Agnes Binagwaho

Global Health Delivery Course

2012-02-25T08:19:00.001-08:00

I will be posting more information in the coming days including videos of lectures, summaries, pictures, and other materials. For the moment, please refer to my article in The New Times about the Harvard Global Health Delivery course that was held in Rwinkwavu from 19-23 February 2012.

You can read my article here:

Conceptualizing Global Health Delivery

And another article by Rwanda Focus journalist Marie-Brigitte Kabalira here:

New Course Looks Beyond Patient As a 'Health Issue'

More materials coming soon...

Conceptualizing Global Health Delivery in Rwanda

2012-02-21T09:18:00.000-08:00

I published the following piece in the New Times on Thursday, 23 February.

The traditional definition of public health has often been relatively narrow and focused on siloed programs, or the management of health for quick “cost-effective” impact. This definition cannot suit Rwanda’s approach to public health, as we know that the ultimate end of our programs must be to break the cycle of poverty and disease. This means managing in a high value way for supporting sustainable development, and this begins with always accounting for the cost of inaction.

Rwanda today is led by a leader who in my point of view runs this country efficiently as a value-driven private enterprise for sustainable and equitable economic growth. He will lead us to a be a middle-income country by 2020. To support Vision 2020, our health laws, policies, strategies, and implementation approaches must be oriented towards breaking the cycle of poverty and disease that pulls down development. This important to keep in mind as face day after day much urgency and we have to solve them without undermining our future, as we know that some “quick win” interventions can in fact be the enemy of sustainable development when they are not designed thoughtfully and with the larger context in mind.

This week, thirty-seven officials and professionals from the Ministry of Health, Rwanda Biomedical Center, and CHUK have gathered together with faculty from Harvard Medical School in Rwinkwavu, Kayonza District for the inaugural Global Health Delivery in Rwanda course. Led by my dear friend Paul Farmer, Kolokotrones Professor and Chair of the Department of Global Health and Social Medicine at Harvard Medical School, the top-ranked American university has pioneered a new approach to global health partnership by teaching this course outside of the United States for the first time and brining it to the heart of Africa.

To make this course possible, Harvard has sent a team of professors to Rwanda, and the Ministry of Health has availed its training facilities in Rwinkwavu, to host the course with the support of Partners In Health/Inshuti Mu Buzima. This partnership has created a unique and collaborative learning environment that will pay dividends throughout the entire health Rwandan sector and beyond.

Last Sunday, young professionals and program managers were trained to be faculty members for future offerings of the Global Health Delivery in Rwanda course, learning how to share their experiences, to conceptualize their work using strategy and value analysis, and how to write their own cases to teach colleagues from around Rwanda and soon from around the entire world.

This course is about strategic thinking for better service delivery all along the cascade of services in the pursuit of optimal outcomes of prevention, care, and treatment. Students, faculty in training, and faculty exchange on techniques for better understanding the value added by each step within the cascade. For example, in our day-to-day management of the health sector, we realize the need to revise the usual approach to focusing on access by focusing on actual provision. Having an open door is sometimes not enough to meet the needs of the most vulnerable; sometimes, we must bring the services directly to them.

We must also work towards a paradigm shift around traditional notions of cost effectiveness by emphasizing measurement tools that account for the impact of population health status on our country’s sustainable development process. This means implementing the health sector’s vision through a holistic approach driven by evidence-based and person-centered policies that are evaluated by rigorous monitoring, just as we would in building and sustaining a successful business. The inaugural Global Health Delivery in Rwanda course runs from 19 to 23 February this week, and will be offered twice per year from now on. I expect it to bring great things to Rwanda in the coming years.

Progress in Rwanda's Fight Against Malaria

2012-02-04T07:37:00.000-08:00

On Monday, 30 January, the African Leaders Malaria Alliance (ALMA) presented to our President, His Excellency Paul Kagame, with a 2012 ALMA Award for Excellence in recognition of Rwanda’s tremendous progress in malaria control.

This is truly a well-deserved honor, as he has supported the Ministry of Health and its partners across the public sector, civil society, and the international community in achieving a 70% decrease in malaria incidence and a 60% decrease in malaria mortality between 2005 and 2010. These dramatic results are the latest data from the 2010 Demographic and Health Survey (which will be publically available online next month).

Last week, I had the great pleasure of launching a new malaria control campaign in Nyagatare District, which alone accounts for 40.4% of malaria incidence across the whole of Rwanda. A cross-sectorial approach to increasing utilization of insecticide-treated bed nets and clearing areas of standing water where mosquitoes breed will help to dramatically reduce this unacceptable figure in the next three months and contribute to the Government’s goal of eliminating malaria within national borders by 2015.

I offer my deepest heartfelt congratulations to all those who have contributed to this success, from His Excellency to the health workers at the community level. Let us all take this opportunity to rededicate ourselves to the fight against malaria and for a Rwanda where no one dies needlessly of preventable and treatable diseases.

Now we must explore sustainable approaches to eliminating malaria as a public health priority. For this to occur, we must have factories manufacturing long-lasting insecticide-treated bed nets and appropriate anti-malarial drugs. We will also need to strengthen cross-border collaborations, including the improvement of anti-counterfeit drug activities and the harmonization of prevention and treatment strategies across the region. When we have achieved our goals, Rwanda’s children will have peaceful nights and parents will not fear when they hear the “bzzzzz” noise coming across the room, for it will not be a mosquito but rather a simple fly suffering from insomnia.

(Image courtesy of Rwanda News Agency)

To Improve Quality of Health Services, We Must Build Trust

2012-01-31T04:26:00.000-08:00

Below is my piece in the New Times published on 30 January 2012. You can click here to read the article on the New Times.

To Improve Quality of Health Services, We Must Build Trust

By Dr. Agnes Binagwaho

Three different but related forms of trust are required to undergird a strong health system. Patients must trust their care providers, providers must trust their patients, and providers must trust each other. Without these three interlocking relationships of trust, patients will not seek health services, and care providers will never sufficiently improve their efforts to increase the quality of the care they deliver.

To encourage patients to trust the health sector in Rwanda, we must not only provide high quality services that are based on the latest science but also employ effective communication strategies to convince patients of this.

At King Faisal Hospital, an internationally accredited hospital in Kigali, we have well-trained and diligent health providers. Across the country, providers are working together with the share goal of improving access and quality of care, from the most highly trained specialist doctors and nurses in referral hospitals to community health workers at village level. Along with our international partners, we are making strides to provide highly specialized services. For example, Rwandan surgeons and their European, American, and Australian colleagues have performed more than 150 heart surgeries in King Faisal operating theaters, as well as two recent kidney transplants and many difficult neurosurgery procedures.

Furthermore, the Ministry of Health has developed a Charter of Patients as well as new guidelines for the implementation of customer care. These include the posting of a phone number and the photo of responsible official at the entrance to each ward, the placement of a suggestion box in each hospital, and a toll-free call center for reporting problems and making requests. While taking these steps is a promising start, we will need to follow through in assuring proper implementation of these measures if they are to contribute to continued increases in the quality of care.

Yet some patients continue to prefer to travel abroad for care, choosing to pay more for basic services, such as dental or antenatal services, that exist in their homeland. Why is it that some Rwandans go spend their money on health services in another country instead of remaining here where those funds could help to develop our health sector? The answer is two-fold: first, we cannot deny that there are some cases of unacceptable malpractices that threaten trust in the entire Rwandan health system. The Ministry of Health is working hard to increase accountability, and we investigate all complaints made through our publicly available channels, the Rwandan Medical Council, the Rwandan Nursing and Midwifery Council, and the Police.

Second, there has historically been a general lack of customer care, with providers not making the effort to smile, to welcome the patient, to carefully explain the causes of suffering to patients and their families. Sometimes it seems to patients that we do not like our work! This is a general problem in Rwanda, as we can also find the same attitude in restaurants, hotels, and administrative areas of the services sector.

Such individual experiences undermine our collective efforts to increase confidence in and utilization of the public health sector. This is why health professionals must have zero tolerance for medical malpractice of any kind, nor for any lack of respect or compassion for patients. We should not expect of ourselves anything less than the highest standard of customer care. Declining trust places a massive cost on all aspects of the health system, for if our own people do not trust the services provided, foreigners paying full prices certainly will not. As a result, potential tourists and investors who would need care during their stay in Rwanda may not wish to seek care here, and we lose money that could have served our development.

The second, and equally important, form of trust needed for a strong health system is that of providers trusting patients. In some critical care situations, health professionals may take risks for themselves to act quickly in order to save a life. If they do not trust the patient, they may take time at first to reflect on the risk they are putting themselves at and be unnecessarily cautious if they believe that the patient may later turn against them.

What are the reasons a provider may not trust their patient? One example occurred just this month, when a patient and family alleged that a doctor had forgotten to remove materials from her womb fully four years ago. A team of multiple Rwandan clinicians, an international expert, and several Rwandan Police are still working to fully resolve the case, having spent significant amounts of time and energy investigating and uncovering the truth. This time could have been used to serve other patients.

The final form of trust essential for the health sector is related to team building and professional development. All members of a team engaged in the provision of medical care must be confident in each other’s ability to act quickly and to act as one for the benefit of their patients. If one provider lacks trust in their colleague, she or he will spend time to re-check everything their colleague has done before proceeding to the next step. Again, the time and energy lost constitutes a missed opportunity to serve additional patients.

So let’s all work together to inspire people and to build an enabling environment for trust to flourish and create positive changes. Trust is needed for the population to feel confident in seeking services, and for the health professionals to effectively deliver them. To advance this work, we will combat false perceptions and work to provide higher quality services and better customer care at all levels of the health system. This is our duty – not a favor that we give to our population.

It is in this spirit of trust that I encourage all in the Rwandan health sector to enter into the year 2012 with inspired standards of care, proper customer care, and overall trust in one another. I wish the entire nation a fruitful and successful year full of progress. We all have been or will one day be clients of the health sector, so let us all commit to working together to build the trust needed to achieve our collective goals. Happy 2012.

The New Times: "Rwandans Among Top Users of Twitter in Africa"

2012-01-27T07:51:00.000-08:00

Rwanda's New Times published an interesting article today about citizens' usage of Twitter, and discussed His Excellency's encouragement to all Rwandas to harness the power of social media.

Rwandans Among Top Users of Twitter in Africa

By Edwin Musoni

A new report places Rwandans as the seventh top users of Twitter in Africa with close to 10,000 tweets in the last three months of 2011, according to a study.

The study was released yesterday by Portland Communications, a political consultancy and public relations agency that provides communications and public affairs advice to top brands and high-profile individuals.

The survey dubbed “How Africa Tweets” indicates that, in the last quarter of 2011, Portland Communications and Tweetminster conducted a unique study into the use of Twitter in Africa.

Analysis of over 11.5 million geo-located tweets originating on the continent and a survey of 500 of Africa’s most active tweeters showed that the seventh most active country was Rwanda with 92,880.

“The first survey of its kind in this region, How Africa Tweets, will serve as a benchmark for measuring the evolution of Twitter on the continent,” reads part of Portland Communications’ report.

South Africa led the table with 5,030,226 tweets, followed by Kenya (2,476,800). Nigeria (1,646,212), Egypt (1,214,062) and Morocco (745,620), while Algeria emerged sixth with 103,200 tweets.

The study also found that 57 percent of tweets from Africa were sent from mobile devices, 60 percent of Africa’s most active tweeters are between 20 to 29 years old and that 81 percent of those polled mainly used it for communicating with friends.

“Sixty eight percent said they use Twitter to monitor news and 22 percent to search for job opportunities,” reads the survey.

President Paul Kagame is among the Heads of State who have taken the microblogging site to directly engage or respond to people inside and outside Rwanda.

The Head of State has previously said he finds time in between his busy schedule to attend to his Twitter account @PaulKagame and answer questions, if any, or comment on current issues around the world.

Commenting on the ranking, Lucy Mbabazi, a public policy and IT specialist, who is also an ardent Tweep (moniker for people who tweet), said that Twitter had managed to contribute highly in the social affairs sector in Rwanda.

“If I can tweet police and ask them to ensure more safety at some junctions and they do it, I think the potential is massive. … Also, the Minister of Health, Dr Agnes Binagwaho’s Monday sessions on twitter are interactive and informative, this has made the ministry very responsive to feedback,” Mbabazi wrote in her tweets.

Jacqueline Ndinda, a Kenyan Freelance journalist, said that Rwanda deserved to come among the best countries in Africa considering the fact that President Kagame has taken the lead in motivating his citizens to use the social media platform.

“Rwandan President gives all other African countries a run. He engages in conversation. Which other African President does that? But I don’t see a big number of tweeps from Rwanda engaging him, it’s an opportunity Rwandans should exploit,” said Ndinda

A hash-tag of #Africatweets was suggested for debate on the findings. Twitters offers 140 characters to microblog and paste links from websites.

Mondays with the Minister: Vaccines and Immunization

2012-01-12T02:01:00.000-08:00

On Monday, 9 January, I held the first Mondays with the Minister of 2012. It was a great start to the New Year. The topic of yesterday’s discussion was “Vaccines and Immunization in Rwanda.” We hosted the discussion on Twitter, and, through my new partnership with the Rwandan company Nyaruka, we were also able to integrate SMS into the discussion and received messages on that platform as well. Anyone who wishes to view either the Twitter or SMS discussions can do so here:

Twitter #MinisterMondays

and

Nyaruka #MinisterMondays

During #MinisterMondays yesterday, I received many questions, including:

What has been most important achievement in the past few years regarding the immunizations?
Can you describe Rwanda’s involvement in efforts to find an HIV/AIDS vaccine?
What are Rwanda’s experiences with the pneumococcal conjugate vaccine and treatment for pneumonia and are these two complimentary?

I posed a few questions for all participants as well, including:

What do all you think is financial/human/moral cost of failing to implement 100% of possibilities provided by vaccines?
Question for all: Developing an HIV vaccine is only longterm gender-equitable solution to pandemic. What do you think?

It was a fantastic discussion and I learned from participants what some of their concerns are concerning vaccines and immunization. I can see that the reach of this forum is expanding and more and more people are beginning to communicate through these platforms. One thing I remarked during this last discussion was that several complaints were voiced (that were unrelated to the topic of this session). From this experience, I realized that the Ministry of Health must improve its sensitization of the population and empower people to use local outlets for complaints and concerns when their rights are not respected. There are faster ways to have your complaint heard in Rwanda, and to make individual and collective rights fulfilled!

Thank you all again for a great discussion yesterday. I look forward to connecting with you all – and more participants – again on 23 January. The next #MinisterMondays topic will be “Gender and Health.”

Follow along on Twitter or by SMS on Nyaruka

Direct Democracy and the Health Sector: Umushyikirano 2011

2012-01-10T11:00:00.000-08:00

Below is my piece in the New Times published on 9 January 2012. You can click here to read the article on the New Times website.

Direct Democracy and the Health Sector: Umushyikirano 2011

By Dr. Agnes Binagwaho

During the holiday season, I took time to reflect on the highs and lows of the past year. Without a doubt, one of the events that made me most proud to be a public servant for the people of Rwanda in 2011 was our National Dialogue Day, or Umushyikirano.

As written in Rwanda’s 2003 Constitution, the country hosts a two-day exchange of ideas, comments, and questions hosted by the President of the Republic at Parliament each December. On December 8 to 9, 2011, officials from the health sector joined representatives of the people as well as leaders from the central government to the village level for the Ninth National Dialogue at Parliament in Kigali.

The Dialogue draws on Rwanda’s principles of transparency and participation, allowing Rwandans from across the country and around the world to join and follow the conversation through free (reverse-billed) SMS messages, phone calls, Twitter, Facebook, live radio, and television broadcasts. Phone calls and SMS have been the foundation of Umushyikirano in past years, but 2011 saw the first incorporation of Twitter and Facebook messages. The addition of social media, a powerful tool for new kinds of interaction across traditional boundaries, made this the most inclusive and intense Umushyikirano yet.

