The importance of claiming our future

I was pleased to co-author an article with Nigel Crisp that was recently published in the Lancet.  

You can view the article here:  http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)60934-5/abstract  

In the piece, we summarize some of the fundamental motivations behind our efforts to contribute to a recent book titled "African health leaders: making change and claiming the future." 

Setting course for 2012

Posted in Ubuzima Journal 

first quarter 2012

By Dr. Agnes Binagwaho

As we embark on yet another year, it is time to check our bearings and determine the direction we want events in the health sector to take during 2012.

While there is no fault in celebrating our achievements in the past year, maintaining those gains should be the overarching priority for 2012. The gains in the health sector are always fragile and could easily be lost if we are not focused. Ten years ago, infectious diseases were killing us. Now those are contained but because they are still there we should not relax our vigilance. The gains made against HIV can be lost in as short a time as one year if we relax our guard.

We shall continue to see progress in the areas where we have done well and this is translating into reductions in the incidence of malaria, HIV/AIDs and TB. For children we are introducing the rotavirus vaccine this year. Two and half years ago we introduced the vaccine for pneumonia and as a result pneumonia has decreased. 

 Aging population

We have made good progress across all the infectious disease profile and people are living healthier and longer.  According to the National Institute of Statistics, the average Rwandan can now expect to live as long as 55 years.

It is a modest number that is at the same time significant in our setting. This year we need to begin focusing on the long term by anticipating health problems that are likely to arise in the not too distant future and preparing solutions now. As the health of our population gets better, they will start to experience health problems related to longevity. So we shall need to focus on those new problems that are changing our epidemiology. Simply by people beginning to live longer we are starting to see cancer and other non-communicable diseases emerge as public health issues.

This means that we have to be prepared to tackle the new diseases that are beginning to emerge in the population such as hypertension, heart disease, metabolic diseases etc. We are also beginning to see that deaths from motor accidents or other injury are beginning to overtake other causes. This is not necessarily because there has been an increase in the rate of accidents but there has been a reduction in other causes of mortality and morbidity.

The simple message from this trend is that we need to focus on non-communicable diseases since communicable diseases are now under control.

There are many areas where we can act on non-communicable diseases and others where we cannot act immediately. An area where we can act immediately and where we have already started is cancer. And even in cancer, it is not all cancer as the initial focus is on women and children. It is not that we are neglecting men but because affordable solutions targeting these cancers happen to be available on the market at this material time. On the other hand we cannot work on everything at the same time. 

For women we are taking action against cervical and breast cancer by detection and early treatment. A vaccine against cervical cancer is also available providing an affordable and sustainable solution. 

We are also going to act on a series of cancers affecting children. We are finalizing the protocols, the guidelines and policies.

We are taking on those cancers against which we can act immediately and which are also the most frequent. For example Lymphoma affects mainly children and there is something that can be done about it. We are not going to wait for big infrastructure but handle whatever we can within the present means. We shall then create facilities for cancer care knowledge. For those for whom it may be too late to offer successful treatment, we shall opt for palliative care.

The guiding philosophy is that Rwanda will always prioritize the most acute problem. So we can now focus on the next major killers and go on like that until such a time as we reach the level of the developed world.

Quality and value for money

The other area of focus this year will be improved management of the health sector to achieve more value with fewer resources as global fund resources are decreasing. Quality of care will come under increased scrutiny as we seek to maximize value from our resources.

Quality care has two sides – the science and the way to implement that science. After that you have the human dimension, the customer care. Already there is progress. When a population is healthy and when you empower them on their rights, they are more demanding. Before, expectations were low because it was the time when you had just two doctors per district hospital. But now we expect quality because the numbers have started to be significant and on the other hand we have pushed the people to demand quality care. 

At one time, many people who were visiting our health facilities would find a good doctor with skills who was critically short on customer care. Today people are legitimately complaining because they expect both quality care and customer care. I may be a good and highly skilled doctor but if am rude that undermines the quality of my overall output. 

On the other extreme you could have someone who may not be even be qualified but has great customer care and people actually prefer to consult him or her just because of that. This happens a lot in our country and potentially creates dangerous gaps in our health system if people choose to seek care from non-professionals. So doctors in the formal sector need to provide the full package of knowledge, science and customer care.

