Sunday, July 20, 2014

Let's Use Evidence-Based Interventions to Save the Lives of Children and Mothers

The 06/25/2014, I had the great pleasure to publish in Huffington Post, this article with Mark Shriver, the Senior Vice President for Strategic Initiatives, Save the Children.

If 18,000 preschool kids and 800 moms were attending a World Cup game and they all died, no newspaper around the world would be silent. But that's exactly what happens every day around the world: 18,000 kids die before they reach the age of five and 800 moms die during pregnancy or childbirth. The biggest tragedy is that in both of these cases, most of these deaths are preventable.
Today, over 500 representatives from governments to non-governmental organizations to the private sector are gathering in Washington, DC to take on this challenge and discuss how we are "acting on the call to end preventable maternal, newborn and child deaths" -- a pledge that 176 governments and over 450 civil society organizations and faith-based organizations signed two years ago.
This is an opportunity not only to reflect on the tremendous progress made on improving maternal and child survival around the world, but also to double-down on our success and demand more attention and resources. Imagine how many lives could be saved if we coupled political will with sufficient resources focused on key interventions.
Over the last two decades we have nearly halved the number of children dying annually and reduced the number of maternal deaths by 45 percent. Twenty-five countries, including Rwanda, have reached Millennium Development Goal Four (reducing child mortality by two thirds) and a number of other countries are on track.
In fact, according to "Countdown to 2015 modeled data in 2013," Rwanda not only had already achieved an under-five-year mortality rate (U5MR) reduction of more than 70 percent, but it has the fastest rate of decline in child deaths of any country, ever.
Rwanda's success, while remarkable, is not a mystery. Investments were based on the evidence, tackling the biggest threats to child survival by increasing effective interventions such as vaccinations and breastfeeding rates. The government has put equity at the core of efforts to strengthen the health system from putting community health workers in villages and ensuring appropriate care facilities at the sector, district and provincial levels, as well as referral hospitals across the country. This approach to bring care and prevention near where the people are living has drastically improved the geographic accessibility for all. And this commitment to reach all Rwandans has been mirrored in the Vision 2020 strategy that will improve socioeconomic conditions.
Rwanda is a success story but much remains to be done: no country should stop before ending the last preventable child death. Many countries in Africa are experiencing success, but the risk of a child dying before five is still highest in the African Region -- about six times higher than that in the Americas. Today, a woman's risk of dying from childbirth in sub-Saharan Africa is more than 47 times greater than in the United States.
Rwanda proves that it doesn't have to be this way. A recent study by the World Health Organization noted that an additional $8 per capita per year investment in Africa could prevent up to four million maternal deaths, 90 million child deaths within a generation in the region. And the benefits can transform not only families, but also economies: investments in maternal and child health yields economic benefits including higher per capita incomes and increased labor force participation.
To end preventable maternal, newborn and child deaths globally, we must increase attention and resources in Africa. Today, USAID is releasing a report, Acting on the Call: Ending Preventable Child and Maternal Deaths that lays out a roadmap for dramatic progress over the next five years. The US and African Presidents will come together in August to talk about investing in future generations. Together, we have an opportunity to use this Summit to accelerate action in Africa to end preventable maternal, newborn and child deaths worldwide. Our hope is that this summit will increase collaboration between the U.S. and African partners to promote and deliver the most effective interventions and identify new and innovative resources.
There is no more important goal we can share, no more important investment in the future health and stability of the continent, than saving the lives of mothers and children.

Thursday, July 17, 2014

Lecture given to Dartmouth University students 'building a health sector alongside a nation"

I gave this lecture given to Dartmouth University students to share how we built a health sector alongside a nation. It is the health sector contribution to Rwandan rebirth the past 20 years
the story of the Rwanda health sector after the 1994 genocide against the Tutsi. a story of ownership accountability participation equity sciences and fight for sustainable development.

Follow the live lecture using the following link:

Saturday, July 12, 2014

We must work hard to own our liberation

By Dr. Agnes Binagwaho, Minister of Health

Published in the NewTimes Rwanda on 7th July 2014

Twenty years after the end of the 1994 Genocide against the Tutsi, this July fourth makes me reflect on what the events we remember today have brought to me as a Rwandan, as an African, and as a woman, a mother, and a daughter. First and foremost, I have come to understand that, to truly honor the sacrifices of our RPF’s brave soldiers—who laid down their lives so that Rwandans might live in a country free of discrimination, free of the fear of violence based on one’s background, and free to pursue lives they value—we must work to own our liberation.

Thanks to our heroes, I now live in a country where all have an equal chance, whether you are the nation’s newest baby girl in the most rural district, or whether you are the head of Parliament. Thanks to this foundation, we have the opportunity to build the future we want through dialogue and transparency.

In this reborn Rwanda, our society is far from homogenous; this is such a blessing, because it is our diversity that fuels the engine of innovation behind recent progress. Certainly, many serious challenges lie ahead, and we have so much more to achieve in order to give all of our brothers and sisters the opportunities that they deserve. But we are continuously progressing each day to achieve that vision, and on this July fourth, I hope we do not take these efforts for granted.

In today’s Rwanda, every citizen inside our borders or living all around the world—whether they support the government’s efforts or hold different views—identify themselves as Rwandans with pride. Today, we celebrate the blessing of our shared identity as Rwandans, and pursue with renewed purpose our mission to accelerate the journey to shared development by transforming our Vision 2020 into our daily reality.

Many of our international friends see Rwanda’s recent achievements as a miracle of humanity, compassion, forgiveness, inclusivity, and progressive thinking that some claim could never be replicated elsewhere. But on this July fourth, as we reflect on a journey spanning twenty years, it is clear that this is no miracle. Anything that we have achieved has been through the determination and shared efforts of millions of Rwandans to liberate our country from the spirit of division, from fear, from ignorance, from the consequences of bad leadership, and from the oppression of poverty.

If we still have a long way to go, we are proud of what has been built to date. In this spirit of reflection, I feel a strong sense of gratitude to the Rwandan Patriotic Front for having halted the Genocide, and for protecting our people and our nation these past two decades. By helping more than two million refugees and displaced citizens to return home to peace and security, by making our communities free from discrimination of any kind, and by building the foundations of a democracy based on human rights, the sacrifices of our countrymen and countrywomen and the leadership of our President Paul Kagame have brought us here today. The liberation of 1994 recovered our dignity; the daily work to liberate our minds is making us proud Rwandans and proud Africans.

With this legacy, the Rwandan people can address the greatest challenges we have face by owning them, working to take full responsibility in the face of complexity, and harnessing the creativity of our people to find the solutions our nation needs. If we carry this spirit forward, we will truly own our future for the next 20 years and beyond. 

Thursday, May 29, 2014

PBS Television Covers Rwanda's Health Sector

On May 29, 2014, PBS Television aired a segment on Rwanda's health sector. Click here to watch the video.


Wednesday, December 11, 2013

Towards Sustainable Health Care: From Community To Medical Tourism

Towards Sustainable Health Care: From Community To Medical Tourism
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.
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. 
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.

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

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.