Sunday, July 21, 2013

Setting course for 2012

Posted in Ubuzima Journal 
first quarter 2012
By Dr. Agnes Binagwaho

As we embark on yet another year, it is time to check our bearings and determine the direction we want events in the health sector to take during 2012.

While there is no fault in celebrating our achievements in the past year, maintaining those gains should be the overarching priority for 2012. The gains in the health sector are always fragile and could easily be lost if we are not focused. Ten years ago, infectious diseases were killing us. Now those are contained but because they are still there we should not relax our vigilance. The gains made against HIV can be lost in as short a time as one year if we relax our guard.

We shall continue to see progress in the areas where we have done well and this is translating into reductions in the incidence of malaria, HIV/AIDs and TB. For children we are introducing the rotavirus vaccine this year. Two and half years ago we introduced the vaccine for pneumonia and as a result pneumonia has decreased. 

 Aging population

We have made good progress across all the infectious disease profile and people are living healthier and longer.  According to the National Institute of Statistics, the average Rwandan can now expect to live as long as 55 years.

It is a modest number that is at the same time significant in our setting. This year we need to begin focusing on the long term by anticipating health problems that are likely to arise in the not too distant future and preparing solutions now. As the health of our population gets better, they will start to experience health problems related to longevity. So we shall need to focus on those new problems that are changing our epidemiology. Simply by people beginning to live longer we are starting to see cancer and other non-communicable diseases emerge as public health issues.

This means that we have to be prepared to tackle the new diseases that are beginning to emerge in the population such as hypertension, heart disease, metabolic diseases etc. We are also beginning to see that deaths from motor accidents or other injury are beginning to overtake other causes. This is not necessarily because there has been an increase in the rate of accidents but there has been a reduction in other causes of mortality and morbidity.

The simple message from this trend is that we need to focus on non-communicable diseases since communicable diseases are now under control.

There are many areas where we can act on non-communicable diseases and others where we cannot act immediately. An area where we can act immediately and where we have already started is cancer. And even in cancer, it is not all cancer as the initial focus is on women and children. It is not that we are neglecting men but because affordable solutions targeting these cancers happen to be available on the market at this material time. On the other hand we cannot work on everything at the same time. 

For women we are taking action against cervical and breast cancer by detection and early treatment. A vaccine against cervical cancer is also available providing an affordable and sustainable solution. 

We are also going to act on a series of cancers affecting children. We are finalizing the protocols, the guidelines and policies.

We are taking on those cancers against which we can act immediately and which are also the most frequent. For example Lymphoma affects mainly children and there is something that can be done about it. We are not going to wait for big infrastructure but handle whatever we can within the present means. We shall then create facilities for cancer care knowledge. For those for whom it may be too late to offer successful treatment, we shall opt for palliative care.

The guiding philosophy is that Rwanda will always prioritize the most acute problem. So we can now focus on the next major killers and go on like that until such a time as we reach the level of the developed world.

Quality and value for money

The other area of focus this year will be improved management of the health sector to achieve more value with fewer resources as global fund resources are decreasing. Quality of care will come under increased scrutiny as we seek to maximize value from our resources.

Quality care has two sides – the science and the way to implement that science. After that you have the human dimension, the customer care. Already there is progress. When a population is healthy and when you empower them on their rights, they are more demanding. Before, expectations were low because it was the time when you had just two doctors per district hospital. But now we expect quality because the numbers have started to be significant and on the other hand we have pushed the people to demand quality care. 

At one time, many people who were visiting our health facilities would find a good doctor with skills who was critically short on customer care. Today people are legitimately complaining because they expect both quality care and customer care. I may be a good and highly skilled doctor but if am rude that undermines the quality of my overall output. 

On the other extreme you could have someone who may not be even be qualified but has great customer care and people actually prefer to consult him or her just because of that. This happens a lot in our country and potentially creates dangerous gaps in our health system if people choose to seek care from non-professionals. So doctors in the formal sector need to provide the full package of knowledge, science and customer care.


