Video for Harvard's Universal Health Coverage Conference 2012

This video was recorded for Harvard's conference on "Universal Health Coverage: Challenges, Measurements, and Evaluation Strategies" on 13 September 2012. In this video, I present Rwanda's community-based health insurance program, Mutuelles de Santé, and describes the principles of policy-making and program implementation in Rwanda.

You can also watch this video by clicking here.

Global Health Delivery in Rwanda Course Featured in New York Times

The New York Times published an article today about the Global Health Delivery in Rwanda course, which resulted from a collaboration between Harvard Medical School and the Rwandan Ministry of Health. You can read it by clicking HERE or reading below.

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Harvard Offers New Global Health Program

The success of Rwanda in providing health care to its poor has drawn the attention of the international community and has inspired a new program at Harvard University.

Rwanda was one of the poorest countries in the world in 1994, after a genocide claimed more than 500,000 lives and left the country with little or no access to medical services. In 2005, it began to rebuild its infrastructure. Now, according to the Rwandan Ministry of Health , the country provides health care and insurance to more than 90 percent of its population, inspiring medical leaders from around the globe to visit the African country to study its transformation.

Now, the Harvard School of Public Health is working with the Rwandan Ministry of Health to teach a course called Global Health Delivery in the village of Rwinkwavu twice a year.

“Rwanda is honestly starting to change the face of global health,” said Dr. Paul Farmer, one of the founders of Partners in Health , a nongovernmental organization that works in Rwanda and other poor countries. He is also the chairman of Harvard’s Department of Global Health and Social Medicine and one of the faculty members for its course in Africa.

In February, 30 African medical leaders met with Harvard faculty at the training and research center in Rwinkwavu to discuss the challenges of delivering health services in resource-poor settings. Six of these students were trained to become faculty members who will teach future classes, with the next sessions scheduled for July.

During the weeklong course, students and professors discussed case studies and conducted field visits throughout Rwanda. Because all the students are currently health workers — most are employees of the Rwandan Health Ministry — they are able to immediately apply what they learned in the Harvard course to their daily work.

Initially, the course was held only on Harvard’s campus, where students would discuss case studies on the difficulties of delivering medical services internationally.

But the course changed in February. A world away from Cambridge, Massachusetts, health professionals in Rwinkwavu discuss the same case studies. They also participate in live cases, in which students and faculty members interview doctors, nurses or other health workers, like the head of an organization working to deliver AIDS medications to the poor in Rwanda, to ask them about the challenges of their work. Visits to Rwandan clinics and hospitals allow students to see health care in action, and give them the opportunity to collaborate with other professionals to discuss solutions.

“To be a good global health provider, it’s good for students to see what others have done,” Dr. Agnes Binagwaho, who is both the Rwandan health minister and a Harvard faculty member, said by telephone.

Seeing potential for the course outside of Massachusetts, Dr. Binagwaho worked with Partners in Health to bring the Harvard curriculum to her home country.

“We hope to have students come from around the world and learn from them as well, and also have the students learning from each other, because they are all coming from countries where there are things ongoing,” she said.

There is now also a new Harvard degree, a Masters in Medical Sciences and Global Health Delivery, which will begin this autumn. Plans to offer a similar degree in Rwanda are under way.

“Above all, you need people who actually do the delivery to tackle the problems,” Dr. Farmer said. He stressed the importance of working not only in Africa, but also with African health care leaders. “Not everyone has the privilege to make it to Harvard — and we needed to reach out,” he added.

The Harvard course is one of the first that focuses exclusively on the challenges of delivering health care. It encourages students to think about how politics, economics and other social factors affect health.

“I don’t know many other groups that are looking at health care delivery as a field of study and bringing that to collaboration with African ministries of health,” said Dr. Joseph Rhatigan, the director of the Global Health Equity residency program at the Brigham and Women’s Hospital, a teaching hospital affiliated with Harvard in Boston.

Partnerships between medical schools and the developing world are increasingly common, but the majority focus on practicing medicine as opposed to delivering care and understanding the effect of social factors, he said.

