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 Pursuit of Shared Wealth through Health for All

My latest article in Commonwealth Health Partnerships journal is below. To visit the website where the article is printed, click here. 

Rwanda is determined to join the ranks of middle-income nations by the year 2020. This determination is largely driven by one thing: the demand for what Rwandans call ‘agaciro,’ or ‘dignity’ for our people. In pursuit of agaciro, the Rwandan people are continuously compelled to find better ways of doing things. Our economy must be vibrant and more independent; our politics must be inclusive and founded on consensus building; and our people must live a decent and dignified life, able to fulfill basic social needs. 

To achieve these ambitious goals, the Government of Rwanda has adopted a number of innovative approaches to policymaking and implementation, including both universally applicable and home-grown solutions that effectively account for context in addressing Rwanda’s most pressing challenges.

Indeed, seeds sown since the 1994 genocide against the Tutsi are beginning to bear fruit. The recent publication of the countrywide household survey indicated that Rwanda has reduced poverty levels by 12 percent over the past five years, from almost 56 percent of the population in 2005 to 44 percent in 2010. 

The understanding underlying this success is that for a nation to be successful, it must invest in and rely upon the human asset or capabilities of its own people. Rwanda’s philosophy for growth starts with a shared vision that a well educated and healthy population is the starting point for any economic development.   

This is why the health sector been a key priority for the country’s Government; 18 years down the road to recovery after 1994, the achievements in this sector speak volumes. 

Documenting Recent Progress

The recently released Demographic and Health Survey (DHS) of 2010 revealed several areas of dramatic progress in health outcomes since the last survey in 2005. Across the spectrum, the findings demonstrate significant progress in combating infectious diseases, improving child and maternal health, and addressing both financial and geographical barriers to accessing health care.

A Rwandan child born today has more hope than ever before of living to celebrate his/her first and then fifth birthdays. Between 2005 and 2010, the infant mortality rate dropped from 86 to 50 per 1,000 live births, while the under-five child mortality rate plummeted by fully 50% from 152 to 76 per 1,000 live births.

Rwanda remains dedicated to surpassing the Millennium Development Goal targets for infant and child mortality by 2015, but as a result of our deeply rooted conviction that our children must enjoy the right to life and hence a right to adulthood, we know that we can drive these figures down even further.

These declines have not come as a surprise; they are partially attributable to the fact that more and more of Rwanda’s mothers are enrolled in and retained by antenatal care programs throughout their pregnancy. This has led to an increase in the number of women giving birth at a health facility from just 30% in 2005 to 69% in 2010.

To adequately address issues concerning maternal and child health (MCH), Rwanda has employed many synergetic interventions along the continuum of care, but all of these are built upon the foundation of a strong community health system driven by Community Health Workers (CHWs) deployed in all villages across the country. These community health workers have bridged crucial access gaps in the health system and have brought prevention, treatment, and care services closer to the people. 

One clear result of CHW’s effectiveness can be seen through Rwanda’s active immunization campaign, which has achieved over 90% coverage of all children and ensured the provision of new vaccines targeting emerging diseases to the population. In 2009, Rwanda was the first country in Africa to roll out the pneumococcal vaccine, and in 2010 became the first low-income country in the world to roll out the human papillomavirus vaccine. Both initiatives have attained over 90% coverage by building on the country’s pre-existing robust vaccination program.

Investing In Our Population

It is well known that Rwanda does not have major natural resources like oil, gold, and diamonds; but our Government knows that our greatest asset is our people themselves. To ensure that we deliver appropriate services in an equitable way that allows each Rwandan to reach their full potential, we have continuously worked to educate our people on the need for smaller families.

Rwanda needs a population whose growth does not outpace that of our economy. Declines in birth rates over recent years are not as dramatic as those that will be needed in the future, but they do show that we are achieving concrete results. Between 2005 and 2010, total fertility rate (the number of children a woman is expected to have throughout her entire life) dropped from 6.1 to 4.6. Uptake of modern family planning methods jumped by 450% during the same period, from just 10% in 2005 to 45% in 2010. Taken in the context of other socioeconomic indicators discussed earlier, we can see a strong relationship between improving child survival and declining birth rates – as fewer children die premature deaths, families feel the need to have fewer children.

Combatting Infectious and Non-Communicable Diseases 

With the support of our global partners, Rwanda has made substantial gains in the fights against HIV/AIDS, tuberculosis, and malaria. HIV prevalence has fallen from 13.9% in 2000 to 3% today due to an integrated approach to tackling the pandemic with urgency and equity.

As of December 2011, fully 100,656 patients at 390 health facilities across Rwanda were receiving antiretroviral therapy for free, accounting for 84% of all patients clinically in need of treatment. When compared to the 870 patients at just 4 facilities who had access to these lifesaving drugs in 2002, it is clear that we have come very far.

A combination of effective policies for malaria prevention and control have likewise contributed to a reduction in prevalence and mortality associated with malaria by almost 50%. This is largely due to an increase in the usage of mosquito nets from 56% of households in 2005 to 82% in 2010, but also tied to the provision of effective diagnosis and treatment at the community level by CHWs.

