Thursday, February 19, 2015

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:

Saturday, December 13, 2014

Securing Health For the Next Generation

An Op-Ed that I recently wrote on ways to improve healthcare for the next generation was featured in Uganda's newspaper New Vision on 12 December. The full article is available at this website: and provided below:

"When I served as a pediatrician in Rwanda’s public hospitals, I devoted myself to building a future where children could reach their full potential without fear of disease.

Today, as Rwanda’s Minister of Health, I can attest to the great progress our country has made to improve the health of everyone living in the “land of a thousand hills.” But I also recognize how critical it is to keep pressing onward, not only as a country, but also as a continent.

Africa is home to some of the fastest growing economies in the world, but the benefits of this progress have not been felt equally.  For far too many, basic health care remains out of grasp. Millions of Africans simply do not have access to health facilities staffed with trained workers, or even to experienced community health workers. Even for those fortunate enough to live in close proximity to a health facility, many cannot afford to pay for basic healthcare services.

The time has come to commit to making affordable, quality health care the cornerstone of Africa’s development. Several African countries have taken a stand on providing health services  
    to all their citizens, and their efforts are already paying off through healthier communities.

Twenty years ago, Rwanda was a nation devastated by genocide and war: Nearly eight in ten people lived in poverty, our health system was all but destroyed, and one in four infants didn’t make it to his or her fifth birthday.

Today, even though we still have a long way to go, Rwanda is flourishing. This is due to many factors, including a collaborative governance structure that aims to extract the most value for our people from the money spent.

Rwanda’s visionary approach to prioritizing the nation’s health has also been instrumental in achieving this progress.

Combining national resources with international donor support, we have developed a system to improve both geographic and financial access to quality basic care for all Rwandans. 

Through our community-based health insurance scheme, called Mutuelles de Sante, approximately 90 percent of the population has health insurance, with another 7 percent reached through civil, military, or private insurance.

Even in the most remote villages, Rwandans can rely on local community health workers to deliver 80 percent of the preventive and primary care services and connect them to advanced care when needed. Under this system, Rwandans can access care without fear of financial ruin.   

The results of this approach, driven by a deep commitment to health equity, have been striking: Since 2000, infant mortality has decreased by 66 percent, child mortality has decreased by more than 70 percent, and deaths from HIV, malaria, and TB have fallen by nearly 60 percent.  Rwanda’s children were the first in sub-Saharan Africa to receive the vaccines for pneumonia and the human papilloma virus (HPV).

Other African nations are also making important strides towards universal health coverage. Each country is developing its own model to provide coverage for its people—informed and influenced by our distinct cultures, histories, populations and settings.  For example, in Uganda, the government has committed to establishing mandatory health insurance for all citizens by 2025. Going forward, it is necessary that each country feel ownership of both the successes and failures of the approach they opt to take.

Whatever the approach, health systems should be participatory in nature, ensuring that communities provide “buy in” to the value of having health insurance, as well as a sustained political commitment to scale up these efforts.  This will help ensure that no one remains beyond the reach of efforts to provide affordable, quality care.

The need for universal health care has never been greater throughout the world, and especially in Africa. Despite commendable progress in health over the past decades, Africa still faces the highest burden of disease, and continues to have far too many weak health systems. The recent Ebola epidemic has highlighted what is at stake for all of us if we fail to invest in both strong health systems alongside good governance. 

Health coverage is also a major financial challenge. Millions of Africans suffer financial hardship due to catastrophic expenditure whenever they are sick. According to the World Health Organization, about half of health care expenses in our region are paid out-of-pocket, and a 2009 study in Health Affairs found that one in every three households in Africa must borrow money or sell their possessions just to pay these fees.  

No family should have to choose between getting well and going bankrupt, especially when we’ve witnessed what a powerful force national health care can be for stability and economic growth. When governments invest in affordable health care, the whole population is healthier.  There are real economic benefits: there is less absenteeism at work, and the money saved by avoiding these consequences of poor health can be invested in building stronger futures for families and communities. School fees can be paid, new business can be started, and households can build savings.

Politically, there has never been a better time for us to invest in universal health coverage. Two years ago today, the United Nations unanimously endorsed universal health coverage. Global institutions such as The Rockefeller Foundation and, more recently, The World Bank, have elevated the benefits of UHC globally, and to date more than 80 countries have asked the World Health Organization for assistance in implementing universal health coverage.

