A Win-Win for Global Health

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Below is my contribution to Ubuzima Magazine, published by the Rwanda Health Communications Center and the Rwanda Biomedical Center.

I recommend you to read the full magazine! Lots of great updates on our health sector from the MOH and RBC. July2012,Vol.69(2)

Specialized medical education:

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

By Dr. Agnes Binagwaho

Minister of Health of Rwanda

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Congratulations, Dr. Mark Dybul

I am delighted to share that US Ambassador Mark Dybul, former leader of the US President’s Emergency Plan for AIDS Relief (PEPFAR), has been announced as the next Executive Director of the Global Fund to Fight AIDS, Tuberculosis, and Malaria. Mark is an inspiring choice by the Global Fund’s Board of Directors. I have believed in his candidacy for this position since the outset, and have great faith in what he can bring to one of global health’s most vital institutions.

Mark has long understood that global health must fundamentally be about equity and the fulfillment of the human right to health – not simply about addressing infectious diseases in far-off places. During his work to launch and expand PEPFAR, he demonstrated time and again that he believes in a person-centered approach to health care delivery and that he knows how to build strong systems that do not leave any among the most vulnerable out of benefits. Mark’s leadership in the global HIV/AIDS response helped to set a new paradigm for global health partnership, transitioning the world towards a long-term approach to tackling the most deadly pandemic in centuries while strengthening systems that have increased access to primary and specialty care for a wide range of diseases.

I am hopeful that Mark’s appointment to lead the Global Fund will help to usher in a new era of results-oriented programming that builds on the legacy of his predecessors, Michel Kazatchkine and Gabriel Jaramillo, while ensuring that the Fund stays true to its roots as an instrument truly of the people. I look forward to fruitful future collaborations with Mark and the Global Fund, and believe that the time for an integrated, solidarity-driven, and country-owned response to global health challenges is within our grasp. There is much work ahead, but the future is bright. Congratulations, Mark!

Global Health Solidarity at a Crossroads

On 5 July 2012, I published an op-ed in Project Syndicate about the importance of fully funding The Global Fund to Fight AIDS, Tuberculosis, and Malaria. You can read the full text below, or access the piece on Project Syndicate's website here.

Global Health Solidarity at a Crossroads

05 July 2012

KIGALI – A decade ago, the global community stood together to declare that where people live should not determine whether they live or die when confronted by the scourge of AIDS, tuberculosis, or malaria.

This act of solidarity – unprecedented in human experience – led to revolutionary advances in promoting health care as a human right. The Global Fund to Fight AIDS, Tuberculosis, and Malaria, along with the United States President’s Emergency Plan for AIDS Relief (PEPFAR), quite literally changed the course of history. Programs directly supported by the Global Fund have saved nearly eight million lives since 2002 – an average of more than 4,400 lives every day.

But, while much has been accomplished, much more remains to be done – and the Global Fund needs at least $2 billion to reverse a funding freeze that is in place through 2014. So the world now plays a waiting game to see whether governments will step up and fill the gap.

To be blunt, many of the world’s largest economies are not fulfilling their financial pledges to the Fund. Their politicians cite budget constraints and the need to prioritize domestic programs over fighting diseases that disproportionately kill the world’s poorest.

My country, Rwanda, has been a recipient of Global Fund grants since 2002. Just 18 years ago, our society was torn apart by a brutal genocide that killed more than one million people. Today, Rwanda is a peaceful country full of promise and hope, with one of the world’s fastest-growing economies.

With Global Fund support for our national institutions, we have achieved universal access to lifesaving antiretroviral therapy for people living with HIV, and we have stabilized HIV prevalence at around 3% of the population. Similarly, Rwanda’s tuberculosis program has become a model for Africa, and all Rwandan families now have access to insecticide-treated bed nets to prevent malaria, contributing to an 87% drop in cases during the last seven years.

Integration of services for infectious diseases and primary care has contributed to some of the steepest declines in child and maternal mortality ever observed. And, as life expectancy in Rwanda continues to climb (from below 30 in 1995 to 55 in 2010), we are now taking action against non-communicable diseases such as heart disease, cancer, and diabetes. The flexible, country-owned support provided by the Global Fund has been crucial to our success.

My country is living proof that investing in health is not only the right thing to do, but that it can also create virtuous cycles that promote security and development. In fact, after receiving Global Fund support for years, Rwanda recently made its first donation of $1 million to the Fund.

Unfortunately, infectious diseases are far from under control around the world. Less than a quarter of the world’s children living with HIV have access to treatment, and up to a million people still die of malaria each year. And, alarmingly, only one in six patients with drug-resistant tuberculosis currently receives proper treatment. Moreover, reports of “totally drug-resistant tuberculosis” have recently emerged from India.

Policymakers would do well to remember that it only takes one airplane flight for such a pathogen to go global. Infectious diseases neither respect national borders nor conveniently follow economies into recession. History has shown that retreating from the fight against an epidemic can lead to a renewed plague that is immune to our best drugs, requiring far more expensive measures to control.

Our choice could not be clearer: either we resolve to answer the call of history and provide the Global Fund with the resources that it needs, or we allow political lassitude to undermine a decade of progress and consign untold thousands to preventable deaths. Investing now, on the other hand, would pay off in the long term: just $6 billion more per year for the AIDS response today would save more than $40 billion in averted treatment costs alone over the next decade.

Today, the Global Fund stands at a crossroads. The international community’s regard for the health of the world’s poorest in the face of financial uncertainty will be a standard by which history measures not only our ability to stand together in weathering economic upheaval, but also our capacity for justice.

Now is the time for donor countries, including middle- and low-income countries, to rise to the challenge and ensure that the Global Fund has the resources needed to accept new grant applications as soon as possible. The costs of inaction are morally – and economically – untenable.