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: http://ic2030.org/2014/09/grand-convergence/ 

"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.

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."

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See full article on this web link: http://ic2030.org/2014/09/grand-convergence/ 

Holding Institutions Accountable

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

http://www.newtimes.co.rw/section/article/2014-09-15/180939/

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

By: DR AGNES BINAGWAHO

• PUBLISHED: September 15, 2014

"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: http://www.newtimes.co.rw/section/article/2014-09-15/180939/

PhD Life and Reflections

Given my background as a pediatrician and enthusiasm for research, I was very proud to be the first person to receive a Doctorate of Philosophy (Ph.D.) from the College of Business and Economics of the University of Rwanda in August 2014.  My thesis on improving the health of children with HIV/AIDS in Rwanda has meant a great deal to me.

More information regarding the announcement of the degree can be found here. I've also included a picture from the special graduation day below:

Additionally, since receiving my PhD, a number of people have inquired about my ability to manage the various responsibilities before me in a given day.  I very much enjoyed my interview with the New Times reporter - Collins Mwai - who captured my reflections on this topic in this piece published on Sept. 3rd: http://www.newtimes.co.rw/section/article/2014-09-03/389/news-career:-dr-binagwaho-tips-on-juggling-education-and-work  (see text below)

"Following its merger, the University of Rwanda passed out its first graduates in various disciplines and levels this year and among them was Dr Agnès Binagwaho, the Minister for Health.

Dr Binagwaho was conferred with a Doctorate of Philosophy (PhD) in Health Management and did research on the HIV/Aids epidemic, with Rwanda as her case study.

Binagwaho, who started the course in 2008 before the merger of the institution, managed to juggle her studies, her ministerial role, her work as a senior visiting lecturer in the Department of Global Health and Social Medicine at Harvard Medical School and clinical professor of pediatrics at the Geisel School of Medicine at Dartmouth, USA.

In an exclusive interview with Women Today’s Collins Mwai, the minister explains the reasons, necessity and modalities of higher learning.

You are a minister, a lecturer in two top universities in the world and you have a stable career. Why the need to return to school?

The President always says “never remain in your comfort zone, always challenge yourself.” I am a strong believer in that too. The day you believe you have nothing to learn is the day you begin to die. Even in retirement, there are numerous lessons to learn.

How did you juggle between your roles through school?

We all have the same number of hours in a day; it is up to you to choose how you will spend your time. I prefer to spend mine learning and doing research. I was comfortable juggling my various roles and school. It is always easier if you have a passion for what you do.

You had the capacity to undertake your PHD anywhere in the world but you chose to do it here, why?

I first registered as a PhD student at the university while it was still National University of Rwanda (NUR). While working, a PhD takes between four and six years, it happened that I graduated after the universities had merged.

I wanted to do a PhD in my country because in many areas, this country is quite advanced in policy planning and strategy. We have riches and innovation. I am against the idea of going out for PhDs when quality education is available here. To anyone in doubt about the quality of our higher learning institution, I can tell them for sure that I did not experience challenges while pursuing the qualification.

I also wanted to prove to people who I work with that it is possible to balance work and school. If I can do it, they too can do it.

At the ministry we have been urging people to take on master’s degrees, currently most people have the qualification while others are pursuing PhDs. I am a strong believer that the best thing you can do for yourself is add more knowledge to what you have.

The requirement to work at the Ministry previously was a degree, now it is a master’s degree; we have made arrangements so that they can all have an opportunity to advance. Higher learning is a benefit to the institution and the people served by the institution. From my Ministry I have seen them have better and in-depth understanding of circumstances and solutions to approach them.

If you research more on what you do, you become a master in the domain and can perform better. It is an advantage to you, your institution and your community.

Most women of the young generation currently view higher learning only as a means to higher salaries; you clearly see it quite differently, why is that?

Money and a high salary is not the end, it should not be, it is just a tool. We have people who are rich but end up taking their lives. Education gives you fulfillment and purpose. Continuous education has numerous benefits. You will never know enough.

There has previously been talk that quality higher learning can only be obtained abroad, do you believe so too?

It is not true, in one way; even those institutions come here to learn from us. They borrow ideas from here and go teach them abroad. That is part of what we are trying to educate people in the Ministry, to do further research, document their findings, and share it on bigger platforms internationally.

I came to Rwanda as a young pediatrician, being here I have had an international dimension and learnt in numerous ways over the years. You do not have to go abroad to learn, I have been known for what I have learnt and done here, I never asked for a job at Harvard, they asked me.

You can create the universal bank of knowledge here. Some ministries in this country have pioneered initiatives and leadership models that have never been practiced anywhere in the world. There is a lot to learn from here, it is time people realised how much the world can learn from us.

Among other things you are a lecturer, what is the one thing you insist on with your students?

The importance of participatory processes; working closely with the community that you are working for, you need to listen to them and learn from them. People in certain positions need to work with the people for the people.

What would you say of people with high academic qualifications but do not reflect their qualifications in performance?

They probably do not further their studies to serve better, or challenge themselves. Some could study to have bigger titles on their business cards. They also probably do not have well laid plans and strategies. Always have one. Since I began working in leadership positions I have learnt that as long as you have a guide like Vision 2020 and Economic Development and Poverty Reduction Strategy (EDPRS2) you can come up with strategies to get there.

What advice do you have for people reluctant to pursue higher learning?

Education is key, the more educated you are the more functional you are. Good education is one that helps you improve the world around you and is practical. There is no limit, the best reward you can have is to see the result of what you do. Do not run after money, it will always be needed, but it is never the end." -New Times, Rwanda - 2014 Sept 3rd (Collins Mwai)

A Grand Convergence for Global Health 

I was very proud to be part of this Lancet Commission, which could help countries in these final miles of the 2015 Millennium Development Goals (MDGs) and to plan beyond...

The entire report overview in .pdf format can be found here: http://www.globalhealth2035.org/sites/default/files/policy-briefs/overview-english.pdf - text and figures are pasted below.

"REPORT OVERVIEW

the growth in full income in low- and middle-income countries between 2000 and 2011 resulted from health improvements. Figure 3 summarizes estimates of the contribution of health to growth in full income in 1990–2000 and in 2000–2011 for different regions of the world.

As the world approaches the 2015 deadline for achieving the Millennium Development Goals and the international community negotiates the next global framework, massive health disparities still exist across countries. The vast majority of people who die from preventable deaths caused by infectious diseases or maternal and child health conditions live in low- and lower-middle income countries.

Global Health 2035 is an ambitious new investment framework to begin closing this health gap within a generation. Written by The Lancet Commission on Investing in Health, a group of 25 renowned economists and global health experts, Global Health 2035 provides a roadmap to achieving dramatic gains in global health through a grand convergence around infectious, child and maternal mortality; major reductions in the incidence and consequences of non-communicable diseases (NCDs) and injuries; and the promise of “pro-poor” universal health coverage.

A “grand convergence” in health is achievable within our lifetimes

A unique characteristic of this generation is that we have the financial and ever-improving technical capacity to begin closing the global health gap. History shows that even poor countries can achieve rapid declines in death rates by investing in health. Global Health 2035 points to the “4C countries”—Chile, China, Costa Rica and Cuba—which started off at similar levels of income and mortality as today’s low-income countries, but sharply reduced their preventable deaths by 2011. The 4C countries are now among the best-performing middle-income countries.

Global Health 2035 outlines a path for today’s low- and lower-middle- income countries to achieve similar rates of dramatic progress, reaching levels of mortality seen today in the 4C countries and averting about 10 million deaths in 2035. The 2035 convergence goals are summarized as “16-8-4”—reducing under-5 mortality to 16 per 1,000 livebirths (see figure 1), reducing annual AIDS deaths to 8 per 100,000 population and reducing annual tuberculosis (TB) deaths to 4 per 100,000 population.

Global Health 2035 lays out a detailed investment framework for national governments to achieve the “16-8-4” convergence goals by:

·       aggressively scaling up new and existing tools to tackle HIV/AIDS, TB, malaria, neglected tropical diseases and maternal and child health conditions; and

·       strengthening their health systems using a so-called “diagonal approach”—that is, building systems that specifically improve these countries’ ability to tackle the highest burden health challenges

About two-thirds of child deaths, AIDS deaths and TB deaths now occur in middle-income rather than in low-income countries. Achieving convergence therefore demands action that goes beyond low-income countries to also focus on poor, rural sub-populations of middle- income countries.

The Commission estimates that the average incremental cost of convergence for 34 low-income countries will be about US $23 billion annually from 2016-2025, rising to around US $27 billion annually from 2026-2035. The incremental cost in lower-middle-income countries will be about US $38 billion annually from 2016-2025, rising to around US $53 billion annually from 2026-2035. The expected economic growth of middle- income countries will easily allow these countries to finance convergence entirely from domestic sources. While low-income countries will require some external assistance, they should be able to finance most of the incremental cost of achieving convergence themselves.