Dr. Corine Karema, director of the programs for malaria and neglected tropical diseases at the Rwanda Biomedical Center and one of the students in the Harvard course who trained to become a faculty member, said the course made her change the way she looked at medical treatment.

“I’ve been working for a long time in public health, and we used to decide on intervention and strategies if they were cost effective without looking at how the strategy will best affect the patient,” she said.

She said she now had higher expectations. The course taught her to advocate the best treatment available, regardless of cost.

“Too many people in public health have been socialized for scarcity, the idea that we just have to make do with less,” said Dr. Farmer. “That socialization for scarcity has prevented innovation. That’s really what the course is about: confronting the socialization to scarcity and combating it.”

Dr. Farmer and other faculty members drew on their experiences at Partners in Health. For more than 20 years, the organization has worked in Haiti, Lesotho, Mali, Peru and other countries to make once-costly treatments for medical conditions like H.I.V. and tuberculosis available to the poor.

Although professors bring Harvard expertise to the table, they say they take as much away from the course as the students.

“I learn a lot more when I teach experienced people,” said Dr. Joia S. Mukherjee, the medical director of Partners in Health and a Harvard professor who helped organize and teach the course. “They are all saying, ‘Well, this is what we did here, this is what we did in Haiti.’ The students are learning more from one another than from professors.”

Dr. Farmer recalls students saying in a group discussion, “‘You mean that happened to you, too? Well, we had the same problem in Burundi.”’

“Within five minutes you had five people discussing a very specific problem that they had all faced,” he said. “That kind of exchange you can’t get out of a classroom, textbook or article. Watching hard-working African health care professionals sharing experiences, just for that hour session alone would have been worth the course.”

The students from Rwanda stay in contact via an online portal , and the case studies are available online as open source information.

“We agreed that in six months, we will all have a case study about something we have done in our daily work and use them as new materials for the Harvard lectures,” Dr. Karema said.

“It’s an outstanding initiative because it relates what is being done in the States to what the needs are overseas,” said Eldryd Parry, founder of THET Partnerships for Global Health, a British organization that works to improve health care in Africa and Asia. “There is so much in international aid and health that is decided in Washington, and that’s not the mind behind this program. It’s a catalyst for further interest.”

Faculty members have said that the main challenge will be maintaining funding, which is currently supported by Partners in Health, Harvard and philanthropies.

Dr. Pat Lee, who teaches at Harvard but is not affiliated with the course, said, “We have some interesting work to do as educators to adapt to the needs of different learners and tailor the curriculum so that it can be accessible to a variety of audiences.”

That will be critical if Dr. Binagwaho’s vision comes to light. In the future, she hopes to invite health professionals from around Africa and other developing countries to participate.

“We can be the example,” she said, “not teaching in theory, but teaching in practice. If you want the developing world to develop, you have to develop teaching. Courses like this have to grow.”

Global Health Delivery Course

I will be posting more information in the coming days including videos of lectures, summaries, pictures, and other materials. For the moment, please refer to my article in The New Times about the Harvard Global Health Delivery course that was held in Rwinkwavu from 19-23 February 2012.

You can read my article here: 

Conceptualizing Global Health Delivery

And another article by Rwanda Focus journalist Marie-Brigitte Kabalira here:

New Course Looks Beyond Patient As a 'Health Issue'

More materials coming soon...

Conceptualizing Global Health Delivery in Rwanda

I published the following piece in the New Times on Thursday, 23 February.




The traditional definition of public health has often been relatively narrow and focused on siloed programs, or the management of health for quick “cost-effective” impact. This definition cannot suit Rwanda’s approach to public health, as we know that the ultimate end of our programs must be to break the cycle of poverty and disease. This means managing in a high value way for supporting sustainable development, and this begins with always accounting for the cost of inaction.

