index report the 18 per cent figure from seven years ago.

How does Rwanda’s progress across broad socioeconomic indicators stack up to the assertion that its people are among the hungriest in East Africa? Fully one million Rwandans pulled themselves above the poverty line between 2005 and 2010 according to the latest Household Living Conditions Survey, and access to electricity, potable water, adequate sanitation have all improved dramatically since 2000. While Rwanda’s population has increased by nearly three million over the past decade, its Food Production Index compiled by the World Bank has increased by two-thirds over the same timeframe and climbed to the highest in East Africa. Finally, cereal yield in kilogrammes per hectare nearly doubled between 2007 and 2010, and is likewise the highest in East Africa.

While Rwanda is on track to meeting or exceeding all eight UN Millennium Goals in advance of the 2015 target, we are not resting on our laurels. We are acutely aware that still we have far to go in eradicating malnutrition and improving health outcomes, especially among children. In order to achieve our goals, however, we are obliged to develop and implement policies based on accurate data along with astute analysis.

In a country and region changing so rapidly, it is the responsibility of institutions such as the International Food Policy Research Institute, Welthungerhilfe, or Concern Worldwide to concern themselves with facts, not conjectures or models when robust and current evidence is easily accessible. If such “watchdog” agencies and the reports they produce are to serve a useful purpose (and I do believe they can when designed well and disseminated transparently), they must hold themselves to the same standards of accountability they seek from countries like Rwanda. No one more than the Ministry of Health knows that Rwanda has a long way to go until chronic malnutrition is not a massive health challenge, but it is our responsibility to base our approach on solid evidence and sharp analysis.

Recommendations based on the latest data can help public sector institutions to improve policies, strategies, and implementation of programmes to tackle challenges like malnutrition, but when they are conducted sloppily, one wonders whether the money spent on consultancies for such a document might be better invested in helping to grow food for improved nutrition of children around the region than using large amounts of overheads to create metrics that are out of date before they are even published.

Agnes Binagwaho is Rwanda’s Minister of Health.

Country Ownership to Strengthen Synergies Between Global Health Initiatives and Health Systems

On Thursday, 8 November, colleagues in the Ministry of Health and I published a brief Comment in Journal of the Royal Society of Medicine: Short Reports responding to a review of interactions between global health initiatives (like the Global Fund and PEPFAR) and country health systems. We shared Rwanda's perspective on the importance of true country ownership in promoting integration and maximizing synergies.

Country Ownership to Strengthen Synergies Between Global Health Initiatives and Health Systems
Agnes Binagwaho, Sabin Nsanzimana, Corine Karema, Michel Gasana, Claire M. Wagner, and Cameron T. Nutt

As policymakers and researchers in Rwanda's health sector, we applaud Josip Car and colleagues' review of interactions between Global Fund investment and country health systems.1 Their trenchant analysis may not close the door on confidently advanced claims about the dangers of global health initiatives that are not based upon rigorous evidence, but it has helped to raise the bar for the debate.Several recent studies focused on Rwanda (that either did not fall within Car et al.'s timeframe or did not specifically investigate Global Fund programs and were thus not included in the review) together provide robust support for the argument that interventions explicitly designed to combat HIV/AIDS, tuberculosis, and malaria can be implemented in such a way as to strengthen the overall health system.2-4

In fact, Rwanda's reductions of greater than 75% in mortality due to AIDS and tuberculosis between 2000 and 2010 were accompanied by a 70% decline in child mortality and a 60% decline in maternal mortality over the same timeframe.5 This was not a fortunate accident, but due to collaborative planning with civil society and development partners, and true country ownership of program implementation and evaluation.

From the beginning of Rwanda's AIDS response, the public sector has been committed to constructing platforms of care able to address multiple chronic and acute conditions. When a clinic is built and staffed to offer HIV services to women, the same woman trying to prevent vertical HIV transmission to her unborn child will also require a safe place to deliver as well as a trained birth attendant. So will her neighbors, whether HIV- positive or not.

As is often said in the Ministry of Health, "if you give Rwanda money to help the youngest child born today, we will ensure that it also helps the oldest person by tomorrow." When implemented according to principles of authentic partnership and when investing in public infrastructure and human resources, disease-specific global health initiatives can not only achieve positive spillover effects, but can also catalyze the development of comprehensive and equitable primary care systems in the poorest countries.
The time has come for scholars and policymakers to move past unfounded worries about whether to invest in the pandemics of AIDS, tuberculosis, and malaria; what we must now devote our full attention to is the question of how best to harness synergies and maximize impact in the pursuit of health as a human right.

1 Car J, Paljarvi T, Car M, Kazeem A, Majeed A, Atun R. Negative health system effects of Global Fund's investments in AIDS, tuberculosis and malaria from 2002 to 2009: systematic review. J R Soc Med Sh Rep 2012;3:70. 
2 Price J, Leslie JA, Welsh M, Binagwaho A. Integrating HIV clinical services into primary health care in Rwanda: a measure of quantitative effects. AIDS Care 2009;21:608-614. 
3 Kalk A, Groos N, Karasi JC, Girrbach E. Health systems strengthening through insurance subsidies: the GFATM experience in Rwanda. Trop Med Int Health 2010;15:94-97. 
4 Shephard D, Zeng W, Amico P, Rwiyereka AK, Avila-Figueroa. A controlled study of funding for Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome as resource capacity building in the health system in Rwanda. Am J Trop Med Hyg 2012;86:902-907. 
5 WHO: World Health Statistics 2012. World Health Organization, Geneva 2012.