Malnutrition

Malnutrition is another priority for this year. The government has committed itself to eradicating the causes of malnutrition before the next Umushyikirano. Looked at objectively, malnutrition is not insurmountable. We have malnutrition not because we cannot produce food but rather because we are using it wrongly. You find families that say they don’t have food but they can grow the food. Others say they don’t have land but the local government can provide collective land for people to grow food. Malnutrition should not occur in this country, eradicating it is just a matter of organization.

Two percent of children under five years suffer severe malnutrition but that malnutrition can not be linked to disease since hunger per se is almost non-existent. There are also cases where malnutrition is a result of mothers not knowing how to feed their children. In the same age bracket we also find 11% that are underweight and 44% that suffer chronic malnutrition.

We have learnt that the primary cause of malnutrition is related to what children and pregnant mothers eat. Most of those children are born malnourished because the mother did not take enough micro-nutrients, vitamins etc when pregnant. The solution lies in increasing the knowledge to fight the habit of not eating some sources of protein. It requires a revolution in the way we are feeding children.

Human Resource for Health 

Another frontier during this year will be developing the Human Resource for Health. Because we have made good progress with what we have now and have achieved reasonable levels of basic care, people are going to get diseases that are related to age. Yet we don’t have the specialists to care for them.

At the district level at a minimum we need one surgeon, a pediatrician, one anesthetist, one internal medicine specialist and an oncologist to deal with cancer and related complications. We also need to develop the capacity to treat or manage metabolic diseases.

It will take us decades to achieve desired staffing levels if we were to continue producing health professionals at the current rate. To mitigate this, we have partnered with 18 American universities that will bring here hundreds of experts to mentor Rwandans to be teachers, teach residents to be good specialists and teach graduates to be good medical directors. Over the next seven years, we shall have attained the capacity to produce our on workforce and we will produce the minimum we need that are capable of giving the care we need.

Infrastructure

We are planning to have radio-therapy facilities and oncologic wards at CHK, Kanombe and Butaro hospitals where we shall provide specialist care for cancer patients. We will have a facility for radiotherapy and places where we shall hospitalize people that need special care. 

We are also going to produce an accompanying complement of Medical Directors with specialist skills in oncology within two years. We plan to create full specialists who will train and supervise others so that we have someone with these skills in every district hospital. The missing gap in the training of our human resource has been mentorship and bedside training.

Mutuelle de Sante

Making progress against infectious diseases does not necessarily free us from spending money because the cost of prevention is also high and that is why the health budget has been increasing year after year in the national budget. On the other hand even as we have increased the national budget for health, the international contribution to that budget is uncertain so the future lies in what we shall be able to do under the national budget and health insurance. 

Fortunately even the out of pocket expenditure is increasing because of the improving economic welfare of Rwandans. We have one million Rwandans who have transitioned from poverty to a better income status. As a result, they have more money out of pocket and are capable of paying for their health insurance. Additional resources for health may come by way of savings made by individuals against future sickness through health insurance and Mutuelle de Sante.

However Mutuelle de Sante is a national institution that is still growing and maturing. If we are not strict in its management we are going to pull it down yet it is a good system.

We have so many sectors and to ensure that all are managing the system properly is a fight that requires day and night vigilance. Because you have money there for healthcare that may seemingly be lying idle, some leaders at the local level may want to use this money for other things. We need to sensitize and convince them that is not right to diverting that money to other priorities and that this constitutes a financial crime. We need to get that message down to the sectors.

Finally, we need to create regional; reflections on how to treat diseases. We have started by seeking to create high efficiency programs for controlling malaria with our neighbours. Half of our problem with malaria is around the border areas and 45% of that burden is in just three sectors of this country meaning we need to work with our neighbours. Rwanda cannot be an island of welfare in a region of desperation. We are proposing common procurement and harmonization of policies and fighting together against counterfeit medicines. We shall tackle these problems jointly by agreeing on the best policies based on the best science of the moment.