However, Rwanda and its leaders will not be complacent following progress against the major infectious killers: we recognize well the need to turn our attention to the growing burden of non-communicable diseases such as heart disease, cancer, diabetes, and respiratory diseases. As more Rwandans live longer, we must focus on the long-term needs of the population by anticipating health problems that are likely to arise and preparing solutions now. 

There are many areas where we can begin to act immediately on non-communicable diseases, such as the prevention and treatment of pediatric and female cancers where the market and partnerships have made new opportunities available today. The Ministry of Health is currently in the process of planning for comprehensive national early detection and treatment programs for breast and cervical cancer for women, who will also benefit from access to the human papillomavirus vaccine to prevent cervical cancer in the first place. 

We are currently in the final stages of assembling protocols, guidelines, and policies for pediatric cancers, beginning with those that are most prevalent and most amenable to immediate action. Non-Hodgkin’s Lymphoma, for example, affects many children in Rwanda, and there is something that can be done about it now even as we work to build the capacity to address more complicated cancers. 

While we understand the urgency of obtaining sufficient infrastructure, Rwanda will not wait for the last brick to be laid or the last road to be paved before we act – we will handle whatever illnesses we can within our present means while striving for a stronger system at the same time. For those who it is too late to offer successful treatment for cancer or other non-communicable diseases, we shall ensure the provision of palliative care. 

Persistent Challenges 

As we take pride in Rwanda’s achievements, we are also mindful of the challenges ahead. Much as the DHS 2010 results provide a roadmap for further improvement of infectious disease control programs, we need to adopt innovative new approaches that will provide quick solutions for transforming our sector across all initiatives. 

Through our Community-Based Health Insurance scheme, known as Mutuelle de Santé, we have addressed the issue of financial accessibility in the health system. More than 80% of Rwandans today are enrolled, guaranteeing them access to quality services. However, gaps persist in geographic accessibility that can be addressed by constructing more health facilities across the country. The Government’s aim is to have one health center serving each local government sector population of 20,000 to 25,000 people, meaning that significant further investment in infrastructure will be needed.   

The Ministry of Health and health providers around the country understand that access alone is not enough – we must also strive to provide the highest possible quality of care to our population. Rwanda aspires to become a hub of exemplary services for the entire East African region, and we will need to continue improving quality if this vision is to be achieved. Such efforts will include not only the acquisition of newer and better equipment, but also bridging the ratio of providers to population. 

Today, the ratio of physicians to population remains unacceptably high at 1 per 17,000. Our target is to reduce this figure to 1 per 10,000 in the near future. The Ministry of Health seeks to have at minimum a surgeon, a pediatrician, an anesthetist, an internist, and an oncologist at each district hospital. 

To this end, we have reached an innovative $34 million agreement with the United States Government that will bring more than 100 senior medical faculty from American universities to Rwanda over the next seven years to train and work with our physicians to build specialty capacity and create new residency programs. This program will begin in July 2012; with sustained commitment and sufficient vision from all involved, it has the potential to affect a massive paradigm shift in global health partnerships and medical education around the world.

Looking to the Future

As a core element to Rwanda’s Vision 2020 national strategic plan, the Government of Rwanda has established ambitious targets for the health sector that must be realized by the end of the decade. The under-five mortality rate, for instance, should be reduced to 30 per 1,000 live births from the current 76 and current prevalence of severe malnutrition must be reduced six-fold. These and many other goals will require concerted efforts from every stakeholder, including our development partners.

In assessing our current situation and where we want to go, we can see that the good news is that Rwanda has built the basics of a dynamic and equitable health system. In order to take the health sector to the next level, we must build upon our solid foundation and continue to seek out ways to improve the value, quality, and compassion of services we deliver. 

It is written in Rwanda’s Constitution that “the human person is sacred and inviolable.” The Ministry of Health could not possibly take this declaration more seriously; the quest for improvement is a civil, moral, and human duty that we accept with great humility and determination.

##

Announcing "Mondays with the Minister"

Dear all,

I would like to announce a new series of online discussions that I will be moderating through my Twitter account (@agnesbinagwaho). One Monday per month, I will log onto Twitter to lead discussion, answer questions, and take comments about a specific topic related to health programs in Rwanda. These chats will be called “Mondays with the Minister,” and you can follow them through my account or by searching Twitter for #MinisterMondays.

I held the first round of “Mondays with the Minister” this past week on Monday, 14 November. The topic was family planning in Rwanda and around the world, and I partnered with the International Conference on Family Planning (@fpdakar2011). Approximately 50 people from many different countries asked questions and sent in comments, which I answered and re-posted on my own Twitter account. The discussion was very instructive and encouraging. I absolutely loved interacting with people with so many different perspectives on this important topic, and hope that the conversations we started will continue long past the Twitter chat.

The New Times published a short article on “Mondays with the Minister” on Saturday, 19 November. You can read it under the Media tab of my blog, or on the New Times website at http://www.newtimes.co.rw/pdf.php?issue=14814&article=47340.