A Win-Win for Global Health

A program partnering health workers in Rwanda and the U.S. needs to continue

The following text has been partially published on November 29, 2013; in the setion Opinion of the US News & Report

http://www.usnews.com/opinion/articles/2013/11/29/how-to-combat-aids-and-the-global-health-worker-shortage-in-rwanda

Over the past decade, humanity has made extraordinary gains in the struggle against the world's deadliest communicable diseases. International solidarity and financing mechanisms such as the US President’s Emergency Plan for AIDS Relief (PEPFAR) and The Global Fund to Fight AIDS, Tuberculosis, and Malaria are saving millions of lives every year. But low-income countries still face a seemingly insurmountable obstacle in addressing these and other public health challenges: a critical shortage of highly-trained health professionals.

While Sub-Saharan Africa bears 24% of the global disease burden, it's served by only 4% of the global health workforce. As the World Health Organization announced last week, the world’s health worker shortage stands at more than 7.2 million today, a gap expected to grow to 12.9 million by 2035.

A report that my colleagues and I published this week in the New England Journal of Medicine offers compelling new evidence about the power of partnership to overcome this obstacle. This new program financed by PEPFAR and The Global Fund provides an example of how we can create a better environment for battling current and future global health challenges in aid-reliant countries.

It's about moving from the condition of dependence to interdependence.

In my country, Rwanda, the Human Resources for Health (HRH) Program is creating a solid infrastructure over the next 7 years to ensure that we are equipping enough health professionals in Rwanda to meet the pressing health challenges facing our people.

Announced in 2012 by Rwandan President Paul Kagame and former US President Bill Clinton and followed by a launch by former US Global AIDS Coordinator and US Ambassador for Global Health Diplomacy, Dr. Eric Goosby, the HRH program deploys nearly 100 American faculty members each year —including physicians, midwives, nurses, dentists and management experts—from a consortium of 25 leading American medical institutions, to partner or “twin” with their peers at Rwandan institutions for at least one year to transfer invaluable skills and knowledge.

This "twinning" enables better curriculum development, teaching, and clinical research that will ultimately empower Rwandan clinicians and educators to take charge of all instruction and healthcare delivery. By 2018, Rwanda’s specialist physician capacity will have more than tripled, and the proportion of the country’s nurses with advanced training will have increased by more than 500%. An additional 550 physicians, 2800 nurses and midwives, 300 oral health professionals, and 150 health managers will have been newly trained in Rwanda—all of whom will have signed contracts to work in the country for a certain number of years based on the degree they obtain. Thereafter, the Rwandan government plans to fully finance the health workforce and medical education system on its own.

By improving the quantity and quality of Rwanda’s health workforce, this innovative program will help us better serve the needs of all Rwanda’s people—from our vulnerable children through improved neonatal services, to our HIV patients who are living longer now that they are on therapy but face a growing burden of chronic diseases like cancer due to their weakened immune systems.

Rwanda is not the only country to benefit from this program, which breaks sharply from old models of foreign aid.  This partnership is also a win-win for our American colleagues, who are learning more each day about what it takes to deliver care in resource-constrained settings. Such experiences are already enriching global health programs at universities throughout the United States and opening new doors for research collaboration between our two countries. Overall, this partnership—in both the clinical and research settings—will help the global health community better understand how we can collectively overcome health challenges in a more sustainable way.

Interdependence in global health is not just an abstract idea. In an age in which a single airplane flight can turn a drug-resistant pathogen into an international public health emergency, better-trained health workers in the developing world will improve prevention by bolstering our first-line of defense against serious global public health threats.

On December 3rd, the world has a critical opportunity to harness the power of partnership, when international leaders gather in Washington D.C. to pledge support for the Global Fund’s work over the next three years. The event provides an opportunity for people to call upon these leaders to continue the fight against the devastating scourges of AIDS, TB, and malaria, but also to sustainably strengthen health systems and reduce the need for foreign aid in the future as countries advance in their journey of development.

Each and every nation—rich and—must do its part to think “out of the box” and create new ways of supporting our common fight against these health challenges.  If this creativity or spirit of collaboration fails on December 3^rd, we will see a chilling number of preventable deaths around the world.

We would also immediately see a projected $47 billion in additional costs to treat HIV infections that would otherwise have been prevented, an estimated $20 billion in lost global GDP due to malaria, and increases in the number of cases of multi-drug resistant TB, each of which costs tens of thousands of dollars to treat—and each of which poses risks that transcend borders.

Infectious diseases have shown us time and time again that the world is just a little village. The achievements of PEPFAR and the Global Fund, and the launch of new initiatives such as the Human Resources for Health Program, show us how much is possible with true solidarity. As my friend Dr. Paul Farmer, co-founder of the nonprofit Partners In Health, likes to say, we live in one world—not three. The time is now to renew our commitments to one another.

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

Specialized medical education: a necessary tool for development and the right to health in Rwanda

Below is my contribution to Ubuzima Magazine, published by 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. July2012,Vol.69(2)

Specialized medical education:

a necessary tool for development and the right to health in Rwanda

By Dr. Agnes Binagwaho

Minister of Health of Rwanda

In Rwanda, equity is a principle written into our Constitution, and is found throughout Vision 2020, our roadmap for development. As in all sectors in Rwanda, the health sector has conceived policies, strategies, and plans based on equity that are aligned to the national developmen plan. Vision 2020 provides clear and flexible directives for achieving health and wealth in the framework of social justice for all.[1] As such, we are wholly dedicated to ensuring that the fruits of science are beneficial to all – both providers and patients alike.