Today, we mark the anniversary of this landmark decision with the first-ever Universal Health Coverage (UHC) Day, a global call-to-action that has garnered unprecedented support from more than 500 organizations.

As we look beyond the 2015 Millennium Development Goals, African leaders face an incredible opportunity: If we invest in our health systems now—which we know yields an impressive return for the investment—we can build an Africa where individuals, families, and entire nations reach their full potential. 

Together, we can chart a course for a stronger, more resilient Africa and world."


From Uganda's newspaper New Vision - web link:  

Friday, December 12, 2014

Rwanda's Health Care System & The Services Investment Forum 2014

At the 2014 Services Investment Forum (SIF) recently held in Kigali, I was delighted to participate in the panel discussion focused on our country's healthcare system.  We covered a number of topics, including how to improve quality, the drivers of prices of healthcare services, the decentralization framework that has improved geographical proximity to care, as well as where we are going as a country.  We also discussed Rwanda's health services strategies, current challenges and opportunities, and proposed solutions to overcome the existing challenges for Rwanda.  There is much to be done to create the infrastructure and environment we need to position Rwanda as a health care hub of excellence for the region and the world. And we are motivated to do this important work.  You can watch my remarks here:

Services Investment Forum 2014 Video - Available at:

Universal Health Coverage

I was so pleased to have the chance to contribute some remarks regarding the importance of Universal Health Coverage (UHC) as a global coalition celebrated UHC Day 2014 on 12 December 2014.  You can view a video of my remarks that was presented at a launch day event in London, UK, at the London School of Hygiene and Tropical Medicine and learn about all of the great work of this coalition through their website: .  We should all continue to monitor and support this great #HEALTHFORALL campaign.


Coverage of my remarks at LSHTM 


The Video of My Remarks


Here are a few additional stories regarding UHC Day

1) Press Release from Rockefeller Foundation -
2) Rwanda New Times Article - 


UHC Campaign 

Saturday, October 4, 2014

How Design Can Heal

Please take a moment to watch this video by our friends in architecture - the MASS Design Group - who helped to construct the Butaro hospital.


Friday, September 19, 2014

The Importance of Innovation in Global Health

Please see this piece that I enjoyed writing with my fellow Lancet Commissioner for the Global Health 2035 report, Gavin Yamey, regarding how critical it is to celebrate, support and encourage innovation as we work diligently to achieve the goals before us to achieve a grand convergence in global health.

Please see the article here: 

"A remarkable opportunity for global health transformation is now at our fingertips.
If we make the right health investments—to scale up existing health interventions and delivery systems and to develop and deliver new tools—we could see a “grand convergence” in global health within our lifetimes. Within one generation, we could reduce the rates of infectious, maternal, and child deaths in nearly all low- and lower-middle-income countries down to the low levels seen today in richer countries like Turkey, Chile, and Costa Rica (Figure 1).
One in ten children in poor countries dies before his or her fifth birthday; by 2035, we could reduce that rate down to one in fifty. We could prevent 10 million maternal, child, and adult deaths each year from 2035 onward. But this grand convergence cannot be achieved without innovation to discover tomorrow’s disease control tools.
We had the privilege of serving as members of The Lancet Commission on Investing in Health, chaired by Lawrence Summers and Dean Jamison. The commission published an ambitious yet feasible road map for achieving convergence, called Global Health 2035. The road map has three key components.
The first is mobilizing financing. The “price tag” for low- and lower-middle-income countries to achieve convergence is an additional $70 billion per year from now to 2035. Fortunately, these countries are on course to add $10 trillion per year to their GDP over that time period. Public investment of less than 1% of this GDP growth could therefore fund the grand convergence. Some countries, of course, will still need external assistance to finance their health programs.
The second is targeting this financing toward the most cost-effective health interventions. Early investment in scaling up modern methods of family planning, antiretroviral medication, and childhood vaccinations would have a particularly large and rapid payoff.
The third is increasing funding for R&D. Our modeling found that even with aggressive scale-up of today’s tools to 90% coverage levels, convergence would not be achieved. Low-income countries would get only about two-thirds of the way. To close the gap, new technologies will be needed. Countries that adopt new tools experience an additional 2% per year decline in their child mortality rate over countries that do not—an “acceleration” that is crucial for reaching convergence.
The most important way that the international community can support the grand convergence is by funding the discovery, development, and delivery of the next generation of medicines, vaccines, diagnostics, and devices. International funding for R&D targeted at diseases that disproportionately affect poor countries should be doubled from current levels (US$3 billion per year) to $6 billion per year by 2020. Game-changing technologies that could help achieve convergence include a single-dose radical cure for vivax and falciparum malaria and highly efficacious malaria, tuberculosis, and HIV vaccines.
Chart showing estimated decline in mortality rate of children under 5, given enhanced health-sector investments.
Figure 1. Estimated decline in child mortality rates from enhanced health-sector investments. The “convergence target” is 20 deaths per 1,000 live births, similar to the current child mortality rates in high-performing middle-income countries.
The public health and economic benefits of achieving convergence would be profound. Every $1 invested from 2015 to 2035 would return $9 to $20, an extraordinary return on investment.
We have at our fingertips one of the greatest opportunities available to improve human welfare. The question is: will we seize it?
Photo: US Centers for Disease Control/James Gathany. Illustration: PATH."
See full article on this web link: 

