Rwanda Is Proud to Pioneer the Pneumococcal Vaccine
November 9, 2011
ONE.org: Rwanda Is Proud to Pioneer the Pneumococcal Vaccine

In this guest blog for World Pneumonia Day on the 12th of November, Dr. Agnes Binagwaho, Minister of Health, writes of Rwanda's partnership with the GAVI Alliance to pioneer the Pneumococcal Vaccine. 
In April 2009, Rwanda became the first low-income country to rollout the pneumococcal vaccine (PCV7) through a partnership with Wyeth. This was a great moment for us, for after having achieved dramatic reductions in malaria incidence, pneumococcal disease had stood as the new leading cause of death among Rwandan children. And it was the dedicated work of our partner, The GAVI Alliance for Vaccines, that ensured the pneumococcal vaccine would be both accessible and affordable for use in our country.
Pneumonia remains the single largest cause of death among children under five around the world. Every 20 seconds, a child dies of this preventable disease.
On November 12, 2011, Rwanda will join other countries in observing the third World Pneumonia Day, a day to celebrate the power of immunization to save lives when access is assured.
The PCV7 vaccine also prevents against pneuomoccal meningitis, a debilitating disease that leaves children who survive it with lifelong mental and physical disabilities.
Certainly immunization is not the only way to prevent pneumonia; breast-feeding, improved nutrition, and the reduction of indoor air pollution are also essential, and children must have access to effective antibiotics when they do fall sick. But immunization removes the burden of hospitalization and treatment on the health system and diminishes the time . This is a major economic advantage in countries like Rwanda, where the time lost by parents lose from work in caring for their children. For immunization to work, it needs to be integrated fully in health and community services. This is what we did in Rwanda.
Last year, the pneumococcal vaccine was scaled up in 16 countries. By 2015, GAVI expects that 58 countries will have introduced the latest generation pneumococcal vaccines nationwide, covering another 90 million children. With sustained commitment among all partners, including both GAVI countries and donor countries, we can achieve remarkable progress in the fight against preventable deaths among children.
The number of lives saved by GAVI is a major contribution towards the world’s pursuit of the fourth Millennium Development Goal, but we must sustain the momentum. In Rwanda today, more than 80% of children have access to the pneumococcal vaccine. The children whose lives are being saved through our partnership with GAVI will help to build a Rwanda where health for all is not simply a dream but one of the foundations of a strong, peaceful nation of tomorrow.

Co-financing - an investment in the future of our children
GAVI Alliance Progress Report 2010: Click to see full report

Contribution of Dr Agnes Binagwaho, Minister of Health of Rwanda

I am proud to say that Rwanda has made great strides in improving the health of our people in the past decade. Our budgets for health and immunisation have steadily increased, accompanied by a strong national health strategy that has been endorsed by all the main actors in the health sector. 

Babies born in Rwanda now receive life-saving vaccines against tuberculosis, diphtheria, tetanus, pertussis, polio, measles, Hib, hepatitis B and pneumococcal disease. In 2009, 97% of the children in our country were given the required three doses of the pentavalent vaccine. 

Our investments have paid off. Between 1990 and 2008, under-five mortality rates dropped from 174 to 103 deaths per 1,000 live births. this success is linked to a range of life-saving interventions, not least to immunisation. 

Rwanda knows that immunisation is a cost-effective investment in the future of our children. Preventing disease is always better than waiting until children fall sick. And because we want to sustain these achievements after GAVI support has ended,  we are committed to contributing financially to the vaccines we introduce. Co-financing is an important step towards ensuring that we maintain our current political ownership and commitment to reducing child mortality, and achieve long-term sustainability of interventions. 

Already in 2008, when co-financing of new GAVI vaccines became mandatory, our Government decided to contribute significantly more than what was required by GAVI – us$ 0.75 per dose instead of the compulsory us$ 0.15 per dose. Between 2008 and 2010, our co-payments amounted to nearly us$ 2.5million, or 26% of the total GAVI vaccine support to Rwanda. 

Although Rwanda is a low-income country, we pay 100% of the cost of our existing vaccines, such as those protecting against  measles and polio, and we have a solid plan for increasing our contribution to full funding for new vaccines in the future. We are hoping to introduce rotavirus vaccines in 2012 and are looking to protect women against cervical cancer by introducing human papillomavirus (HPV) vaccines as soon as possible. 

In addition to vaccine support, GAVI funding helps us strengthen the health system to deliver immunisation and other integrated high-impact services. our network of local hospitals, health centres and outreach health workers has been effective in encouraging improved hygiene, good nutrition and exclusive breastfeeding – all of which help to combat disease. Immunisation is an important entry point for these interventions, as well as for other initiatives such as family planning, HIV testing, vitamin A supplementation, deworming and bednet distribution. 

Our country is currently on track to achieve millennium development Goal 4 on reducing child mortality. Whether we will succeed depends not only on continued support from development partners, but also on our own commitment and contribution. co-financing is one of the ways in which we seek to ensure that we will continue to reap the benefits of our investments in health in the long term.

Rwanda Takes on Cervical Cancer
May 14, 2011

Dr Agnes Binagwaho, Minister of Health of Rwanda and Dr Fidele Ngabo, Director of Maternal and Child health in the Ministry of Health in Rwanda and Ms Cynthia Kamikazi of the GAVI Alliance discuss a comprehensive new program to eliminate cervical cancer in Rwanda.

In 2002, the Rwandan government set up a strategy to tackle priority diseases that were the major killers of both adults (HIV/AIDS, tuberculosis and malaria) and children (gastroenteritis, pneumonia, malaria, meningitis and HIV).

