American Medical Association Journal of Ethics feature on Rwanda's Health Sector

In July of 2016 the AMA Journal of Ethics featured a podcast, which gives an accurate view of our current health sector.  The link to the podcast is here:

http://journalofethics.ama-assn.org/podcast/ethics-talk-jul-2016.mp3

Lecture given to Dartmouth University students 'building a health sector alongside a nation"

I gave this lecture given to Dartmouth University students to share how we built a health sector alongside a nation. It is the health sector contribution to Rwandan rebirth the past 20 years
the story of the Rwanda health sector after the 1994 genocide against the Tutsi. a story of ownership accountability participation equity sciences and fight for sustainable development.

Follow the live lecture using the following link: https://www.youtube.com/watch?v=_PfKMAb1I-g

Towards Sustainable Health Care: From Community To Medical Tourism

Towards Sustainable Health Care: From Community To Medical Tourism

By Dr. Agnes BINAGWAHO

Published in  Ubuzima Magazine, of the Rwanda Health Communications Center and the Rwanda Biomedical Center. I recommend you to read the full magazine! Lots of great updates on our health sector from the MOH and RBC. issue No4 2013

Ultimately, our strategy is to tap into medical tourism but this can only happen if we first secure the health of our own people and build the soft and hard infra- structure – people, facilities and a quality regime assurance to provide a world class health product.

Rwanda has the ambitious but achievable vision of building a self-sustaining state. To achieve this, the country must accelerate and sustain economic growth at 11.5 percent annually for the next two decades.

Every sector must play its part in contributing towards the realisation of that vision. The health sector is an integral part of the journey to economic self-sustainability and our contribution will be measured by the extent to which we are able to provide the preventive, palliative and curative care, using the best quality state of science to each and every Rwandan at an affordable price with the idea of equity in mind. That would mean that wherever one happens to be in the country, they will have the same rights and enjoy access to what we can offer to each and every Rwandan.

Ultimately, our strategy is to tap into medical tourism but this can only happen if we first secure the health of our own people and build the soft and hard infrastructure – people, facilities and a quality regime assurance to provide a world class health product.

Over the past five years, we have been putting in place the building blocks to a sustainable healthcare delivery system. We have already made good progress towards making the first point of contact with the health system, the Community Health Worker (CHW) self-sustaining. We have three CHW’s per village. These are people that are elected by the community members and the Ministry of Health gives them six weeks training and an annual refresher course which equips them with skills to provide quality care with a community-centric approach. They are supervised by the health centers and the doctors at district level.

They provide care at village level diagnosing and treating pneumonia, bronchitis, and malaria. With the exception
of implants and IUD, they provide the full range of family planning services from condom, pills, and injections. They also treat diarrhea and they provide counseling for HIV. One of the CHW’s is a maternal health assistant who fol- lows up pregnancies in the community and children under one year. They follow up children ensuring that everyone is vaccinated.

CHW’s now take care of around 80 per cent of the disease burden and the cost of this care will soon be covered
by cooperatives with money mobilised by the Ministry
of Health for this purpose. We now have more than 470 cooperatives and our target is to reach 500.

The profits generated by the cooperatives are used to grow businesses for the Community Health Workers and to sustain them. The business opportunities are identified by the CHW’s in their own communities and some have started hostels, shops, farms while others have gone into agribusiness. The profits from those cooperatives have created a pool of funds from which care at the community level can be paid for through performance based financing. A percentage of the profits from the cooperative belong to the health sector and are used to pay for the services of community care. This means nothing is free, everything has a cost and no one works for free in Rwanda even though we have to generate the money to pay for healthcare.
We have been paying CHW’s since 2008 but the difference now is that instead of the resources coming from outside the community, they will be paid from revenue generated within the community with clear management and financial guidelines.

The percentage that is not secured for the health sector will go directly to CHW’s. Weighed against the diseases burden, that means that 100 percent of the cost of care at village level will be paid for by the com- munity itself so we provide sustainable health care. This approach will be scaled up to cover the different levels of the health system.

Above the village we have the cell. A cell is made up of about ten villages and we plan to have a health post in each cell. The community will provide the space – 4 rooms – one for examination, a reception area, observation room as well as a storage room and pharmacy. From here patients can either be referred for hospitalization at a health center or district hospital or get discharged to return home after treatment.