Monday, September 15, 2014

Holding Institutions Accountable

Please see my OpEd that was published in today's New Times:

World Health Organisation and UNICEF accountability – we are not yet there

"I am very proud to serve for a country that has prioritized the health and wealth of its children. This is evidenced by activities, laws, policies, strategies and plans implemented by various sectors. This is normal because our people are our riches. And among them – the most precious are our children because they are our future and we always fight to improve their health and well-being.
On a personal note, as a pediatrician, I am deeply motivated to improve the lives of children. Any effort to reduce unnecessary suffering and harm to a country’s future generation is laudable because – like so many Rwandans – I believe that the value of a country is how it treats the most vulnerable among its people. And our children are the most vulnerable of our citizens.
This is why that I, along with so many others, was shocked to see news of a report that was released by the United Nation’s Children Fund (UNICEF) titled “Hidden in Plain Sight: A Statistical Analysis of Violence against Women and Children”, which included findings – that if true – would make Rwanda one of the most violent countries in the world vis-à-vis its treatment of children.
When looking more closely at the story behind the implausible numbers, however, it was astonishing to see how many flaws existed in this report. Even the report authors made disclaimer after disclaimer about how limited their methods were. They reported projections of data – as opposed to real data – and failed to explain what informed these projections. Not surprisingly, their findings are so far from the truth.
For instance, the Rwanda Demographic Health Survey – which is an internationally recognized data source to document the status of the health and well-being of our people and is done in partnership with those who published and promoted this report (WHO, UNICEF), shows a very different picture relative to the recent flawed report. Additionally, the real data on child homicides recorded by the Rwanda police suggests that the UNICEF report estimated a child homicide rate that was over 10 times as high as reality in Rwanda. (see table below)
Observations on the data related to Rwanda profile:

Table: Observations on the data related to Rwanda profile.
Flawed data – such as these – cannot simply be apologized for in a “technological appendix” or the “limitations” of a study (which never would make news headlines). Instead, they have real consequences. They can easily damage the reputation of development plans of a country. They can easily redirect time and policymaking efforts to “problems” that don’t actually exist.
This report teaches us to reflect upon a few key things:
First, efforts to hold international institutions accountable are blocked and they still allow themselves total impunity to publish defamatory reports without any consequences to themselves.
Second, this puts into question the commitment of these institutions to human rights. One of the major principles of human rights is a participatory process. By extension – as countries are made up of human beings – the people of these countries should be given the right to participate or review the report. Reports – right or wrong – on country performance should never be disseminated without being shared with the country to inform them of the findings so that eventually, they can show evidence of the false allegations or use the information – if accurate – to generate positive change.
In conclusion, I just want to recall the imihigo contract that we have just signed across sectors and level of responsibilities as a country to guarantee accountability of each leader at all levels. It is something that the UN may consider adopting to help guarantee better use of their organization’s influence and the other useful work that they undertake everyday in partnership with member states.
The Author is the Rwanda Minister of Health."
Published in the New Times - 15 September 2014 - Link: