Wednesday, December 11, 2013

Towards Sustainable Health Care: From Community To Medical Tourism


Towards Sustainable Health Care: From Community To Medical Tourism
By Dr. Agnes BINAGWAHO
Published in  Ubuzima Magazine, of 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. issue No4 2013

Ultimately, our strategy is to tap into medical tourism but this can only happen if we first secure the health of our own people and build the soft and hard infra- structure – people, facilities and a quality regime assurance to provide a world class health product.
Rwanda has the ambitious but achievable vision of building a self-sustaining state. To achieve this, the country must accelerate and sustain economic growth at 11.5 percent annually for the next two decades.
Every sector must play its part in contributing towards the realisation of that vision. The health sector is an integral part of the journey to economic self-sustainability and our contribution will be measured by the extent to which we are able to provide the preventive, palliative and curative care, using the best quality state of science to each and every Rwandan at an affordable price with the idea of equity in mind. That would mean that wherever one happens to be in the country, they will have the same rights and enjoy access to what we can offer to each and every Rwandan.
Ultimately, our strategy is to tap into medical tourism but this can only happen if we first secure the health of our own people and build the soft and hard infrastructure – people, facilities and a quality regime assurance to provide a world class health product.
Over the past five years, we have been putting in place the building blocks to a sustainable healthcare delivery system. We have already made good progress towards making the first point of contact with the health system, the Community Health Worker (CHW) self-sustaining. We have three CHW’s per village. These are people that are elected by the community members and the Ministry of Health gives them six weeks training and an annual refresher course which equips them with skills to provide quality care with a community-centric approach. They are supervised by the health centers and the doctors at district level.
They provide care at village level diagnosing and treating pneumonia, bronchitis, and malaria. With the exception
of implants and IUD, they provide the full range of family planning services from condom, pills, and injections. They also treat diarrhea and they provide counseling for HIV. One of the CHW’s is a maternal health assistant who fol- lows up pregnancies in the community and children under one year. They follow up children ensuring that everyone is vaccinated.
CHW’s now take care of around 80 per cent of the disease burden and the cost of this care will soon be covered
by cooperatives with money mobilised by the Ministry
of Health for this purpose. We now have more than 470 cooperatives and our target is to reach 500.
The profits generated by the cooperatives are used to grow businesses for the Community Health Workers and to sustain them. The business opportunities are identified by the CHW’s in their own communities and some have started hostels, shops, farms while others have gone into agribusiness. The profits from those cooperatives have created a pool of funds from which care at the community level can be paid for through performance based financing. A percentage of the profits from the cooperative belong to the health sector and are used to pay for the services of community care. This means nothing is free, everything has a cost and no one works for free in Rwanda even though we have to generate the money to pay for healthcare.
We have been paying CHW’s since 2008 but the difference now is that instead of the resources coming from outside the community, they will be paid from revenue generated within the community with clear management and financial guidelines.
The percentage that is not secured for the health sector will go directly to CHW’s. Weighed against the diseases burden, that means that 100 percent of the cost of care at village level will be paid for by the com- munity itself so we provide sustainable health care. This approach will be scaled up to cover the different levels of the health system.
Above the village we have the cell. A cell is made up of about ten villages and we plan to have a health post in each cell. The community will provide the space – 4 rooms – one for examination, a reception area, observation room as well as a storage room and pharmacy. From here patients can either be referred for hospitalization at a health center or district hospital or get discharged to return home after treatment.
Those posts will be headed by nurses trained to A2 level. They will provide services that will be reimbursed by Mutuelle de Sante. They will have no salary and will be paid directly in return for the services they provide, just like any private practitioner. They will also operate a drug shop. That means they will be offering services under a frame- work dubbed public-private –community partnership.
We are also going to create a national cooperative for these A2 nurses and in a couple of years, the proceeds from that cooperative combined with Mutuelle de Sante and the proceeds from selling drugs at the drug shop will pay for the care at cell level. They will also be supervised by the health center and the leadership at the sector level. Once we are through with this arrangement, we should have completed the loop of providing health care at the community level in a sustainable manner. We are close to our target of having one health center in each sector.