For the past few years, anti-retroviral coverage for HIV patients in need of treatment has increased from 10 percent in 2003 to 82% in 2010. The rate of coverage for prevention of maternal-to-child transmission services has reached 78% of pregnant women. Malaria incidence has declined by 70% between 2001 and 2010. In 2010, the cure rate for tuberculosis treatment was 87%. For multi-drug resistant tuberculosis, the cure rate was 91 percent.

During the same year, 98% of TB patients were tested for HIV. Other indicators of progress include 94% of children vaccinated against pneumococcal disease, and community health workers treating gastroenteritis without delay at village level.

Having met most of the targets set in regards to infectious diseases, as well as achieving improvements in the heath system more generally, Rwanda has noted an increase in life expectancy. As the population has begun to live longer, chronic, non-communicable diseases, such as cancer, rheumatic heart diseases, diabetes and hypertension are becoming more visible. And as a result, the Ministry of Health has initiated a new strategy of tackling priority chronic and non-communicable diseases, so as to continue to provide a better and longer life to the Rwandan population. Cervical cancer is one of such diseases.

According to research conducted in Rwanda, cervical cancer accounts for 27% of all the women’s cancer in the two university hospitals. The World Health Organization has reported that the incidence of cervical cancer in Rwanda is 49 per 100,000 in the population.

Knowing the magnitude of cervical cancer, and the fact that cervical cancer is one of the few cancers that can be fully prevented through vaccination and screening, and treated in its early stages, the Government of Rwanda decided to start their fight with a comprehensive program against cervical cancer.

In light of this, the Ministry of Health, in collaboration with its partners, has developed a national plan for prevention, screening and treatment of cervical cancer in Rwanda. This comprehensive plan includes HPV vaccination of girls aged 11 to 15, early detection of women aged between 35 to 45 years, as well as building in country the capacity to treat any stages of cervical cancer according to different levels of the health system. Through the work of the first lady, the Ministry of Health has negotiated with partners to support this first ever national comprehensive plan for cervical cancer. As a start, MERCK has donated 2 million HPV vaccine doses while QIAGEN has donated 250,000 HPV DNA-tests for screening.

It is in this light that on April, 26, the Government of Rwanda officially launched a Rwandan comprehensive cervical cancer program. The program started with vaccination of school girls in Primary 6, beginning with the Kanyinya sector in Nyarugenge District, followed by 2 days of vaccination in all primary schools in Rwanda, as well as a national summit on women’s cancers.

In collaboration with the MINEDUC, the Ministry of Health has made the HPV vaccine available to all health centers; and because 95% of girls are enrolled in school during the ages targeted, all primary schools have been identified as vaccination sites.

Using the national network of three community health workers per village and the commitment of the local leaders, girls who did not attend schools during the two days of vaccination have been identified at home and vaccinated in the community. As a result, 94% of girls have received their first dose of HPV vaccine while the rest will receive it during the catch-up phase in collaboration with CHWs.

This comprehensive cervical cancer program will avail prevention, screening and treatment for the entire population at risk. All of this will be done for a period of 3 years, while Rwanda works on its sustainability plan after this period.

The parents and community members interviewed during the vaccination days were very happy to have an opportunity to prevent cancer among their daughters, and there was an excellent adherence to this program on a voluntary basis.

Rwanda is the first country in the world to offer a comprehensive plan to eliminate cervical cancer despite social and economic challenges. The Rwandan plan is for the country to be free from cervical cancer within 40 years (by 2050) as a result of consistent vaccination, regular screening and timely treatment.

Letter to the Global Fund from Dr Agnes Binagwaho, Minister of Health, Rwanda
Letters to the Editor: Responses to Auditing the Auditor
June 20, 2011
Global Fund Observer (GFO)

Firstly, I would like to give a word of thanks to a few members of the OIG team who visited us in 2010 and who displayed a high level of professionalism when interacting with the Rwandan teams. However, I would like to share my disapproval of the behaviour of the other members of the OIG team who were less than appropriate and very unprofessional at times during their interaction with our teams – because sharing this may help shape the way audits are performed by the OIG teams in the near future. 

In Rwanda, while it is true that we are in a process to build the capacity of our accountants, the approach used by some OIG team members was undesirable and not called for. They undermined our accountants, behaved unpleasantly and even in an insulting manner in certain instances. Though the Team Leader stressed the importance of professionalism, respect and collaboration during the audit exercise, these team members diverted from their core mission and objectives and, instead, appeared to play a police rather than an auditing role. Despite being proven wrong on some of the claims they made, they continued repeating the same statements without taking into account answers and clarifications provided to them. 

The attitude of some members of the OIG team did not uphold the human right for respect. They reminded us of how power can be abused. These experts should have been more respectful. It was as if their motivation was to find the flaws and see us fail the audit. Surprisingly, the team members I am referring to never thought about apologizing for their inappropriate conduct. However, I recognize that the Team Leader was continuously keen on trying to ensure an atmosphere of respect and that a few members of the OIG team acted in a professional and courteous manner; it is just a pity that, though key, they were a minority in terms of numbers. 

An audit should be done with a view to promote capacity building rather than with an objective to prove you wrong. Its basis should be rooted in good practices and lessons learnt for better performance. Until everyone involved in these audits understands their objectives and the importance of professionalism in conducting them, the OIG will have to monitor the behaviours of his teams, including the subcontracted ones, as we hear unacceptable stories from countries from the Southern constituency. This is critical, as we want to continue seeing the OIG’s audits as opportunities to learn about our strengths and weaknesses and improve the management of disease programs.

