Reflections on Global Health Delivery

This is a video commenting on a recent paper written by World Bank President Jim Yong Kim, Dr. Paul Farmer, and Professor Michael Porter, entitled "Redefining global health-care delivery" and published in The Lancet. Click here to read the paper.

This video was recorded by Daniel Murenzi

Partnerships to Accelerate Progress in Global Health: The Case of Cervical Cancer

Rwandan health minister hits back at critics of drug company deal

The debate must move on from seeing pharmaceutical companies as evil predators and poor people as hapless victims

Published in the  guardian.co.uk, Tuesday 21 May 2013 16.31 BST
http://www.guardian.co.uk/world/2013/may/21/rwanda-health-minister

A hero of mine wrote from prison that “human progress never rolls in on wheels of inevitability; without hard work, time itself becomes an ally of social stagnation.”  Dr. Martin Luther King Jr.’s words have long resonated with Africa’s struggle against global cynicism in the fight against AIDS. At the turn of the millennium, while I practiced as a pediatrician in Rwanda, international experts brandishing computer-generated prescriptions of cost-effectiveness told us then that the time just wasn’t right to provide access to the effective treatment widely available in their own countries. In short, African lives were worth less than American or European lives. Costs were just too high, they said (never mind that activists soon drove AIDS drug prices down from $12,000 to $100 per year). African governments and patients simply weren’t prepared, they cautioned (never mind that studies show Africans have far higher adherence to treatment than North American counterparts).

Dr. King’s words came to mind again last week, when I read with interest a recent commentary in The Guardian on pharmaceutical company donations in Africa. As an example of the pitfalls of corporate philanthropy in global health, author Adam Green cited Rwanda’s partnership with Merck to provide universal access to the human papillomavirus (HPV) vaccine for the prevention of cervical cancer. He echoed claims made two years ago by some experts that Rwanda jumped the gun, allowing itself to be used as a pawn by a predatory multinational corporation.

Most in global health have moved on from this debate, as the world came to recognize the mounting burden of cervical cancer in Africa, as the price of the HPV vaccine dropped from $16.95 to $5 per dose by mid-2011, and as the GAVI Alliance added the vaccine to its portfolio of support. And despite skepticism from some about the feasibility of nationwide HPV vaccination in Africa, Rwanda reached more than 93% of eligible girls with all three doses through a school-based program in 2011. When Rwanda already had 90% or higher coverage for vaccines against 10 other diseases, when cervical cancer now rivals HIV and maternal mortality as a leading killer of our women, and when GAVI’s budget grew 42% last year, it is difficult for me to see this as some kind of dangerous precedent.

Yet such arguments keep recurring (for HIV, drug-resistant tuberculosis, cancer, cholera, and so on) because of a larger divide in global development. Many who advance or tacitly endorse the claims echoed in Green’s piece often do so because they believe ideological purity (that is, the view that drug companies often pursue only self-interest) is a moral imperative, and that cost-effectiveness (that is, poor people should get cheap things) should always trump other considerations.

But do we truly live in such a zero-sum world that a win-win outcome from a public-private partnership for health is unimaginable? Certainly, competition is better for promoting access to medicines than voluntary donation programs. Yet there are already two companies making the HPV vaccine, and generic versions are not so far off. Furthermore, the historical gap between new vaccine introduction in rich and poor countries is two decades; by working with Merck, Rwanda reduced it to four years and showed the world one possible strategy for reaching universal coverage. Just this past week, GAVI made international news by announcing even lower prices for the HPV vaccine (down to $4.50 per dose) through agreements with two manufacturers, and approved a grant to continue Rwanda’s national program after Merck support stops in 2014.

So much can be achieved in global health with shared commitments to teamwork and humility, a willingness to grapple with complexity, and a big dose of imagination. Indeed, for the very health issues that Green argued should rank higher than the HPV vaccine, Rwanda (and many other nations) are already engaged in novel collaborations to address. On top of the HPV vaccine rollout, we are working with groups around the world to build synergistic screening and treatment programs for cervical and many other cancers. In tackling maternal and child mortality, we’re strengthening health and sanitation systems in addition to teaming up with development partners on a mobile-based notification system for community health workers. With the support of GAVI, we’ve rolled out three new childhood vaccines against pneumonia, diarrhea, and rubella nationwide since 2009. With two-dozen American schools, we are training hundreds of nurses and specialist physicians.