Those posts will be headed by nurses trained to A2 level. They will provide services that will be reimbursed by Mutuelle de Sante. They will have no salary and will be paid directly in return for the services they provide, just like any private practitioner. They will also operate a drug shop. That means they will be offering services under a frame- work dubbed public-private –community partnership.

We are also going to create a national cooperative for these A2 nurses and in a couple of years, the proceeds from that cooperative combined with Mutuelle de Sante and the proceeds from selling drugs at the drug shop will pay for the care at cell level. They will also be supervised by the health center and the leadership at the sector level. Once we are through with this arrangement, we should have completed the loop of providing health care at the community level in a sustainable manner. We are close to our target of having one health center in each sector.

Less than 50 health centers remain to be built.
Under this arrangement, the sector will be the first point of interface between a patient and a public sector health facility. The system starts with a CHW at village level on to the public-private-community partnership at cell level and then the public health facility at sector level. Next are the district hospitals and then referral hospitals.

Forty per cent of health facilities in sectors and district hospitals (we have 42 district hospitals) belong to Non- Governmental Organizations (NGOs), associations and Faith Based Organizations (FBOs). We have an agreement with FBOs and NGOs. In return they offer treatment to each and every Rwandan in need. This has allowed us to have the same number of health centers and district hospitals in each part of the country rather than wait until the public sector can build its own.

The government through its budget pays subvention to each health facility or hospital. Mutuelle de Sante reimburses 90 percent of the cost of care but also there is a
10 percent out of pocket which patients pay directly to
the health unit when getting care. We are creating an e-system for better administrative and financial management of the health sector because we have private health facilities that for now do not get this contribution from the government but may be able to benefit of the e-system. We are therefore going to make the financial management more rigorous and private sector oriented.

Each district hospital will also become a teaching site with a director in charge of education for doctors and a director in charge of education for nurses. They will report directly to the College of Medicine and Allied Sciences that the Government of Rwanda is creating under the single university system. The same approach to self-sustenance will be employed when it comes to referral. Because all referral hospitals are also teaching hospitals that means they will have income from both the health and education sectors.

If we come to the ministry of health and the role of the Rwanda Biomedical Center; this center has been created to generate income to help the health sector become self- sustainable. We are now going into a phase of intensive business creation through RBC. PPP’s to create factories for consumables and drugs and goods for sale to the health sector are some of the options we are considering to decrease importation of what we bye anyway. We already have Labophar which has a unit for manufacturing infusions. Its capacity will be expanded; and we are going to build on that. The proceeds generated by these businesses will be reinvested to make the health sector self-sustaining at health center and hospital level. Because the system
at community up to cell level will be self-financing, the money generated from these activities will pay for services at sector, district and central level.

TAKING ON NCD’s

With a 50 percent decrease in acute malnutrition, we have made progress but our goal is to eliminate malnutrition all together. There is hope after the Clinton Foundation and World Food Programme teamed up with the Ministry of agriculture and the Ministry of commerce to set up a factory for nutritious foods.

This will help the health sector fight malnutrition by providing children and pregnant women with all the nutrients that they need. Malnutrition starts during pregnancy with malnourished mothers giving birth to malnourished children.

Sensitization to improve the nutritional status of children and mothers continues and the one cow per family programme has helped increase the consumption of milk. We now envisage a situation where we can use all those health posts we are creating to facilitate distribution of milk. We are progressing in creating systems, sensitization and what it takes to deliver the service.
 As we make progress against infectious disease; non- communicable diseases are gaining prominence. It is
not because these are new diseases, it is just that we are not dying of infectious diseases as we used to. Due to improvements to the health system we have doubled life expectancy and reduced the mortality of children. Life expectancy in Rwanda is now around 63 years at birth
and the profile of disease is beginning to be different as
a result. So we are beginning to see more cases of heart disease and lung disease that are related to longevity because the population is aging. 
 We are now educating medical personnel to manage this new challenge and we have introduced a diploma course in emergency medicine. We need 42 graduates to cover the 42 district hospitals. We have also created a residence of emergency medicine in provincial and referral hospitals. The school of medicine has almost completed the curriculum for a bachelor’s in cardiology so that we can have at least one medical doctor with special skills in cardiology in each district hospital. This is intended to accelerate the diagnosis and referral of patients to a full specialist if need arises and also do the follow-up of the people who have been treated.

