New Times Op Ed - Why We Must Strengthen Our Institutions for Rwanda's Health

I hope you will take a moment to read my OpEd published by the New Times on 18 February 2015 regarding the need to strengthen our institutions to assure a better health system for Rwandans.

"We know how far we have come to be where we are today. As I reflect upon several achievements attained not only as the health sector but the entire nation, I am also reminded of the long journey ahead to meet the set goals in the interest of all Rwandans.

A good example is the positive outcomes we have witnessed following the decentralization of our health system. Decentralization in Rwanda has translated into real and meaningful empowerment, placing critical responsibility in the hands of the local leaders.

This empowerment has grown in parallel with the increasing capacity of the central government to monitor, evaluate, and strengthen its auditing role. This has helped improve accountability across all levels to ensure we are doing all we can to better the healthcare system.

For instance, by applying the fiscal decentralization with the national budget, hospitals have been assigned their funds through the district budgeting process. Also, other health financing strategies for the country are based on decentralization.

This includes the community-based health insurance known as Mutuelles de Sante, which serves as a useful example to demonstrate how the local and central governing structures work together. It also shows how we are continually learning and adapting to improve the program.

Mutuelles was created about 15 years ago and it is now undergoing its third major reform. The first reform involved changing the amount that each household paid for their health insurance premiums.

At first, each household paid for a single household, but the reform ensured that each household would contribute the amount appropriate to reflect the number of people in their domicile to improve fairness of the contributions across the country as well as financial access for all.

The second reform involved the implementation of the stratification system, so that each person would pay in accordance with their income as opposed to a flat fee per person. The third reform is ongoing.

The government is transitioning the management of Mutuelles to the financial professionals at the Rwandan Social Security Board which has the mission to provide quality management of health insurance.  This will ensure the sustainability of the programme.

All of these reforms have relied upon an effective decentralization of responsibility and authority to the local governments that also oversee Mutuelles starting at the district level; the direct management of the Mutuelle staff by the local administration puts the Mayor in charge of this programme in that district.

In general, this decentralization structure has been working well. Having local leadership overseeing the local implementation of Mutuelles has been helpful.  These local leaders have, on the whole, been loyal, trustworthy and hardworking, and are dedicated to their mission vis-a-vis their administrees.

Unfortunately, however, there have been a handful of local leaders who have been dishonest – acting as though they were more powerful than Rwandan institutions.  They did so by stealing the hard-earned money that people had placed to get their health insurance locally.

And such dishonest acts were discovered through the complementary, central auditing system in place through the Ministry of Internal Affairs, the Ministry of Local Government, Ministry of Finance and Economic Planning, and the Ministry of Health.

In Rwanda, we have a zero tolerance for corruption. Thus, at all levels, we create institutions, such as the auditing system noted above, that reinforces accountability and discourages dishonest actionsby making the cost of corruption high.

In this case, those local leaders who unjustly took money from the health insurance pool for their own personal gain were appropriately identified by this system. These individuals will be held accountable for their criminal actions and will reimburse up to the last penny of what they have taken, even if this means that they have to sell their assets.

Rwandans should rest assured that their investment into their health insurance will not be lost. We have learned from this experience that we can be even more vigilant in our fight against any form of corruption, nepotism, or any crime moving forward.

Creating systems that reinforce honesty and accountability is very vital to protecting our integrity, our rights, and development as a country, especially as we strive to reach our Vision 2020 goals.

Yet this experience has taught us that we need to foster the growth of honest local leaders coupled with improved central level institutions that bolster accountability and reassure the people that their interests are being protected.

I am grateful to live and work in a country where systems are strong enough to identify and correct problem areas or loopholes. Our effort to learn from both our successes and mistakes allows us to continuously improve every day in our efforts to protect public goods, community assets and people’s rights.

 The writer is the Minister of Health "

*Published in the New Times on 18 February 2015.  Available at: http://www.newtimes.co.rw/section/article/2015-02-18/186076/

Uniting to uproot malnutrition in Rwanda

I published the following article in December 2012 in The New Times. The full text is available online, and you can also read it below.

