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.

Rwanda's approach proves perfect antidote to counterfeit drugs


Wednesday 3 July 2013  i
You can read it on their webpage: 
http://www.reverso.net/translationresults.aspx?lang=EN&direction=english-french

Rwanda's integrated solution to combating fake drugs could inform a global treaty on medical safety


Globalisation has brought people many wonderful things, but occasionally it brings them death, thanks to the growing international trade in bad medicines. At least 100,000 people each year succumb to medicines that are negligently made, or sometimes deliberately faked with bogus ingredients. The solution demands local and global measures to improve regulation and make penalties tougher for medicine criminals. We simply cannot afford the cost of inaction.

This week, we published research in Public Library of Science Medicineshowing that tuberculosis drug quality is variable in low- and middle-income countries. Of 713 samples of the tuberculosis medicines isoniazid and rifampicin collected in 17 countries, 9.1% contained insufficient quantities of the active pharmaceutical ingredient, and failed basic quality control tests. The situation is even worse in some African countries, where 16.6% of medicines failed; 7% were outright fakes, containing no active ingredient. These failing medicines won't cure tuberculosis infections and could even fuel drug resistance, which makes the disease much more difficult and expensive to cure.

Yet one encouraging result stood out: no fake tuberculosis drugs were found in the sample from Rwanda. This is consistent with other recent studies, which found that the east African state has few substandard and no obviously falsified malaria medicines. So what is Rwanda doing right?

First, over the past decade the government has taken legal and technical steps to secure the whole of its medicine supply chain. It buys high-risk drugs, such as those for tuberculosis, exclusively from manufacturers certified by the World Health Organisation (WHO), and distributes them in a dedicated, controlled supply chain to hospitals and clinics.

Second, the Rwandan government has trained the healthcare workers who handle the medicines how to spot and report substandard and falsified products.

Third, a taskforce of health regulators and customs officials inspects all medicines entering the country at the border, notifying the police (who in turn notify Interpol) when something is amiss. The Rwandan approach is holistic, and draws on resources from across the government.

It is tempting to say that Rwanda does all this because – unusually forAfrica – it has a strong publicly funded health system to treat tuberculosis. Yet, without a holistic approach, the system would be undermined by criminal activity and collapse. It is not just the healthcare workers and the quality of programme management that make the system function; in terms of medicines, it is the police and regulatory officials too. "Health is too important to leave to doctors," people say around Rwanda's health ministry.

Unfortunately, there is opposition to fighting fake and substandard medicines in this holistic way. Some countries, such as India, vocally oppose commingling public health and policing at an international level. Setting up that conflict seems a tactical mistake, because, as we know from many examples – food safety, airline safety, road safety – regulation and policing are necessary to prevent accidents and protect wellbeing. In fairness, India's parliament now acknowledges (pdf) the country has medicine quality problems that "can harm patients".

But for Rwanda to fix problems outside its borders, it needs the co-operation of other countries. A global treaty is needed to make medicine safety a priority, both by building the capacities of drug regulators and by making medicine falsification an international crime.

One perspective on the problem is that the world has done a dangerously imbalanced job of globalisation. Starting with the WTO agreements in 1995, free trade in legitimate medicines has helped patients who have access to quality drugs at affordable prices, but free trade in falsified and substandard medicines is hurting and killing many others. Without reversing the good half of this equation, countries need to clamp down on criminal activity. An international law that sets standards for medicine quality and safety in international trade – which, today, it does not – is essential.

Precedents abound: you can board an aircraft in country X and land safely in country Y because there are treaties on flight safety to which all countries agree. Likewise, you cannot print the banknotes of country X and pass them off in country Y without being arrested, because there are treaties criminalising counterfeiting. If international law can promote safe flights and criminalise fake money, surely it does not take too much imagination to negotiate and agree a treaty to promote safe medicines and criminalise fakes to protect people in low- and middle-income countries.

Agnes Binagwaho is Rwandan health minister, senior lecturer at Harvard Medical School, and clinical professor of paediatrics at the Geisel school of medicine, Dartmouth University. Amir Attaran is Canada research chair in law, population health and global development policy, and professor in law and medicine at the University of Ottawa