This approach has driven the gains made over the past decade by Rwanda in improving the health of its population, particularly in the area of infectious diseases. Mortality due to HIV disease decreased by nearly 78% between 2000 and 2010, and malaria mortality decreased by 76% between 2005 and 2011. [2],[3] The utilization of primary health care interventions has increased dramatically, and we have seen rapid declines in both maternal and child mortality rates of approximately 50% in recent years.[4] Rwanda offers ten vaccines at no cost to all children; coverage rates for these vaccines range between 90-96%.⁴ Life expectancy in Rwanda has increased from 30 in 1995 to 55 in 2010. This gain has given ground for degenerative and chronic illnesses to commonly be expressed whereas in the past the Rwandan population had not survived to the age where those pathologies existed regularly enough to make them public health priorities.[5] These achievements are due in part to equitable policies, evidence-based interventions, continuous adoption of scientific innovation, with a focus on community-based approaches. By virtue of the work of Rwanda’s 45,000 community health workers who receive constant training in preventive, diagnostic, and curative skills to be able to address 80% of the disease burden at the village level. In light of these achievements, it is time to take the health sector’s progress to the next level. To do this, we must educate current and future professionals in medical specializations and sub-specializations enabling them to prevent, diagnose, and treat pathologies common and new to our population, including chronic care for HIV positive persons, and side effects of antiretroviral therapy.

In 2009, the President of the Republic of Rwanda spurred the Ministry of Health to find an inventive way to increase the number of highly specialized health professionals practicing in Rwanda in order to accelerate Rwanda’s pace toward becoming a middle-income country. After deep reflection within the health sector, we identified a way to increase the quality and quantity of health professionals who not only can maintain gains since 2000 in their capacity to tackle infectious diseases, but who can also address new pathologies and adaptations in the epidemiological landscape in Rwanda.

We decided to conceive a plan to improve human resources for health by building a knowledge base and increasing Rwanda’s capacity to provide academic and clinical training to the next generation of highly skilled health care providers who will then become the teachers and trainers themselves. The training program, coupled with purchasing new medical equipment and improving the health infrastructure, will certainly increase access to high quality care and advance Rwanda’s overall development.

The result is the National Human Resources for Health Strategic Plan 2011 – 2016 and its implementation plan: the Human Resources for Health (HRH) Program.  The HRH program has been conceived within the framework of using the “3 Ones” principle of having one governance body (the Government of Rwanda), one action plan (National Human Resources for Health Strategic Plan 2011 – 2016), and one monitoring and evaluation plan. By repurposing existing bilateral and multilateral donor funds from development partners including PEPFAR, USAID, the Global Fund, GIZ, BTC, DFID, and the Swiss Cooperation, the Ministry of Health has been able to secure enough funding for a successful launch of the HRH Program in August 2012. The Government of Rwanda has also contributed greatly to the resources available through the Capacity Development Public Secretariat.

The HRH program seeks to address Rwanda’s critical gap of skilled specialized health workers and the inadequate amount and caliber of equipment available in health facilities that presently hinders clinical training and service delivery. The program was designed to increase the quality and quantity of physicians, nurses, and hospital managers through partnership and mentorship.  The Ministry of Health has established a partnerhsip with over a dozen top American universities, including five schools of nursing, seven schools of medicine, and one school of public health.  These schools comprise the US Academic Consortium, which has been working with Rwanda to develop more than 15 specialty and sub-specialty areas including: anesthesiology, surgery, internal medicine, obstetrics and gynecology, pediatrics, critical care and traumatology nursing, surgical nursing, healthcare administration, and more.

For this seven-year program starting in August 2012, ever year 100 US faculty members will be deployed to Rwanda for one year at minimum. They will be paired with Rwandan educators in the Faculty of Medicine and Faculty of Nursing Sciences at the National University of Rwanda as well as all schools for A1 Nursing. US faculty will work together with their Rwandan counterparts to increase local training capacity and the quality of clinical teaching offered to students.  As each year of the program progresses, Rwandan faculty will obtain increased capacity in teaching and training, and will eventually assume full responsibility for specialized medical education in Rwanda.

The investment of American, European, and Rwandan taxpayers for the development of Rwanda’s health sector in this novel and unprecedented model will be sustainable in the long-term because all residents who benefit from this training will sign a contract with the government to serve in the public sector for several years upon completion.

This new initiative for human resources for health in Rwanda is included in the legal framework, in the Health Sector Strategic Plan III, and in the development of the new Economic Development and Poverty Reduction Strategy that is currently underway. The planning and execution of this major program have been truly multi-sectoral and reflect the commitment and collaboration of leaders in across the health, finance, education, and justice sectors, in addition to medical professional associations. We have worked as a team to revolutionize the way Rwanda can train its health professionals in such a way that guarantees equity in the quality of an increased quantity of services to all Rwandans no matter where they live or who they are. Our fellow Rwandan citizens deserve nothing less than the best.

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[1] Ministry of Finance and Economic Planning, Government of Rwanda. (2000). Vision 2020. Kigali, Rwanda.

[2] World Health Organization. (2012). World Health Statistics 2012. Geneva, Switzerland: World Health Organization.

[3] Karema C. (2012). Personal Communication.

[4] National Institute of Statistics of Rwanda and Macro International, Inc. (2012). Rwanda Demographic and Health Survey 2010. Calverton, MD: Macro International, Inc.

[5] World Bank. (2012). DataBank: World Development Indicators and Global Development Finance. Available: http://databank.worldbank.org/ (Accessed 21 June 2012).

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.