Malnutrition is another priority for this year. The government has committed itself to eradicating the causes of malnutrition before the next Umushyikirano. Looked at objectively, malnutrition is not insurmountable. We have malnutrition not because we cannot produce food but rather because we are using it wrongly. You find families that say they don’t have food but they can grow the food. Others say they don’t have land but the local government can provide collective land for people to grow food. Malnutrition should not occur in this country, eradicating it is just a matter of organization.

Two percent of children under five years suffer severe malnutrition but that malnutrition can not be linked to disease since hunger per se is almost non-existent. There are also cases where malnutrition is a result of mothers not knowing how to feed their children. In the same age bracket we also find 11% that are underweight and 44% that suffer chronic malnutrition.

We have learnt that the primary cause of malnutrition is related to what children and pregnant mothers eat. Most of those children are born malnourished because the mother did not take enough micro-nutrients, vitamins etc when pregnant. The solution lies in increasing the knowledge to fight the habit of not eating some sources of protein. It requires a revolution in the way we are feeding children.

Human Resource for Health 

Another frontier during this year will be developing the Human Resource for Health. Because we have made good progress with what we have now and have achieved reasonable levels of basic care, people are going to get diseases that are related to age. Yet we don’t have the specialists to care for them.

At the district level at a minimum we need one surgeon, a pediatrician, one anesthetist, one internal medicine specialist and an oncologist to deal with cancer and related complications. We also need to develop the capacity to treat or manage metabolic diseases.

It will take us decades to achieve desired staffing levels if we were to continue producing health professionals at the current rate. To mitigate this, we have partnered with 18 American universities that will bring here hundreds of experts to mentor Rwandans to be teachers, teach residents to be good specialists and teach graduates to be good medical directors. Over the next seven years, we shall have attained the capacity to produce our on workforce and we will produce the minimum we need that are capable of giving the care we need.


We are planning to have radio-therapy facilities and oncologic wards at CHK, Kanombe and Butaro hospitals where we shall provide specialist care for cancer patients. We will have a facility for radiotherapy and places where we shall hospitalize people that need special care. 

We are also going to produce an accompanying complement of Medical Directors with specialist skills in oncology within two years. We plan to create full specialists who will train and supervise others so that we have someone with these skills in every district hospital. The missing gap in the training of our human resource has been mentorship and bedside training.

Mutuelle de Sante

Making progress against infectious diseases does not necessarily free us from spending money because the cost of prevention is also high and that is why the health budget has been increasing year after year in the national budget. On the other hand even as we have increased the national budget for health, the international contribution to that budget is uncertain so the future lies in what we shall be able to do under the national budget and health insurance. 

Fortunately even the out of pocket expenditure is increasing because of the improving economic welfare of Rwandans. We have one million Rwandans who have transitioned from poverty to a better income status. As a result, they have more money out of pocket and are capable of paying for their health insurance. Additional resources for health may come by way of savings made by individuals against future sickness through health insurance and Mutuelle de Sante.

However Mutuelle de Sante is a national institution that is still growing and maturing. If we are not strict in its management we are going to pull it down yet it is a good system.

We have so many sectors and to ensure that all are managing the system properly is a fight that requires day and night vigilance. Because you have money there for healthcare that may seemingly be lying idle, some leaders at the local level may want to use this money for other things. We need to sensitize and convince them that is not right to diverting that money to other priorities and that this constitutes a financial crime. We need to get that message down to the sectors.

Finally, we need to create regional; reflections on how to treat diseases. We have started by seeking to create high efficiency programs for controlling malaria with our neighbours. Half of our problem with malaria is around the border areas and 45% of that burden is in just three sectors of this country meaning we need to work with our neighbours. Rwanda cannot be an island of welfare in a region of desperation. We are proposing common procurement and harmonization of policies and fighting together against counterfeit medicines. We shall tackle these problems jointly by agreeing on the best policies based on the best science of the moment.