Agnes Binagwaho, Kigali, Rwanda

March 11, 2010; Health and Human Rights Journal Blog

Monday, March 8 marked the celebration of International Women’s Day, a global tribute to the economic, political and social achievements of women past, present and future. In this guest post, Dr. Agnès Binagwaho, Permanent Secretary of Rwanda’s Ministry of Health, reflects on the human rights of women in Rwanda.
Sixteen years ago, during the 1994 Rwandan Genocide, perpetrated by Hutu extremists against Tutsis and the Hutu moderates, where one million people were killed — more than one tenth of the Rwandan population — women’s rights were profoundly denied, as many of our mothers, sisters, and girls endured systematic massive rape that resulted, often intentionally, in the devastating effects of a slow death by HIV/AIDS infection. During that time the country was destroyed, its health system ceasing to function as health professionals were killed or left the country and infrastructure and materials were destroyed. As this week we celebrated International Women’s Day 2010, I salute the fact that rape as a weapon of war has been recognized as a crime against humanity.
Times have changed in Rwanda. Thanks to the new leadership since 1994, most of the population thinks “out of the box,” with a strong belief that there is always a solution if we work hard to find it and if we search for solutions within our culture and within ourselves. In this short essay, I would like to share how the situation during the time of the genocide has been reversed to favor women rights and how it impacts my work.
Click here to continue reading Agnès Binagwaho’s piece, “What do human rights mean for a working woman in the Rwandan health sector? Reflections on International Women’s Day.”

October 28, 2009
Click here to read the article on the Health and Human Rights Journal Blog:

Adolescents remain a neglected group in Rwanda’s health care model according to a new report on adolescent health by Dr. Agnes Binagwaho,Permanent Secretary of Rwanda’s Ministry of Health. While the country’s health care infrastructure has vastly improved since 1994, so that vulnerable groups such as mothers, infants, and people living with HIV/AIDS experience better health outcomes, few efforts focus on behavioral and preventative health care for adolescents. Dr. Binagwaho argues that adolescents are a neglected group in the country’s health care model primarily because they are considered comparatively healthy with a low disease burden. Yet the choices adolescents make today affect their health — and the health of their families — in the future, especially as these choices relate to family planning and STDs.
The new report emerges from Dr. Binagwaho’s research on the gap between the right of HIV-infected children to health services and the reality in Rwanda. Finding little research or advocacy focused on adolescent health, Dr. Binagwaho decided to undertake the task herself. She found that although adolescents may be equipped with knowledge, they lack “life skills,” for example, the ability to negotiate safer sex or to seek the help of family planning services. She offers practical suggestions for addressing this gap, including policy changes, training, and social support designed specifically for adolescents.
The report’s Executive Summary is provided below. Her full report on “Adolescent Health in Rwanda” is available here.
Executive Summary of the “Report on Adolescent Health in Rwanda,” by Dr. Agnes Binagwaho
The Government of Rwanda, supported by outside partners, has been able to significantly improve the health status and HIV services of the population in the last decade. Life expectancy increased; infant, child and maternal mortality has been reduced; and the spread of HIV/AIDS has been contained. Nevertheless, there is still a lot of room for further improvement of health care in Rwanda, in particular by increasing access to quality health and HIV care services.
One area that has been widely neglected in Rwanda is the adolescents health. A comprehensive strategy to advance health services (including STIs and HIV prevention and treatment) that meet adolescent needs is presently missing but absolutely in light of the fact that adolescents make up about a third of Rwanda’s population.
Adolescents are often perceived as healthy, since they face a relatively low disease burden. While this is true regarding traditional measures of disease burden such as DALYs, adolescents impact their immediate and their future health outcomes by their behavior today. Therefore, compared to other age groups, adolescent health and HIV status are concerned with a higher share of preventive and behavior changing health services compared to curative health services.
The key health issues faced by Rwanda’s adolescents today are related to reproductive health, including family planning, STIs and HIV – which is particularly important given its public health implications. Mental health and substance abuse are perceived as an important but less pressing health concern in Rwanda. Injuries and accident-related traumas – often a main health threat for adolescents in developed countries – seem to be less relevant in Rwanda.
Several challenges to improve adolescent health and sexual and reproductive health in particular, exist in Rwanda: Even though adolescents’ knowledge about protective health behavior and risk factors for poor health has increased, there is a clear gap between knowledge and the ability to apply it in critical situations – including situations that increase the risk of HIV infection. A lack of independence and assertiveness, such as being able to negotiate safer sex, is perceived as an obstacle to better health through reduced risk behavior.
Despite an impressive rebuilding of the whole health care system since 1994, youth-friendly health services are still widely missing. This is true for all the component of a clinical program, such as infrastructures, personnel trained to meet adolescents’ needs, and guidelines defining HIV packages for this group. 43% of the children surveyed were treated with adults, – 6 – not in a separate pediatric ward. Furthermore, 90.7% of children and their parents stated that they felt the need for the establishment of an adolescent ward. Finally, in a hierarchical society with strong roles and norms, social pressure on adolescents regarding their behavior is another factor that often hinders adolescent health seeking behavior. In particular if HIV and family planning services are not used by adolescents due to fear of social consequences, and in the absence of relevant information provided by adult family members, this can lead to worse health outcomes.
Findings in this report indicate that:
1. Policies should ensure that adolescents not only receive technical health and HIV information, but are also trained in how to apply this knowledge in their daily life. To achieve adequate adolescent training and education, health care providers have to be sensitized on this issue and enabled to provide this kind of training.
2. To ensure adolescent access to high quality health and HIV services, adequate guidelines infrastructures, and trained personnel must be available to ensure that quality youth-friendly services can be offered.
3. Social support has to be ensured for adolescents. This should include a very wide array of activities and interventions aimed at actively engaging adolescents in changing social norms limiting their access to health and HIV services. Messages concerning adolescent health, such as HIV and STI prevention and treatment, should be included whenever possible in adolescent related activities.
4. A national adolescent health policy should be developed as an instrument to establish a common policy base between relevant ministries, agencies, health partners and civil society – thereby ensuring the necessary support to provide an implementation framework and to keep institutions accountable. This policy should also define a national mechanism for coordination between government institutions, as well as between government agencies and partners working in adolescent health and HIV issues.