Rwanda's approach proves perfect antidote to counterfeit drugs

Posted in the Guardian by Agnes Binagwaho and Amir Attaran

Wednesday 3 July 2013  i

You can read it on their webpage: 

http://www.reverso.net/translationresults.aspx?lang=EN&direction=english-french

Rwanda's integrated solution to combating fake drugs could inform a global treaty on medical safety

Globalisation has brought people many wonderful things, but occasionally it brings them death, thanks to the growing international trade in bad medicines. At least 100,000 people each year succumb to medicines that are negligently made, or sometimes deliberately faked with bogus ingredients. The solution demands local and global measures to improve regulation and make penalties tougher for medicine criminals. We simply cannot afford the cost of inaction.

This week, we published research in Public Library of Science Medicineshowing that tuberculosis drug quality is variable in low- and middle-income countries. Of 713 samples of the tuberculosis medicines isoniazid and rifampicin collected in 17 countries, 9.1% contained insufficient quantities of the active pharmaceutical ingredient, and failed basic quality control tests. The situation is even worse in some African countries, where 16.6% of medicines failed; 7% were outright fakes, containing no active ingredient. These failing medicines won't cure tuberculosis infections and could even fuel drug resistance, which makes the disease much more difficult and expensive to cure.

Yet one encouraging result stood out: no fake tuberculosis drugs were found in the sample from Rwanda. This is consistent with other recent studies, which found that the east African state has few substandard and no obviously falsified malaria medicines. So what is Rwanda doing right?

First, over the past decade the government has taken legal and technical steps to secure the whole of its medicine supply chain. It buys high-risk drugs, such as those for tuberculosis, exclusively from manufacturers certified by the World Health Organisation (WHO), and distributes them in a dedicated, controlled supply chain to hospitals and clinics.

Second, the Rwandan government has trained the healthcare workers who handle the medicines how to spot and report substandard and falsified products.

Third, a taskforce of health regulators and customs officials inspects all medicines entering the country at the border, notifying the police (who in turn notify Interpol) when something is amiss. The Rwandan approach is holistic, and draws on resources from across the government.

It is tempting to say that Rwanda does all this because – unusually forAfrica – it has a strong publicly funded health system to treat tuberculosis. Yet, without a holistic approach, the system would be undermined by criminal activity and collapse. It is not just the healthcare workers and the quality of programme management that make the system function; in terms of medicines, it is the police and regulatory officials too. "Health is too important to leave to doctors," people say around Rwanda's health ministry.

Unfortunately, there is opposition to fighting fake and substandard medicines in this holistic way. Some countries, such as India, vocally oppose commingling public health and policing at an international level. Setting up that conflict seems a tactical mistake, because, as we know from many examples – food safety, airline safety, road safety – regulation and policing are necessary to prevent accidents and protect wellbeing. In fairness, India's parliament now acknowledges (pdf) the country has medicine quality problems that "can harm patients".

But for Rwanda to fix problems outside its borders, it needs the co-operation of other countries. A global treaty is needed to make medicine safety a priority, both by building the capacities of drug regulators and by making medicine falsification an international crime.

One perspective on the problem is that the world has done a dangerously imbalanced job of globalisation. Starting with the WTO agreements in 1995, free trade in legitimate medicines has helped patients who have access to quality drugs at affordable prices, but free trade in falsified and substandard medicines is hurting and killing many others. Without reversing the good half of this equation, countries need to clamp down on criminal activity. An international law that sets standards for medicine quality and safety in international trade – which, today, it does not – is essential.

Precedents abound: you can board an aircraft in country X and land safely in country Y because there are treaties on flight safety to which all countries agree. Likewise, you cannot print the banknotes of country X and pass them off in country Y without being arrested, because there are treaties criminalising counterfeiting. If international law can promote safe flights and criminalise fake money, surely it does not take too much imagination to negotiate and agree a treaty to promote safe medicines and criminalise fakes to protect people in low- and middle-income countries.

Agnes Binagwaho is Rwandan health minister, senior lecturer at Harvard Medical School, and clinical professor of paediatrics at the Geisel school of medicine, Dartmouth University. Amir Attaran is Canada research chair in law, population health and global development policy, and professor in law and medicine at the University of Ottawa

Video for Int'l Society for Neglected Tropical Diseases Coinfections

Via YouTube (due to scheduling conflicts), I spoke at the International Society for Neglected Tropical Diseases Coinfections Meeting on 12 February 2013 via video. The meeting took place at The Wellcome Trust in London, UK, and is a fantastic step in the right direction for the movement to address the global burden of NTDs. Thank you for inviting me to participate.

