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

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

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

Agnes Binagwaho, Sabin Nsanzimana, Corine Karema, Michel Gasana, Claire M. Wagner, and Cameron T. Nutt

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

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

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

As is often said in the Ministry of Health, "if you give Rwanda money to help the youngest child born today, we will ensure that it also helps the oldest person by tomorrow." When implemented according to principles of authentic partnership and when investing in public infrastructure and human resources, disease-specific global health initiatives can not only achieve positive spillover effects, but can also catalyze the development of comprehensive and equitable primary care systems in the poorest countries.

The time has come for scholars and policymakers to move past unfounded worries about whether to invest in the pandemics of AIDS, tuberculosis, and malaria; what we must now devote our full attention to is the question of how best to harness synergies and maximize impact in the pursuit of health as a human right.

References 

1 Car J, Paljarvi T, Car M, Kazeem A, Majeed A, Atun R. Negative health system effects of Global Fund's investments in AIDS, tuberculosis and malaria from 2002 to 2009: systematic review. J R Soc Med Sh Rep 2012;3:70. 

2 Price J, Leslie JA, Welsh M, Binagwaho A. Integrating HIV clinical services into primary health care in Rwanda: a measure of quantitative effects. AIDS Care 2009;21:608-614. 

3 Kalk A, Groos N, Karasi JC, Girrbach E. Health systems strengthening through insurance subsidies: the GFATM experience in Rwanda. Trop Med Int Health 2010;15:94-97. 

4 Shephard D, Zeng W, Amico P, Rwiyereka AK, Avila-Figueroa. A controlled study of funding for Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome as resource capacity building in the health system in Rwanda. Am J Trop Med Hyg 2012;86:902-907. 

5 WHO: World Health Statistics 2012. World Health Organization, Geneva 2012.

Global Health Solidarity at a Crossroads

On 5 July 2012, I published an op-ed in Project Syndicate about the importance of fully funding The Global Fund to Fight AIDS, Tuberculosis, and Malaria. You can read the full text below, or access the piece on Project Syndicate's website here.

Global Health Solidarity at a Crossroads

05 July 2012

KIGALI – A decade ago, the global community stood together to declare that where people live should not determine whether they live or die when confronted by the scourge of AIDS, tuberculosis, or malaria.

This act of solidarity – unprecedented in human experience – led to revolutionary advances in promoting health care as a human right. The Global Fund to Fight AIDS, Tuberculosis, and Malaria, along with the United States President’s Emergency Plan for AIDS Relief (PEPFAR), quite literally changed the course of history. Programs directly supported by the Global Fund have saved nearly eight million lives since 2002 – an average of more than 4,400 lives every day.

But, while much has been accomplished, much more remains to be done – and the Global Fund needs at least $2 billion to reverse a funding freeze that is in place through 2014. So the world now plays a waiting game to see whether governments will step up and fill the gap.

To be blunt, many of the world’s largest economies are not fulfilling their financial pledges to the Fund. Their politicians cite budget constraints and the need to prioritize domestic programs over fighting diseases that disproportionately kill the world’s poorest.

My country, Rwanda, has been a recipient of Global Fund grants since 2002. Just 18 years ago, our society was torn apart by a brutal genocide that killed more than one million people. Today, Rwanda is a peaceful country full of promise and hope, with one of the world’s fastest-growing economies.

With Global Fund support for our national institutions, we have achieved universal access to lifesaving antiretroviral therapy for people living with HIV, and we have stabilized HIV prevalence at around 3% of the population. Similarly, Rwanda’s tuberculosis program has become a model for Africa, and all Rwandan families now have access to insecticide-treated bed nets to prevent malaria, contributing to an 87% drop in cases during the last seven years.

Integration of services for infectious diseases and primary care has contributed to some of the steepest declines in child and maternal mortality ever observed. And, as life expectancy in Rwanda continues to climb (from below 30 in 1995 to 55 in 2010), we are now taking action against non-communicable diseases such as heart disease, cancer, and diabetes. The flexible, country-owned support provided by the Global Fund has been crucial to our success.

My country is living proof that investing in health is not only the right thing to do, but that it can also create virtuous cycles that promote security and development. In fact, after receiving Global Fund support for years, Rwanda recently made its first donation of $1 million to the Fund.

Unfortunately, infectious diseases are far from under control around the world. Less than a quarter of the world’s children living with HIV have access to treatment, and up to a million people still die of malaria each year. And, alarmingly, only one in six patients with drug-resistant tuberculosis currently receives proper treatment. Moreover, reports of “totally drug-resistant tuberculosis” have recently emerged from India.

Policymakers would do well to remember that it only takes one airplane flight for such a pathogen to go global. Infectious diseases neither respect national borders nor conveniently follow economies into recession. History has shown that retreating from the fight against an epidemic can lead to a renewed plague that is immune to our best drugs, requiring far more expensive measures to control.

Our choice could not be clearer: either we resolve to answer the call of history and provide the Global Fund with the resources that it needs, or we allow political lassitude to undermine a decade of progress and consign untold thousands to preventable deaths. Investing now, on the other hand, would pay off in the long term: just $6 billion more per year for the AIDS response today would save more than $40 billion in averted treatment costs alone over the next decade.

Today, the Global Fund stands at a crossroads. The international community’s regard for the health of the world’s poorest in the face of financial uncertainty will be a standard by which history measures not only our ability to stand together in weathering economic upheaval, but also our capacity for justice.

Now is the time for donor countries, including middle- and low-income countries, to rise to the challenge and ensure that the Global Fund has the resources needed to accept new grant applications as soon as possible. The costs of inaction are morally – and economically – untenable.

Leadership and the fight against HIV/AIDS

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