August 3, 2009

In addition to Dr. Binagwaho, Dr. Fidele Ngabo, Cathy Mugeni, and Niloo Ratnayake also contributed writing to this post.
Access to care in resource-constrained countries has three major barriers to overcome: finances, infrastructure, and geography. Community health workers (CHWs) are an unavoidable solution for both infrastructure and geography. The Government of Rwanda has recognized that CHWs are necessary in order to 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.
Rwanda has set up a system where each village (100 to 150 households) elects two volunteers to act as CHWs for the general population. Because each community votes on one woman and one man to serve the village in this capacity, becoming a CHW is now a position of respect, raising gender equity throughout Rwanda.
These two CHWs are then trained to monitor growth and development in children, to care for people living with HIV, and to refer sick patients to the nearest health facility. Their training is designed by the Ministry of Health, which enables them to provide services in a harmonized manner throughout the country. By sensitizing the local village and making themselves available, they improve access to care; because of CHWs, a greater number of previously unreachable Rwandan citizens now have access to care. The CHWs trained this year to provide services to their villages are trained to treat certain diseases using amoxicillin and to distribute family planning tools (condoms, contraceptive pills, and injectable contraception). Read more

Participation as a developmental tool for the health sector: The Rwandan experience
September 16, 2009

Participation is a right situated at the very heart of the human rights vision. Participation holds this central place because it requires and activates the full range of other human rights. People can only fully exercise their right to participation if they are correctly informed and free to express their views on the situation in which they live, the priorities that should be emphasized, the actions to be taken, and the way in which those actions should be implemented, followed-up, and evaluated.

My experiences as a manager of national public health programs has taught me that no solid, lasting progress in health is possible without applying the principle of participation. I would like to illustrate this point through several examples that have an impact on my daily work.
In 1994, the genocide in Rwanda completely devastated our health system. The infrastructure was destroyed. Human resources were drastically diminished by the massacres and by the departure of people who either feared being killed or were taken hostage by the genocidaires as they fled.
Today, 15 years later, we still have a long road ahead, to build the optimal health system for our country. We are far from declaring ourselves satisfied. However, we have managed not only to recoup the losses of the genocide period but to improve substantially on what existed before 1994.
Our health indicators show that we are on the right path in our construction of a robust health system based on the principle of universal access to health, with a special focus on the most vulnerable individuals.
Presently, in Rwanda:
Health insurance now covers 92% of all Rwandans, including 83% at community level;
The uptake of curative care has tripled;
Vaccination now covers more than 90% of children;
Malaria mortality has been reduced by 2/3; and
70% of HIV-positive people in need of ARV treatment are receiving it.
To reach this result, we have relied on the effective contribution of all of our people — thus we have relied on participation.
The involvement of all stakeholders means that communities, civil society, and both the private and public sectors are involved.
For the community sector, participation is enabled through massive information campaigns on the right to health and through training. We raise awareness about people’s responsibility to participate in goal setting, decision making, and the fight for transparency and against corruption. The goal is for each dollar to buy the greatest possible amount of health while respecting equity.
This is written into Rwanda’s Community Health Policy: “Community Health is seen as a holistic and integrated approach that takes into account the full involvement of communities in planning, implementation and evaluation processes, and assumes communities to be an essential determinant of health and the indispensable ingredient for effective public health practice.”
The principle of participation is also applied in the public sector. The public sector departments of education, infrastructure, roads, energy, water, finance, social issues, gender, foreign policy, cooperation, and so forth must all participate actively in the work of the health sector if we want health action to respond effectively to demand. The requirement for participation is included in the “Manual of Procedure of the Ministerial Cabinet,” which stipulates that no policy, ministerial instruction, or legislative proposal can be discussed in the Cabinet without ensuring that all those constituencies who may be affected have been informed and have actively participated in developing the proposal to be discussed.
With civil society and the private sector, the lessons drawn from their active, synergistic participation in the response to the HIV pandemic have recently been expanded to the whole of the health sector.
The fight against HIV/AIDS is based on the concept of GIPA: “Greater Involvement of People Living with HIV/AIDS: Never do for us without us.” In each of nine sub-sectors — PLWHA, faith-based organizations, community-based organizations, transportation, media, the private sector, people living with disabilities, and young people and women — Rwandan NGOs have formed what we term “umbrella” groups to enable and coordinate participation. These groups have identified representatives who can speak for their interests in each district and at the central government level.
Today, the nine umbrella organizations involved have transformed themselves into “Umbrellas for the fight against HIV/AIDS and the promotion of health.” Their representatives participate in decision making, planning, follow-up, and the evaluation of health sector activities at the district and central levels.
We all know that a healthy population accelerates development. I hope that I have been able to show you why, on Rwanda’s path to development, the urgency of action makes the principle of participation in the health sector indispensable. Health is also coordinating with other sectors. For participatory efforts to be effective and sustainable, they must be anchored institutionally and taken forward using a multi-sectoral approach.

Ray of hope from 1000 hills
03 December 2010
Global Health Delivery Online: Click here to go to GHD Online Website.