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Uniting to uproot malnutrition in Rwanda

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

While Rwanda has made dramatic progress in decreasing child mortality over the past ten years, reducing the rate of deaths from 183 per 1,000 live births in 2000 to 54 in 2011, chronic height-for-age malnutrition (or stunting) has remained too high among children under the age of five. Earlier this year, His Excellency President Paul Kagame challenged the nation to eliminate the root causes of stunting by working together through a multi-sectorial approach from the community to the central level and across sectors. 

The rate of stunting among children under the age of five years was found to be 51 per cent in 2005; by 2010, it was still far too high at 44 per cent. Over the same timeframe, the prevalence of underweight had declined by roughly 30 per cent, from 18 per cent to 11 per cent of children. Based on this and numerous studies by the Ministries of Health and Agriculture, it was clear that the driver of persistent malnutrition was not a lack of sufficient food, but a complex set of social, cultural, and economic factors interacting to prevent many children from accessing a healthy diet.

This challenge necessitated a multi-pronged approach to identify and combat the fundamental causes of malnutrition with significant emphasis on prevention. The most important strategies identified as priorities for action were the diversification of food sources, systematic growth monitoring of children at the community level, early detection of malnutrition,  access to clean drinking water, and, most importantly, widespread awareness about the kinds nutritious diets children need and how to prepare them.

Existing programmes to promote access to a balanced diet among the most vulnerable have been strengthened, and new initiatives have been launched to fill gaps. The Ministry of Agriculture has continued to provide leadership in the national Girinka (One-Cow-per-Family) programme, Akarima k’igikoni (kitchen gardens), and One Cup of Milk per Child programs, and the central government has supported these initiatives by doubling the agriculture budget between 2006 and 2011.

More than 200,000 cows have now been distributed to families categorized as ubudehe socioeconomic  1 and 2 (equivalent to the poorest households), and these animals have begun to bear offspring which recipient families then pass along to their neighbors who have yet to receive a cow. 

With the support of local communities through monthly umuganda communal work days, kitchen gardens consisting of nutritious vegetable and fruit plants have continued to be scaled up across the country among ubudehe 1 and 2 families. Schools in 14 of 30 districts now receive one liter of milk per 3 each week, and this programme will be expanded to cover every school in the nation in the near future.

To ensure that children who do become malnourished – whether through severe or moderate growth shortfalls, underweight, or stunting – are linked to the health system and provided with appropriate treatment (from Plumpy’nut Ready-to-Use-Therapeutic Food to multivitamin supplementation), the Ministry of Health has incorporated monthly growth monitoring into the national community health system. 

The country’s 45,000 community health workers (responsible for child health, reproductive health, and health promotion) now make regular household visits and can report children found to be malnourished to their local health centre, district hospital, and the central level via the cell phone-based RapidSMS system. Referrals of malnourished children have begun to occur much more rapidly than in years past, and preliminary data from the Ministry’s community health information system (SISCOM) show that moderate malnutrition has fallen by half between January and November 2012 – from 1.2 per cent to 0.6 per cent at the community level.

To contribute to improving the population’s access to potable drinking water, in addition to the work done by the Ministry of Infrastructure, the Ministry of Health has worked with partners to provide water filters to nearly 2,000 households in ubudehe1 and 2 across the country, with plans to scale up to the 600,000 poor households across the entire country

 In addition to existing forms of filtration and purification (such as chlorination tablets), these filters help to improve hygiene and hence minimise children’s exposure to pathogens that cause diarrheal disease. Furthermore, recent international data from the United Nations project Rwanda to be on track for Millennium Development Goal 7, which includes key indicators for access to water and sanitation. 

These developments are crucial to the fight against malnutrition, as persistent diarrheal disease prevents children from absorbing the nutrients they need and makes them feel sick so that they do not eat enough. This is another reason why the Ministry of Health worked with the GAVI Alliance to roll out the rotavirus vaccine for the prevention of one of the most dangerous causes of diarrhea this May, and preliminary data show nearly 95 per cent coverage among infants.

All of these interventions will be essential if Rwanda is to succeed in our goal of dramatically reducing the prevalence of all forms of malnutrition. With the bounty of agricultural resources our land provides and the wisdom of the Rwandan farmer, we have all the tools we need to keep every child healthy and growing. 

But ensuring that improved availability and diversity of food sources translates into better health outcomes for the most vulnerable children requires more than accelerating production – it necessitates a revolution in the way that families prepare their children’s food and understand the importance of their children receiving nutritious diets for a brighter future. 