We have already conducted more than 300 successful cardiac surgeries in Rwanda and those people are living in the villages. It is therefore necessary to have a doctor with the relevant skills living near them to keep them in good health through follow-up and ensuring they take their medicine. That way, they will not need to come back to Kigali because it is far and sometimes they come when it is already too late. 
The diploma in emergency medicine has already started and we hope to commence admissions to the bachelor
of cardiology next academic year. With these incremental steps, in five years, we hope to have a good referral system and fully functioning center of excellence for cardiology. We are also working on creating a residency in oncology and a diploma in oncology that again will allow us
to have in each district, somebody with skills in oncology and who through specialists, can follow up, seek advice via telemedicine and be available to see the patient on regular basis since we are equipping all our districts with telemedicine capacity over the next 3 years.
 Routine specialised care will be offered at district level. So renal disease, cardiac disease, cancer and other complications will be taken covered by system we are creating now to serve all the population in an equitable manner. 

MEDICAL TOURISM

We see medical tourism as a spinoff of care that will first and foremost be available to our own people and this is how we shall provide care for Rwandans.
 We are working with 23 institutions of higher learning in the United States that every year second 100 high level faculty members from their ranks who come to mentor their Rwandan counterpart’s under a twinning program. The aim is to create highly qualified and skilled clinical staff for both medical and nursing as well as lab technicians.

We are reinforcing high education in the health sector through the coming school of medicine and allied sciences. There are 60 A0 nurses to be trained to be tutors in specialized areas such as nephrology, theatre, neonatology, emergency, ICU, pediatrics and mental health. So we shall have highly qualified teachers for both the nursing and medical school. Through this twinning programs we hope to create very good educative tutors with a university that will be one of the best in Africa and attractive to students from outside Rwanda.

Once we have those highly qualified tutors, the system should produce highly qualified service providers. We have are sending to India, 16 people – surgeons, cardiologists, anesthetists, nurses, and lab technicians to train in cardiac surgery to help create a center of excellence for cardiac surgery here.

We are searching for the same opportunities for renal transplants. We have entered a partnership with the Chinese to transform Masaka hospital into a huge public teaching hospital and a separate partnership with the Japanese to have another high level public specialised hospital.

We are also promoting partnerships with anybody who may want to come do fair business in the health sector because we have a beautiful country where one can create set up a beautiful hospital for the discerning patient who may want to combine a medical checkup in a high quality facility space in serene and scenic surroundings to mix tourism and reinvigoration of their health.

And just as we are doing cardiac and renal surgery, we will do the same in neurosurgery so that we can attract here people who will, come to pay for quality care in Africa as
it is done in other other parts of the world. That is how we will come to medical tourism. But before serving in such a segment you need to have first secured the care for your own people.

Community care is already on track, and RBC has begun the next phase of its evolution or the first steps to turn this institution into a business oriented entity. For medical tourism, the paperwork is in progress at RDB and a project proposal is already with the African Development Bank and other development partners for analysis. We are off to a good start and all we need to do is pull in the same direction to get to our destination.
 Medical tourism results into regional centers of excellence and good medicine is generally a good business.

© RBC/Rwanda Health Communication Centre 2013

Partnerships to Accelerate Progress in Global Health: The Case of Cervical Cancer

Rwandan health minister hits back at critics of drug company deal

The debate must move on from seeing pharmaceutical companies as evil predators and poor people as hapless victims

Published in the  guardian.co.uk, Tuesday 21 May 2013 16.31 BST
http://www.guardian.co.uk/world/2013/may/21/rwanda-health-minister

A hero of mine wrote from prison that “human progress never rolls in on wheels of inevitability; without hard work, time itself becomes an ally of social stagnation.”  Dr. Martin Luther King Jr.’s words have long resonated with Africa’s struggle against global cynicism in the fight against AIDS. At the turn of the millennium, while I practiced as a pediatrician in Rwanda, international experts brandishing computer-generated prescriptions of cost-effectiveness told us then that the time just wasn’t right to provide access to the effective treatment widely available in their own countries. In short, African lives were worth less than American or European lives. Costs were just too high, they said (never mind that activists soon drove AIDS drug prices down from $12,000 to $100 per year). African governments and patients simply weren’t prepared, they cautioned (never mind that studies show Africans have far higher adherence to treatment than North American counterparts).