As the sun set, a ray of hope was rising from the country of a thousand hills, a ray that cast its light towards saving the lives of those affected by HIV/AIDS, malaria and tuberculosis.
There are some moments in life when you are simply proud. This time, I was proud to be an African watching an event led by the Rwandan Government, which involved both the Rwandan private sector and the wider African private sector.
Certainly, the beam’s origin is a group of business executives that converged at the invitation of Mrs Jeannette Kagame, the First lady of Rwanda, for a Private Sector Summit dinner in Rwanda’s capital, Kigali, on November 6, 2010.
After the 1994 genocide the successful rebuilding of Rwanda has relied on multiple pillars, among them solidarity and responsibility. These values have found memorable expression in the commitment undertaken in November 2010 by the Rwandan private sector, along with the African private sector. Their joint action was guided by solidarity, social responsibility, common development goals and the inspiration provided by the Government of Rwanda, which has led the way by its commitment to improve the health of Rwandans. Such solidarity and responsibility were vital in the ancient African setting, and should be nurtured today and tomorrow, as we seek solutions to respond to African challenges, particularly those that concern the health sector.
I would not be far from the truth in describing this initiative as an indicator of tangible results that can be achieved when African leaders from government and the private sector join forces: not only to fight HIV/AIDS, malaria and tuberculosis on the African continent, but to contribute to a truly global cause.
Africa bears more than 80% of the global HIV, TB and malaria burden. This explains why about 60% of the resources of the Global Fund to Fight HIV/AIDS, Malaria and Tuberculosis are allocated to Africa. 2010 is the year of replenishment for the Global Fund. Organizations of Friends of Global Fund across the world are advocating and mobilizing around this crucial year. On November 6, 2010, at the initiative of Mrs. Janet Kagame, member of the Board of Friends of the Global Fund Africa and wife of His Excellency Paul Kagame, President of Rwanda, the Government of Rwanda hosted an African Private Sector Summit as a fundraising event in favour of Global Fund replenishment. Those attending the Summit include his Excellency President Paul Kagame, First Lady Jeannette Kagame, and Michel Katzatchine, the Executive Director of the Global Fund and Mr. Aigboje Imokhuede, Chair of Global Fund Africa.
During this event, $3 million were raised in the country of 1000 hills. The Rwandan private sector committed $1,200,000, the African Private Sector an additional $800,000 and the Government of Rwanda $1,000,000. Compared to how much the Global Fund needs, $3 million may seem like a drop in the ocean. Yet this event holds significance that reaches far beyond a simple monetary sum.
This contribution to the Global Fund aims at improving the lives of the vulnerable and promoting health on the African continent. It reminds us that each drop of water in the ocean is made by millions of years of preparation. That means that what we see here is not a futile raindrop in a sea, but rather an oasis in a desert that will and should continue to provide a life-giving spring in the years ahead. We see Africans–African governments and the African private sector–exercising their humanitarian duty and responsibility by improving the wealth and the health of the African people.
The central lesson is that solidarity is paramount to attaining national goals and building a national vision. Solidarity in this concrete sense expresses the principle that those who have greater resources can pay more, contributing to save the lives of those who have less, and thereby enabling them to be healthy and productive citizens. Such solidarity contributes to the development of the country and of Africa as a whole. Thus, it ultimately benefits all. Such tangible solidarity exists in the Rwandan system of health insurance, for example. That is how 92% of Rwandans enjoy health insurance coverage that allows all to access the prevention, care and treatment available in Rwanda when needed.
The contribution by Rwanda’s private sector to the Global Fund replenishment has demonstrated that even developing economies can participate and contribute to a global cause. Whether the strict monetary value is large or small, lives are saved, and the beam of hope will shine on the lives of many in Africa and beyond. It is true that Africans deserve to receive according to their needs, but it is also true that Africans should contribute according to their capabilities. Thanks to the commitment of the government of Rwanda and the Rwandan and African private sectors, this principle is becoming a reality.

The Role of Social Capital in Successful Adherence to Antiretroviral Therapy in Africa
This Perspective co-authored with Niloo Ratnayake discusses the new study by Ware et al. Published in PLoS Medicine.
02 February 2009

In the late 1990s and early 21st century, some public health officials in the Western world believed that Africans would never be compliant with antiretroviral therapy (ART) because the continent's uneducated, illiterate population was driven by day-to-day concerns without much thought for the long-term future. On top of this, many claimed that ART was a luxury for Africans and that the complex disease would be too difficult for African doctors to manage in the middle of nowhere with no water or electricity. Some went so far as to insist that giving ART to a likely noncompliant population would create drug resistance and were willing to sacrifice Africa for the good of global public health [1].

However, recent research has shown that levels of adherence to ART in sub-Saharan Africa are in fact higher than those in North America [2]. Why are Africans with HIV more adherent to ART than their counterparts in North America despite being less educated about HIV and having more obstacles to overcome? A new study by Norma Ware and colleagues published in PLoS Medicine sets out to answer this complicated question [3]. This study investigates the surprising finding that Africans would want to take drugs that would give them life and keep them healthy. Anthropologically, this first question leads to another complex question: Why is it that when things are successful in Africa the rest of the world looks for a reason, but when things fail, there are few who question the failure?

