ONE.org: Rwanda Is Proud to Pioneer the Pneumococcal Vaccine
Rwanda Is Proud to Pioneer the Pneumococcal Vaccine
November 9, 2011
In April 2009, Rwanda became the first low-income country to rollout the pneumococcal vaccine (PCV7) through a partnership with Wyeth. This was a great moment for us, for after having achieved dramatic reductions in malaria incidence, pneumococcal disease had stood as the new leading cause of death among Rwandan children. And it was the dedicated work of our partner, The GAVI Alliance for Vaccines, that ensured the pneumococcal vaccine would be both accessible and affordable for use in our country.
Pneumonia remains the single largest cause of death among children under five around the world. Every 20 seconds, a child dies of this preventable disease.
On November 12, 2011, Rwanda will join other countries in observing the third World Pneumonia Day, a day to celebrate the power of immunization to save lives when access is assured.
The PCV7 vaccine also prevents against pneuomoccal meningitis, a debilitating disease that leaves children who survive it with lifelong mental and physical disabilities.
Certainly immunization is not the only way to prevent pneumonia; breast-feeding, improved nutrition, and the reduction of indoor air pollution are also essential, and children must have access to effective antibiotics when they do fall sick. But immunization removes the burden of hospitalization and treatment on the health system and diminishes the time . This is a major economic advantage in countries like Rwanda, where the time lost by parents lose from work in caring for their children. For immunization to work, it needs to be integrated fully in health and community services. This is what we did in Rwanda.
Last year, the pneumococcal vaccine was scaled up in 16 countries. By 2015, GAVI expects that 58 countries will have introduced the latest generation pneumococcal vaccines nationwide, covering another 90 million children. With sustained commitment among all partners, including both GAVI countries and donor countries, we can achieve remarkable progress in the fight against preventable deaths among children.
The number of lives saved by GAVI is a major contribution towards the world’s pursuit of the fourth Millennium Development Goal, but we must sustain the momentum. In Rwanda today, more than 80% of children have access to the pneumococcal vaccine. The children whose lives are being saved through our partnership with GAVI will help to build a Rwanda where health for all is not simply a dream but one of the foundations of a strong, peaceful nation of tomorrow.
GAVI Alliance Progress Report 2010
Click to see full report
Click to see full report
Co-financing - an investment in the future of our children
Contribution of Dr Agnes Binagwaho, Minister of Health of Rwanda
I am proud to say that Rwanda has made great strides in improving the health of our people in the past decade. Our budgets for health and immunisation have steadily increased, accompanied by a strong national health strategy that has been endorsed by all the main actors in the health sector.
Babies born in Rwanda now receive life-saving vaccines against tuberculosis, diphtheria, tetanus, pertussis, polio, measles, Hib, hepatitis B and pneumococcal disease. In 2009, 97% of the children in our country were given the required three doses of the pentavalent vaccine.
Our investments have paid off. Between 1990 and 2008, under-five mortality rates dropped from 174 to 103 deaths per 1,000 live births. this success is linked to a range of life-saving interventions, not least to immunisation.
Rwanda knows that immunisation is a cost-effective investment in the future of our children. Preventing disease is always better than waiting until children fall sick. And because we want to sustain these achievements after GAVI support has ended, we are committed to contributing financially to the vaccines we introduce. Co-financing is an important step towards ensuring that we maintain our current political ownership and commitment to reducing child mortality, and achieve long-term sustainability of interventions.
Already in 2008, when co-financing of new GAVI vaccines became mandatory, our Government decided to contribute significantly more than what was required by GAVI – us$ 0.75 per dose instead of the compulsory us$ 0.15 per dose. Between 2008 and 2010, our co-payments amounted to nearly us$ 2.5million, or 26% of the total GAVI vaccine support to Rwanda.
Although Rwanda is a low-income country, we pay 100% of the cost of our existing vaccines, such as those protecting against measles and polio, and we have a solid plan for increasing our contribution to full funding for new vaccines in the future. We are hoping to introduce rotavirus vaccines in 2012 and are looking to protect women against cervical cancer by introducing human papillomavirus (HPV) vaccines as soon as possible.
In addition to vaccine support, GAVI funding helps us strengthen the health system to deliver immunisation and other integrated high-impact services. our network of local hospitals, health centres and outreach health workers has been effective in encouraging improved hygiene, good nutrition and exclusive breastfeeding – all of which help to combat disease. Immunisation is an important entry point for these interventions, as well as for other initiatives such as family planning, HIV testing, vitamin A supplementation, deworming and bednet distribution.
Our country is currently on track to achieve millennium development Goal 4 on reducing child mortality. Whether we will succeed depends not only on continued support from development partners, but also on our own commitment and contribution. co-financing is one of the ways in which we seek to ensure that we will continue to reap the benefits of our investments in health in the long term.
