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." 

PhD Life and Reflections

Given my background as a pediatrician and enthusiasm for research, I was very proud to be the first person to receive a Doctorate of Philosophy (Ph.D.) from the College of Business and Economics of the University of Rwanda in August 2014.  My thesis on improving the health of children with HIV/AIDS in Rwanda has meant a great deal to me.

More information regarding the announcement of the degree can be found here. I've also included a picture from the special graduation day below:

Additionally, since receiving my PhD, a number of people have inquired about my ability to manage the various responsibilities before me in a given day.  I very much enjoyed my interview with the New Times reporter - Collins Mwai - who captured my reflections on this topic in this piece published on Sept. 3rd: http://www.newtimes.co.rw/section/article/2014-09-03/389/news-career:-dr-binagwaho-tips-on-juggling-education-and-work  (see text below)

"Following its merger, the University of Rwanda passed out its first graduates in various disciplines and levels this year and among them was Dr Agnès Binagwaho, the Minister for Health.

Dr Binagwaho was conferred with a Doctorate of Philosophy (PhD) in Health Management and did research on the HIV/Aids epidemic, with Rwanda as her case study.

Binagwaho, who started the course in 2008 before the merger of the institution, managed to juggle her studies, her ministerial role, her work as a senior visiting lecturer in the Department of Global Health and Social Medicine at Harvard Medical School and clinical professor of pediatrics at the Geisel School of Medicine at Dartmouth, USA.

In an exclusive interview with Women Today’s Collins Mwai, the minister explains the reasons, necessity and modalities of higher learning.

You are a minister, a lecturer in two top universities in the world and you have a stable career. Why the need to return to school?

The President always says “never remain in your comfort zone, always challenge yourself.” I am a strong believer in that too. The day you believe you have nothing to learn is the day you begin to die. Even in retirement, there are numerous lessons to learn.

How did you juggle between your roles through school?

We all have the same number of hours in a day; it is up to you to choose how you will spend your time. I prefer to spend mine learning and doing research. I was comfortable juggling my various roles and school. It is always easier if you have a passion for what you do.

You had the capacity to undertake your PHD anywhere in the world but you chose to do it here, why?

I first registered as a PhD student at the university while it was still National University of Rwanda (NUR). While working, a PhD takes between four and six years, it happened that I graduated after the universities had merged.

I wanted to do a PhD in my country because in many areas, this country is quite advanced in policy planning and strategy. We have riches and innovation. I am against the idea of going out for PhDs when quality education is available here. To anyone in doubt about the quality of our higher learning institution, I can tell them for sure that I did not experience challenges while pursuing the qualification.

I also wanted to prove to people who I work with that it is possible to balance work and school. If I can do it, they too can do it.

At the ministry we have been urging people to take on master’s degrees, currently most people have the qualification while others are pursuing PhDs. I am a strong believer that the best thing you can do for yourself is add more knowledge to what you have.

The requirement to work at the Ministry previously was a degree, now it is a master’s degree; we have made arrangements so that they can all have an opportunity to advance. Higher learning is a benefit to the institution and the people served by the institution. From my Ministry I have seen them have better and in-depth understanding of circumstances and solutions to approach them.

If you research more on what you do, you become a master in the domain and can perform better. It is an advantage to you, your institution and your community.

Most women of the young generation currently view higher learning only as a means to higher salaries; you clearly see it quite differently, why is that?

Money and a high salary is not the end, it should not be, it is just a tool. We have people who are rich but end up taking their lives. Education gives you fulfillment and purpose. Continuous education has numerous benefits. You will never know enough.

There has previously been talk that quality higher learning can only be obtained abroad, do you believe so too?

It is not true, in one way; even those institutions come here to learn from us. They borrow ideas from here and go teach them abroad. That is part of what we are trying to educate people in the Ministry, to do further research, document their findings, and share it on bigger platforms internationally.

I came to Rwanda as a young pediatrician, being here I have had an international dimension and learnt in numerous ways over the years. You do not have to go abroad to learn, I have been known for what I have learnt and done here, I never asked for a job at Harvard, they asked me.

You can create the universal bank of knowledge here. Some ministries in this country have pioneered initiatives and leadership models that have never been practiced anywhere in the world. There is a lot to learn from here, it is time people realised how much the world can learn from us.

Among other things you are a lecturer, what is the one thing you insist on with your students?

The importance of participatory processes; working closely with the community that you are working for, you need to listen to them and learn from them. People in certain positions need to work with the people for the people.

What would you say of people with high academic qualifications but do not reflect their qualifications in performance?

They probably do not further their studies to serve better, or challenge themselves. Some could study to have bigger titles on their business cards. They also probably do not have well laid plans and strategies. Always have one. Since I began working in leadership positions I have learnt that as long as you have a guide like Vision 2020 and Economic Development and Poverty Reduction Strategy (EDPRS2) you can come up with strategies to get there.

What advice do you have for people reluctant to pursue higher learning?

Education is key, the more educated you are the more functional you are. Good education is one that helps you improve the world around you and is practical. There is no limit, the best reward you can have is to see the result of what you do. Do not run after money, it will always be needed, but it is never the end." -New Times, Rwanda - 2014 Sept 3rd (Collins Mwai)

Video for Salzburg Global Seminar on Leadership and Health Care

This video was recorded for the panel titled "Strengthening Leadership and Policy for Improving Care in Low and Middle Income Economies" for presentation at the Salzburg Global Seminar on Improving healthcare in low and middle income economies. Thank you for the honor to participate.

You can also watch the video by clicking here.

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

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.