Wednesday, June 29, 2011

Accelerating the MDGs through ICT: The Case of Rwanda

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

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

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

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

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

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

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

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

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

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

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

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

Wednesday, June 15, 2011

In Rwanda disability is not solely viewed as health issue; it is also viewed as an issue of development and human rights

Last week, in New York, I participated in the launch of the first ever World Report on disability alongside the World Health Organization and the World Bank. This launch marks a critical step toward expanding our reach as global health activists.

According to the Report, 15.3% of Africans have disabilities. This equates to approximately 151 million African men, women, girls and boys or about 15 times the population of my own country, Rwanda. In Rwanda, the ratification of the Convention on the Rights of Persons with Disabilities (CRPD) and the Optional Protocol occurred in 2008. We are committed to ensuring that all Rwandan citizens are supported and included in our society.

Disability is not just a health issue; it is also an issue of development and human rights as people with disabilities face particular barriers to health, education and social services. Many are poor or become poorer due to their disability, and find great challenge in accessing appropriate transport and communication devices. From the perspective of a health minister, policy must address barriers faced by people with disabilities. These barriers should be removed or minimized for the health of the individual and also for the health of society.

The World Report on disability recommends better education and training of health workers so that they can better understand the need to include people with disabilities in mainstream services. I fully endorse this principle. However, this is not enough. We also must invest in the training and provision of skilled staff to rehabilitate persons with disabilities, a service that is vital for those who are born with disability, and for those who become disabled as a result of disease, injury or conflict. This concerns physicians who specialize in rehabilitation, in addition to psycho-social therapists, and engineers.

Human resource capacity for health care is a serious problem in Africa. We do, however, know that rehabilitation delivered at the community level (as opposed to transfers to central hospitals) can ensure the timely delivery of care, and ensure that disabled persons continue to be integrated into their community in positive ways. In the community based approach, children can be empowered to go to school, and adults enabled to engage in productive work. Without rehabilitation, and without appropriate devices, people with disabilities remain dependent and excluded from mainstream society. We must do something about this problem in the months and years ahead, and make sure we permit everyone to access the services they require to maximize their functioning. Rwanda is committed to this effort, in line with our responsibility to implement Article 26 of the CRPD.

And yet we must also remain vigilant, for impressive treaties and comprehensive reports will not have their desired impact, unless we are willing and able to make a difference at the grassroots level - in the clinics, in our schools and in workplaces.

Much needs to be done in this regard, and we can start by learning from best practices in Africa that address the barriers encountered by people with disabilities.

There is also a need to ensure that people with disabilities and their families are supported and informed so that they can take control of their own health. People with disabilities often face extra costs as they must pay for a taxi given that the bus is not accessible. They may require special diets, or other types of extra support. We must tackle these barriers and added costs. In low income countries, lack of funding prevents us from providing the entire package of healthcare services needed. Given this limitation, as the Report emphasizes, people with disabilities are 50% more likely to suffer catastrophic health expenditure than non-disabled people. Thus, it is important to reduce out-of-pocket health costs wherever we can.

If we do not remove or minimize the barriers, and if we do not meet these specific needs, then we are not including and supporting people with disabilities to the best of our ability. This report has  two chief recommendations that we must strive to achieve with efficiency, appropriately and effectively. (1) Remove barriers to our mainstream services, and (2) ensure the provision of specialist services. Each country will have to find the strategic plan that works the best in that setting, and and will need improved policies, changed attitudes, more research, more involvement of people with disabilities in policy development, and more coordinated action.

There is also a need to focus on removal of specific barriers created by individual disabilities, giving people with different ailments the same chance to access promotional, preventive, and curative health services. This approach will reduce marginalisation and stigma, and provide access to services adapted to the specificity of different handicaps. Such programs would be integrated across the health system. We need specific tools and specific counselling approaches, adapted to each disability. All such programs would respect confidentiality, be of good quality and protect human rights. This is how Rwanda aims to provide health services for its sick and disabled..

Currently in Rwanda we have over 30 specialized centers across the country receiving and taking care of persons with handicaps. We have promoted the creation of more than 15 associations concerned with the Rights of Persons with disabilities. Many of the associations operate at the national level. People living with disabilities have a representative in Parliament; and we have an umbrella of associations of people living with disabilties that promote HIV/AIDS awareness and other health issues. This umbrella association is fully supported by the government and elected among the associations of  people with disabilities, by the associations themselves, to represent them. This umbrella serves as their voice in all matters concerning health. People living with disabiltiies are included in planning and follow up of programmatic and financial impelementation of activities in the health sector. In order to improve planning and advocacy we decided two years ago to conduct a census of people leaving with disabiltiies. In 2010 we called on each of the 3 community health workers in each village to visiting all houses in their communities to do the census of people with disabilities – including age, gender, and type of disabilty. Out of a total population of 11 million, approximately 522,850 people were found living with disabilites. Now we are designing a project for clinical evaluation of all the disabilities in order to budget the care and treatment needed to rehabilitating these persons. As written in the Rwandan constitution: health is a human right for all. In that context, Rwanda will make every effort to advance this agenda for the rights and inclusion of persons with disabilities. This is the duty of each and every person in the health sector. This report should inspire our friends and neighbors in Africa and around the world.