Umushyikirano is a home-grown communications platform that facilitates open and deep dialogue. Over the close to eighteen years since the 1994 Genocide against the Tutsi, Rwanda has created many original innovations to ensure good governance and continual progress in the country. As one of the most empowering innovations, Umushyikirano is enshrined in the Constitution, guaranteeing that the people of Rwanda retain their right to participate in all decisions that guide their life and always have this forum (among many others) for expressing their proposals for improved policies as well as their judgments on the work of their elected leaders.

In reflecting on the central role of Umushyikirano in the Government’s decision-making process, I do find myself wondering how anyone who takes the time to learn the fundamentals of Rwanda’s political process could feel justified in saying that this country lacks political space or the freedom of speech. I grew up in Belgium and have spent years in other European countries and spent time in the United States, but I have never seen anything else quite like Umushyikirano – direct democracy on such a scale that harnesses the power of the telephone and internet; this exists only in my motherland, Rwanda.

Thanks to the rapidly expanding penetration of the mobile phone in Rwanda today, citizens from each and every corner of the country’s 15,000 imidugudu villages and countless diaspora communities can offer their views on every subject – whether the topic they wish to address is on the day’s agenda or not. Together, leaders and citizens reflect on potential solutions to the biggest challenges to our national development and the welfare of all Rwandans. This is true and direct democracy, where the officials entrusted with implementing national policy can be held accountable for their actions by each and every citizen.

I have attended each Umushyikirano since 2003, but this year was my first as Minister. The main themes for the 2011 discussion were governance, social welfare, justice, and the pursuit of economic development. All Ministers and directors of central government institutions directly concerned, were organized into panels that discussed each of the four topics with the live assembly of approximately 1,000 at Parliament and the rest of the nation through phone and computer.

The health sector presented on recent developments in Rwanda’s community-based health insurance program, Mutuelles de Santé, describing progress towards universal enrollment and the implementation of the new policy dividing premiums into three tiers based on families’ socioeconomic status. All Directors of specific health programmes and departments and other key staff from the Ministry of Health participated remotely throughout the entirety of Umushyikirano; some watched the live video feed in the main meeting room, others listened through the radio and read SMS messages, while several others joined through Twitter and Facebook. All together, we responded to each and every question regarding the health sector.

As always in Rwanda, we presented not only the Ministry of Health’s achievements but also our greatest challenges so that we might collectively reflect on ways to overcome them and to perform better for the population. This year, we have delayed the collection of insurance premiums for the 75% of the population who pay their own premiums and also the transfer to districts and communities the funding to cover premiums for the 25% who are fully supported by the Government after being identified as indigent through Ubudehe - Rwanda’s community-based system for establishing each household’s level of insurance premiums (and other socioeconomic indicators).

One major challenge facing the health sector that was closely examined during Umushyikirano is malnutrition. An unacceptable 44% of children under the age of five remain chronically malnourished or “stunted” (to be distinguished from acute malnutrition or “wasting”), and 38% of children under the age of five suffer from some form of anemia. During Umushyikirano, we collectively determined that the way forward in combating malnutrition must be a multi-sectorial approach driven by a cultural revolution aimed at sustainably changing the ways we teach families about growing, cooking, and serving the foods that end up on the plates of pregnant women and young children.

Rwanda does not lack the agricultural resources to properly nourish all our people, but we have been inadequately educating families about proper nutrition for too long. It is time to accompany the population in working together as one, for improved maternal and child health through nutritious diets. At Umushyikirano, the people of Rwanda set a deadline for the Government and its partners to eliminate the root causes of malnutrition within just six months. This approach is similar to that of tackling one of the greatest challenges of poor living conditions by guaranteeing all households with iron sheet roofing in order to eradicate thatched roofing through the Bye-bye Nyakatsi programme.

A third issue concerning the Health sector, discussed during Umushyikirano is the fact that Rwanda still depends on external financing for more than 45% of the health sector annual budget. As our Government and people know well, self-reliance can only be achieved through economic growth. Rwanda’s path away from dependency will be driven by sustainable development, and will involve generation of revenues through the health sector in the near future. The Ministry of Health will continue to do its part to reduce the importation of expensive drugs and consumables by relying on high-quality locally manufactured generics when possible as well as promoting private health facilities and providers. By encouraging the growth of the private sector, we can increase domestic tax revenues without raising taxes – this revenue will then be used to help increase the availability and quality of public sector services for all including the poor, as well as to invest in the education of more highly trained medical specialists for the benefit of all Rwandans.

In addition to debating major challenges facing the health sector, participants in Umushyikirano raised questions about the organization and quality of health care in Rwanda. Several Facebook users asked why some health professionals with diplomas remain unemployed by the public health sector, and the Ministry of Health responded by observing that the employment in the health sector depends on mindset – professionals should stop waiting for the government to automatically employ them and instead create their own opportunities or explore jobs in the private sector to serve the population across the country. We also received questions from some patients via SMS asking why they were not transferred outside of the country for certain kinds of care. We answered that the national referral system is organized to provide decisions that are based on cost-effectiveness depending on available scientific evidence about when and where to send patients in the case that treatment cannot be offered in Rwanda. In some cases, medicine cannot do much for diseases at advanced stages (or for some diseases at any stage), and this is why we invest much more in preventive services and quality improvement in Rwanda’s health system.

I wholeheartedly congratulate each of my colleagues in the Ministry of Health for their responsiveness to participants through SMS, Facebook, and Twitter, and I am proud to serve as their Minister. At this year’s Umushyikirano, there were no major criticisms targeted by the population at any sector, and the health sector has achieved a high satisfaction rate at 75%. Of course, we will not be satisfied until this figure reaches 100%; we know that the remaining 25% represents our weakness in customer care and the way that patients are handled – we commit to strive for improvements in these areas at all levels.

At this year’s Umushyikirano, multiple home-grown solutions were presented and still others developed through dialogue between citizens and their elected leaders. Economic development and self-sufficiency were at the heart of the debate throughout the sessions; this gave me a strong sense of pride in my Rwanda. Our nation’s constant emphasis on accountability and access to information as a human right gives me great hope for our future. At the Tenth National Dialogue in December 2012, I look forward to being able to say that we at the Ministry of Health have done our very best to live up to the expectations of the Rwandan population, for they deserve nothing less.

Honorable Minister Agnes Binagwaho will be hosting a discussion on vaccines in Rwanda through Twitter and SMS on Monday, 9 January 2012 from 5:00 – 7:00 p.m. You can join her “Mondays with the Minister” chats twice each month by following her on Twitter at @agnesbinagwaho or by sending comments by SMS to 0788 38 66 55 during the specified time.

Mondays with the Minister: Vaccines and Immunizations

2012-01-03T01:59:00.000-08:00

On Monday, 9 January, I will host my first Mondays with the Minister of 2012. The session will run from 5:00-7:00PM Rwanda time (3:00-5:00PM GMT). The topic for this coming session is Vaccines and Immunizations in Rwanda.

You can tweet questions or comments to me at @agnesbinagwaho, you can follow the discussion by searching #MinisterMondays, and you can send an SMS with your questions or comments at 0788 38 66 55. (If dialing from outside of Rwanda, please dial: +250 788 38 66 55). You can also follow the SMS discussion by visiting http://listen.nyaruka.com/

I welcome all of your questions and comments and look forward to another great #MinisterMondays conversation.

##

Male Circumcision and the Path to an AIDS-Free Generation: My Washington Post Op-Ed

2011-12-15T02:20:00.000-08:00

On Tuesday, 14 December 2011, I published an opinion column about scaling up non-surgical voluntary male circumcision in the Washington Post, an American newspaper based in Washington DC. You can read my column below or here at the newspaper's website.

Male circumcision and the path to an AIDS-free generation

Agnes Binagwaho is the Minister of Health of the Republic of Rwanda and recipient of an honorary PhD in sciences from Dartmouth College for her lifetime achievement in treating and preventing AIDS.

We have an opportunity to lay the foundation for an AIDS-free generation, as Secretary of State Hillary Clinton declared on Nov. 8. Unfortunately, we’re trying to dig that foundation with a spoon when we have a shovel at our disposal.

We have the capacity to save nearly 4 million lives in sub-Saharan Africa, the hardest hit region in the world, by scaling up voluntary medical male circumcision — the best tool we have for HIV prevention. But the only method widely approved for funding is the surgical method, which is expensive and impractical for countries lacking physicians and surgical infrastructure.

Rwanda’s national goal is to decrease HIV incidence by 50 percent for boys ages 10 to 19 and 30 percent among men age 20 and older. It would take more than 12 years for Rwanda to achieve its national goal to offer voluntary medical male circumcision to the nation’s male population using formal, surgical procedures. We need to reach 2 million men in two years to benefit from the protective effect of the procedure in order to achieve this as part of a comprehensive, combination HIV prevention strategy.

We have clinically studied and approved PrePex, non-surgical device for voluntary adult male circumcision that requires no injected anesthesia. Over 50 percent of nearly 1,100 Rapid Male Circumcision (RMC) procedures were conducted by low-cadre nurses. Using this device, the out-patient circumcision procedure is safe, fast, bloodless and virtually painless. This device aligns with our national policy change, allowing for task-shifting of circumcision way from surgeons and family physicians to nurses and possibly even community health workers.

What’s more, whereas a surgical circumcision can take as long as 20 minutes per patient, this device reduces procedure time to a total of 1.5 minutes to place the device and 1.5 minutes to remove it, meaning we can circumcise more men faster and without compromising their safety or the device’s effectiveness. In fact, in our comparison study between the device and the surgical method, audited on site by WHO and USAID delegates, we found that this device is in fact safer than the surgical method.

Such simple solutions can be game-changers in the fight against HIV/AIDS. Public health officials set a goal to reach nearly 20 million men ages 15 to 49 by 2015, but in four years, Africa has reached less than 3 percent of its target goal. Research consistently proves that circumcised men reduce their risk of HIV infection by 60 percent. By scaling up circumcision to reach the at-risk population of adult men, we could avert millions of new infections and save billions of dollars in donor funds.

It is time to reinvent the vocabulary for what is possible, and I propose to start talking about RMC, Rapid Male Circumcision, because the device we studied can revolutionize our prevention toolkit in Africa. RMC is not a silver bullet but an extremely powerful tool when promoted in combination with other proven prevention strategies.

We need to be able to use every HIV prevention tool at our disposal, and I call on the international community to effectively support the scale up of Rapid Male Circumcision, through the more efficient non-surgical devices that will make the procedure possible in countries with fewer skilled health-care professionals and surgical infrastructure.

Such scalable solutions provide the clearest path to reaching short-term prevention goals, allowing us to continue efforts toward longer-term efforts to abolish the spread of HIV/AIDS for generations to come.

Mondays with the Minister #3: Malnutrition in Rwanda

2011-12-15T02:08:00.000-08:00

On Monday 12 December 2011, I hosted the third consecutive“Mondays with the Minister” Twitter chat on the topic of malnutrition inRwanda. For the first time, SMS was used in addition to Twitter. I recently partneredwith a local company, Nyaruka, to integrate SMS into the bi-weekly discussions. Nyarukamoved fast to design a superb web platform where I can receive, respond to, andpublicly display SMS messages. During this first Twitter/SMS Mondays with theMinister, approximately 40 people participated on Twitter, asking questionsfrom across Rwanda and other countries in the region. Students and researchersinterested in global health also joined from Europe and North America.

We will be improving the publicity on the SMS portion of the discussion incoming weeks. Radio announcements and a Ministry of Health press release willhelp to publicize it more widely for future chats, allowing Rwandans across thecountry to contribute questions or comments about the chosen topic in thelanguage of their choice (Kinyarwanda, English, or French) during the timeframe of the discussion. Five total questions were contributed by SMS in English andKinyarwanda this past Monday, and I look forward to seeing many more in futureweeks.

This week’s discussion on malnutrition in Rwanda touched oncurrent chronic malnutrition and anemia statistics in Rwanda, which remain veryhigh. We discussed the state of the Ministry of Health’s response tomalnutrition, and many Rwandans were interested in behavioral changecommunication efforts underway to promote balanced diets in addition tostructural anti-poverty interventions (such as One Cow per Family, kitchengardens, milk for students at school, and ubudehe)that seek to combat food insecurity at the community level. Others wereinterested in institutional collaborations to address malnutrition,public-private partnerships in Government programs, the linkages betweennutrition and care for chronic diseases such as HIV and tuberculosis, oversightof UNHCR refugee camps, and the prevention of obesity as Rwanda’s economicgrowth continues. I asked what participants thought was the weakest part of theMinistry of Health’s response, and this led to an exchange about meeting theneeds of vulnerable youth – particularly “street kids.”

All in all, the discussion was very interesting andinformative for me as Minister of Health. As is the case with Rwanda’s Umushyikirano (National Day of Dialogue),it is so important for Rwandans to be able to communicate with theirGovernment. In the Ministry of Health and throughout the central Government, westrive for transparency, accountability, and accessibility.

I’d like to thank again Nyaruka’s staff, especially Nic,Eugene, and Eric, for their hard work on creating this new platform. Iappreciate this partnership and highly recommend them for other ICT for health initiatives. For all those interested, you can visit theircompany’s website at http://nyaruka.com.

My next “Mondays with the Minister” discussion on Twitterand SMS will be held on 9 January 2012 (time TBD). The topic will bevaccinations, and we will discuss the impact, delivery, and sustainability ofvaccines in Rwanda. As a reminder, you can follow the discussion through myTwitter account @agnesbinagwaho andby searching for #MinisterMondays.You can also send a question or comment in Kinyarwanda, English, or French bySMS to 0788 38 66 55. SMS questions and my answers can be viewed onlineat listen.nyaruka.com. I greatly look forward to our next discussion.

Outdated Evidence at the WHO: Case of Rwanda

2011-12-13T08:28:00.000-08:00

Below is my piece in the New Times published on 11 December 2011. You can click here to read the article on The New Times website.

Outdated Evidence at the WHO: Case of Rwanda

By Dr. Agnes Binagwaho

As the world’s coordinating authority on international public health issues with the mission of, among other priorities, “articulating evidence-based policy options and monitoring and assessing health trends,” one would expect the World Health Organization to take seriously the responsibility of assuring that the evidence derived from these assessments is accurate and up-to-date. As the case of Rwanda illustrates, however, policy options articulated by the WHO can often be based on outdated and misleading evidence.

Country-level health data for Rwanda is often years behind, despite the fact that the Ministry of Health regularly makes publicly available the latest annual data from our Health Management Information System (HMIS) and our Demographic and Health Surveys (DHS). In fact, the country office of WHO even has member seats on the national steering committee for planning, implementing, and analyzing the DHS. Yet after all of the painstaking effort undertaken by Rwanda and our partners (including UNICEF, the CDC, ICF Macro, and the WHO) to ensure accurate and representative information, the WHO delays for years before updating figures in reports and databases.

Validated preliminary results from Rwanda’s 2010 DHS have been publicly available on the Ministry of Health website, the ICF Macro website, and accessible through a simple Google search since early July 2011 (see http://www.measuredhs.com/publications/publication-PR7-Preliminary-Reports.cfm), yet the WHO continues to disseminate country-level statistics for key health indicators from 2005 and 2007 for Rwanda. For example, the WHO World Health Statistics 2011 report cites Rwanda’s under-five child mortality rate as 111/1,000 live births while the 2010 country DHS figure is 76/1,000. In fact, even the 2007 DHS figure is below the current estimate, at 102.6/1,000 – by exactly what metrics is the WHO adjusting their data?

If Rwanda’s own fully-validated indicators from the DHS which WHO advised are not sufficient, one would still expect those in Geneva to take note of data and analysis from their M&E partners in the United States and Europe. But the internationally respected Institute for Health Metrics and Evaluation of Seattle published a comprehensive report on child mortality in The Lancet (one of the world’s most respected peer-reviewed medical journals) three months ago with an under-five child mortality figure of 75.4/1,000 (see http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)61337-8/abstract), and the WHO still does not move to revise its figures.