You can also watch the video by clicking here. 

Panel at Rockefeller Foundation Global Health Summit

On January 26-27 I spoke on a panel at the Rockefeller Foundation Global Health Summit in China. Below you can watch the entire panel, (my presentation on Rwanda begins at 16:00).

You can also access this video on YouTube by clicking here.

The Future of Innovation in Rwanda's Health Sector: Equity, Participation, Science, Sustainability

I published the following article in October 2012 in Andrew Mwenda's East African journal The Independent. The full text is not available online, but you can read below.

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The Future of Innovation in Rwanda’s Health Sector:

Equity, Participation, Science, Sustainability

Dr. Agnes Binagwaho, Minister of Health of the Republic of Rwanda

The world has begun to pay increased attention to Rwanda’s rapid rate of progress in the health sector, particularly as we approach the 2015 deadline set for the health-related Millennium Development Goals. Our country has likely already achieved goals of reducing the 1990 child mortality figure by two thirds and halting the spread of HIV/AIDS, tuberculosis, and malaria; we are on track to achieve the goal of reducing maternal deaths by three quarters by 2015.

What Rwanda has managed to achieve has been the subject of much dialogue (and much debate); I do wish to repeat what has been covered better elsewhere or to make it seem as if our health sector is resting contentedly for even one second when more than 22,000 of our children will die this year. Instead, I want to focus on the why, and to reflect on what must come next for our country and our region if we are to sustain, exceed, and spread this progress.

I firmly believe that the secret ingredient to Rwanda’s recent successes is something very simple in principle that requires a very serious commitment to implement effectively: the absolute insistence that nobody is left out of benefitting from our collective progress. This understanding forms the core of our national development plan, and all from the central level to the community realize that when we tackle the needs of the most vulnerable first, we are sure to also reach all the rest. Moving equity from the realm of the political into the realm of practice and policy has been a true force multiplier for everything that we do.

Rwanda has learned from our long history of segregation and division – due to sources both external and internal – that the only way forward is through complete inclusion. Therefore, before any single policy is implemented in the health sector (or any other), all stakeholders are invited to participate in a process of true consultation. The often complex task of implementation and dissemination is rendered simple when all are engaged to participate from the beginning.

But even policies that are formulated in the most open and inclusive manner will not succeed if they are not based on the highest quality of scientific evidence. It is often said that “you cannot improve what you cannot measure,” and one of Rwanda’s most important innovations has been the establishment of robust systems of monitoring and evaluation focused primarily on actual health outcomes. By implementing a national maternal death audit program, whereby health workers and communities analyze all dimensions of every situation where a pregnant woman dies in childbirth, we have been able to chart a reduction in the number of deaths from 8 women per day in 2004 to less than 3 per week today. By giving a name and a face to every lost mother has sparked each person’s innately human determination to stop this tragedy all the way from the most rural health post to the highest levels of the central government.

Putting evidence into practice requires more than just good tracking tools, however. It means bringing science to bear on both the root causes and the immediate causes of preventable suffering and death. Rwanda has prioritized increasing access to both essential health services (such as safe deliveries through a community-based SMS notification system for ambulances) and to the fruits of medical progress (such as new vaccines against pneumonia, the virus that causes cervical cancer, and the virus that causes many cases of diarrhea in infants). We are particularly proud to see our Ugandan sisters and brothers also scaling up access to the human papillomavirus vaccine this year, which will prevent thousands of young women from developing cervical cancer in the future.

The final building block of success, in my experience, is the honest pursuit of sustainability. I do not mean sustainability as a buzzword, in the way it is so often tossed around and how it comes to fill up a third of the word count for bureaucratic reports. Instead, I mean a sense of deep accountability and responsibility to ensure that programs are built to last and designed with an eye towards continual improvement.

We have a saying in the Ministry of Health that pilot projects are not a solution in Rwanda – the only pilots here are in the sky, working for RwandAir! When negotiating about a new opportunity for our population, we insist that we go national as soon as possible, or we go nowhere. This is not a reckless strategy that makes the perfect and enemy of the good. We simply know that as policymakers and citizens tasked with improving the health of the entire population (not a catchment area or capital city), we must strive for the most robust and long-lived programs possible.