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The Role of Social Capital in Successful Adherence to Antiretroviral Therapy in Africa
This Perspective co-authored with Niloo Ratnayake discusses the new study by Ware et al. published in PLoS Medicine.
02 February 2009
02 February 2009
In the late 1990s and early 21st century, some public health officials in the Western world believed that Africans would never be compliant with antiretroviral therapy (ART) because the continent's uneducated, illiterate population was driven by day-to-day concerns without much thought for the long-term future. On top of this, many claimed that ART was a luxury for Africans and that the complex disease would be too difficult for African doctors to manage in the middle of nowhere with no water or electricity. Some went so far as to insist that giving ART to a likely noncompliant population would create drug resistance and were willing to sacrifice Africa for the good of global public health .
However, recent research has shown that levels of adherence to ART in sub-Saharan Africa are in fact higher than those in North America . Why are Africans with HIV more adherent to ART than their counterparts in North America despite being less educated about HIV and having more obstacles to overcome? A new study by Norma Ware and colleagues published in PLoS Medicine sets out to answer this complicated question . This study investigates the surprising finding that Africans would want to take drugs that would give them life and keep them healthy. Anthropologically, this first question leads to another complex question: Why is it that when things are successful in Africa the rest of the world looks for a reason, but when things fail, there are few who question the failure?
The New Study
Ware and colleagues asked patients, treatment partners (those who assisted patients in their efforts to take antiretroviral medications), and health care providers what the driving factors were behind adherence in three sites: (1) The Immune Suppression Syndrome clinic at Mbarara University of Science and Technology in Mbarara, Uganda; (2) the ART clinic of Amana District Hospital in Dar es Salaam, Tanzania; and (3) the HIV/AIDS clinic at Jos University Teaching Hospital in Jos, Nigeria. Patient interviews focused on experiences with taking ART, clinic visits, and help from treatment partners. Treatment partner interviews targeted the types of help that they give, feelings about being a treatment partner, and opinions on their impact. Health care workers, such as clinicians, nurses, and others, were asked to describe typical clinic visits, ways adherence is discussed at these visits, and views of patient obstacles towards adherence. The researchers also conducted observations of clinic visits, with a focus on observing routine follow-up visits of patients taking ART, counseling sessions, health education sessions, and the dispensing of antiretroviral medications. In all, 158 patients, 45 treatment partners, and 49 health care workers were interviewed. There were 414 interviews and 136 observation sessions conducted across the three sites.
The study shows that Africans overcome economic obstacles to get ART by begging and borrowing money from friends, families, and even their health care providers. They may choose to use money for transportation for their clinic appointments over food for them or their family, over school fees for their children, and over treatment for their sick child. Patients without money would take their medications without food despite the increased risk of side effects and would walk to health clinics despite long distances. Health care providers also made sacrifices by keeping their offices open longer to accommodate patients who arrived late and gave food, money, and even loans to needy patients.
The study also shows the significant impact of social responsibility upon adherence. Families and friends often help finance health needs, but this assistance becomes more difficult to justify if it is believed the patient is near death or incurable. Treatment partners insisted on adherence to ART by those they cared for because it made the treatment partner's burden lighter. The treatment partners' help created an obligation to patients to be adherent. Some health care providers threatened to discontinue giving treatment to nonadherent clients, further emphasizing the social responsibility patients had to remain adherent.
Public Health Implications
Ware and colleagues' multi-country, multi-setting study used a methodology of interpersonal interaction that allowed people to talk simply to the researchers, without complicated study designs getting in the way. Instead of coming with experts and boxes to check, the researchers captured the viewpoint of the patient, treatment partner, and grassroots-level health care worker. The findings show the importance of social capital (the connections between people) and reveal that social responsibility in Africa pushes people to be “good” (adherent) patients. Social capital has been used in other countries such as Rwanda, where those who want treatment must come to the clinic with a relative or members of their association.
Those who have truly been working in Africa should not have learned anything new. Social capital can be easily seen in day-to-day health care work. This new study will, however, hopefully change the way the rest of the world views Africa. The study proves that human rights activists were correct in believing that giving ART in underdeveloped settings does not put the world in danger. When future myths about Africa are presented, people can point to this study to show that the uneducated, illiterate, and poor still want to survive, perhaps even more than those in Europe or the United States. Although this study does not change policies and will not affect future clinical decisions, it can be a useful tool to create support for access to treatment in Africa.