There are many other examples of outdated and inaccurate WHO data on Rwanda. The recent World AIDS Day 2011 report (a wonderful report in all other aspects) lists Rwanda’s coverage rate for antiretroviral therapy among HIV-positive children in need as 45%, while the Ministry of Health’s publicly available HMIS figure for 2011 is 82%. WHO estimates for Rwanda’s coverage of BCG (against pediatric tuberculosis) and measles vaccinations in 2010 are 75% and 82%, respectively, while the 2010 DHS cites figures of 99.1% and 95.0%.

I suppose we should not be so surprised by these inaccuracies, as a 2011 WHO report identified the whole of Rwanda as a high-risk area for yellow fever despite the fact that we have not seen a confirmed case since the mid-1950s (and the WHO’s own database shows 0 cases over the past decade).

While delays in providing accurate and up-to-date information to inform international public health policy may not be new, they are unacceptable and do have consequences. The WHO should be made fully accountable to ensure that reliable new information is incorporated within a reasonable time frame into its reports and databases so that the phrase “evidence-based” does not become an empty statement.

Bringing Mondays with the Minister to Communities

2011-12-11T11:05:00.001-08:00

As previously discussed on my blog, I recently began a series of online discussions through Twitter to allow Rwandans, colleagues, and partners around the world to discuss issues related to health policy. These chats, held on Monday afternoons twice per month, are entitled “Mondays with the Minister.”

I believe that equitable access to information and participation in debates around public health issues is a right of all citizens of the world, and I particularly avail myself for my fellow Rwandan citizens. I find this access important in all aspects of the Ministry of Health’s work. I am grateful to the owner of the ICT company Nyaruka, who leads by the same principles and worked at no cost with me on this project in order to allow Rwandans to send questions and comments by SMS for the discussion. Because cell phone coverage in Rwanda is over 60%, and because each of the three community health workers per village have cell phones, all Rwandans should be able to contribute a question or comment if they wish. The owner of the ICT company Nyaruka also graciously proposed to make this access free forever, as far as it is for a program that shares the same goals of open communication for improving health.

Mondays with the Minister discussions will be held every two weeks. The time of may change, but they will always last for two hours duration.

The next Mondays with the Minister chat will be Monday, 12 December from 3:00 p.m. to 5:00 p.m. The topic for discussion and debate will be malnutrition in Rwanda and what the Ministry of Health is doing to address the problem.

To join on Twitter, follow me on Twitter at @agnesbinagwaho. To join by SMS, send a message to 0788 38 66 55 between 3:00 p.m. and 5:00 p.m. And, if dialing from outside of Rwanda, please dial: +250 788 38 66 55. You can also see the questions submitted by SMS and their answers at listen.nyaruka.com. I consider this and the Twitter forum to be a great opportunity for improving service delivery by incorporating the direct suggestions of the population, who are at the center of all decisions made by the Ministry of Health. I welcome your questions and look forward to productive and inclusive discussions!

Twitter: @agnesbinagwaho

SMS: 0788 38 66 55

Web: listen.nyaruka.com

Health, Human Rights, and Democracy in Rwanda

2011-12-11T02:05:00.001-08:00

Below is my piece in the New Times published on 11 December 2011. You can click here to read the article on the New Times website.

Health, Human Rights, and Democracy in Rwanda

By Dr. Agnes Binagwaho

Success in Rwanda’s health sector is due to the fact that the Government works as one in pursuit of an integrated and community-driven development process. This past year, I have read and listened to many great newspaper articles and speeches about Rwanda’s social and economic progress since 1994 that highlight the country’s unprecedented achievements but conclude with a single sentence or two that intends to make the reader or listener doubt all of these achievements.

Listening to such reflections on my country has caused me to reflect on a number of trends since my return to Rwanda in 1996. Still much needs to be done and as a nation and as a people, we have pursued with fierce urgency the integration of participatory democratic principles and equitable social policy to ensure that all Rwandans benefit from the process of development. We promote and strengthen our democracy by always engaging our people – Rwanda’s true wealth – in the formulation and implementation of policies for health, education, gender, youth, decentralization, financing, infrastructure and other.

In order to do so, the Government must apply an integrated and collaborative approach across all sectors. His Excellency Paul Kagame, the President of Rwanda, makes this quite clear when responding to a new policy proposal from a member of his Cabinet, asking first without fail: “What will this mean for the people, and how does it link to our poverty reduction and economic development strategy?” The evidence and results of such an approach can be seen at all levels, exemplified by a number of uniquely Rwandan approaches to the empowerment of our citizens.

One fine example of communities working together for national development is the monthly day ofUmuganda, a voluntary work day on the final Saturday of each month. Community members in villages, towns, and cities across Rwanda collaborate on various service projects. Activities are identified and selected through a participatory process, and often include building schools or health centres, planting trees, or clearing areas for the construction of new homes for the community’s most vulnerable families. Umuganda creates momentum for the development of all sectors, as public sector agencies often choose to contribute resources to these projects (and Ministry officials often join in the work around the country). All of these initiatives serve the pursuit of health; even the construction of a school will facilitate increased uptake of health services in the next generation because a well-educated woman is a highly valued member of a family who is well taken care of.

Other national programs similarly fight poverty and promote economic growth in ways that amplify the work of the health sector. For instance, the Ubudehe process of village-level community decision-making that includes “poverty-mapping” (or communal categorization of households into socio-economic categories based on income and needs) allows for better targeting of social services and pro-poor subsidies for items such as our community-based health insurance program, Mutuelles de Santé. In the Ministry of Health, we use Ubudehe and district level data to proportionally allocate our malnutrition interventions (such as the One Cow per Family and kitchen garden programs) towards the most affected areas of the country.

In order to catalyze economic development at the community level, our Government undertakes massive sensitization campaigns around financial savings. Umurenge Savings and Credit Cooperatives (SACCO) were established across Rwanda to increase access to financial services among the rural poor. Today, all of the country’s sectors manage their own SACCO with technical assistance from the central government. These cooperatives are voluntary, and they allow each citizen to contribute what they want to the communal savings pool. With these savings, the community can provide loans (same amount as invested by the citizen) to individuals who agree to reimburse the cooperative for the amount. One district I visited two weeks ago, Burera, has a savings pool of over one billion Rwanda francs. Umurenge SACCO is a very successful program for economic empowerment through the creation of community-owned and directed capital.

The Ministry of Health also uses cooperative savings mechanisms to compensate our 45,000 clinical services providers the community health workers (CHWs) through performance-based financing. Each community elects the CHWs in a participatory and open manner, after which they are trained by the Ministry of Health in prevention, care, and referral of the most common causes of diseases and mortality among communities in Rwanda. As I have written about elsewhere, our massive team of CHWs has contribute to dramatic improvements in health outcomes over the past five years, including a 50% decline in child mortality, a 70% decline in malaria incidence, a 52% increase in the proportion of mothers delivering at health facilities, and a 450% increase in the uptake of modern family planning methods. They serve as the first line of defence against the biggest killers, addressing 80% of the burden of disease through home-based care, but also stand ready to link patients to health centres or district hospitals via ambulances that they contact with their cell phone.

Economic development at the community level is crucial to Rwanda’s long-term vision for the health sector, because we want every Rwandan to be capable of contributing premiums to the Mutuelle de Santé program. When visiting officials from our partners in the United States or Europe ask how we plan to make this vision sustainable, I like to show them a graph of Rwanda’s recent economic growth – about 8% for the past several years, which has contributed to the expansion and flourishing of our poverty reduction programs.

Rwanda has the vision of becoming a middle-income country that is able to self-finance our pro-poor social interventions and guarantee equitable access to high-quality medical care. When I join in for Umuganda or visit a SACCO and see our people’s unwavering commitment to our nation’s vision, I have no doubts that we will make it. To empower Rwandan citizens economically, we promote a spirit of independence to make the best choices for themselves. This is the basis of democracy; when you are dependent and begging, you cannot direct your life.

Full civil and political rights are essential to human development and are highly valued in Rwanda, but we can never forget that these must be built upon a foundation of social and economic rights. If a woman fears that her child may die of malaria for want of a 500 Rwandan franc treatment, being able to vote will not serve her in the short term if it is not link with economic growth; if a man does not have enough money to feed his family or send his children to school, the ability to nonviolently express grievances will not fill stomachs or pay school fees. Civil and political rights and social and economic rights can and must be mutually reinforcing; neither is sufficient alone – we must assure them all. This understanding is woven into the very fabric of our nation’s Constitution and each of our major social sector policies; we must never forget it.

I am truly delighted that more and more high-level officials from the Governments of our long-time development partner countries are coming to see firsthand what we are doing in Rwanda. I have the feeling that we are all truly contributing to a revolution that will bring more health and wealth to our people. Our partners deserve to see how we are using the investment in the health and wealth of our population. In the global humanitarian market, the value of money invested in Rwanda is incredibly high due to lack of corruption, our dedication to participatory processes, and our reliance on integrated cross-sectorial approaches to tackling policy challenges. As a public servant, I am so proud to belong to Rwanda, a country that has pro-poor human-focused policies in practice, and to its population, who are the most valuable resource our country will ever have.

Press Release: MoH appreciates support from USG

2011-12-10T12:23:00.000-08:00

Below is the press release I published in the New Times on 10 December 2011. Click here to read the article on the New Times website.

Press Release: MoH appreciates support from USG

Kigali - The Ministry of Health would like to clarify a story published in the Chronicles Newspaper issue no. 008/5th-11th Dec 2011 titled, “US responds to Minister Binagwaho’s criticism,’ which was captured in a wrong context.

The Author of the story plays around with figures and creates a false impression of discontent on the part of the Government of Rwanda, and the Health sector in particular, regarding the US Government’s support.

This is wrong.

The U.S. Government is a great friend of Rwanda and the major supporter of our Health sector. U.S. Government support has saved thousands of lives in Rwanda and strengthened our health system. By implying that we do not understand how the global economic crisis has impacted the global flow of aid—and U.S. Government support included —the article misleads your readers.

We commend Washington’s flexibility during this period of economic difficulties, having agreed to reorient funds to support some of our major strategies for sustainable health sector development. For example, the PEPFAR transition process allows all clinical services to be managed directly by the national system, which serves to strengthen district hospitals and support our decentralization efforts.

The article does not recognize our appreciation for this thoughtful and innovative support.

Friends may not agree 100% of the time, but we know that the U.S. Government is committed to working closely with us through this challenging period and will keep supporting us more with less, as President Obama said months ago.

The article ignores the tremendous achievements that we have made together, and the important discussions that are ongoing in order to sustain our success in the health sector, and embrace change to make more sustainable investments for better health. We all understand this, and Rwanda is up to the task.

MOH management

Minister of Health

Leadership and the fight against HIV/AIDS

2011-12-10T01:08:00.001-08:00

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.

Click here to see UNAIDS coverage of this panel

HPV Vaccine in Rwanda: Different Disease, Same Double Standard

2011-12-02T11:43:00.000-08:00

Youtube Video: HPV Vaccine Rollout in Rwanda

On December 2, a Correspondence letter that I co-authored was published in The Lancet regarding debates about using and paying for the Human Papillomavirus vaccine in low-income countries: “HPV Vaccine in Rwanda: Different Disease, Same Double Standard.” The text of the letter is copied below, and you can click here to read it on The Lancet website. This Youtube Video was recorded to complement the Letter in the Lancet.

We respond to a group of public health researchers who wrote a piece in July that was critical of Rwanda's program and made several claims which have been echoed in other corners of the international community. We draw parallel between this resistance and that of many debates about providing antiretroviral therapy in Africa last decade.

We have detailed articles on strategy, delivery, and outcomes of Rwanda’s program underway, and will post on my blog once they are published.

________________________________________________________________

Published in The Lancet on 2 Dec 2011

HPV vaccine in Rwanda: different disease, same double standard

Agnes Binagwaho, Claire M Wagner, Cameron T Nutt

In a Correspondence letter (July 23, p 315) [1] regarding Rwanda's human papillomavirus (HPV) vaccine roll-out, Nobila Ouedraogo and colleagues express “serious doubts that [a national HPV immunisation programme] is in the best interest of the people”. Are the 330 000 Rwandan girls who will be vaccinated against a highly prevalent, oncogenic virus for free during the first phase of this programme not regarded as “the people”?

Ouedraogo and colleagues argue that cervical cancer ranks behind other vaccine-preventable diseases in resource-constrained settings. But for the diseases cited (measles and tetanus), Rwanda has 95% and 96·8% vaccination coverage rates, respectively [2]. Second, Ouedraogo and colleagues state that HPV vaccine effectiveness is unknown. Many studies say otherwise [3]. Third, the cost-effectiveness analysis cited does not account for vaccine market dynamics by presenting assumptions as immutable facts. The initial price of the pneumococcal vaccine provides a helpful lesson, and Merck announced a two-thirds reduction in the price of Gardasil for GAVI-eligible countries (to US$5 per dose) [4] more than a month before Ouedraogo and colleagues published their Correspondence letter. Finally, Ouedraogo and colleagues accuse Merck and Rwanda of conflicts of interest regarding connections to the GAVI Alliance. Actually, Merck representatives are non-voting GAVI observers, and GAVI's website clearly shows Rwanda's board membership terminating on Dec 31, 2011 [5]. GAVI will have no role in the HPV vaccine programme before 2014.

Ouedraogo and colleagues' argument reminds us of nihilistic claims against provision of antiretroviral therapy in Africa. Their argument constitutes but the latest backlash against progressive health policies by African countries. When the possibility of prevention exists, writing off women to die of cancer solely because of where they are born is a violation of human rights.

The opinions expressed in this Correspondence are entirely those of the authors and should not be attributed to Harvard Medical School or Dartmouth College. We declare that we have no conflicts of interest.

References

1) Ouedraogo N, Müller O, Jahn A, Gerhardus A. Human papillomavirus vaccination in Africa. Lancet 2011; 377: 315-316. PubMed
2) Ministry of Health of Rwanda. Demographic and health survey 2010: preliminary report. Kigali: National Institute of Statistics of Rwanda, 2011.
3) Schiffman M, Wacholder S. Success of HPV vaccination is now a matter of coverage. Lancet Oncol 201110.1016/S1470-2045(11)70324-2. published online Nov 9. PubMed
4) Merck . Merck offers further commitment to sustainable vaccine access. http://www.merck.com/newsroom/news-release-archive/corporate-responsibility/2011_0605.html. (accessed Aug 9, 2011).
5) GAVI Alliance. Board members. http://www.gavialliance.org/about/governance/gavi-board/members/. (accessed Aug 9, 2011).

Entrenching a Service Culture in Rwanda’s Health Care System

2011-11-23T05:49:00.000-08:00

Below is my contribution to the first issue of Ubuzima Magazine, published by the Rwanda Health Communications Center and the Rwanda Biomedical Center. You can click here to download the full magazine, I recommend you do! Lots of great updates on our health sector from the MOH and RBC.

Ubuzima, the quarterly magazine of the Rwandan health sector published by RHCC/RBC

Entrenching a Service Culture in Rwanda’s Health Care System

By Dr. Agnes Binagwaho

Over the past decade, Rwanda’s health sector has made some laudable strides. 98 percent of the population has access to health insurance, mainly as a result of Mutuelle de Sante; maternal deaths are down to 70 percent and the incidence of malaria has been reduced by the same margin. More than 80,000 people that need treatment for HIV are receiving medication while pediatric HIV has been brought down to 2 percent.

The primary health care system is working. Health units are stocked, equipped are manned by appropriately trained care givers. As we acknowledge these achievements however, we are reminded that the higher you go the more difficult it becomes to achieve incremental progress.

Yet much as they are more challenging, those next few steps are all the more important in terms of the impact they are likely to have on performance of the sector. We have diversified services and spread them across the country and the population will have better health if they maximize use of those services.