Dr. King’s words came to mind again last week, when I read with interest a recent commentary in The Guardian on pharmaceutical company donations in Africa. As an example of the pitfalls of corporate philanthropy in global health, author Adam Green cited Rwanda’s partnership with Merck to provide universal access to the human papillomavirus (HPV) vaccine for the prevention of cervical cancer. He echoed claims made two years ago by some experts that Rwanda jumped the gun, allowing itself to be used as a pawn by a predatory multinational corporation.

Most in global health have moved on from this debate, as the world came to recognize the mounting burden of cervical cancer in Africa, as the price of the HPV vaccine dropped from $16.95 to $5 per dose by mid-2011, and as the GAVI Alliance added the vaccine to its portfolio of support. And despite skepticism from some about the feasibility of nationwide HPV vaccination in Africa, Rwanda reached more than 93% of eligible girls with all three doses through a school-based program in 2011. When Rwanda already had 90% or higher coverage for vaccines against 10 other diseases, when cervical cancer now rivals HIV and maternal mortality as a leading killer of our women, and when GAVI’s budget grew 42% last year, it is difficult for me to see this as some kind of dangerous precedent.

Yet such arguments keep recurring (for HIV, drug-resistant tuberculosis, cancer, cholera, and so on) because of a larger divide in global development. Many who advance or tacitly endorse the claims echoed in Green’s piece often do so because they believe ideological purity (that is, the view that drug companies often pursue only self-interest) is a moral imperative, and that cost-effectiveness (that is, poor people should get cheap things) should always trump other considerations.

But do we truly live in such a zero-sum world that a win-win outcome from a public-private partnership for health is unimaginable? Certainly, competition is better for promoting access to medicines than voluntary donation programs. Yet there are already two companies making the HPV vaccine, and generic versions are not so far off. Furthermore, the historical gap between new vaccine introduction in rich and poor countries is two decades; by working with Merck, Rwanda reduced it to four years and showed the world one possible strategy for reaching universal coverage. Just this past week, GAVI made international news by announcing even lower prices for the HPV vaccine (down to $4.50 per dose) through agreements with two manufacturers, and approved a grant to continue Rwanda’s national program after Merck support stops in 2014.

So much can be achieved in global health with shared commitments to teamwork and humility, a willingness to grapple with complexity, and a big dose of imagination. Indeed, for the very health issues that Green argued should rank higher than the HPV vaccine, Rwanda (and many other nations) are already engaged in novel collaborations to address. On top of the HPV vaccine rollout, we are working with groups around the world to build synergistic screening and treatment programs for cervical and many other cancers. In tackling maternal and child mortality, we’re strengthening health and sanitation systems in addition to teaming up with development partners on a mobile-based notification system for community health workers. With the support of GAVI, we’ve rolled out three new childhood vaccines against pneumonia, diarrhea, and rubella nationwide since 2009. With two-dozen American schools, we are training hundreds of nurses and specialist physicians.

And it seems to be working: while spending less than $60 per capita on health, Rwanda is now on track for the Millennium Development Goals. Indeed, to those interested in working here, we like to say, “Don’t come for charity. Come for partnership.”

Adam Green’s piece voiced concerns about programs like those described above serving as “market priming to create the conditions for adoption.” From Rwanda’s view, the jury is in: with more women dying of cervical cancer than in childbirth worldwide, the market is quite primed and demand readily apparent. Supply of the HPV vaccine and many other tools of modern medicine, on the other hand, remains in doubt for those who need them most. But with no global solidarity fund for cancer today, how else should we get started but to forge smart new partnerships? One lesson from AIDS is that if the world stalls, you just need to act and show that it can be done.

As Dr. King said, in the face of challenges like growing global health inequalities, “We must use time creatively, in the knowledge that the time is always ripe to do right.” Let’s use our time and talents—as health workers, researchers, and journalists—to work together towards a future in which where a patient lives doesn’t determine if they live.

Agnes Binagwaho is Minister of Health of Rwanda, Senior Lecturer at Harvard Medical School, and Clinical Professor of Pediatrics at the Geisel School of Medicine at Dartmouth.