Rwanda today is led by a leader who in my point of view runs this country efficiently as a value-driven private enterprise for sustainable and equitable economic growth. He will lead us to a be a middle-income country by 2020.  To support Vision 2020, our health laws, policies, strategies, and implementation approaches must be oriented towards breaking the cycle of poverty and disease that pulls down development. This important to keep in mind as face day after day much urgency and we have to solve them without undermining our future, as we know that some “quick win” interventions can in fact be the enemy of sustainable development when they are not designed thoughtfully and with the larger context in mind. 

This week, thirty-seven officials and professionals from the Ministry of Health, Rwanda Biomedical Center, and CHUK have gathered together with faculty from Harvard Medical School in Rwinkwavu, Kayonza District for the inaugural Global Health Delivery in Rwanda course. Led by my dear friend Paul Farmer, Kolokotrones Professor and Chair of the Department of Global Health and Social Medicine at Harvard Medical School, the top-ranked American university has pioneered a new approach to global health partnership by teaching this course outside of the United States for the first time and brining it to the heart of Africa.

To make this course possible, Harvard has sent a team of professors to Rwanda, and the Ministry of Health has availed its training facilities in Rwinkwavu, to host the course with the support of Partners In Health/Inshuti Mu Buzima. This partnership has created a unique and collaborative learning environment that will pay dividends throughout the entire health Rwandan sector and beyond.

Last Sunday, young professionals and program managers were trained to be faculty members for future offerings of the Global Health Delivery in Rwanda course, learning how to share their experiences, to conceptualize their work using strategy and value analysis, and how to write their own cases to teach colleagues from around Rwanda and soon from around the entire world.

This course is about strategic thinking for better service delivery all along the cascade of services in the pursuit of optimal outcomes of prevention, care, and treatment. Students, faculty in training, and faculty exchange on techniques for better understanding the value added by each step within the cascade. For example, in our day-to-day management of the health sector, we realize the need to revise the usual approach to focusing on access by focusing on actual provision. Having an open door is sometimes not enough to meet the needs of the most vulnerable; sometimes, we must bring the services directly to them. 

We must also work towards a paradigm shift around traditional notions of cost effectiveness by emphasizing measurement tools that account for the impact of population health status on our country’s sustainable development process. This means implementing the health sector’s vision through a holistic approach driven by evidence-based and person-centered policies that are evaluated by rigorous monitoring, just as we would in building and sustaining a successful business. The inaugural Global Health Delivery in Rwanda course runs from 19 to 23 February this week, and will be offered twice per year from now on. I expect it to bring great things to Rwanda in the coming years. 

Video for Harvard Course: Case Studies in Global Health

This video was recorded for the Harvard College course SW25: "Case Studies in Global Health: Biosocial Perspectives." In this video, I presents the linkages between health, social justice and Rwanda's national vision.

You can also watch this video by clicking here.

Harvard Ministerial Leadership in Health Program: Advisory Board Meeting

On Saturday, 5 November 2011, the Harvard Ministerial Leadership in Health Program held an Advisory Board meeting in South Africa. I gave a talk over Skype on what kind of support would be valuable to Ministers from an international collaboration seeking to provide counsel and expertise. You can read it below. You can also download a PDF copy of the slides I designed and presented for the meeting as well.

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What Kind of Support Would Be Valuable to Ministers?

Honorable Ministers and dear colleagues, ladies and gentlemen:

Before beginning, I would like to quickly thank: the organizers of the Harvard Ministerial Leadership Advisory Board for the invitation to join; and to my colleagues from around the world for your dedication and collaboration. Your question for me was: “What kind of support would be valuable for Ministers”. I would like to first lay the foundation by defining what the role of the Minister is within the Government. And I will use the example of Rwanda.

The role of the Minister depends on the Cabinet; and the role of the Cabinet is to get the country from Point A to Point B in order to improve the situation of the population. Cabinet is akin to a steering committee that validates and enforces decisions of technical sectors for the implementation of the nation’s vision under the leadership of the President-elect. So the Minister’s role boils down to being the implementer of a national vision that is guided by the Cabinet, articulated by the President, and informed by the population.