They also need to be part of the process, highlighting any shortfalls we may have in the health sector such as hygiene and customer care. If they can understand that those services are meant for them and they insist on those simple rights, then the quality of care should improve. We have adopted a participatory approach in the health sector and the major goal right now is to bring the consumer of health services on board, to learn to demand services and help ensure that we provide services that are appropriate and relevant to their needs.

Even though the consumers of our services are not technical and we may sometimes disagree, involving them will help understand what we are doing and trying to achieve.

By just getting consumers to play their civic role of opposing wrong practices, we can take the quality of health care to the next level within the same resource envelop; without adding a single coin to our budget. This should help us on our journey to improvement. We have had a problem of lack of compliance with quality guidelines and lack of acceptance by consumers that they are paying for this service and are therefore entitled to quality care.

People need to know that they can complain and we shall listen to them; it is a right to be attended to in a clean healthy facility, to have a health professional wash hands before touching a patient, have a clean bed and to be attended to and receive medication in time. There are so many small things that can improve the quality of service- care and speed all comings at low costs.

We need to make the public aware of these goals through sensitization and demonstrating that we have no tolerance for those malpractices. This will be achieved by making them know that if they bring a complaint about a person who does not give them the expected quality of care, we shall listen to them and if their complaints are valid, we shall act.

Manpower

Manpower is still a problem in the sense that we need more doctors, specialists, nurses and professionals in allied sciences to improve the quality of care. We have a seven- year plan for which we are mobilizing resources.

We want to introduce provincial hospitals that will act as an intermediate level between the district and referral hospitals. Those provincial hospitals have to be equipped with diagnostic and treatment tools and specialists to provide specialized care that is now only available at referral hospitals.

Even as we work towards providing specialized care, we must be careful not to compromise basic care. Our population is aging and the healthcare system needs to be prepared to adapt proactively to this mutation of the population.

With life expectancy now above 50 years, we are beginning to see heart diseases, hypertension, cancer etc emerge as public health issues. In the first place, the population has reached that age because of the improvement in basic care. If we don’t plan ahead to create requisite services and specialists, we shall be caught napping because developing these capacities takes time.

And some of these capacities are not just about unique disease conditions. For instance pregnancy is not a disease but if you have a pregnancy complication and you don’t have a gynecologist, you die. So we need specialists even for basic care.

We also need to equip the health facilities at sector level with health professionals at a grade that is higher than A1 that can attend to most of the problems that arise in the community without the need to transfer patients to the district hospital. While sometimes necessary, transfers are not always in the best interest of patients. They take them far from home, thus disrupting the flow of routine activities in their homes. Bringing specialists to their communities is the best as this will bring more comprehensive care to the surrounding population.

For now, Rwanda has 423 health centres. Five of these are at referral level and another 42 are district hospitals. Five of these district hospitals are going to be upgraded to provincial level to create a layer between the district and referral hospitals.

This is the current structure but the objective is to have one medical officer in all health centres at sector level and to have one specialist in each district hospital meaning an anesthetist, surgeon, gynecologist, internists and a pediatrician. In the provincial hospitals we shall have more specialized health care including the capacity to treat cancer and carry out more advanced operations. Above these will be the teaching and referral hospitals. This is the future plan.

To address manpower challenges in the sector in a sustainable manner, medical education will now be under the ministry of health. That will allow us to produce the health profession we need without passing through another sector. The law establishing the Rwanda University of Medicine and Health Sciences is in development.

We have also created four schools of nursing and we are now able to produce 100 A1 graduates a year. Some of these are new recruits while the others are upgrading from A2 to A1.

For doctors the plan is to liaise with foreign Universities to bring lecturers to Rwanda. Our biggest problem is lecturers. Even if we want to increase the number of doctors we need to have lecturers. So we are going to partner with foreign Universities to bring teachers that will mentor Rwandans to be good teachers that will over time produce doctors and specialists through academic training and mentorship. This is in progress and we are keeping our fingers crossed that we shall succeed.

HIV/AIDS

We now have universal access to treatment. There is nobody who is HIV positive and needs treatment and cannot get it. We have more than 80,000 people on high quality treatment. A few of these are on second line treatment for resistance and there is also universal access to treatment for children.

We now have an ambitious program to eliminate pediatric HIV by preventing Mother to Child Transmission by giving tri-therapy at all health centres. Five years from now,

we hope to have reduced the risk of Mother to Child Transmission below the current 2 percent. That is almost elimination; not eradication, but that is about the closest one can get to the elimination of pediatric HIV as a public health issue.

Available statistics indicate that 200,000 people in Rwanda carry HIV and slowly by slowly they will progress towards AIDS and need treatment. That means the mobilization to put them on treatment must continue.

Thirdly, if we are to sustain that effort we need to succeed in prevention. If we have no new infections we can care for those already infected, but if we have new infections at one time we are going to face a situation where we shall not be able to put any more people on treatment.

That will not only roll back the gains so far made and lead to higher mortality rates among AIDS sufferers but also increase the velocity of new infections. Putting people on treatment is therefore a public health need because of its ability to slow down the rate of transmission.

Muteulle de Santé

Ninety two percent of Rwandans are now on public health insurance. Another 6 percent are on other health insurance schemes meaning 98 percent of Rwandans are covered under one form of health insurance or another. Beneficiaries were contributing 1000Rwfr to get care. In 2003, we discovered that the per capita cost of dispensing care was 3750Rwfr. That excluded the cost of doctors, nurses etc. That raises the question of who covers the funding gap. So we needed to find a way of making Mutuelle more sustainable.

We decided to get people to pay according to income since Mutuelle is a contributory scheme. We have arrived at a rate that is now being implemented. The new system does not lock out anybody; the people who can’t pay will still be entitled to care. They will be identified. Those who have little income and those with high income will pay according to their means.

Beneficiaries have been categorized into three classes. The extremely poor – will not pay anything, the government will pay for the care and premium.

So far there has been good accountability for resources in the health sector as part of the wider culture of accountability in Rwanda. Part of the fight against corruption revolves around zero tolerance for the vice.

This has created a culture and strong administrative guidelines that require signatures at every step. This is how we protect public money. And it is not about not stealing money but making money work.

These are values that have carried us this far and will continue to lead us on the road to progress as we tackle the pending challenges.

Dr. Agnes Binagwaho

Hon. Minister for Health

Announcing "Mondays with the Minister"

2011-11-21T04:52:00.001-08:00

Dear all,

I would like to announce a new series of online discussions that I will bemoderating through my Twitter account (@agnesbinagwaho). One Monday per month,I will log onto Twitter to lead discussion, answer questions, and take commentsabout a specific topic related to health programs in Rwanda. These chats willbe called “Mondays with the Minister,” and you can follow them through myaccount or by searching Twitter for #MinisterMondays.

I held the first round of “Mondays with the Minister” thispast week on Monday, 14 November. The topic was family planning in Rwanda andaround the world, and I partnered with the International Conference on FamilyPlanning (@fpdakar2011). Approximately 50 people from many different countriesasked questions and sent in comments, which I answered and re-posted on my ownTwitter account. The discussion was very instructive and encouraging. Iabsolutely loved interacting with people with so many different perspectives onthis important topic, and hope that the conversations we started will continuelong past the Twitter chat.

The New Timespublished a short article on “Mondays with the Minister” on Saturday, 19November. You can read it under the Media tab of my blog, or on the New Timeswebsite at http://www.newtimes.co.rw/pdf.php?issue=14814&article=47340.

Medical Grant Writing Training in Kigali

2011-11-21T04:41:00.001-08:00

Group photo at the medical grant writing training in Kigali hosted by Imbuto Foundation and IAVI

Last week, I spoke at the opening ceremony of a two-day medical grant writing workshop in Kigali. To follow up, I am sharing my thoughts on the relevance and importance of such trainings.

It is essential that Rwanda own its research, results, and publications. Today, the normalcy of foreign researchers studying and publishing Africa’s own results must be tackled just as seriously as we tackle diseases. If we don’t start to document our own progress on the continent, we will inevitably allow foreigners to continue to study our population’s health and write about it without including national researchers and implementers. Certainly there are examples of non-Rwandans who have successfully partnered with Rwandan researchers on studies and publications, but this type of partnership must become the norm across the continent.

One very important way to improve regional ownership over data and results is to train our young professionals on how to write grants for medical research. A workshop held on 11-12 November 2011 hosted by the Imbuto Foundation and the International AIDS Vaccine Initiative drew young professionals from across the region for a training in medical grant writing. The forum was called, “Africa Young and Early Career Grant Writing” and was attended by Ugandans, Kenyans, Zambians and Rwandans. A strong skill-set in medical grant writing is absolutely key for winning funds for research and building a career in clinical medicine and public health. There is no time like now to start training our young health professionals in the region. We need regional ownership of research and data, and in order to do so, we need diligent young people who are well-trained in the science and art of medical grant-writing.

Click here to read more about this initiative on The New Times.

Harvard Ministerial Leadership in Health Program: Advisory Board Meeting

2011-11-08T03:38:00.000-08:00

On Saturday, 5 November 2011, the Harvard Ministerial Leadership in Health Program held an Advisory Board meeting in South Africa. I gave a talk over Skype on what kind of support would be valuable to Ministers from an international collaboration seeking to provide counsel and expertise. You can read it below. You can also download a PDF copy of the slides I designed and presented for the meeting as well.

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What Kind of Support Would Be Valuable to Ministers?

Honorable Ministers and dear colleagues, ladies and gentlemen:

Before beginning, I would like to quickly thank: the organizers of the Harvard Ministerial Leadership Advisory Board for the invitation to join; and to my colleagues from around the world for your dedication and collaboration. Your question for me was: “What kind of support would be valuable for Ministers”. I would like to first lay the foundation by defining what the role of the Minister is within the Government. And I will use the example of Rwanda.

The role of the Minister depends on the Cabinet; and the role of the Cabinet is to get the country from Point A to Point B in order to improve the situation of the population. Cabinet is akin to a steering committee that validates and enforces decisions of technical sectors for the implementation of the nation’s vision under the leadership of the President-elect. So the Minister’s role boils down to being the implementer of a national vision that is guided by the Cabinet, articulated by the President, and informed by the population.

In Rwanda, Ministries are working together into Clusters in order to maximize synergies and overlaps in target interventions. This Cluster method began in 2009, and divided all Ministries into three Clusters. The Ministry of Health is part of and chair of the Social Cluster, which includes Gender, Education, Local Government, Infrastructure and Youth. These are all of the important ministries for social development. This organization enhances collaboration and cooperation, while allowing Ministers to lead policies and make strategic decisions according to the availability of infrastructural, financial and human resources. This assures connections and smooth implementation. Decisions made must be harmonized with Ministries within and outside of a given Cluster. This also increases each member’s knowledge of what is needed for good social development – it is the same for increasing the economic knowledge for the economic cluster, etc.

Ministers must plan, reach countless targets, and monitor closely – these are not easy tasks, as we need to coordinate and get many national and international partners to work together around one plan. This gathering can bring valuable support to Ministers to identify the goals of the goals of their health sector, what it takes to get there, and identifying what is needed to ensure that the plan stays on course. Based on this example, I see some opportunities for improvement where support for Ministers would be valuable.

For Setting Targets

Agreeing on a shared and inspired vision for your country, because alone you will achieve nothing.
Articulating goals and policies to achieve them by using participatory processes and evidence-based decisions.

For Strategic Planning

Working across clusters and constituencies to build consensus and synergies, and taking a holistic approach for development, as health is not a stand-alone. Health is too important to leave it just to Ministers of Health!

For Monitoring & Evaluation

We need to do periodic measurement of progress and shortfalls by structuring systems for documentation and learning so that we can take lessons to improve our future work. This allows us to rectify quickly when needed – if you implement fast, you increase your targets. In Rwanda, we have already achieved many health sector targets for our Vision 2020, so we sit and review for more ambitious ones. This brings a culture of flexibility and allows us to always do the best at the moment.
Inculcating culture of transparency and accountability for all is key for the success of the sector.

All of this said, we must be very careful to avoid the trap of thinking that simply articulating a vision and planning your monitoring and evaluation strategy will be enough. Setting targets, and measuring how you are doing against them, these are the fun parts. The real trick is in the delivery, and let me be very clear: there are no magic shortcuts here. As the Harvard Ministerial Leadership Advisory Board, we must be sure to also focus on the key middle part of the equation in the middle of this slide – the process of implementation.

I believe that there are seven steps for executing your vision, and each of these must draw on a ministerial culture of discipline and entrepreneurship. First, a Minister must be able to honestly assess the situation of your health sector – to plot where you are right now.

Next, you must choose your team – a team designed to succeed, not one that you are most comfortable with. You need people who have the courage to stand and challenge you. You must have the right people before you can start moving in the right direction.

Third, you must focus on building momentum; this does not mean that you are always progressing at a fast pace – it may be very hard to get things moving at first, but with consistency, small steps add together to become a powerful force with a life of its own.

In order to build such a culture in all members of your team, you as the Minister must lead by a disciplined example. Act out your Ministry’s values in your own actions.

Fifth, I believe that the key to successful execution is to focus on your outputs, in the way that a well-run business does, but in the social realm.

Your team must understand the importance of running your health sector like a business focused on social outputs of health and wealth for the population. You are not after financial profits, but you must measure your progress in health outcomes with the same careful attention that the best CEOs apply to their bottom line. Always have in mind that your end product is health and wealth in a cost-effective manner, meaning the best you can possibly achieve given the investment you make.

Finally, you must be aware of the right time to take advantage of technology to help accelerate your planning cycle and your delivery process. This does not mean jumping at every new gadget – you must be strategic about how a new technology well-applied could make your vision take off. This requires the ability to see ahead. It must also to be a cost-effective analysis, like a chief of industry sometimes invests one million to save ten million.

All of this matters only if Ministers of Health are ready to be the leaders that our health sectors need. When the health sector experiences success, give credit to the. When there is failure, the Ministers have to look in the mirror and take responsibility instead of looking out the window. I thank you again for having me. This presentation contains many ideas that I am ready to develop with you and to share with my colleagues.

Thank you so much for the opportunity to speak with you all.

Health Systems Strengthening and the Role of NGOs

2011-11-07T11:21:00.000-08:00

During the week of November 7-11, 2011, I participated on an expert panel of Global Health Delivery Online. GHD Online is an online platform where health care professionals can come together in online communities to pose questions, debate, and learn from each others' experiences in health care delivery in different parts of the world. (It is free and open to anyone who creates a user account). This expert panel was entitled “Strengthening Health Systems: The Role of NGOs.” The growth in international non-governmental organizations (NGOs) working in health care around the globe raises questions regarding how they can best support in-country governments to strengthen local health systems, and the experts on the panel as well as participants like yourselves will work to unpack some of these complex issues. The panelists included:

Dr. Agnes Binagwaho, Minister of Health, Rwanda
Ted Constan, Chief Operating Office, Partners in Health
Dr. Felix Kayigamba, Access Project Country Director
Christina Bethke, Program Coordinator, Tiyatien Health
James Pfieffer, Medical Anthropologist, “NGO Code of Conduct” Author, and Director of Mozambique Operations, Health Alliance International

These expert panelists were asked to share their thoughts on the role of NGOs in strengthening health systems and address the following questions:

Please describe some of the aspects you consider crucial to NGOs and Ministries of Health working in partnership to strengthen local health care delivery.
What are some of the main challenges of administering joint programs?
How can NGOs best support building local human resource capacity?
How should partnerships between NGOs and the public sector deal with infrastructure needs?
Are there examples of current partnerships you think have been particularly successful at strengthening health systems?

Below I have copied the responses I sent out through the GHD Online Expert Panel Discussion.

QUESTION #1

1) What are the most crucial aspects that make for successful partnerships between NGOs and Ministries of Health?