The New Study

Ware and colleagues asked patients, treatment partners (those who assisted patients in their efforts to take antiretroviral medications), and health care providers what the driving factors were behind adherence in three sites: (1) The Immune Suppression Syndrome clinic at Mbarara University of Science and Technology in Mbarara, Uganda; (2) the ART clinic of Amana District Hospital in Dar es Salaam, Tanzania; and (3) the HIV/AIDS clinic at Jos University Teaching Hospital in Jos, Nigeria. Patient interviews focused on experiences with taking ART, clinic visits, and help from treatment partners. Treatment partner interviews targeted the types of help that they give, feelings about being a treatment partner, and opinions on their impact. Health care workers, such as clinicians, nurses, and others, were asked to describe typical clinic visits, ways adherence is discussed at these visits, and views of patient obstacles towards adherence. The researchers also conducted observations of clinic visits, with a focus on observing routine follow-up visits of patients taking ART, counseling sessions, health education sessions, and the dispensing of antiretroviral medications. In all, 158 patients, 45 treatment partners, and 49 health care workers were interviewed. There were 414 interviews and 136 observation sessions conducted across the three sites.

The study shows that Africans overcome economic obstacles to get ART by begging and borrowing money from friends, families, and even their health care providers. They may choose to use money for transportation for their clinic appointments over food for them or their family, over school fees for their children, and over treatment for their sick child. Patients without money would take their medications without food despite the increased risk of side effects and would walk to health clinics despite long distances. Health care providers also made sacrifices by keeping their offices open longer to accommodate patients who arrived late and gave food, money, and even loans to needy patients.

The study also shows the significant impact of social responsibility upon adherence. Families and friends often help finance health needs, but this assistance becomes more difficult to justify if it is believed the patient is near death or incurable. Treatment partners insisted on adherence to ART by those they cared for because it made the treatment partner's burden lighter. The treatment partners' help created an obligation to patients to be adherent. Some health care providers threatened to discontinue giving treatment to nonadherent clients, further emphasizing the social responsibility patients had to remain adherent.

Public Health Implications

Ware and colleagues' multi-country, multi-setting study used a methodology of interpersonal interaction that allowed people to talk simply to the researchers, without complicated study designs getting in the way. Instead of coming with experts and boxes to check, the researchers captured the viewpoint of the patient, treatment partner, and grassroots-level health care worker. The findings show the importance of social capital (the connections between people) and reveal that social responsibility in Africa pushes people to be “good” (adherent) patients. Social capital has been used in other countries such as Rwanda, where those who want treatment must come to the clinic with a relative or members of their association.

Those who have truly been working in Africa should not have learned anything new. Social capital can be easily seen in day-to-day health care work. This new study will, however, hopefully change the way the rest of the world views Africa. The study proves that human rights activists were correct in believing that giving ART in underdeveloped settings does not put the world in danger. When future myths about Africa are presented, people can point to this study to show that the uneducated, illiterate, and poor still want to survive, perhaps even more than those in Europe or the United States. Although this study does not change policies and will not affect future clinical decisions, it can be a useful tool to create support for access to treatment in Africa.

Social coercion in Africa is high because people are more responsible for each other. Yes, Africans want to live, but more than that, they want to keep their relationships alive. Patients living with HIV in North America often have negative experiences and complicated backgrounds, such as traumatic events and mental illness, with little social support, and they face a great deal of stigma [4]. Social capital is less strong in the United States than in Africa as people in the US tend to be more individualistic and therefore less focused upon and connected to the group as a whole. There is less concern about others and less of a feeling that others are concerned about you. Ware and colleagues state that: “In North America, adherence to ART for HIV/AIDS has been interpreted as the product of information, motivation, and behavioral skills operating at the individual level.” In other words, the driving factor for Americans to take their drugs is not social responsibility, but intellectualization of what to do to remain alive. Patients take the drugs they are given for themselves and not for others. Therefore, when a patient becomes depressed, adherence often declines. Research has shown that depressed people living with HIV progress to AIDS faster than those who are not depressed, due in part to nonadherence [5]. In Africa, on the other hand, taking prescribed ART is a community effort. Even when patients no longer care for themselves, they continue to take the medication for the community around them.

Next Steps

Having clearly established the importance of social capital in promoting adherence to ART, future studies should focus both on its protective effects outside of the scope of HIV/AIDS and on how to maintain social capital while improving economic development, which can bring a more individualistic way of life. A developed economy provides an environment that allows the growth of individualism, while the poor tend to depend on their community for survival. Social capital can be a useful tool in promoting adherence to medications in patients with chronic diseases, who are at higher risk of depression than the general population [6]. As countries in Africa become more economically developed, it will be increasingly more important for them to actively find tools to maintain their social capital.

Male Circumcision Scale-Up with New Technology
18 February 2011

Dear All,

The Government of Rwanda has decided to scale-up its voluntary male circumcision program using the PrePex™ system, a new device for rapid adult male circumcision deployment in resource-limited settings (http://www.moh.gov.rw/index.php?option=com_content&view=article&id=181:rwanda-leads-breakthrough-innovation-in-hiv-prevention&catid=1:latest-news&Itemid=2). The PrePex system works through a special elastic mechanism that fits closely around an inner ring, trapping the foreskin, which dries up and is removed after a week. The procedure is quick, simple, bloodless and safe.

In 2010, a nationally sponsored study to test the safety and efficacy of the system was initiated: http://clinicaltrials.gov/ct2/show/NCT01150370. Results showed its potential to revolutionize male circumcision as an HIV prevention method. And a new study is currently under way in Rwanda to compare it to surgical circumcision for rapid scale-up of male circumcision in resource limited setting:http://clinicaltrials.gov/ct2/show/NCT01284088.

This roll-out is part of a national comprehensive plan for HIV prevention that you can download in PDF here: http://www.moh.gov.rw/index.php?option=com_docman&task=cat_view&gid=67&Itemid=14

We hope to decrease the HIV incidence rate by 50% by circumcising two million adults in two years.