When we designed our new pediatric cancer center of excellence in Butaro near the Rwanda-Uganda border, for instance, it was not only for that one district – it was as a referral center for the nation. When we rolled out the national community-based health insurance scheme, mutuelles de santé, we began by subsidizing the annual contributions and copayments for the poorest one million citizens; soon enough, the middle-class and others bought in because they saw that the most vulnerable were indeed enjoying the best access through this new program. If we had attempted to move from an experimental mutuelles program in one or two cities to nationwide rather than this phased strategy, we would certainly not be able to count 92% of our population as enrollees today.

Underlying all of these principles, and ensuring that they are collectively translated into results, has been innovation in partnerships. To harness synergies and maximize value, we mobilize each and every willing partner according to the framework and timeline of our national plan. This has fostered national ownership of our programs and our success, but it has also led to novel collaborations that simultaneously encourage service delivery, teaching, and research. Rwanda’s Human Resources for Health Program, launched this year with 13 American universities, is a great example.

The lesson for me, then, from Rwanda’s experiences in the health sector has been that anything is possible when you apply the principles of equity, participation, science, sustainability. To better do so, we require constant out of the box thinking, and a commitment to solidarity and shared improvement. My colleagues and I look forward to fruitful cross-border collaborations, and we know that we can make it together.

The Importance of Using Accurate Data: Case Study of Hunger in East Africa

On Saturday, 3 November, I published an op-ed in The East African responding to a recent article describing the findings of the "Global Hunger Index 2012," a European report analyzing the state of food insecurity around the world. The report's authors used extremely outdated data for Rwanda in their calculations, skewing their conclusions. My response attempts to call attention to the importance of using the latest and most accurate data in such global assessments.

http://www.theeastafrican.co.ke/OpEd/comment/Hunger+Index+used+outdated+data+for+Rwanda/-/434750/1611056/-/11hpa0p/-/index.html

Hunger Index Used Outdated Data for Rwanda

By Dr. Agnes Binagwaho

As with many international reports derived from complex and non-transparent methodologies to assess relatively straightforward challenges, the Global Hunger Index of 2012 represents an outdated and poorly designed approach to quantifying progress towards Millennium Development Goal 2. -As recently reported in The East African, the Index report ranks Rwanda behind only Burundi for food insecurity in the East African Community.

Based primarily on inputs of child mortality rates and chronic malnutrition or stunting among children under age five, the Hunger Index calculation could not possibly be using updated data for Rwanda, as the child mortality rate has declined by fully 50 per cent between 2005 and 2010 according to both our own internationally-validated Demographic and Health Surveys (DHS) and the World Health Organisation’s modelled estimates. The latest WHO figure shows that Rwanda’s child mortality rate is 54 deaths per 1,000 live births. Yet the Global Hunger Index report cites Rwanda’s child mortality as 91 deaths per 1,000 live births – using an old Unicef report from 2009 that is based on the 2008 DHS.

If child mortality has been falling so much but Rwanda’s Hunger Index has not, then malnutrition must be paradoxically skyrocketing despite increased access to all other child health interventions? But one look at DHS or WHO data shows otherwise: Chronic malnutrition among children under five years old decreased from 51 per cent to 44 per cent between 2005 and 2010. The proportion of children underweight plummeted from 18 per cent to 11 per cent over the same timeframe. But the Global Hunger Index report the 18 per cent figure from seven years ago.

How does Rwanda’s progress across broad socioeconomic indicators stack up to the assertion that its people are among the hungriest in East Africa? Fully one million Rwandans pulled themselves above the poverty line between 2005 and 2010 according to the latest Household Living Conditions Survey, and access to electricity, potable water, adequate sanitation have all improved dramatically since 2000. While Rwanda’s population has increased by nearly three million over the past decade, its Food Production Index compiled by the World Bank has increased by two-thirds over the same timeframe and climbed to the highest in East Africa. Finally, cereal yield in kilogrammes per hectare nearly doubled between 2007 and 2010, and is likewise the highest in East Africa.

While Rwanda is on track to meeting or exceeding all eight UN Millennium Goals in advance of the 2015 target, we are not resting on our laurels. We are acutely aware that still we have far to go in eradicating malnutrition and improving health outcomes, especially among children. In order to achieve our goals, however, we are obliged to develop and implement policies based on accurate data along with astute analysis.