First and foremost, the country in question needs a vision and a national plan. In Rwanda, it was essential that this plan was part of the national development framework. Further, within that national plan, the health sector must have its own strategic plan. This allows for NGOs to work within the framework of a sector-wide approach like we have in Rwanda (we call it the SWAp, as it is focused on capacity transfer as well as harmonization of NGO and governmental activities). This means that all NGOs working in a country must be committed to the national vision and that the Ministry of Health does not allow NGO partners to diverge from its plan. This structure facilitates coordination within the health sector. However, in order to make this work for in the long run, the national strategic plan must be accompanied by plans for both implementation and monitoring and evaluation.

It is crucial that NGOs do not simply come to Rwanda to implement interventions that have proven effective in Geneva or New York or Washington. Instead, NGOs should implement what has been proven effective (or to work with us to determine what will be even more effective) in Rwanda and respond to the actual need of Rwandans. For this to work across the entire health sector, Rwanda ensures that all planning takes place in a decentralized and participatory process, involving stakeholders at all levels – from the community, all constituencies of civil society, and the local and central government. When the planning is complete, all actors must stick to the result.

Another key aspect for successful partnerships with NGOs is the equitable distribution of activities across the country in order to ensure that the entire population benefits from their presence. The Ministry of Health must ensure that NGOs do not concentrate themselves exclusively in only a few parts of the country. Ministries should make NGOs work together and capitalize on synergies between their areas of work. If they are involved in medical procurement, they should coordinate their activities together to take advantage of economies of scale. Such actions help to avoid duplication of efforts, and they maximize benefits for the population.

For NGOs, it is very important to support the government’s leadership of the national plan, but also to contribute to its design. If there is no comprehensive national plan yet, NGOs should be ready to assist with the planning and implementation of a national strategy that they can be a part of. Such a strategy is not simply a plan for the central government, but the expression of a vision of the entire nation. Collaboration is key – everybody must be brought on board for the inclusive and community-driven planning process in order than it can respond to community needs. Again, however, the government itself must lead, because it is the central agent of planning and implementation efforts. The NGOs and public implementing agencies should be there to buttress and assist in realizing the vision of the government.

As a brief illustration, let us examine the situation in Haiti right now. First and foremost, what should be done is to convince all NGOs operating in the country for the long-term reconstruction efforts to come together and resolve to assist the government in a comprehensive national development plan for the country’s future. A national consultation should be undertaken that identifies the various constituencies and lists all stakeholders in Haiti. The population should be asked directly what their vision for Haiti looks like. All should participate, but the lead voices in orienting the vision should be those of the Haitian population. Together, the government, the population, and Haiti’s many NGO partners could move forward with strategies and planning activities to pursue that common vision for the country. This may seem like a tiring process but it is the only way to assure a comprehensive, participatory plan that takes into account the needs of all.

Fighting corruption is also critical to making the maximum use of the money available. So it remains crucial for NGOs to be honest and transparent about their overhead costs, and for all actors to be accountable be in a framework of zero-tolerance for corruption. In the case of Haiti, the government and the NGOs together need to maintain the primary goal of rebuilding Haiti for all Haitians – never to use the suffering of the population to take advantage of them or gain financially.

In 2005, UNAIDS developed the “3 ONEs” concept for the fight against AIDS: One national authority (the government), one national plan, and one monitoring and evaluation plan. In Rwanda, we have applied the depth and breadth of our participatory approach to planning, implementation and tracking in order to leave no Rwandan outside of the benefits of our progress. And to that end, we always focus first on the most vulnerable to ensure that our entire population enjoys the advancements of our nation’s development."

QUESTION #2

2) What are some of the main challenges of administering joint programs (i.e. numerous implementing organizations with multiple agendas competing for funding and space)?

First and foremost in the health sector is the process of developing a national vision, one that all policies of the Ministry and its NGO partners follow from. It is important for the Ministry of Health to have zero tolerance for any plan other than the national strategic plan for the country. To my fellow public sector officials, you had better demonstrate that you can say no to some partners, because the time that you spend working towards their goals set up in a city very far from your city that are certainly not aligned with your country’s needs is time that you cannot get back. In Rwanda, we are always ready to kindly accompany NGOs to the airport when they are not willing to work with us towards our vision and our plan.

A second and significant challenge is convincing these various organizations that the program to implement is your program – the Ministry of Health’s program, the national program of the health sector. If the program of the Ministry is well done, meaning in a participatory manner involving all constituencies concerned and responding to the needs of the communities, people should understand that we should not compete over labels or ownership over success, because success is shared. This involves convincing everybody that it is a win-win situation for them to join in the Ministry’s program and work to implement it, as they have worked with their national counterparts to design it.

A third major challenge comes from the multiple planning processes we must undertake simultaneously to meet the requirements of our different donor partners. This makes us lose time, does not serve to increase the quality of our services, and decreases the amount of time that all actors dedicate to service delivery. These duplications result from having to report to donors according to different timeframes and different indicators, despite the fact that we have our own indicators that are adjusted to our own context. If all of our partners used one set of indicators, reporting and harmonization would be much easier, but it is very difficult to push others to use your own indicators.

What we have done in Rwanda is to prioritize our indicators and ask our partners to conform to them. This has not worked for all partners, and it is a continuous fight over definitions even with the best partners such as The Global Fund to Fight AIDS, Tuberculosis, and Malaria. For example, we wasted months two years ago in a struggle with TGFATM over the definition of good diagnosis and treatment for sexually transmitted infections; our national protocol wanted to follow the World Health Organization guidelines of using a syndromic approach. The Global Fund insisted on laboratory confirmation. So, they told us that we were using a bad practice, and were about to cut grant money for these activities, and we had to struggle for weeks to impose our national protocol.

A fourth challenge is to make evidence-based decisions and to convince partners to join in the implementation. This means that we need to promote operational research and to obtain the capacity to do fair and true assessment, analysis, and monitoring and evaluation. This requires the creation of a culture of discipline and entrepreneurship throughout the Ministry of Health and the entire health sector; once this culture is created, NGOs themselves need to be part of and strengthen it. The challenge here is also that partners do not have the same needs in the realm of research that we have; we simply want research that shows us where we stand and where we want to go – research that we have ownership over. Partners, however, often have their own research priorities that are generalizable and based in many countries so that they can compare their own work over time. If you are not careful, you can find your health sector spending time on research that does not benefit your programs or your population. Setting up your own national research agenda is important.

To return to the example of Haiti, we need NGOs and their leaders to have the moral and ethical foundation to commit to helping the government construct an inclusive national plan that respects national ownership. It is the duty of the government to articulate a vision using a participatory process with the population first of all, to design a national strategic plan, to coordinate its implementation – meaning the activities of all sectors: public, private, community, national, and international.

The final challenge has largely been untouched by many in global health – ministries of health and NGOs alike. We can have the vision, the strategic plan, a good M&E system, but we need to use rational ways of implementing our policies to make the money work. An area that very few people are focusing on but one that makes all the difference is in the details of how you implement – how you actually deliver the services most equitably and most effectively.

We need better NGOs, and we need the government to understand that it is its duty to design a strategic plan and to regulate the activities of their NGO partners so that they truly meet the needs of the population and implement in the best of our collective capacity."

QUESTION #3

3) How can NGOs best support building local human resource capacity?

From the perspective of the government, there are several critical concepts to understand, develop according to context, implement and maintain on all levels with respect to supporting human resource capacity. Underlying these four steps is ensuring that the definition of the word “support” in a given country is understood in the same way by the government and the non-governmental entities. In Rwanda, to support does not mean to dictate or to take the lead and control a given initiative or partnership. Support is technical assistance with long-term capacity transfer components to ensure sustainability. Governments cannot complain about their development partners if they don’t take the lead to assure a shared understanding of the word support.

Before inviting technical assistance, a country should always have a human resource capacity vision that is articulated in a national human resources strategic plan and an annual implementation plan. If you do not know where you want to go – how many cardiologists and pediatricians you want – how can you know what assistance to invite to your country? And how many you have to train to replace these foreigners over time? It is impossible. When a country has a national human resources strategic plan, we should not allow NGOs to do something outside of that plan. Instead NGOs should strengthen the plan. Moreover, governments must maintain and stand by their definition of support and their vision for human resources. If there is any flexibility in the aforementioned, you risk allowing development partners to run your health sector strategy on human resources forever, as you will not have built the capacity to replace them over time.

The first mechanism to put in place after defining the word support and articulating a national vision is to ensure that incentives are in place to keep human resources in-country and in the public sector. It is essential to have similar salaries in the public sector and in the NGOs. In Rwanda, there are specific guidelines for all people employed by NGOs doing care delivery. For those with very specific specializations, these salaries need not match public sector salaries. However, Rwanda still enforces the rule that the NGO-employed specialized care provider transfers capacity to health professionals working in the public sector. This mitigates national brain drain from public service to NGOs.

This brings me to the second mechanism. All development partner-employed care providers are to be paired with national professionals in order to enhance the capacity of our public health system and to uphold Rwanda’s valuation of equity. In fact, in Rwanda, to be a technical assistant you must prove to the Ministry of Immigration and Emigration that you are paired with a Rwandan national to transfer capacity.

The bottom line is to ensure that financial incentives are in place to keep your “brains” in the public sector, and ensure that the assistance you are receiving is sustainable and aligned with your country’s vision.

As all medical training is done with public money out of multilateral and national support (including taxes), we ensure that the training that our physicians receive is paid back to the population over time. Even within the public sector, all Rwandan-trained physicians must sign a contract on completion of their MDs that they have to work for 2 years at the district level. For Rwandan-trained physicians who wish to specialize, each person must sign a contract that they will work for 4-5 years in the Rwandan public sector according to the specialization they receive. During these timeframes where physicians work in the public sector, they are fully paid. This assures an equitable distribution of expertise, and assures that after 2-5 years we can replace them with a newly trained physician if they wish to leave the public sector or leave Rwanda.

But, I must tell you that so far nobody leaves Rwanda, people are even coming back from their training in other places. In place of brain drain, we have a brain faucet. And I am one example of that! What I can achieve here is far more than I could have achieved in the West or North if I count my work in lives saved and improved. And all of my colleagues here have the same feeling because of the environment we are working in in Rwanda.

To make NGOs work, you need a national human resources strategic plan. To avoid brain drain, you need to harmonize salaries between those who provide services that are paid by the public sector and those who are providing services that are paid by NGOs. To avoid international brain drain, you must create an enabling environment for your health care practitioners, including those with specializations."

QUESTION #4

4) How should partnerships between NGOs and the public sector deal with infrastructure needs?

This is the weakest part of our partnerships so far. This doesn’t concern only buildings but also equipment and material, in addition to the national capacity to build infrastructure, and to choose and use and maintain equipment. So often in many countries, partners find it very easy to buy the pills to put in the mouths of the patient, but not to train practitioners to do it, not to buy equipment that can accurately measure effect of drug, and not to pay for infrastructure required for service delivery. Then, when support is finished, partners leave nothing behind. And there is no sustainability.

To overcome these challenges, we have set human resources development as our priority through our human resources for health strategic plan. We have included in this plan not only physicians and nurses, but also engineers because this technical expertise is a requisite for sustainability in service delivery. In Rwanda, we have set a policy on equipment and maintenance allowing and ensuring that the Ministry verifies all equipment, assures it can be maintained by our people and so on. But this was not the case before, which is why we receive a dialysis machine from an donor organization in a Western country. On it was written “NOT FOR HUMAN USE”. We don’t know what it was supposed to be used for, but it cost us a lot of money to destroy that. This is how the developing world sometimes turns into the filthiest garbage dump full of refuse from the Western world.

We also try to coordinate all the materials we purchase in order to assure that maintenance capacity exists either in Rwanda or in a neighboring country. If this is not in place, we can remain idle for months with a fantastic piece of equipment that is not working for us because we do not have the support to repair or maintain it.

For infrastructure and building, we have sought very special partnerships with those who can support valuable construction. We especially seek partnerships with those NGOs that are using national materials, ensuring infection control, and are also teaching our students of architecture and engineering how to construct valuable buildings. But I can count those partners on my left hand, unfortunately. We have very few, but we hope that there will be more because this is true sustainability and true development."

QUESTION #5

5) Are there examples of current partnerships you think have been particularly successful at strengthening health systems? Conversely, can you provide examples of 'partnerships' that aren’t working and explain why not?

For the most helpful illustrations of such polar opposites, I find it best to think in general terms. Below I have outlined the characteristics of strong partnerships between governments and NGOs, and weak or harmful partnerships between governments and NGOs. While this outline is not exhaustive, it includes some of the key aspects of each pole that are of most concern in Rwanda.

An NGO seeking to work as a strong and useful partner to the Ministry of Health:

Joins the country in designing a national plan for economic and social development
Helps the health sector to develop a strategic plan as an integral piece of the overall national development plan, and help all subsectors (NGOs, disease-specific divisions of the Ministry, procurement agencies, etc.) to develop their own plans in a way that is well-aligned with the national health sector plan
Goes where the biggest needs are (not the prettiest beaches!), and partners with the public sector to prioritize the most vulnerable first and foremost… when we focus on the most vulnerable, we bring everyone up
Undertakes their work with the aim of “working themselves out of a job” – not staying forever with the intention of creating job opportunities for their own grandchildren at the same NGO

A self-serving NGO that can undermine the goals of the Ministry of Health:

Moves about the country with an arrogance that says, “we love your people more than you… we know your needs better than you do… and we know how to implement programs better than you.”
Undertakes activities with the primary aim of looking good in the eyes of others in the international community, prioritizing the image they see of themselves in the mirror instead of truly investing in national development
Confuses the notion of working as partners for development with lounging at Club Med, simply researching good beaches and pay grades, not actual means of addressing the suffering they exploit from a distance
Swallows more than 15% of the money they receive to work in your country for overhead… To put it simply, we are merely the pretext for the staff of such NGOs to have a good life
Makes humanitarian work a systematic business for themselves, with outcomes measured in money for themselves – not health and wealth for our population
Leaves the country in a worse state than before they arrived, because they didn’t work to create sustainable health systems but rather dependency… When such NGOs depart, the people don’t even know how to do what they knew before"

Rwanda, The Entrepreneurial Nation

2011-10-20T01:15:00.000-07:00

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

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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.

My Message to Activists at Dartmouth Rallying for Global Health Funding

2011-10-15T11:35:00.000-07:00

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.

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

2011-10-03T14:18:00.000-07:00

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 (ClinicalTrials.gov: 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.

Sincerely,

Agnes Binagwaho, MD, PhD

Minister of Health of the Republic of Rwanda

ODI Report: Mapping Progress

2011-09-20T22:41:00.000-07:00

On Thursday, 15 September 2011, the Overseas Development Institute (ODI) launched its “Mapping Progress: Rwanda” report in Kigali. The report represents the culmination of a research project on progress made in various areas of development that was undertaken across 24 countries. ODI identified Rwanda as a country that has made surprising progress in the Health Sector.

The ODI report’s central message that Rwanda “has defied the odds by delivering unexpected progress in health” by “rebuilding its health sector and delivery significant improvement to the health status of its population.” Rwandans have known this for years, and I would argue that our results are not so unexpected when one considers the strong leadership and unwavering commitment to health equity from His Excellency President Paul Kagame, our dedicated healthcare providers at all levels of the sector, and, of course, the Rwandan people.

The Ministry of Health is proud of how far our country’s health sector has come, but realizes that much work remains in assuring every Rwandan geographic and financial access to high-quality medical care. Please find below a press release about the event by ODI. The full report can also be downloaded for free at: http://bit.ly/pkXoJf.

Progress against the odds in Rwandan health

Rwanda has defied the odds by delivering unexpected progress in health according to a newly published global research project. The UK based Overseas Development Institute reports that following years of civil war and genocide, Rwanda has managed to rebuild its health system and deliver significant improvements to the health status of its population. Life expectancy in the country has doubled since the civil war, and today 60% of the population lives within 5km of a health centre. An effective partnership between donors and the Government, coupled with a community health insurance system covering the whole population, have been instrumental in delivering this progress.