For this reason, the government has started a massive educational campaign on “how to cook,” and pamphlets have been distributed across the country detailing the kinds of foods that children need, how to cook them, and the importance of proper hygiene and exclusive breastfeeding for children under the age of six months. 

Demonstration kitchens are being rolled out in districts across the country, to show families recipes that make use of local foods in such a way as to maximise their nutritional value to children using traditional cooking methods. 

Each umudugudu will hold a meeting to strategise on ending malnutrition on December 27 of this year, and these meetings will result in the publication of comprehensive local plans.

To conclude, Rwanda has made great progress this year towards the goals we have set as a people under the leadership of our President. But our job will not be finished until every single child is assured a healthy and balanced diet, until no mother worries about how to feed her baby, until no household goes without a clean water source or a hygienic and sustainable toilet. 

From scaling up drugs for HIV to reducing child mortality, our nation has proven that we have what it takes to achieve what some have called impossible, and I have absolute faith that together we will successfully apply this same sense of purpose to the fight against malnutrition. 

I can guarantee you that your public servants in the Ministries of Agriculture, Gender and Family Promotion, Local Government, Education and Health are spending sleepless nights working with our colleagues and partners to devise, scale, and monitor solutions to the root causes. 

If you have specific complaints about the response to malnutrition or suggestions on how to improve, I urge you to engage with us via Twitter through @RwandaMOH and my personal account @agnesbinagwaho. Be specific –name names, share exact locations, and we will explore every claim. Furthermore, the next #MinisterMondays Twitter and SMS (via 0788386655) discussion on Monday, December 17 will address the state of the malnutrition response, and I look forward to your participation.

The writer is the Minister of Health of the Republic of Rwanda.

Accelerating the MDGs through ICT: The Case of Rwanda

On June 10, 2011, I was part took part in a high level working session at the United Nations Headquarters in New York on “Digital Health for Digital Development: Connecting the Millennium Development Goals and Non-Communicable Diseases in 2011.” In Rwanda, information and communications technology (ICT) in the health sector is key to what we have accomplished in the past five years.

Utilizing various forms of ICT, we have been able to create and monitor a health system that allows both urban and rural populations to benefit from services. This system has improved financial and geographic access to quality health care throughout the country, even to those most impoverished.

Over the course of the last five years, the under-five mortality rate has dropped by half, we have achieved universal access to HIV therapy and we are now addressing HIV/AIDS as a chronic disease. The percentage of married women using any modern method of contraception went up from 10 % to 45%, and the access gap has narrowed rural and urban married women. More women than ever before are now delivering their babies in health facilities; the current facility-based delivery is 69%, much higher than the  30% we had in 2005. More than 95% of Rwanda’s 11 million people have health insurance. Full vaccination coverage is now 90%, when it was 70% in 2005. The percentage families who seek treatment for children from a health facility provider has also increased. Pediatric treatment sought for acute respiratory disease has risen from 26% to 50%; for diarrhea it increased from 14% to 37%; and for fever it went from 27% to 43% in 2005.

The aforementioned achievements have led to a dramatic increase in life expectancy in Rwanda. And yet, in fighting the current top killers, we are only able to increase life expectancy to approximately 54 years, since infectious diseases do not fully account for morbidity and mortality rates in Rwanda. Our health sector still has serious gaps with respect to delivery of services for non-communicable diseases (NCDs). The World Health Organization has estimated that NCDs account for about 25% of the national burden of disease in Rwanda; however these disease have yet to be addressed in a strategic and systematic way.

To be able to reach the Millennium Development Goals, we need to reinforce prevention, care, treatment and rehabilitative services needed for both communicable and non-communicable diseases without decreasing the attention we currently have on combating communicable diseases. In doing so, we will need to ensure that care for all diseases – including chronic illnesses – is accessible to all.

Accordingly, over the next five years, Rwanda anticipates expanding access to integrated chronic care by building on the existing healthcare platforms established by programs fighting infectious diseases. We plan to embrace information and communications technology to expand care through several high impact interventions, mainly referred to as e-Health solutions. E-Health solutions are vital in order to create an effective and sustainable health system. Such innovations help to solve challenges in health system, including the lack of infrastructure and the shortage of professionals. Since roads are still difficult to traverse in some remote areas, ICT facilitates the sending of information, plans, and reports between urban and rural areas, saving both time and money.

Rwanda further supports ICT for health because the right to health cannot be separated from the right to information. And the use of new technologies and communications interventions are the most accurate and timely way to provide information. The flow of information in Rwanda concerns four stakeholders in the health sector: the patients, the policy makers, the healthcare providers and the program managers. As for patients, there must be strong health education platforms to inform them of how, when, and where to seek proper care. Also, once on treatment, patients should know the reasons for which it is important to go for timely medical follow up appointments and be compliant to treatment. This is extremely relevant, since follow-up appointments not only aid their recovery, but they also avoid dangerous resistances to epidemic diseases like TB. Patients would be informed of these issues through ICT tools made available to health professionals at all levels: community health workers would use their cellphones and central and district managers, health centres, district hospitals and referral hospitals would use web-based tools. For policy makers and program managers, ICT is essential because it enables the design of health policies and programs that are informed by evidence and based on up-to-date information. In general, the use of ICT has proven to be a very effective, secure, rapid and accurate way to serve patients and program managers. This is why the Government of Rwanda has put ICT as a top priority for the development of its health sector recognizes that there is an urgent need to build e-Health capacity.

As such, Rwanda has embarked on an ambitious journey to ensure that technological innovation becomes a central part of the healthcare ecosystem.

The initial phase began with devleoping a policy, a strategy and an action plan. Our health sector ICT plan is integrated into two master plans: our health sector strategic plan and our national ICT plan. Many applications of E-health have already been installed. One example of such applications are web dialogues. These are entry points for information access and exchanges between professionals and semi-professionals who work in remote areas, and therefore have difficult access to journals and books. It is also a tool of sensitization, reflection, idea expression, and innovation. Since it is virtual, it does not require physical infrastructure and runs at no cost. Through the exchange of biological and immunological patient information, x-rays, ultrasounds, lab samples for cancer, and so forth, clinicians can receive data, confirm diagnoses and make informed decisions. For example, health facilities in the US and Europe connect Rwandan health professionals to counterparts in other countries through the internet. This allows for free communication between these countries and comparison of differential diagnoses, among other core features. ICT also allows for the horizontal exchange of information between policy makers, programs managers, and community workers at the grassroots level. It allows for vertical exchange between those three categories, thereby breaking down barriers to knowledge and communication.  This has created an international family of global health workers that help to bring international communities on board with the decisions that concern them. These communication exchanges can take on many different models allowing countries to choose which one best suits them. As a result, we can quickly gain time by building on the experience of our peers around the world and web-based free information can dramatically improve local, national and global health.

Without ICT, all of Rwanda’s programs in the health sector would be unmanageable. For example, the healthcare financing system is web-based and manages over 90% of Rwandans enrolled in health insurance, along with a performance-based compensation program in our 450 health facilities. Rwanda’s ART program, which provides antiretroviral therapy for 80% of people living with AIDS in need of treatment, is also managed through web based technology. Now that we have started to tackle non-communicable disease we are in need of ICT more than ever.

Over the past few years, we have also seen an emerging area where healthcare is delivered using mobile phones, otherwise known as mobile health (or mHealth). ICT also allows Rwanda to gather localized MDG reports. Community health workers and health professionals do active case findings on fever and malnutrition, perform maternal mortality audits, and collect information on all maternal deaths in the country via mobile technology in order to better understand why young healthy Rwandan women can be at risk of death during pregnancy or delivery. Additionally, many other programs in Rwanda have web-based management, such as health surveillance, public health reporting, drug procurement, drug tracking, the blood bank, and E-learning. One of our big challenges is in coordinating ICT tools so that these web based management systems are efficient and synergetic.

Given all above reasons, it is clear why the Government of Rwanda has put ICT as a top priority in the development of our health sector, as it recognizes the urgent need to build e-Health capacity in order to provide and maintain highly effective, reliable, secure, and innovative information systems to support clinical decisions, patient management, education and research functions. This approach will be crucial to ensuring the sustainability of an integrated and coordinated healthcare system in Rwanda which will efficiently provide high quality, gender-, geographical- and age-equitable services.

The final advantage of using an ICT approach is that we save trees since we are saving the paper used for plans, reports, files, mails, and so on. At a time when experts recognize the danger of global warming to the Earth, environmental programs should also award the use of ICT by the Government of Rwanda!