And it seems to be working: while spending less than $60 per capita on health, Rwanda is now on track for the Millennium Development Goals. Indeed, to those interested in working here, we like to say, “Don’t come for charity. Come for partnership.”

Adam Green’s piece voiced concerns about programs like those described above serving as “market priming to create the conditions for adoption.” From Rwanda’s view, the jury is in: with more women dying of cervical cancer than in childbirth worldwide, the market is quite primed and demand readily apparent. Supply of the HPV vaccine and many other tools of modern medicine, on the other hand, remains in doubt for those who need them most. But with no global solidarity fund for cancer today, how else should we get started but to forge smart new partnerships? One lesson from AIDS is that if the world stalls, you just need to act and show that it can be done.

As Dr. King said, in the face of challenges like growing global health inequalities, “We must use time creatively, in the knowledge that the time is always ripe to do right.” Let’s use our time and talents—as health workers, researchers, and journalists—to work together towards a future in which where a patient lives doesn’t determine if they live.

Agnes Binagwaho is Minister of Health of Rwanda, Senior Lecturer at Harvard Medical School, and Clinical Professor of Pediatrics at the Geisel School of Medicine at Dartmouth.

MY IMPRESSIONS ON THE COMMEMORATION OF THE 19TH ANNIVERSARY OF THE 1994 GENOCIDE AGAINST TUTSIS

Commentary published in New Times - Rwanda   29 April 2013

http://www.newtimes.co.rw/news/index.php?a=66380&i=15342

On 25 April, hundreds of health professionals and partners in the health sector came together to commemorate our colleagues who were victims of the 1994 Genocide against the Tutsi.

We undertook a remembrance walk in the spirit and communion with what Rwanda has put in place for the remembrance month, during which the Nation, the sectors, communities, families come together, to reflect on what has happened and what can happen again any place in the world when bad leadership takes over a country. This was the case in Rwanda with leadership during the post independence up to June 1994, that was sectarian and imposed tribalism in a country that ironically never had tribes.

This year our driver; Abdu Ndayisaba gave a moving testimony, as a survivor, he wisely started with the story at the time of our great grand fathers and gave a very vivid portrait of the genesis of the 1994 Genocide against the Tutsis, followed by Rwanda’s liberation as well as the stopping of the genocide by RPF Inkotanyi, without forgetting the country’s recovery that His Excellency President Paul Kagame lead in the aftermath.    

Now we are 19 years later and it is true that many of our brothers and sisters are still traumatized by what happened during the 1994 Genocide against the Tutsi. However, with time, slowly, wounds are mitigated by the better lives Rwandans have today due to the economic growth our peace and stability that promote health and wealth of Rwandan people.

Another highlight of the commemorations was the testimony of two children whose father Abdallah was killed in the horrific events of April 1994. Their dignity and pride as they stood testifying in front of us, describing what they did with their lives since then, symbolized the expression of a unified Rwanda’s renaissance. They demonstrated that those who planned to finish the Tutsis have failed

My advice to my colleagues, the health professionals, is that we work tirelessly for the health of our brothers and sisters and carry out our work with a smile and good customer care as we contribute to take our country forward. The joy we will have as we work that way will be for 365 days the celebration of the new Rwanda where all Rwandan are equal.

Abdu’s voice broke with emotion and shock as he engaged us with his testimony and I admire him because he still remained a sensitive human being when he was talking about his fallen sisters and brothers. Every year I pay tribute to the millions of Rwandans killed during the Genocide against the Tutsi by visiting a memorial. I wish that for the next forty years, if God gives me the chance, I will have the same tears and emotions when in memorials, I will be passing through the rooms dedicated to the children fallen in the Genocide, because I feel that this is the pillar of my humanity.  

But I have a message for all perpetrators of the 1994 Genocide against the Tutsi both outside, or hidden inside our beloved country, I warn them not to misinterpret our tears and sadness dedicated to the good people they killed. We are using them as energy to spur us to work harder for a brighter and sustained future for our people and our country.