So-called Surprise Performers such as Rwanda have delivered progress against the odds, often recovering from crisis and war or dealing with ongoing conflict, challenging political situations and highly inaccessible topography. The surprise elements of progress in these countries often lie in the speed of recovery, sometimes allowing them to surpass previous levels of development.

Dr Liesbet Steer of ODI said: “The performance of Rwanda is a reason to be optimistic about the country’s future. It’s time the world woke up to the change that is happening across the developing world and we believe this report provides the evidence needed to begin altering perceptions.

“We have identified four key drivers of progress but there is no one-size-fits-all solution to the conundrum of progress. What we can now say with clarity is that progress in development is not only possible, it is happening.

“Looking at the strongest examples across Africa we can see that the most transformative and sustainable developments have occurred when the commitment to change has come from within countries and communities.”

My New York Times Letter to the Editor: "Mobilized Against AIDS"

2011-08-24T04:24:00.000-07:00

Last week, New York Times reporter Donald McNeil Jr. published a story comparing the global fight against HIV/AIDS to smallpox eradication (http://nyti.ms/nAxfZH). He made several misinformed claims about AIDS activism in Africa that I thought should be challenged.

My Letter to the Editor, entitled “Mobilized Against AIDS,” was published today: http://nyti.ms/pmnhEC.

Below is the full text of a Letter to the Editor that I submitted before it was shortened by an editor.

To the Editor:

Re “Pathogens May Change, but Fear Remains the Same” (Essay, Aug. 15):

Rwanda has fought for the last decade to provide free universal access to antiretroviral therapy for all HIV-positive residents who are clinically in need. Who do you suppose is most responsible for this achievement? Not the European Union or America. It is our government. Activists here and around the continent continue to mobilize and, in partnership with countries like yours, are making incredible progress in the fight against HIV/AIDS.

Monday’s article in the Times painted a false picture of all Africans as fatalistic victims of the virus instead of activists who are building the global movement to demand access to the fruits of modern medicine. Rwandans are in no way resigned. We battle not only for ARVs, but also for peace and reconciliation. We battle for quality healthcare, and we are winning. In just five years, we have reduced child mortality by 50%; I could go on if I had space.

Next time, before printing, do not use metaphorical anecdotes about your experience in airports as an anthropological metric – actually come see what we are doing to fulfill the human rights of our population. You are welcome in Rwanda.

Agnes Binagwaho 

Kigali, Rwanda 

The writer is Rwanda’s minister of health and a senior lecturer at Harvard Medical School.

Accelerating the MDGs through ICT: The Case of Rwanda

2011-06-29T09:36:00.000-07:00

On June 10, 2011, I was part took part in a high level working session at the United Nations Headquarters in New York on “Digital Health for Digital Development: Connecting the Millennium Development Goals and Non-Communicable Diseases in 2011.” In Rwanda, information and communications technology (ICT) in the health sector is key to what we have accomplished in the past five years.

Utilizing various forms of ICT, we have been able to create and monitor a health system that allows both urban and rural populations to benefit from services. This system has improved financial and geographic access to quality health care throughout the country, even to those most impoverished.

Over the course of the last five years, the under-five mortality rate has dropped by half, we have achieved universal access to HIV therapy and we are now addressing HIV/AIDS as a chronic disease. The percentage of married women using any modern method of contraception went up from 10 % to 45%, and the access gap has narrowed rural and urban married women. More women than ever before are now delivering their babies in health facilities; the current facility-based delivery is 69%, much higher than the 30% we had in 2005. More than 95% of Rwanda’s 11 million people have health insurance. Full vaccination coverage is now 90%, when it was 70% in 2005. The percentage families who seek treatment for children from a health facility provider has also increased. Pediatric treatment sought for acute respiratory disease has risen from 26% to 50%; for diarrhea it increased from 14% to 37%; and for fever it went from 27% to 43% in 2005.

The aforementioned achievements have led to a dramatic increase in life expectancy in Rwanda. And yet, in fighting the current top killers, we are only able to increase life expectancy to approximately 54 years, since infectious diseases do not fully account for morbidity and mortality rates in Rwanda. Our health sector still has serious gaps with respect to delivery of services for non-communicable diseases (NCDs). The World Health Organization has estimated that NCDs account for about 25% of the national burden of disease in Rwanda; however these disease have yet to be addressed in a strategic and systematic way.

To be able to reach the Millennium Development Goals, we need to reinforce prevention, care, treatment and rehabilitative services needed for both communicable and non-communicable diseases without decreasing the attention we currently have on combating communicable diseases. In doing so, we will need to ensure that care for all diseases – including chronic illnesses – is accessible to all.

Accordingly, over the next five years, Rwanda anticipates expanding access to integrated chronic care by building on the existing healthcare platforms established by programs fighting infectious diseases. We plan to embrace information and communications technology to expand care through several high impact interventions, mainly referred to as e-Health solutions. E-Health solutions are vital in order to create an effective and sustainable health system. Such innovations help to solve challenges in health system, including the lack of infrastructure and the shortage of professionals. Since roads are still difficult to traverse in some remote areas, ICT facilitates the sending of information, plans, and reports between urban and rural areas, saving both time and money.

Rwanda further supports ICT for health because the right to health cannot be separated from the right to information. And the use of new technologies and communications interventions are the most accurate and timely way to provide information. The flow of information in Rwanda concerns four stakeholders in the health sector: the patients, the policy makers, the healthcare providers and the program managers. As for patients, there must be strong health education platforms to inform them of how, when, and where to seek proper care. Also, once on treatment, patients should know the reasons for which it is important to go for timely medical follow up appointments and be compliant to treatment. This is extremely relevant, since follow-up appointments not only aid their recovery, but they also avoid dangerous resistances to epidemic diseases like TB. Patients would be informed of these issues through ICT tools made available to health professionals at all levels: community health workers would use their cellphones and central and district managers, health centres, district hospitals and referral hospitals would use web-based tools. For policy makers and program managers, ICT is essential because it enables the design of health policies and programs that are informed by evidence and based on up-to-date information. In general, the use of ICT has proven to be a very effective, secure, rapid and accurate way to serve patients and program managers. This is why the Government of Rwanda has put ICT as a top priority for the development of its health sector recognizes that there is an urgent need to build e-Health capacity.

As such, Rwanda has embarked on an ambitious journey to ensure that technological innovation becomes a central part of the healthcare ecosystem.

The initial phase began with devleoping a policy, a strategy and an action plan. Our health sector ICT plan is integrated into two master plans: our health sector strategic plan and our national ICT plan. Many applications of E-health have already been installed. One example of such applications are web dialogues. These are entry points for information access and exchanges between professionals and semi-professionals who work in remote areas, and therefore have difficult access to journals and books. It is also a tool of sensitization, reflection, idea expression, and innovation. Since it is virtual, it does not require physical infrastructure and runs at no cost. Through the exchange of biological and immunological patient information, x-rays, ultrasounds, lab samples for cancer, and so forth, clinicians can receive data, confirm diagnoses and make informed decisions. For example, health facilities in the US and Europe connect Rwandan health professionals to counterparts in other countries through the internet. This allows for free communication between these countries and comparison of differential diagnoses, among other core features. ICT also allows for the horizontal exchange of information between policy makers, programs managers, and community workers at the grassroots level. It allows for vertical exchange between those three categories, thereby breaking down barriers to knowledge and communication. This has created an international family of global health workers that help to bring international communities on board with the decisions that concern them. These communication exchanges can take on many different models allowing countries to choose which one best suits them. As a result, we can quickly gain time by building on the experience of our peers around the world and web-based free information can dramatically improve local, national and global health.

Without ICT, all of Rwanda’s programs in the health sector would be unmanageable. For example, the healthcare financing system is web-based and manages over 90% of Rwandans enrolled in health insurance, along with a performance-based compensation program in our 450 health facilities. Rwanda’s ART program, which provides antiretroviral therapy for 80% of people living with AIDS in need of treatment, is also managed through web based technology. Now that we have started to tackle non-communicable disease we are in need of ICT more than ever.

Over the past few years, we have also seen an emerging area where healthcare is delivered using mobile phones, otherwise known as mobile health (or mHealth). ICT also allows Rwanda to gather localized MDG reports. Community health workers and health professionals do active case findings on fever and malnutrition, perform maternal mortality audits, and collect information on all maternal deaths in the country via mobile technology in order to better understand why young healthy Rwandan women can be at risk of death during pregnancy or delivery. Additionally, many other programs in Rwanda have web-based management, such as health surveillance, public health reporting, drug procurement, drug tracking, the blood bank, and E-learning. One of our big challenges is in coordinating ICT tools so that these web based management systems are efficient and synergetic.

Given all above reasons, it is clear why the Government of Rwanda has put ICT as a top priority in the development of our health sector, as it recognizes the urgent need to build e-Health capacity in order to provide and maintain highly effective, reliable, secure, and innovative information systems to support clinical decisions, patient management, education and research functions. This approach will be crucial to ensuring the sustainability of an integrated and coordinated healthcare system in Rwanda which will efficiently provide high quality, gender-, geographical- and age-equitable services.

The final advantage of using an ICT approach is that we save trees since we are saving the paper used for plans, reports, files, mails, and so on. At a time when experts recognize the danger of global warming to the Earth, environmental programs should also award the use of ICT by the Government of Rwanda!

In Rwanda disability is not solely viewed as health issue; it is also viewed as an issue of development and human rights

2011-06-15T19:55:00.000-07:00

Last week, in New York, I participated in the launch of the first ever World Report on disability alongside the World Health Organization and the World Bank. This launch marks a critical step toward expanding our reach as global health activists.

According to the Report, 15.3% of Africans have disabilities. This equates to approximately 151 million African men, women, girls and boys or about 15 times the population of my own country, Rwanda. In Rwanda, the ratification of the Convention on the Rights of Persons with Disabilities (CRPD) and the Optional Protocol occurred in 2008. We are committed to ensuring that all Rwandan citizens are supported and included in our society.

Disability is not just a health issue; it is also an issue of development and human rights as people with disabilities face particular barriers to health, education and social services. Many are poor or become poorer due to their disability, and find great challenge in accessing appropriate transport and communication devices. From the perspective of a health minister, policy must address barriers faced by people with disabilities. These barriers should be removed or minimized for the health of the individual and also for the health of society.

The World Report on disability recommends better education and training of health workers so that they can better understand the need to include people with disabilities in mainstream services. I fully endorse this principle. However, this is not enough. We also must invest in the training and provision of skilled staff to rehabilitate persons with disabilities, a service that is vital for those who are born with disability, and for those who become disabled as a result of disease, injury or conflict. This concerns physicians who specialize in rehabilitation, in addition to psycho-social therapists, and engineers.

Human resource capacity for health care is a serious problem in Africa. We do, however, know that rehabilitation delivered at the community level (as opposed to transfers to central hospitals) can ensure the timely delivery of care, and ensure that disabled persons continue to be integrated into their community in positive ways. In the community based approach, children can be empowered to go to school, and adults enabled to engage in productive work. Without rehabilitation, and without appropriate devices, people with disabilities remain dependent and excluded from mainstream society. We must do something about this problem in the months and years ahead, and make sure we permit everyone to access the services they require to maximize their functioning. Rwanda is committed to this effort, in line with our responsibility to implement Article 26 of the CRPD.

And yet we must also remain vigilant, for impressive treaties and comprehensive reports will not have their desired impact, unless we are willing and able to make a difference at the grassroots level - in the clinics, in our schools and in workplaces.

Much needs to be done in this regard, and we can start by learning from best practices in Africa that address the barriers encountered by people with disabilities.

There is also a need to ensure that people with disabilities and their families are supported and informed so that they can take control of their own health. People with disabilities often face extra costs as they must pay for a taxi given that the bus is not accessible. They may require special diets, or other types of extra support. We must tackle these barriers and added costs. In low income countries, lack of funding prevents us from providing the entire package of healthcare services needed. Given this limitation, as the Report emphasizes, people with disabilities are 50% more likely to suffer catastrophic health expenditure than non-disabled people. Thus, it is important to reduce out-of-pocket health costs wherever we can.

If we do not remove or minimize the barriers, and if we do not meet these specific needs, then we are not including and supporting people with disabilities to the best of our ability. This report has two chief recommendations that we must strive to achieve with efficiency, appropriately and effectively. (1) Remove barriers to our mainstream services, and (2) ensure the provision of specialist services. Each country will have to find the strategic plan that works the best in that setting, and and will need improved policies, changed attitudes, more research, more involvement of people with disabilities in policy development, and more coordinated action.

There is also a need to focus on removal of specific barriers created by individual disabilities, giving people with different ailments the same chance to access promotional, preventive, and curative health services. This approach will reduce marginalisation and stigma, and provide access to services adapted to the specificity of different handicaps. Such programs would be integrated across the health system. We need specific tools and specific counselling approaches, adapted to each disability. All such programs would respect confidentiality, be of good quality and protect human rights. This is how Rwanda aims to provide health services for its sick and disabled..

Currently in Rwanda we have over 30 specialized centers across the country receiving and taking care of persons with handicaps. We have promoted the creation of more than 15 associations concerned with the Rights of Persons with disabilities. Many of the associations operate at the national level. People living with disabilities have a representative in Parliament; and we have an umbrella of associations of people living with disabilties that promote HIV/AIDS awareness and other health issues. This umbrella association is fully supported by the government and elected among the associations of people with disabilities, by the associations themselves, to represent them. This umbrella serves as their voice in all matters concerning health. People living with disabiltiies are included in planning and follow up of programmatic and financial impelementation of activities in the health sector. In order to improve planning and advocacy we decided two years ago to conduct a census of people leaving with disabiltiies. In 2010 we called on each of the 3 community health workers in each village to visiting all houses in their communities to do the census of people with disabilities – including age, gender, and type of disabilty. Out of a total population of 11 million, approximately 522,850 people were found living with disabilites. Now we are designing a project for clinical evaluation of all the disabilities in order to budget the care and treatment needed to rehabilitating these persons. As written in the Rwandan constitution: health is a human right for all. In that context, Rwanda will make every effort to advance this agenda for the rights and inclusion of persons with disabilities. This is the duty of each and every person in the health sector. This report should inspire our friends and neighbors in Africa and around the world.

The Right to Health cannot be separate from the Right to Information

2011-04-22T14:22:00.000-07:00

Every human has a fundamental right to health. This includes the right to accessible services, and the rights to prevention, care, and treatment. In theory, the right to access should be equally distributed to all. In Rwanda, we strongly believe in this tenet. However, at present, it would be impossible for Rwanda provide all to everyone given how limited resources are. And yet, what we are able to do is to ensure that we continue to take the maximum measures to break barriers to access as the right to health care access also means making sure you take care of the most vulnerable groups. In targeting the most vulnerable populations, we remove financial, geographic, gender and age barriers and thereby render the situation more equitable. By focusing our efforts toward vulnerable children, pregnant women, and marginalized people, we expect to advance the quality of life for Rwandans and make life in Rwanda enjoyable for all.

In understanding what it means to grant individuals the right to health, we must acknowledge that this right is inextricably linked to the right to information. The right to information not only concerns the quality of the information but also the availability and dissemination of information through all channels, including the Internet. For policy makers and program managers, it is vital to be well informed in order to design health policies and programs that are evidence-based with accurate information. Moreover, in order for people to seek health services they need to be informed about existing services, and also about foreseen benefits or possible side effects or other disadvantages. If not, people will come to the wrong place, or go to the wrong person, at the wrong time.

Today, the right to information must also be considered a basic human right. We can recall in wartime Germany that Hitler started by controlling the information citizens were given in order to control their lives. Today the Internet is the biggest source of information. Access to the Internet provides persons with access to information from around the world. This is why Rwanda has put information and communications technology (ICT) as a top priority in our development plan. In the past, before 1994, Rwanda has seen its fair share of poor politics of information sharing.