In a country and region changing so rapidly, it is the responsibility of institutions such as the International Food Policy Research Institute, Welthungerhilfe, or Concern Worldwide to concern themselves with facts, not conjectures or models when robust and current evidence is easily accessible. If such “watchdog” agencies and the reports they produce are to serve a useful purpose (and I do believe they can when designed well and disseminated transparently), they must hold themselves to the same standards of accountability they seek from countries like Rwanda. No one more than the Ministry of Health knows that Rwanda has a long way to go until chronic malnutrition is not a massive health challenge, but it is our responsibility to base our approach on solid evidence and sharp analysis.

Recommendations based on the latest data can help public sector institutions to improve policies, strategies, and implementation of programmes to tackle challenges like malnutrition, but when they are conducted sloppily, one wonders whether the money spent on consultancies for such a document might be better invested in helping to grow food for improved nutrition of children around the region than using large amounts of overheads to create metrics that are out of date before they are even published.

Agnes Binagwaho is Rwanda’s Minister of Health.

Progress in Rwanda's Fight Against Malaria

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

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

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

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

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

(Image courtesy of Rwanda News Agency)

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

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

Rwandans Among Top Users of Twitter in Africa

By Edwin Musoni

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Male circumcision and the path to an AIDS-free generation

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

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

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

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

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

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

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

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

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

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

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Leadership and the fight against HIV/AIDS

Panel on leadership in Africa in the fight against HIV/AIDS, ICASA 2011. (Photo credit: UNAIDS/J. Ose)

Last Monday, December 5 - 2011, I had the great honor the speak on behalf of His Excellency, Paul Kagame, President of the Republic of Rwanda, at the International Conference on AIDS and STIs in Africa (ICASA 2011). I spoke on a panel with esteemed representatives of institutions and national health sectors, alongside Festus Gontebanye Mogae, Eric Goosby, Abune Paulos, Michel Sidibe, Oueld Zbel Yastahel Kadad, Madeleine Ba Diallo, and Bience Gawanas.

We were asked to speak about how African leaders can advance the agenda of addressing the burden of HIV/AIDS around the world. As we all now face financial challenges, such a question is vital as leadership will be the key to ensuring Africa does not backtrack on the progress made over the past decade.

When it was my turn to speak I stated that it is our duty to stand up for our people, as Africans are the most affected, especially in the Sub-Sahara region which accounts for more than 70% of all those living with HIV worldwide.

There is no doubt that a lot has been accomplished. The majority of African Governments have made the fight against HIV a top priority for the past 10 years since the Abuja declaration, leading to UNGASS 2001. Much more need to be doe as too many African are still dying due to AIDS.

Today the global economic crisis is a threat to the fight against HIV in Africa as it has impacted the global flow of foreign aid. The challenge we face today is the proof that overall national development (economic growth, self-sufficiency, etc.) is the key for sustainable success in the fight against HIV. I illustrated this point during the panel – taking my country, Rwanda as an example – and elaborated on our fight against HIV as a cross-cutting pillar of Rwanda’s Vision 2020, and our Economic Development and Poverty Reduction Strategy. From the outset, we made the multi-sectorial national HIV response a cross-cutting issue, which strengthened our health system as a whole and supported our national development. Our HIV response included prevention, treatment and the mitigation of the social burden mitigation of disease, as expressed in the National HIV&AIDS Strategic Plan.

Today the global fight against HIV does face constraints, but we also have many solutions that have not been explored widely in other countries. As such, even if many believe that nothing can be done without the money to make it happen, we do not believe this is totally true. There are many ways we can continue to advance.

For example we can use effective decentralization to break geographic barriers and scale-up HIV interventions at the district level. In addition, the Community Health Workers can sensitize Rwandans at the village level about issues of HIV/AIDS at almost no cost. This also goes for politicians, as well as community and administrative leaders who can take upon themselves the task of major sensitization campaigns on the radio, or newspaper, or internet. HIV sensitization could be included in every interaction with the population or in major speeches. It is not costly and it is effective and it creates a sense of national responsibility and solidarity.