The international community should unite around the vision of Global Health 2035 and support the innovation and technical assistance needed to achieve it

The international community can best support convergence by renewing its commitment to providing global public goods, particularly health research and development (R&D), and managing cross- border externalities, such as preparing for influenza pandemics. These core functions have been neglected in the last 20 years. Convergence cannot be achieved with today’s health tools, many of which are decades old. The international community should double its current R&D spending from US $3 billion (see figure 2) to US $6 billion annually by 2020, with half of this additional amount coming from middle- income countries.
Some low-income and lower-middle- income countries will continue to require external financial assistance to scale up tools for achieving convergence. Eliminating malaria and combating drug-resistant TB and the threat of drug-resistant malaria will in some cases require assistance to middle- income countries.

The returns to investing in health are even greater than originally estimated

The costs of convergence are substantial, but the payoffs—in both health and economic terms—are much greater. Global Health 2035 proposes a more comprehensive approach to measuring the returns to investing health.

The impact of health on economic productivity has been well documented in recent years. Improved health has contributed importantly to income growth in low-income and middle- income countries, as measured using traditional national income accounting (based on GDP).

But while GDP captures the benefits that result from improved economic productivity (the so-called instrumental value of better health), it fails to capture the intrinsic value of better health—the value of health in and of itself. Global Health 2035 reports a more comprehensive understanding of the returns to investing in health by estimating this intrinsic value using a “full income” approach. This approach combines growth in national income (GDP) with the value people place on increased life expectancy—that is, the value of their additional life years (VLYs). Global Health 2035 estimates that 24% of

Using the full income approach to estimate the economic benefits of convergence in low-income and lower-middle-income countries from 2015-2035, the benefits exceed costs by a factor of 9-20, making the case for action even stronger.

The full income approach provides finance ministries, donors and other decision-makers with a strong rationale for investing in health to put their countries on a path to rapid improvement in national welfare.

Fiscal policies can dramatically curb NCDs and injuries, as well as leverage significant new revenue for low-and middle-income countries

One paradox of success in global health is that when low- and middle-income countries successfully reduce deaths from infections and maternal and child conditions, they then accelerate the shift in their disease burden to NCDs and injuries in adults. Global Health 2035 lays out the steps that all low- and middle-income countries could take now to delay the onset of NCDs to as late as possible in life and thus reduce premature illness and death.

National governments can curb NCDs and raise significant revenue by heavily taxing tobacco and other harmful substances, such as alcohol. They can redirect finances toward NCD control by reducing subsidies on items such as fossil fuels, which produce air pollutants that cause NCDs.
A tobacco tax is the single most powerful lever for curbing NCDs. In the next 50 years, for example, a 50% tax on tobacco could prevent 20 million deaths in China and 4 million in India and generate US $20 billion and US $2 billion annually in each country, respectively.

Donors and UN agencies should focus on provision of technical assistance on tax and subsidy policies, regional cooperation on tobacco (e.g. to reduce smuggling), and funding of population, policy and implementation research on scaling-up of interventions for NCDs and injuries.

Progressive universalism, a pro-poor pathway toward universal health coverage (UHC), is an efficient way to achieve health and financial protection

In order to protect the poor from impoverishing health costs, and to ensure that they benefit the most from the investments laid out in Global Health 2035, countries should adopt “pro-poor” pathways to insuring their citizens.

The Commission endorses two pathways to achieving UHC within a generation, which commit to covering the poor from the outset (“progressive universalism”). In the first, publicly financed insurance would cover essential health-care interventions to achieve convergence and tackle NCDs and injuries (figure 4). This  pathway would directly benefit the poor, since they are disproportionately affected by these problems. The second pathway provides a larger benefit package, funded through a range of financing mechanisms (e.g. payroll taxes, insurance premiums, copayments), with poor people exempted from all payments. Governments should approach UHC through progressive universalism—a commitment to reach the poor at the outset—to yield high health gains per dollar spent and ensure the poor benefit from health and financial protection.

One immediate way that the international community can support countries in implementing progressive universal health coverage is by financing critical research, such as on the mechanics of designing and implementing evolutions in the benefits package as the resource envelope for public finance grows.

Global Health 2035: A Call to Action

Global Health 2035 offers a new vision for profoundly transforming the global health landscape within a generation. Meeting its ambitious goals will require scaled up investments and innovations in global health technology, health systems and policies.

As an immediate first step toward realising this vision, global leaders—including low- and middle-income countries, donor nations, international agencies and civil society organisations—should unite around the goal of convergence and incorporate it into the post-2015 framework that is currently being negotiated.

By harnessing the financial and ever-improving technical capacity of our generation, we can avert 10 million deaths in 2035 and ensure healthy, productive lives for millions more people—a remarkable step toward closing the massive gap that has defined global health for the past three decades.

Figures (all from the Report Overview document)

the full report was published in the Lancet on 3 December 2013 and can be found at www.lancet.com." 

The above text and figures are from http://www.globalhealth2035.org/sites/default/files/policy-briefs/overview-english.pdf