In what ways did former leaders prepare the Rwandan genocide in 1994? They controlled the Radios and TV. Without free access to information, people are bound only to what they are told.

Today the world is a big village. With the Internet there is access to a web-based library in less than one second. With the Internet, I can inform the global family of health providers of a question that is disturbing me, give an answer to a colleague, or simply send information.

Concretely, and in practice, what does it mean for Rwanda to make ICT a top priority? It means providing Internet access to all, particularly the 57% of Rwandans living below the poverty line. We are doing this by making primary education accessible to all, and we are continuing and improving a program called “ One laptop per child ”. Through this program, in all schools, every child will in the future, have access to a computer and to Internet.

People have questioned us: “Why do you need Internet when Africans are illiterate?” We answer, “Bring the tool, make people love it, and they will learn to use it.” Learning by doing is a principle for quick development. Furthermore, computer literacy is proven to improve reading and writing skills – the two are linked. Rwanda has shown that even in remote areas people are using the Internet. We can not leave out any Millennium Development Goal (MDG) if we want to succeed in our journey to development, and communication is an essential MDG.

Open Access Journals are strong modes through which we can improve access to health care.

Free, web-based medical journals are a good entry point for granting access to information for those in the health field. Free online journals are tools for sensitization, reflection, expression of ideas, and innovation; and they are virtual, and cost nothing.

It is necessary to not only have passive access to information, but also to exchange information with our peers. Such exchanges allow professionals to confront ideas and challenge each other in order to make better, more informed decisions. Increasing knowledge is not like mathematics in which one piece of information plus one piece of information equals two pieces information. In the context of online exchanges about health issues, pieces of information are more than the sum of their parts. Open Access Medical Journals are great tool to multiply knowledge, and to make a thousand pieces of information out of two. And yet, this is just one piece of the puzzle to improve healthcare. We need to consider open access in association with other tools: for example Global Health Delivery Online (GHDonline.org) a website that connects and allows dialogue between media specialists, health specialists, general practitioners, nurses, Community Health Workers in more that 140 countries.

Global Health Delivery Online and other open access sources (e.g. journals) allow communication between countries on several levels. They allow horizontal exchanges of information not only between policy makers in different parts of the world, but also between programs managers, and community workers at the grassroots level. But more importantly, it allows vertical communication between all those categories as well. As such, we are enabled to break horizontal and vertical barriers to knowledge and communication. This creates an international family of global health workers who bring communities on board with decisions that concern them. Finally, these modes of exchange break the affectation of people who believe that knowledge is only for selected part of societies.

These open tools create a progressive, and efficient revolution for the good of humanity. Web-based, free information will dramatically improve global health as it will make many models available for countries to choose from and decide what best suits them. As a result we gain time by using knowledge from around the world, and we are able to quickly build on the experience of our peers living near or far, and they from us.

Another basic development tool is access to education. As stated above, for access to health care, people need to be educated. For instance, in the fight against infection the presence of many health centers does not mean people go to the centers. If people have a diagnosis, but do not seek care and treatment they may spread the disease. Therefore, we need to inform the population on where to get care. In addition, we must educate people on how to care for themselves; how to take drugs; and why its important to be compliant to the treatment not only for them but to avoid resistance; and why noncompliance is dangerous for the region, for the country, and for the world.

Increasing health, education, and information is all tied to poverty reduction; and increasing access to education, information, and health is at the heart of fighting against the cycle of poverty. Supporting Open Access Journals is supporting the world on its journey to real democracy, development, and welfare. Taking the example of Rwanda, during the decades of colonialism and before the current leadership, the country was run based on segregation. Education, health care, and information were not “for all”. The segregation was based on geography (North versus South), and on ethnicity (Tutsi versus Hutu). There was no promotion of gender or child wellbeing. This led to the denying of human rights and to the horrific genocide of 1994 – one million persons murdered in one hundred days as a result of brainwashing by leaders using information against humanity to push people to kill and to destroy. It rolled back our development. People are not bad at birth, but bad information and bad education can do this to good people.

In sum, we must continue promoting access to information, education, health care, …

Promoting family planning is a necessity for saving mothers’ lives and for Rwandan development

2011-03-30T11:55:00.001-07:00

Family planning means controlling the size of your family to one with the number of children you are able to feed, educate and care for in general. Rwanda has several reasons to promote family planning. One of our most important targets right now is the fight against maternal and child mortality – this is a substantial challenge for the health sector in Rwanda. We know that birth spacing of fewer than two years is linked with a child mortality of 186 deaths for 1,000 live birth but if we manage to convince families to have birth spacinf of 4 years the child mortality will reduce to 65 deaths for 1,000 births. With respect to maternal deaths, we have the evidence that shows that a birth spacing of 3 years reduces maternal mortality by 45%.

Another important reason to promote family planning is that our economic development needs it. For example, the most recent national demographic and health survey, in 2005, shows that Rwanda has a fertility rate of 5.5. With this fertility rate we will count 21.5 million Rwandans (up from apprxomiately 11 million now) by 2035. Since we have a very young population, even if we reduce dramatically the fertility rate to 2.3 children per woman we shall still have a population of 16 million Rwandans by 2035. In not reducing the population growth we are at risk of having huge consequences on many other sectors in addition to that of health. For example, in the education sector, we have fewer than 30,000 teachers in primary school. If we continue at the same fertility rate, by 2035 we will have 3.4 million children in primary school in need of more than 76,000 teachers. Even if we reduce the fertility rate to 2.3 we will have 2 million children in primary schools in need of 46,000 teachers. This second scenario is not ideal, but certainly would be better. Fewer children in the classroom will allow us to train them better, with higher quality and better trained teachers. In other sectors, the growth of the population might outrun our economic growth and land capacity causing overexploitation, deforestation, erosion, loss of soil fertility, and an overall fall in productivity.

We are on the journey to development, and we are better today than we were before. But we may reverse all of this if we do not put family planning at the forefront of our programs. This would force us to divide the gains we have now with too many people which would create a serious negative impact on access to quality health care and to quality education ultimately oiling the vicious wheel of poverty.

That is why in our Vision 2020 and Economic Development and Poverty Reduction Strategy (EDPRS) for 2008–2012, Rwanda recognizes the impact of rapid population growth on socioeconomic development and is committed to reducing high rates of fertility through family planning.

That is also why the Ministry of Health promotes all type of safe modern methods of family planning recommended by the World Health Organization. The objective is to meet the needs and the preferences of families. This realistic and strategic approach allows us to effectively satisfy the demands for family planning, ensuring that all Rwandan couples who want to space or limit their births have the choice of and access to quality reproductive health services, including a full range of contraceptives consistently available at affordable prices.

These methods comprise, among others, vasectomy for men and tuber ligation for women. The applicants to these definitive methods have to sign a consent form as these non-reversible methods require evidence of voluntary choice after full counseling.

To raise awareness about vasectomy and tuber ligation, the Ministry of Health provides true information to the population through multimedia campaigns. Moreover family planning is discussed during community meetings such as Umuganda and meetings with committees and opinion leaders. For vasectomy, associations of men speak about how they have experienced it, and talk about it to applicants. Vasectomy is a safe and effective permanent contraceptive method that makes men play an active role in controling the family size. When compared with tubal ligation, which usually requires hospitalization and general anesthesia, vasectomy is more simply done under local anesthesia as an outpatient procedure. Men recover quicker from vasectomy (1 hour) than women do from tuber ligation.

We know why people who want to undermine Rwandan development and progress brought the controversy about vasectomy. They say we want to use that tool for bad political purposes against the rights of humanity. But this was a lie, and was aimed to serve bad politicians. Nevertheless I have a question to those who have listened with complacency to that controversy around vasectomy? And why they didn’t assoiate themselves to an identical controversy around tuber ligation – especially since tuber ligation has been performed for so many decades, and is more painful and has more side effects? Was this controversy supported by underground machismo intent?

We need to take the extra mile to reduce mortality and morbidity due to infectious diseases

2011-03-23T11:35:00.001-07:00

The world has made great progress in the fight against infectious diseases. Rwanda is no exception, and yet there is still a long way to go.

The restitution of the mid-term review of malaria progress, disseminated over the last two weeks, show us we can be proud of our achievements. Results showed that in Rwanda, consultation, hospitalization and deaths due to malaria have decreased by over 60%. These are great results but the major lessons learned during the mid term review is that these gain are fragile; and if we don’t keep up efforts we can roll back the malaria-safe environment we have created for our population.

Concerning the fight against HIV, 78% of pregnant women are correctly using PMTCT services along with 75% of they companions. If we take the extra mile, pediatric HIV may become history. As a pediatrician, this is a dream for me. People living with AIDS are currently being provided with universal access to anti-retroviral therapy (ARTs); ARTs is accessible to all those in need ( around 84000 people). And yet, we need to remain vigilant by continuing to perform well in starting treatment on time to and sensitize people to ensure 100% compliance. This will avoid resistance to drugs and future deaths.

In the area of prevention we have the new Prepex device that we have proved to be safe quick and requiring no anesthesia, no sterile environment and no specialized professionals.

Regarding the fight against tuberculosis: the policy for TB/HIV services has led to great success in detection and treatment. But there must be consisten effort to avoid multi-resistance tuberculosis.

At the community level, Community Health Workers are trained by the Ministry of Health on how to treat at home for gastrointestinal diseases with oral rehydration solution and improved diet as well as pulmonary diseases with Ampiciline.

It is clear we have made much progress in tackling communicable diseases; yet we still we face many challenges in basic hygiene such as washing hands, safe latrines etc. The ongoing hygiene campaigns in Rwanda under the leadership of His Excellency President Paul Kagame will help to go the extra mile for the reduction of morbidity and mortality due to infectious diseases. We are working hard on this.

My message to Partners In Health (PIH): an association that has dedicated decades to improving the welfare of the world's vulnerable

2011-03-22T05:30:00.000-07:00

The Government of Rwanda views healthcare as a basic human right. National healthcare delivery is rooted in Rwanda’s commitment to addressing the health concerns of all Rwandans while paying close attention to the most vulnerable persons. This rights-based approach has permeated Rwanda’s health strategy. It is articulated in Rwanda’s Economic Development and Poverty Reduction Strategy, Rwanda’s Vision 2020, and the United Nations’ Millennium Development Goals. The general aim is to engage the nation in a participatory effort to eradicate poverty and the many ills it brings.

This Guide aligns itself with the overall healthcare strategy of the Ministry of Health of Rwanda, specifically in the regulation of development partner initiatives, and in the promulgation of policies and the execution of programs.

Over the past decade, Rwanda has seen under-five mortality drop by half. We have achieved universal access to HIV therapy and now are able to address HIV/AIDS as a chronic disease. More women than ever are delivering their babies in health facilities, and more than 95% of Rwanda’s 11 million people have health insurance. Rwanda’s successes in preventing and treating top killers – malaria, tuberculosis, HIV/AIDS, respiratory infections, and diarrheal diseases – have led to a dramatic increase in life expectancy. With over 400 health centers, 42 district hospitals, and 45,000 community health workers providing care at village level, Rwanda has created a system to bring health care to both its urban and rural populations. The reality that all Rwandans – even the poorest – have access to primary health care represents the strength of the Government and its development partners’ stance on health care and human rights.

Achievements such as these are pivotal. In another decade, Rwanda will undoubtedly continue to see its people living longer, healthier lives. The gross domestic product per capita will also likely increase, and Rwanda’s population will be in better economic shape.

And yet, the current top killers do not account for all of the country’s disease burden. Regretfully, there remains a serious gap in Rwanda’s current health care system. Noncommunicable diseases (NCDs) – probably accounting for about 25% of the national burden of disease – have yet to be addressed in a strategic and systematic way.¹ These diseases include cardiovascular disease, cancer, epilepsy, pulmonary disease, and diabetes among others. These are global diseases and yet, more often than not, NCDs are thought to be problems of middle and high-income countries. In such countries, risk factors for NCDs include obesity, tobacco use, and other factors termed poor lifestyle choices. However, in Rwanda, and other developing countries, this is not the case. NCDs are instead linked to malnutrition, infection, congenital abnormalities, toxic environments, and lack of access to basic health care. These are all ultimately caused by poverty. And HIV/AIDS, tuberculosis, malaria and neglected tropical diseases – all diseases endemic to the poorest nations – further contribute to risk factors for NCDs whether treated or untreated.

Rwanda is acutely aware of the need to both treat its population and to protect its population from emerging risk factors that accompany urbanization. Over the next five years, the country foresees itself expanding access to integrated chronic care by building on the existing healthcare platforms established by HIV/AIDS programs. Expanded access and improved options for preventing and treating chronic illnesses and NCDs would have a tremendous impact on morbidity and mortality. Currently, there are many disease-specific advocacy groups in Rwanda fighting for advanced care for conditions such as cardiovascular illness, diabetes, epilepsy, and hemophilia. The challenge for Rwanda is to identify and execute the right set of integrated strategic plans for preventing and treating NCDs. Chronic care integration is one such plan.

Inshuti Mu Buzima (IMB) – the sister organization to the Harvard-affiliated non-profit, Partners in Health (PIH) – was invited to work in partnership with the Ministry of Health of Rwanda at the end of 2003. IMB-PIH has put itself at the service of Rwanda’s vision for health care by devoting itself to the needs of the entire populations of three districts. In particular, it has made a unique contribution in the area of chronic care and NCDs. This approach has led to a joint undertaking between the Ministry of Health and IMB-PIH, including a conference in January 2010, which was focused on how to tackle non-communicable diseases in Rwanda. Through such discussions, chronic care integration has been identified as a central unit of strategic planning to improve the health of the Rwandan population. Other units of planning for NCDs include gynecologic care at district hospitals; improving the quality of generalist physician care at district hospitals; histopathology; cancer care; cancer surgery; cardiac surgery and neurosurgery. Now, in January 2011, Rwanda finds itself equipped with a healthcare system capable of launching chronic care integration; and IMB-PIH finds itself prepared to advise, advance and support the effort.

Many Rwandans could afford the prevention and treatment of uncomplicated cases of common diseases such as malaria or pneumonia, but most could not afford the costs of chronic care of HIV/AIDS, heart disease, diabetes, epilepsy or cancer. Therefore, chronic lifelong treatment and managed care for NCDs must be rooted in a publicly-sponsored, tactical and efficient plan to achieve accessibility and affordability. Already Rwanda has taken steps to tackle some of the prevention issues unique to NCDs, including the improvement of household cooking stoves and access to treatment for streptococcal pharyngitis, among myriad other steps. But we have much work to do. And we implore other low-income countries to take seriously the non-communicable ailments of their patient populations – ailments which most of their citizens must simply endure, because they cannot pay for treatment. Rwanda has made great strides in combatting communicable diseases under the leadership of the Government. The Ministry of Health and our development partners affirm our unwavering dedication to preventing and treating noncommunicable diseases, and making chronic care available to all. It is in this context that I am proud to be collaborating on this publication by Inshuti Mu Buzima - Partners in Health.

Visit with the Executive Director of UNAIDS to see non-surgical circumcision in the Nyamata Distict Hospital in the East Province of Rwanda

2011-03-19T19:37:00.000-07:00

On 16 March, we had the great pleasure of accompanying the Executive Director of UNAIDS, Michel Sidibe on a visit to the Nyamata Distict Hospital in the East Province of Rwanda. We went to see a major revolution in the global fight against HIV, showcasing PrePex - a new non-surgical device for circumcision that allows health care providers to perform each procedure in fewer than 3 minutes without anesthesia, without blood and without suture.

Michel Sidibé traveled to the Nyamata District Hospital after visiting His Excellency President Paul Kagame in Uruguiro. According the New Times – a daily journal in Rwanda – Michel Sidibe said, “President Kagame’s leadership and vision demonstrate clearly that we can produce results when you have commitment at the higher levels.” This applies to the fight against HIV and AIDS.