Please share your thoughts/experience. Thank you.
Keywords: Developing targeted interventions, Scaling up & managing at scale, adult, bloodless, circumcision, no anesthesia, no sterile settings, no sutures

Fight for Cervical Cancer Prevention, Diagnostics and Treatment in Africa!
21 February 2011

Today, I have been reflecting on the progress the world has made in the fight against infectious diseases. Even though there is a long road ahead, there are many achievements we can be proud of. In my country, Rwanda, we have decreased the rate of deaths due to malaria by more than 65% since 2005. We are now providing universal access to anti-retroviral therapy (ART) for all those diagnosed to be in need of treatment, a total of over 83,000 people. Rwanda currently has multiple hygiene campaigns; and has provided 60,000 Community Health Workers with antibiotics (Ampiciline), oral rehydration solution, and training on how to treat digestive and pulmonary diseases at home. Through these interventions, we are sure to continue to make progress in tackling communicable diseases.

In Rwanda, now that morbidity and mortality due to infectious diseases have both decreased, we are looking to take a step forward and tackle the other serious causes of death. According to the WHO, non-communicable diseases (NCDs) are responsible for 25% of mortality in our region of the world. For the past two years, the Ministry of Health of Rwanda has been considering various initiatives specific to NCDs. Cancer is one of the top killers among this category of disease. It is a leading cause of death worldwide accounting for an estimated 7.9 million deaths in 2007 alone. Knowing that over 70% of these deaths occur in low- and middle-income countries, where resources available for prevention, diagnosis and treatment of cancer are limited or nonexistent, I argue that it is time for us to focus on a strategy to reduce the burden of NCDs. The challenge will be to do so without reducing our energy currently put into fighting communicable diseases.

Among women, cancers of the breast, uterus, cervix and ovaries represent the most common cancers diagnosed. Until recently, there was no certain way to prevent these cancers. Yet now one of the most common causes of cancer among women in our region, cervical cancer, is preventable with a simple vaccination. As such, here in Rwanda in 2009, under the leadership of President Paul Kagame, we began to work on a plan to provide universal access for primary prevention of cervical cancer by vaccinating our girls with the HPV vaccine before any sexual intercourse. Now we have finished our strategy for national cervical cancer prevention, screening and treatment, and we are strongly pushing global leaders to help make our plan a reality.

Our program is very simple: One full package for girls (primary prevention = 3 doses of HPV vaccine before any sexual intercourse) and One full package for women (screening technology = HPV/DNA technology and access to treatment at ages 35 and 45). The best place to implement the vaccinations will be where our girls and women are living. Because we are experienced in offering our population a very high vaccine coverage, we are confident in the plan to provide universal coverage for cervical cancer prevention by vaccination. In the case of malaria and HIV, Rwanda has effectively implemented diagnostic and treatment capacities from communities to referral systems. Rwanda has introduced new vaccines and effectively achieved high coverage of these vaccines; we were the first country to introduce pneumococcal vaccine in Africa. Now we have built on our existing capacity to implement preventive, diagnostics and treatment measures at all levels of care, and have used lessons learned to ensure the same for the management of cancer. Therefore, we need the world to believe that such a medical intervention and such technologies should be accessible to Rwandan women; and to believe that we can do this just as we have successfully implemented myriad other public health programs.

Unfortunately, some influential partners contradict their mandate by trying roll us back. This situation reminds me of the late 1980s when activists proposed to make ART accessible to African people living with AIDS. Many argued against this – particularly deliberating about whether African health professionals would be able to manage such complicated treatment instead of working with them on how best to implement such an intervention in resource-poor settings. In the fight against cancer, we will build on the lessons learned from the successful HIV and malaria programs already firmly established in Rwanda. So let’s all push together to make it happen today.

What are your thoughts?
Keywords: Addressing structural risk, Community engagement, Developing targeted interventions, HPV, Integration and linkages to care, Rwanda, Scaling up & managing at scale, cervical cancer

The Use of Information and Communications Technologies (ICT) to Provide and Support Healthcare Delivery Services in Rwanda
04 February 2010