In Rwanda, Ministries are working together into Clusters in order to maximize synergies and overlaps in target interventions. This Cluster method began in 2009, and divided all Ministries into three Clusters. The Ministry of Health is part of and chair of the Social Cluster, which includes Gender, Education, Local Government, Infrastructure and Youth. These are all of the important ministries for social development. This organization enhances collaboration and cooperation, while allowing Ministers to lead policies and make strategic decisions according to the availability of infrastructural, financial and human resources. This assures connections and smooth implementation. Decisions made must be harmonized with Ministries within and outside of a given Cluster. This also increases each member’s knowledge of what is needed for good social development – it is the same for increasing the economic knowledge for the economic cluster, etc.

Ministers must plan, reach countless targets, and monitor closely – these are not easy tasks, as we need to coordinate and get many national and international partners to work together around one plan. This gathering can bring valuable support to Ministers to identify the goals of the goals of their health sector, what it takes to get there, and identifying what is needed to ensure that the plan stays on course. Based on this example, I see some opportunities for improvement where support for Ministers would be valuable.

For Setting Targets

• Agreeing on a shared and inspired vision for your country, because alone you will achieve nothing.
• Articulating goals and policies to achieve them by using participatory processes and evidence-based decisions.

For Strategic Planning

• Working across clusters and constituencies to build consensus and synergies, and taking a holistic approach for development, as health is not a stand-alone. Health is too important to leave it just to Ministers of Health!

For Monitoring & Evaluation

• We need to do periodic measurement of progress and shortfalls by structuring systems for documentation and learning so that we can take lessons to improve our future work. This allows us to rectify quickly when needed – if you implement fast, you increase your targets. In Rwanda, we have already achieved many health sector targets for our Vision 2020, so we sit and review for more ambitious ones. This brings a culture of flexibility and allows us to always do the best at the moment. 
• Inculcating culture of transparency and accountability for all is key for the success of the sector.

All of this said, we must be very careful to avoid the trap of thinking that simply articulating a vision and planning your monitoring and evaluation strategy will be enough. Setting targets, and measuring how you are doing against them, these are the fun parts. The real trick is in the delivery, and let me be very clear: there are no magic shortcuts here. As the Harvard Ministerial Leadership Advisory Board, we must be sure to also focus on the key middle part of the equation in the middle of this slide – the process of implementation.

I believe that there are seven steps for executing your vision, and each of these must draw on a ministerial culture of discipline and entrepreneurship. First, a Minister must be able to honestly assess the situation of your health sector – to plot where you are right now.

Next, you must choose your team – a team designed to succeed, not one that you are most comfortable with. You need people who have the courage to stand and challenge you. You must have the right people before you can start moving in the right direction.

Third, you must focus on building momentum; this does not mean that you are always progressing at a fast pace – it may be very hard to get things moving at first, but with consistency, small steps add together to become a powerful force with a life of its own.

In order to build such a culture in all members of your team, you as the Minister must lead by a disciplined example. Act out your Ministry’s values in your own actions.

Fifth, I believe that the key to successful execution is to focus on your outputs, in the way that a well-run business does, but in the social realm.

Your team must understand the importance of running your health sector like a business focused on social outputs of health and wealth for the population. You are not after financial profits, but you must measure your progress in health outcomes with the same careful attention that the best CEOs apply to their bottom line. Always have in mind that your end product is health and wealth in a cost-effective manner, meaning the best you can possibly achieve given the investment you make.

Finally, you must be aware of the right time to take advantage of technology to help accelerate your planning cycle and your delivery process. This does not mean jumping at every new gadget – you must be strategic about how a new technology well-applied could make your vision take off. This requires the ability to see ahead. It must also to be a cost-effective analysis, like a chief of industry sometimes invests one million to save ten million.

All of this matters only if Ministers of Health are ready to be the leaders that our health sectors need. When the health sector experiences success, give credit to the. When there is failure, the Ministers have to look in the mirror and take responsibility instead of looking out the window. I thank you again for having me. This presentation contains many ideas that I am ready to develop with you and to share with my colleagues.

Thank you so much for the opportunity to speak with you all.