He spoke with the journalists about the research we have done on Prepex to and affirm our goal to perform 2 million male circumcisions using this new technology nationwide which will revolutionize HIV prevention in Rwanda.

The PrePex device includes an elastic band that fits around an inner ring, to trap the foreskin of the penis, in order to stop the blood flow in the foreskin. The dry foreskin is than removed after one week, (See the blog post March). For the first time, this action can be done on a massive scale for men and will support the prevention of HIV infection not only through the procedure, but also through HIV counseling and testing along with condom distribution and use sensitization of men waiting to be circumcised.

Miche Sidibe said how he was impressed and promise to be the champion of the utilization of this innovation that takes less than 3 minutes to perform and reduces the risk of HIV infection by 66%.

It is time to tackle non-communicable diseases

2011-03-16T22:46:00.000-07:00

The Government of Rwanda views healthcare as a basic human right, and as such, our healthcare delivery model aims to serve all Rwandans, especially the most vulnerable. This rights-based approach is at the root of Rwanda’s health strategy. It is articulated in Rwanda’s Economic Development and Poverty Reduction Strategy, Rwanda’s Vision 2020, and our commitment to the United Nations’ Millennium Development Goals. A major objective of Rwanda is to engage the nation in a participatory effort to eradicate poverty and the many ills it brings.

Over the past decade, Rwanda has seen under-five mortality drop by half. We have achieved universal access to HIV therapy and now are able to address HIV/AIDS as a chronic disease.

More women than ever are delivering their babies in health facilities, and more than 95% of Rwanda’s 11 million people have health insurance. Rwanda’s successes in preventing and treating top killers – malaria, tuberculosis, HIV/AIDS, respiratory infections, and diarrheal diseases – have led to a dramatic increase in life expectancy.

With over 400 health centers, 40 district hospitals, and 45,000 community health workers providing care at village level, Rwanda has created a system to bring health care to both its urban and rural populations. This system has improved financial and geographic access to health services to all Rwandans, even the poorest. And our accomplishments represent the strength of the Government’s stance on health care and human rights and the support of its development partners.

Achievements such as these are pivotal. In another decade, Rwanda will without any doubt continue to see its people living longer and healthier lives. The gross domestic product per capita will also likely increase because of a healthier population, and Rwanda’s population will be in better economic shape.

However, by fighting the current top killers we are only able to increase the life expectancy to approximately 54 years as infectious diseases do not account for all of the country’s morbidity and mortality burden. Our service delivery still has serious gaps as noncommunicable diseases (NCDs) which probably account for about 25% of the national burden of disease according to World Health Organisation have yet to be addressed in a strategic and systematic way.¹

These diseases include cardiovascular disease, cancer, epilepsy, pulmonary disease, and diabetes among others. These are global diseases and yet, more often than not, NCDs are thought to be problems of middle and high-income countries. I want to stand strongly against that. If in the North, risk factors for NCDs include obesity, tobacco use, and other factors called poor lifestyle choices, tobacco and nutritional factors impact also the health of our population. Tobacco because the quality of the cigarettes in Africa is not controlled and it contain more toxics. The nutrition factors are important but more because of undernutrition than overnutrition. But if we don’t tackle life style and nutrition now, when our economy will grow, overnutrition will replace undernutrition as the main cause of malnutrition.

In general, NCDs in the developing world are linked to malnutrition, infection, congenital abnormalities, toxic environments, and lack of access to health care services required to tackle NCDs early enough. All of these factors are ultimately exacerbated by poverty. On top of that, HIV/AIDS, tuberculosis, malaria and neglected tropical diseases contribute seriously to increasing the risk factors for NCDs whether treated or untreated.

Rwanda is aware of the need to both treat its population and to protect its population from emerging risk factors that accompany urbanization and we have started to work on it. Over the next five years, the country anticipates expanding access to integrated chronic care by building on the existing healthcare platforms established by programs fighting infectious diseases.

Currently, there are many disease-specific advocacy groups in Rwanda and in the world fighting for advanced care for conditions such as cardiovascular illness, diabetes, epilepsy, and hemophilia. The challenge for a country like Rwanda is to coordinate those efforts, and identify and execute the right set of integrated strategic plans to prevent and treat NCDs in a holistic manner. This is important as infectious diseases, chronic diseases, non-communicable diseases, hurt the same members of our communities; and also, service will be delivered by the same health professionals in the same health centers across all illnesses. We talk about human as an entity, and so infectious disease, NCDs and chronic care has to be integrated to serve those human individuals without making them lose time and continium of care. For example, when someone has a cardiac disorder and gets malaria and suffers from cancer – we must make sure that all care should be should be timely given. And because of equity, and equality in access to care, we need to do our best to provide quality integrated care where people are living.

Currently, many Rwandans are able to afford the prevention and treatment of uncomplicated cases of common diseases such as malaria or pneumonia, but most cannot afford the costs of chronic care of HIV/AIDS, heart disease, diabetes, epilepsy or cancer. Therefore, chronic lifelong treatment and managed care for NCDs must be derive from a publicly-sponsored, tactical and efficient plan to achieve accessibility and affordability. Already Rwanda has taken steps to tackle some of the prevention issues unique to NCDs, including the improvement of household cooking stoves and access to treatment for streptococcal pharyngitis, among myriad other steps. But we have much work to do. We will never achieve our development goals if we don’t take seriously the non-communicable illnesses of our patient populations – illnesses which most of our citizens must simply endure since they cannot pay for treatment. Without decreasing the attention we currently have on combating communicable diseases, we affirm our constant dedication to preventing and treating noncommunicable diseases, and making chronic care available to all.

Role of community health in strengthening Rwandan health system

2011-03-16T22:43:00.000-07:00

SUNDAY, MARCH 13, 2011

Recently the three-day international conference on Community health was organised in Kigali by the Ministry of Health. The theme was “The role of community health in Strengthening Health Systems” This was the first conference of its kind.

In Rwanda in each village (100 to 200 households) elects three volunteers to act as CHWs for the general population – a binome comprising of a man and a women for general diseases and a women as assistant maternal to follow antenatal care, women after delivery and children below 9 months Once elected the CHWs are trained by the Ministry of Health throughout the country to deliver quality of services and to monitor health at village level and to refer sick patients to the nearest health facility. By sensitizing the local village and making themselves available, they improve access to care. Because each community votes on two women to serve the village as CHWs, becoming a CHW is now a position of respect, raising gender equity throughout Rwanda.

The community health workers are an important component of health services, by bridging between the need of services service delivery, social and economic development, and the Millennium Development Goals (MDGs). They strength the health system and avoid the population to take long walks to the nearest health centres.

Community health workers reinforce the six building blocks of WHO . The first one: Good health services – as they are trained and supervised by health professional at sector level. The second one: A well-performing health workforce – the 3 CHWs per village (45000 in the country) increase service delivery. The third one: A well-functioning health information system – the report provided by the community health workers. : The fourth one Equitable access to essential medical products, vaccines and technologies – CHWs diagnose and treat malaria, diarrhea pneumonia, they give family planning drugs, they facilitate outreach for vaccination, and sensitise for HIV testing. The fifth: A good health financing system as these volunteers are compensated only by creating cooperatives in their sector receiving money for services they provide to their village they generate community economic growth through health activities. The last one Leadership and governance – as elected people they are role models.

Access to care in resource-constrained countries face financial, infrastructural, and geographical barrier. Community health workers (CHWs) are a solution for overcoming those and improve access to health in rural communities. By using CHWs, with their approach to health at the community level, Rwanda hopes to solve 80% of health problems in the country.

All activities of CHWs are included in the health reporting system through reports that they give to the Executives Secretary of each Sector, who in turn report activities to the Director of Health at the District level. These report are sent to the Ministry under the responsibility of Mayors. That and the election guaranty the local and community ownership

Male circumcision at different ages in Rwanda. A cost-effectiveness study.

2011-03-16T22:42:00.000-07:00

Friday, March 11, 2011

There is strong evidence in favour of MC to reduce HIV infection and other STI. In Rwanda, where adult HIV prevalence is 3%, MC is not a traditional practice. To inform policy and programmatic decisions in relation to introducing MC, the Rwanda National AIDS Commission modelled cost and effects of MC at different ages. This study was needed given that the MC debate in Southern Africa had focused primarily on MC for adults.

A cost-effectiveness model was developed and applied to three hypothetical cohorts in Rwanda: newborns, adolescents and adult men. Effectiveness is defined as the number of HIV infections averted, and is the product of the number of people susceptible to HIV infection in the cohort, the HIV incidence rate at different ages and the protective effect of MC; discounted back to the year of circumcision and summed over the life expectancy of the circumcised person. Direct costs were based on interviews with experienced health-care providers to determine inputs involved in the procedure (from consumables to staff time) and related prices. Other costs included training, patient counselling, treatment of adverse events and promotion campaigns and were adjusted for the averted lifetime cost of health care (ART, OI, laboratory tests). One-way sensitivity analysis was performed for different values of the main inputs of the model and the thresholds at which each intervention is (a) no longer cost-saving and (b) at which it costs more than one GDP/capita/life year gained were calculated.

Neonatal male circumcision is less expensive than adolescents and adult male circumcision (15 USD instead of 59 USD per procedure) and is cost-saving (the cost effectiveness ration is negative); even though savings from infant circumcision will be realized later in time. The cost per infection averted is 3,932 USD for adolescent MC and 4,949 USD for adult MC. Results for infant MC appear robust. Infants MC remains highly C-E for a reasonable amount of changes in the base case scenario. Adolescent male circumcision is highly cost-effective for the base case scenario but no longer so for very small changes in the input variables. Adults MC is neither cost-saving nor highly cost-effective when considering only the direct benefit for the circumcised man. Additionally, infant MC can be easily integrated into existing health services (i.e. neonatal visits and vaccination sessions) and has a better potential to achieve the very high coverage over time of the population required for maximal reduction on HIV incidence, than adolescent and adult circumcision.

African leaders and development partners should stop managing the HIV response as an emergency issue and release themselves from a one-year or even a five-year planning perspective to focus on sustainable long-term choices for countries. The study suggests that Rwanda should be simultaneously scaling up circumcision across a broad range of age groups, with highest priority to the very young. In the presence of infant MC, adolescent and adult MC should become a sort of “catch up” campaign that would be needed at the start of the program but would then become superfluous over time.

Rwanda Leads Breakthrough Innovation in HIV Prevention: Male circumcision with no anesthesia, no sutures, no blood and no sterile settings requirement.

2011-03-16T22:38:00.000-07:00

Tuesday, March 8, 2001

I had the fantastic opportunity to participate in the Government of Rwanda sponsored study to test the PrePex System, a new device and methododology for rapid adult male circumcision deployment in resource-limited settings.

The study, in line with the World Health Organization’s and UNAIDS’s recommendations to encourage voluntary male circumcision, began in March 2010 and proved the safety and efficacy of the device.

Many studies have proven that circumcised men in high risk areas, including sub-Saharan Africa, reduce their risk of HIV infection by about 60%.

The existing surgical techniques and devices require time of highly trained health professionals, surgical settings and and out of work time for patients to recover. This limits the ability of many African countries to scale up male circumcision initiatives given the regional shortage of health professionals and medical infrastructure and the economic impact of the patient time to recover.

Because we have the conviction that all need to be done to protect our population in the context of the fight against HIV, the Ministry of Health in Rwanda has the national goal to decrease its HIV incidence rate by 50% by circumcising two million adults in two years but so far Current male circumcision efforts have been a drop in the ocean compared to the masses required.

That is why the Ministry of Health of Rwanda, in partnership with the PrePex Compagny a social private entreprise, undertake researches on viable non-surgical male circumcision method. In that context the Government of Rwanda sponsored second clinical study (N°:NCT01284088 on ClinicalTrials.gov) which is showing very promising preliminary results on the cost effectiveness of the use of this new device for HIV prevention, as well as reaffirming our knowledge of the safety and efficacy.
http://clinicaltrials.gov/ct2/show/NCT01150370.

Except for a few hours on the day of deployment, patients circumcised with the PrePex device required no additional recovery days for pain or wound management. This has major economic ramifications for a country like ours, where rural men work their fields and cannot afford to lose so many days of work for a preventative procedure.

The UN press agency wrote about this great development - click here to see the story.

Hello

2011-03-16T22:36:00.000-07:00

SATURDAY, MARCH 5, 2011

I look forward to writing about meaningful developments and challenges in my country, Rwanda.

Thank you for your interest.

Dr. Binagwaho

The Role of King Faisal Hospital Today

2011-03-16T02:59:00.000-07:00

I wrote the following blog post, "The Role of King Faisal Hospital Today," in 2007. I am sharing it on my new blog as it has not been previously published, but some of the information is out-of-date. It does accurately describe the vision of the Ministry of Health for King Faisal Hospital and its role in our health system.

All sectors of the Rwandan Government are dedicating substantial efforts to achieving our national development objectives. Together with the support of partners from around the world, the Government has strived to endow the country with innovative tools and programs that aim to make the necessary changes in the health sector to enlarge the range of quality services given to the population. The programs in question are complementary and have specific objectives. Through this support, Community-Based Health Insurance, RAMA, the decentralization of sanitary systems, the equipment of district hospitals, referral hospitals, and King Faisal Hospital in Kigali have become essential pillars of the development plan of the health sector.

Among the health sector’s various achievements, one of the most impressive is that more than one million Rwandans now have community-based health insurance and all Rwandan civil servants are now covered by RAMA as of late 2007. Among other resources available to public programs, we now have substantial funds for the fight against HIV/AIDS that are being used to control the epidemic in a way that builds the national health sector, as well as funds for new equipment in district hospitals, referral hospitals, and health centers across the country. These achievements have benefited the whole population.

At the same time, thanks to the Government's advocacy in negotiating with partners across many continents, King Faisal Hospital has increased its capacity to provide services to the country’s sick. King Faisal Hospital can now offer very specialized abdominal surgery by laparoscopy as well as other state-of-the-art technology in orthopedics, orthodontic care, and ophthalmology services. More specialties will continue to join the array of services offered on a regular basis.

Beyond this immediate improvement in the spectrum of available services, King Faisal Hospital has a mission of training that aims to assure capacity building of Rwanda’s medical students, general practitioners, and specialists. With the support of the Ministry of Health and the United Nations Development Program, the hospital now has a telemedicine center that allows exchanges and continuing education programs through linking King Faisal to teaching hospitals around the world. Our population, our medical students, and our physicians are increasingly benefiting from it. Other strong partnerships have been created to allow cardiac catheterization and open heart surgery, treatments usually outside of the financial means of most Rwandans. Now, thanks to solidarity on the part of Australian, American, and Belgian physicians who come on surgical and capacity-building trips, the average Rwandan can benefit from these services at King Faisal Hospital.

Thanks to Community-Based Health Insurance, RAMA, and the Ministry of Health’s national referral system, patients referred through the normal process can receive specialized care offered King Faisal at costs comparable to care offered at CHUK. A patient is generally referred from a health center to a district hospital to a referral hospital if necessary. These referral hospitals can then refer to King Faisal Hospital for care that is not available elsewhere. In the case of severe medical emergencies, a patient can be referred directly to King Faisal Hospital without progressing through the standard tiered referral process.

Referral to King Faisal Hospital is free for the poorest Rwanda if they have the requisite administrative documents from ubudehe. As a result of this social justice-based access policy, the more King Faisal Hospital has high-level quality and varied care, the better the Rwandan population will be taken care of. King Faisal Hospital also allows our tourists or our investors who spend time in Rwanda to be assured that they will have access to high-quality health care should the need arise. This is a great way to attract and retain investors.

We have a long way to go, but the Government along with its partners has put in place a system so that all can receive affordable and quality care, even for the poorest citizens because the Government pays for them. Rwanda has a national goal of becoming a middle-income country within the coming decades. Therefore, it is essential to sustain efforts to assure access to high-quality health care to all.