Rebuilding Rwanda’s health system

April 2013

Post on GAVI Web

These are exciting times for the people of Rwanda. Less than two decades after the1994 genocide,we are making substantial progress. Recent studies suggest that more than one million Rwandans were lifted out of abject poverty and our people are better protected from some of the most devastating diseases that not only threaten our health but also our continued productivity and economic growth. As we continue to focus our efforts on the improvement of our health and look forward to continuing progress on many of the health-related Millennium Development Goals (MDGs), it is important to take stock of how far we have come and the reasons for our achievements.

In Rwanda public health policies have been inspired by our vision 2020 and commitment to the MDGs. Not only have they helped guide our public health plans and activities, they have also served as important progress indicators. Consistent with MDGs 4, 5 & 6, we have made improvements of the health of our mothers and children a national priority. To date, Rwanda has more than halved child mortality and we look set to achieve the MDG targets for cutting both infant mortality, under-five mortality and maternal mortality by 2015. Rwanda is ranked among five countries recognized for having reduced maternal mortality by more than half; alongside Malawi, Ethiopia, Nepal and Yemen. This is partially because we have been prioritizing family planning and women’s health.

From the very beginning, we recognized that efforts to better our health could not try to fully replicate those of more developed nations. Constrained by limited financial and human resources, we needed to find a model that worked for our people and that was based on our shared history, culture and health realities. As part of our Vision 2020 process, we reached out to the Rwandan people to reflect on how to accelerate our development with innovative strategies and being as ambitious as the developed countries for we want the best for our people.  We then developed a process and strategic plan that we once again took to the people to ensure that it was workable at the local level.  We needed to do it the Rwandan way and I believe our home grown solutions have helped us to focus on substantial targets.

Much of our work has been guided by a focus on engagement with all levels of our society, because we believe that 80% of the burden of disease needs to be solved at the community level. We have decreased the financial and geographic barriers in the access of health. A better service delivery system combined with basic education and awareness campaigns have resulted in a broad utilization of health services. In each village our three elected Community Health workers have helped to ensure the accountability and transparency needed to implement effective health interventions at the local level. This has given us a large advantage in the implementation of broad immunization efforts that must encompass the vast majority of the population to be successful.

Our government’s commitment to adequate prevention efforts and in particular our focus on the scaling of immunization program have been a significant driver of our results. The government of Rwanda has worked closely with the GAVI Alliance and its partners, WHO and UNICEF, to immunize children against many common diseases. As a result of this support, by 2008, we have reached 95% of babies born in Rwanda with essential vaccines to protect them against five key childhood diseases. This level of coverage is seldom reached on the continent of Africa or anywhere else in the world and is a testament to the political will of our leaders at all level, combined with the support of our people and our international partners. We have been at the forefront in terms of vaccinating our girls against HPV. Rwandan children now have access to the 11 vaccines recommended by WHO for routine immunization. Just recently, in March, we launched the Measles and Rubella immunization campaign. Over four days in which  healthcare workers worked around the clock, across the country, to vaccinate almost five million children between the ages of 9 months and 14 years.

The partnership with GAVI Alliance also extended to strengthening the health system so that once we secured these vaccines we could effectively deliver them to our children. Our delivery system now has the capacity and ability to protect the cold chain supply so that we will be able to leverage this work to continue to deliver vaccines.

Despite all this, we still have a long way to go. Among children and women, chronic childhood malnutrition remains high, as well as severe anemia; contraception remains underused by many Rwandans and while infant and child mortality have decreased dramatically, neonatal mortality remains a challenge. Rwanda also faces a substantial burden of non-communicable diseases. We have developed actions plans at village, sector, district and referral point of care to tackle these and other unmet challenges.

Our health efforts – similar to many of our development efforts- have been implemented in partnership between the government, the people and our international partners. We have adopted the processes of using scientific evidences, equity, and participation for more efficient results with our few resources.

The government of Rwanda is committed to building on its proven achievements and to expanding immunization so that we can reach the universal goal of reducing child mortality by two thirds by 2015. The 1994 genocide has devastated Rwanda and made it very difficult to achieve the MDGs. It was a said impossible challenge to achieve the MDGs, however, the determination of the people of Rwanda, the good leadership at all levels focussing on the health of Rwandans and the policies that have been adopted have open the way to achieve the MDGs and laid the foundations for a healthier future.