Less than 50 health centers remain to be built.
Under this arrangement, the sector will be the first point of interface between a patient and a public sector health facility. The system starts with a CHW at village level on to the public-private-community partnership at cell level and then the public health facility at sector level. Next are the district hospitals and then referral hospitals.
Forty per cent of health facilities in sectors and district hospitals (we have 42 district hospitals) belong to Non- Governmental Organizations (NGOs), associations and Faith Based Organizations (FBOs). We have an agreement with FBOs and NGOs. In return they offer treatment to each and every Rwandan in need. This has allowed us to have the same number of health centers and district hospitals in each part of the country rather than wait until the public sector can build its own.
The government through its budget pays subvention to each health facility or hospital. Mutuelle de Sante reimburses 90 percent of the cost of care but also there is a
10 percent out of pocket which patients pay directly to
the health unit when getting care. We are creating an e-system for better administrative and financial management of the health sector because we have private health facilities that for now do not get this contribution from the government but may be able to benefit of the e-system. We are therefore going to make the financial management more rigorous and private sector oriented.
Each district hospital will also become a teaching site with a director in charge of education for doctors and a director in charge of education for nurses. They will report directly to the College of Medicine and Allied Sciences that the Government of Rwanda is creating under the single university system. The same approach to self-sustenance will be employed when it comes to referral. Because all referral hospitals are also teaching hospitals that means they will have income from both the health and education sectors.
If we come to the ministry of health and the role of the Rwanda Biomedical Center; this center has been created to generate income to help the health sector become self- sustainable. We are now going into a phase of intensive business creation through RBC. PPP’s to create factories for consumables and drugs and goods for sale to the health sector are some of the options we are considering to decrease importation of what we bye anyway. We already have Labophar which has a unit for manufacturing infusions. Its capacity will be expanded; and we are going to build on that. The proceeds generated by these businesses will be reinvested to make the health sector self-sustaining at health center and hospital level. Because the system
at community up to cell level will be self-financing, the money generated from these activities will pay for services at sector, district and central level.
TAKING ON NCD’s
With a 50 percent decrease in acute malnutrition, we have made progress but our goal is to eliminate malnutrition all together. There is hope after the Clinton Foundation and World Food Programme teamed up with the Ministry of agriculture and the Ministry of commerce to set up a factory for nutritious foods.
This will help the health sector fight malnutrition by providing children and pregnant women with all the nutrients that they need. Malnutrition starts during pregnancy with malnourished mothers giving birth to malnourished children.
Sensitization to improve the nutritional status of children and mothers continues and the one cow per family programme has helped increase the consumption of milk. We now envisage a situation where we can use all those health posts we are creating to facilitate distribution of milk. We are progressing in creating systems, sensitization and what it takes to deliver the service.
 As we make progress against infectious disease; non- communicable diseases are gaining prominence. It is
not because these are new diseases, it is just that we are not dying of infectious diseases as we used to. Due to improvements to the health system we have doubled life expectancy and reduced the mortality of children. Life expectancy in Rwanda is now around 63 years at birth
and the profile of disease is beginning to be different as
a result. So we are beginning to see more cases of heart disease and lung disease that are related to longevity because the population is aging. 
 We are now educating medical personnel to manage this new challenge and we have introduced a diploma course in emergency medicine. We need 42 graduates to cover the 42 district hospitals. We have also created a residence of emergency medicine in provincial and referral hospitals. The school of medicine has almost completed the curriculum for a bachelor’s in cardiology so that we can have at least one medical doctor with special skills in cardiology in each district hospital. This is intended to accelerate the diagnosis and referral of patients to a full specialist if need arises and also do the follow-up of the people who have been treated.
We have already conducted more than 300 successful cardiac surgeries in Rwanda and those people are living in the villages. It is therefore necessary to have a doctor with the relevant skills living near them to keep them in good health through follow-up and ensuring they take their medicine. That way, they will not need to come back to Kigali because it is far and sometimes they come when it is already too late. 
The diploma in emergency medicine has already started and we hope to commence admissions to the bachelor
of cardiology next academic year. With these incremental steps, in five years, we hope to have a good referral system and fully functioning center of excellence for cardiology. We are also working on creating a residency in oncology and a diploma in oncology that again will allow us
to have in each district, somebody with skills in oncology and who through specialists, can follow up, seek advice via telemedicine and be available to see the patient on regular basis since we are equipping all our districts with telemedicine capacity over the next 3 years.
 Routine specialised care will be offered at district level. So renal disease, cardiac disease, cancer and other complications will be taken covered by system we are creating now to serve all the population in an equitable manner. 
MEDICAL TOURISM
We see medical tourism as a spinoff of care that will first and foremost be available to our own people and this is how we shall provide care for Rwandans.
 We are working with 23 institutions of higher learning in the United States that every year second 100 high level faculty members from their ranks who come to mentor their Rwandan counterpart’s under a twinning program. The aim is to create highly qualified and skilled clinical staff for both medical and nursing as well as lab technicians.
We are reinforcing high education in the health sector through the coming school of medicine and allied sciences. There are 60 A0 nurses to be trained to be tutors in specialized areas such as nephrology, theatre, neonatology, emergency, ICU, pediatrics and mental health. So we shall have highly qualified teachers for both the nursing and medical school. Through this twinning programs we hope to create very good educative tutors with a university that will be one of the best in Africa and attractive to students from outside Rwanda.
Once we have those highly qualified tutors, the system should produce highly qualified service providers. We have are sending to India, 16 people – surgeons, cardiologists, anesthetists, nurses, and lab technicians to train in cardiac surgery to help create a center of excellence for cardiac surgery here.
We are searching for the same opportunities for renal transplants. We have entered a partnership with the Chinese to transform Masaka hospital into a huge public teaching hospital and a separate partnership with the Japanese to have another high level public specialised hospital.
We are also promoting partnerships with anybody who may want to come do fair business in the health sector because we have a beautiful country where one can create set up a beautiful hospital for the discerning patient who may want to combine a medical checkup in a high quality facility space in serene and scenic surroundings to mix tourism and reinvigoration of their health.
And just as we are doing cardiac and renal surgery, we will do the same in neurosurgery so that we can attract here people who will, come to pay for quality care in Africa as
it is done in other other parts of the world. That is how we will come to medical tourism. But before serving in such a segment you need to have first secured the care for your own people.
Community care is already on track, and RBC has begun the next phase of its evolution or the first steps to turn this institution into a business oriented entity. For medical tourism, the paperwork is in progress at RDB and a project proposal is already with the African Development Bank and other development partners for analysis. We are off to a good start and all we need to do is pull in the same direction to get to our destination.
 Medical tourism results into regional centers of excellence and good medicine is generally a good business.