Disruptive Women in Health Care Blog

Human beings have a fundamental right to health, which must be equally distributed to all. To be able to provide the prevention, care, treatment and rehabilitative services needed for its population, Rwanda has embarked on an ambitious journey to transform its socio-economic situation by changing its economy from an agriculture-based to a knowledge-based economy. In this context, Rwanda has identified the use of science and technology as a key tool for achieving our socio-economic transformation and reaching the MGDs. Although a high tech strategy may appear inappropriate for the health system of a developing country, this is is not applicable to Rwanda because our health sector ICT plan is integrated into two master plans: our health sector strategic plan and our national ICT plan. We know that e-Health is vital in order to create an effective and sustainable health system, as it will help us solve challenges in our health system, such as the lack of infrastructure and the shortage of professionals (since roads are still a problem in some remote areas, sending information, plans, and reports by ICT saves time and money).
Another reason why ICT for E-Health should be developed is because the right to health cannot be separated from the right to information, and the use of new information and communication technologies is the most accurate and timely way to provide information.
A good flow of information concerns four categories in the health sector: the patients, the policy makers, the care providers and the program managers. When it comes to patients, they need to be educated on their health needs and on how, when, and where to seek proper care. Also, once on treatment, patients should know why it is important to go for timely medical follow up appointments and be compliant to treatment, since it not only aids their recovery, but also helps to avoid dangerous resistances to epidemic diseases like HIV. Patients would be informed of these things by making ICT tools available to health professional at all level: community health workers would use phones, while central and district managers, health centres, district hospitals and referral hospitals would use web-based tools. For policy makers and program managers, ICT is important because it helps to design health policies and programs that are informed by evidence and based on accurate information. In general, the use of ICT has proven to be the more 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 its health development and recognizes that there is an urgent need to build e-Health capacity.
Many applications of E-health have already been provided. One good example are the web dialogues, which are good 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 infrastructures and costs nothing. Through the exchange of biological and immunological patient information, Xrays, echographies, etc, clinicians can receive ideas, confirm diagnoses and make correct decisions. For example, Harvard’s Global Health website connects Rwandan health professionals to counterparts in other countries, such as the United States, Haiti, and Peru, and allows for free communication between these countries on several levels. ICT also allows for the horizontal exchange of information between policy makers, programs managers, and community workers at the grassroots level. It also allows for vertical exchange between those three categories, thereby breaking barriers to knowledge and communication.  Such information flows create an international family of global health workers and help to bring communities on board with the decisions that concern them. These communication exchanges can take on many different models so countries can choose which one best suits them. As a result, one gains time by quickly building on the experience of peers around the world, and this web-based free information can dramatically improve national and global health.
Without ICT all Rwanda sub programs in the health sector would be unmanageable, since it greatly helps the day to day work of health care providers. For example, the healthcare financing system is web based and manages more than 90% of the Rwandans enrolled in health insurance, along with the performance based program in the 480 health facilities. Rwanda’s ART program, which provides antiretroviral therapy for 70% of people living with AIDS who need them, is also managed via web based technology. ICT also helps to gain data for Rwanda’s localized MDG report, since community health workers and health professionals do active case finding of fever and malnutrition, perform maternal audits, and collect information on all maternal deaths in the country via this technology, in order to better understand why young healthy Rwandan women can be at risk of death during pregnancy or delivery. Also, 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. The big challenge is coordinating ICT tools so that these web based management systems are efficient and have synergy.
All of the above reasons show why the Government of Rwanda has put ICT as a top priority in our health development, 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 within Rwanda’s health sector. This approach will be crucial in enabling the sustainability of an integrated and coordinated healthcare system in Rwanda that will efficiently provide high-quality, gender, geographical and age balanced services.
The last advantage of using an ICT approach is that we save trees since we are saving the paper used for plans, reports, files, mails, etc… At this time when experts recognize the danger of global warming to the Earth, “saving CO2” environmental programs should also award the use of ICT by the Government of Rwanda!

Mental Health is a Basic Human Right to Fight For
13 December 2009
Disruptive Women in Health Care Blog

A few days ago the world celebrated Mental Health Day, and more recently it was the Human Rights Day, as such I have decided to post a reflection on the rights of all people to access mental health care as a part of the access to health care as a basic Human Right. I especially dedicate this reflection to the issues surrounding access to quality mental health care services for women.
Unfortunately, in the majority of the developing world, mental health is not an issue that is given adequate attention. However, if we take the definition of WHO, mental health plays as important part in overall health as the physical aspects do. To improve mental health, governments have to create a well-trained and well-equipped workforce to care for mental health and ensure that the funding and human and physical infrastructures are available. This will help to increase access to mental health care, but should be completed by making drugs available, like psychotropic drugs. Many of these medications are not so expensive and can be part of public essential drugs available at public health facilities. It is a matter of paying attention to the problem.
Also, the general population should be educated via mass media campaigns so that they will have less fear and a better understanding of mental health diseases and those who suffer from them, causing mental health patients to suffer from less isolation, stigma and discrimination. This can be done by partnering the government with civil society organizations to improve the public education on this issue through TV, radio, speeches, billboards and community events.
Both of these points are vital and necessary if we wish to improve the care of people who suffer from mental illness, because they will encourage the community to send people for care when mentally ill, and when the patient arrives, the health care providers will be ready to give proper care.
This is the system that the Government of Rwanda is creating by having one psychiatric nurse in each district hospital working in an integrated manner with hospital personnel, and by training general practitioners in the diagnosis and treatment of simple mental diseases and in the identification of severe ones so that such patients can be transferred to the national referral hospital for mental health. We also have some psychotropic drugs available as essential drugs, but we still have a long way to go to ensure that every Rwandan in need of mental health receives it.
An extremely important area of mental health care for women is trauma due to conflict situations, where many women are devastated because of rape and other sexual violence, as these health issues are often neglected. Mass rape has been used as a tool for war for centuries, and can be found in modern history as well: from the rape by German and Japanese armies during World War II, to the use of systematic rape and deliberately infect women with HIV during the Rwandan 94 genocide against Tutsis; this: from the rape of women during the Kosovo conflict, to the current use of rape to intimidate and humiliate women in the eastern regions of the Democratic Republic of Congo and through the devastation of their genital organs. For these women, international organizations should play a bigger role, since most of the conflicts are predictable and usual time for rape, sexual abuse and violence and psychological traumas.
In post conflict situations such psychological destruction needs specific attention to rebuild mental health and care for psychological reconstruction as a priority. Instead, the thousands of individual women suffering from this type of trauma are totally neglected and suffer in silence. Furthermore, in some countries these women additionally face stigma because of forced sex and pregnancy out of marriage, and are sometimes even forced to leave their households and villages because of that – doubling their trauma. In this manner, the communities who should be helping these women instead end up being on the same side of the perpetrators of this violence. For the prevention of mental health illness in women post wartime sexual violence, we must do massive behavior change campaigns for tolerance in countries recovering from wars.  That was we did and still do in Rwanda. If not, these women will be denied their basic human rights to gender non-discrimination, to live without violence, and to access care for mental illness and other health issues like STIs, HIV, and genital organ damage.