We can improve the performance and quality of services as well as the retention of personnel in remote areas using a Performance Based Financing (PBF) framework.  This framework helps district health teams to ensure the availability of qualified health personnel, and to ensure that utilization in rural areas is commensurate with health needs by providing financial incentives to health workers. We can integrate HIV in all curricula in our formal education, aiming to break geographic barriers to access information about HIV/AIDS.

We can also shift the proportion of our national budget that is given to health financing, which would benefit the fight against HIV. Financial barriers can also been reduce by creating a health insurance program. This will enable people’s access to health services, and will prevent PLWHA from dying of common diseases. In Rwanda we developed the community-based health insurance (CBHI) scheme called Mutuelles de Santé. It is one of our key governmental programs, which addresses issues of equity, accessibility and utilization of services, including HIV.

If we use all of these strategies and continue to innovate to find new ones, we will make the money work, save lives, and increase equity in access to prevention, care, and treatment. In Rwanda we have implemented these strategies in order to leave no group out of the benefits of our health services and national development.

Our inclusion principle is largely based on age and gender equity. Children are a priority in service delivery; while we have improvements to make, we know that healthy and educated children are the path to a healthy, peaceful future for Rwanda. Women are equally prioritized, and we have more women on ARVs than men (more women are infected than men) and as a result we have now 80% of women accessing PMTCT, 94% of eligible HIV infected people on ARVs: children, women and men.

These gains are important as they allow us to provide better general services. In many hospitals, beds previously occupied by PLWHA are now free for people coming in with other diseases. This was certainly not the case 10 years ago, when many people were dying outside the hospital due to curable diseases because people with HIV/AIDS occupied many beds.

We are facing a global budget cut in different programs to fight HIV/AIDS and we know that if we don’t increase the proportion of PLWHA on treatment (who need treatment) the disease that is now largely under control will spread again and the world will lose its current gain. Some countries are facing that reality already.

We need to react by making our development partners fulfill their promises, but we need also to have smarter public health approaches as aforementioned. The integration of services is also key. HIV is a chronic disease and must be integrated into our service delivery for other chronic diseases and stop vertical programs. In Rwanda, integration is a policy we adhere to. We have started to tackle non-communicable diseases building on the success of our HIV program.

In this time of crisis, it is also imperative to be more innovative. We have created an Internet clinical based reporting system called TRAC-Net for all people on ARVs. It gives us monthly reports of the clinical, biological and immunological status of our patients and the status of drugs storage across the country. Building on our experience fighting HIV, we are now creating an Electronic Medical Record system for all Rwandan citizens, to be used in all health facilities, thus moving away from paper based medical recording.

In Rwanda, we have put in place an HIV evidence-based operational monitoring and evaluation system, and a Web-based resource-tracking mechanism for all finances in the health sector. It allows us to better plan and to align all actions of all stakeholders to our overall national development plan. But we still have a long way to go.

In 2011, Africa must have zero-tolerance for partners who do not respect the critical importance of country ownership. It is a matter of sustainability. We need better plans and to truly work hand in hand with our national partners and our development partners. But for sustainable success we need to reinforce the structure wth which we we coordinate everyone around our national plan. All of this will bring an economy of scale and will allow us to reach the imperative dictated by the diminution of aid: doing more with either the same or less investment.

We also need to center our fight against HIV in our development plan. We need to build pharmaceutical manufacturing companies on our continent, and continue to fight counterfeits to assure the quality of drugs. Building these companies here is necessary because although the cost of ARVs has declined dramatically, only 47% of all those eligible to receive ARVs in low- and middle-income countries are actually receiving it.

So, if we need to make our partners in the North, and in the West fulfill their promises in funding support, we may call upon them to reduce their overhead and inject that money into the fight against HIV. Let us all, together, commit to investing in a sustainable fight against HIV. We should commit ourselves to focus our fight against HIV on improved decentralization, better integration, more participation of our people and a stronger link between HIV/AIDS services and national development agendas.

Click here to see UNAIDS coverage of this panel

HPV Vaccine in Rwanda: Different Disease, Same Double Standard

Youtube Video: HPV Vaccine Rollout in Rwanda

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

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

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

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Published in The Lancet on 2 Dec 2011

HPV vaccine in Rwanda: different disease, same double standard

Agnes Binagwaho, Claire M Wagner, Cameron T Nutt

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

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

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

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

References


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