© RBC/Rwanda Health Communication Centre 2013



Friday, December 6, 2013

VOA’s news programme, Africa 54, Minister of Health Agnes Binagwaho's interview


Health Agnes Binagwaho discusses how


Rwanda managed to lower its rates of deaths and new


infections of HIV, TB, and malaria in the
 
past 10 years. 


Her interview starts at the 16:20 mark.

http://www.voanews.com/media/video/africa-54/1802655.html?z=3589&zp=1

Saturday, November 30, 2013

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 3rd, 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.

Tuesday, August 6, 2013

Can It Be Replicated? Look at Rwanda's Development Gains in Context


This session of the Skoll 2013 Forum in Oxford was an interesting moment to review the progress of the health sector in Rwanda in service delivery. The discussion were done in the framework of Rwanda’s goal to grow GDP at 11% in the coming years, up from the current rate of 8%, by decreasing the number of people in poverty and with a spirit of change using the principle of  social entrepreneurship for development. The human rights were also evocated and discuss against right to health to development and decent life. The discussion tried to understand the principles behind Rwanda recovery in 19 years after the 1994 genocide against the Tutsis; questioning the signification of democratic, the difference in the South, between people members of communities that are generaly poor and civil society that are generaly rich. The lack of accountability of a certain bad prototype of NGOs ...

I advise to se this video








www.youtube.com/watch?v=AFWwrMnVFzs
4 days ago - Uploaded by Skoll World Forum
A Look at Rwanda's Development Gains in Context 2013 Skoll World Forum. 

Sunday, July 21, 2013

Honorary degree to Agnes Binagwaho (Doctor Of Science)

The 13 June 2010, I had the tremendous honor of being welcomed to Dartmouth by my friend Jim Kim to receive an Honorary Doctor of Sciences. This is the video from the ceremony.


https://www.youtube.com/watch?v=wifKgJ3UjaM


Honorary degree citation to Agnes Binagwaho (Doctor Of Science)
by Jim Kim 
President of Dartmouth

Agnes Binagwaho, you are a healer for whom healing alone is not enough. In your life’s work as a pediatrician and leader in public health, you have never rested in trying to make today better than yesterday and tomorrow better than today.
You believe that any problem can be solved if we work hard enough to find solutions within our culture and within ourselves. Your tenacity demonstrates the power of that belief.
You trained as a doctor in Belgium and France. But rather than remaining in Europe for a successful and comfortable career, you returned to your native Rwanda, where you rose to the herculean task of rebuilding a country devastated by genocide.
In the process, you helped to create a health care system that has become a model for all of Africa. Malaria mortality in your homeland has been reduced by two thirds. Seventy percent of Rwandans with HIV/AIDs now have access to antiretroviral drugs. And, more than 90 percent of Rwandans now have health insurance.
Today, as Rwanda’s Permanent Secretary of the Ministry of Health, yours is a clarion voice in support of women’s rights and you are an eloquent champion of participatory health care. You are empowering adolescents to make choices that will lead to better health outcomes. You are a savior to them and an inspiration to us all.
And for all the seriousness of your life’s work, you have never let it weigh down your spirit or drive the joy from your soul. For all this and all of your accomplishments, the Dartmouth community is proud to confer on you the honorary degree, Doctor of Science.

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.