Social coercion in Africa is high because people are more responsible for each other. Yes, Africans want to live, but more than that, they want to keep their relationships alive. Patients living with HIV in North America often have negative experiences and complicated backgrounds, such as traumatic events and mental illness, with little social support, and they face a great deal of stigma . Social capital is less strong in the United States than in Africa as people in the US tend to be more individualistic and therefore less focused upon and connected to the group as a whole. There is less concern about others and less of a feeling that others are concerned about you. Ware and colleagues state that: “In North America, adherence to ART for HIV/AIDS has been interpreted as the product of information, motivation, and behavioral skills operating at the individual level.” In other words, the driving factor for Americans to take their drugs is not social responsibility, but intellectualization of what to do to remain alive. Patients take the drugs they are given for themselves and not for others. Therefore, when a patient becomes depressed, adherence often declines. Research has shown that depressed people living with HIV progress to AIDS faster than those who are not depressed, due in part to nonadherence . In Africa, on the other hand, taking prescribed ART is a community effort. Even when patients no longer care for themselves, they continue to take the medication for the community around them.
Having clearly established the importance of social capital in promoting adherence to ART, future studies should focus both on its protective effects outside of the scope of HIV/AIDS and on how to maintain social capital while improving economic development, which can bring a more individualistic way of life. A developed economy provides an environment that allows the growth of individualism, while the poor tend to depend on their community for survival. Social capital can be a useful tool in promoting adherence to medications in patients with chronic diseases, who are at higher risk of depression than the general population . As countries in Africa become more economically developed, it will be increasingly more important for them to actively find tools to maintain their social capital.
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The Use of Information and Communications Technologies (ICT) to Provide and Support Healthcare Delivery Services in Rwanda
04 February 2010
Human beings have a fundamental right to health, which must be equally distributed to all. To be able to provide the prevention, care, treatment and rehabilitative services needed for its population, Rwanda has embarked on an ambitious journey to transform its socio-economic situation by changing its economy from an agriculture-based to a knowledge-based economy. In this context, Rwanda has identified the use of science and technology as a key tool for achieving our socio-economic transformation and reaching the MGDs. Although a high tech strategy may appear inappropriate for the health system of a developing country, this is is not applicable to Rwanda because our health sector ICT plan is integrated into two master plans: our health sector strategic plan and our national ICT plan. We know that e-Health is vital in order to create an effective and sustainable health system, as it will help us solve challenges in our health system, such as the lack of infrastructure and the shortage of professionals (since roads are still a problem in some remote areas, sending information, plans, and reports by ICT saves time and money).
Another reason why ICT for E-Health should be developed is because the right to health cannot be separated from the right to information, and the use of new information and communication technologies is the most accurate and timely way to provide information.
A good flow of information concerns four categories in the health sector: the patients, the policy makers, the care providers and the program managers. When it comes to patients, they need to be educated on their health needs and on how, when, and where to seek proper care. Also, once on treatment, patients should know why it is important to go for timely medical follow up appointments and be compliant to treatment, since it not only aids their recovery, but also helps to avoid dangerous resistances to epidemic diseases like HIV. Patients would be informed of these things by making ICT tools available to health professional at all level: community health workers would use phones, while central and district managers, health centres, district hospitals and referral hospitals would use web-based tools. For policy makers and program managers, ICT is important because it helps to design health policies and programs that are informed by evidence and based on accurate information. In general, the use of ICT has proven to be the more 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 its health development and recognizes that there is an urgent need to build e-Health capacity.
Many applications of E-health have already been provided. One good example are the web dialogues, which are good 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 infrastructures and costs nothing. Through the exchange of biological and immunological patient information, Xrays, echographies, etc, clinicians can receive ideas, confirm diagnoses and make correct decisions. For example, Harvard’s Global Health website connects Rwandan health professionals to counterparts in other countries, such as the United States, Haiti, and Peru, and allows for free communication between these countries on several levels. ICT also allows for the horizontal exchange of information between policy makers, programs managers, and community workers at the grassroots level. It also allows for vertical exchange between those three categories, thereby breaking barriers to knowledge and communication. Such information flows create an international family of global health workers and help to bring communities on board with the decisions that concern them. These communication exchanges can take on many different models so countries can choose which one best suits them. As a result, one gains time by quickly building on the experience of peers around the world, and this web-based free information can dramatically improve national and global health.
Without ICT all Rwanda sub programs in the health sector would be unmanageable, since it greatly helps the day to day work of health care providers. For example, the healthcare financing system is web based and manages more than 90% of the Rwandans enrolled in health insurance, along with the performance based program in the 480 health facilities. Rwanda’s ART program, which provides antiretroviral therapy for 70% of people living with AIDS who need them, is also managed via web based technology. ICT also helps to gain data for Rwanda’s localized MDG report, since community health workers and health professionals do active case finding of fever and malnutrition, perform maternal audits, and collect information on all maternal deaths in the country via this technology, in order to better understand why young healthy Rwandan women can be at risk of death during pregnancy or delivery. Also, 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. The big challenge is coordinating ICT tools so that these web based management systems are efficient and have synergy.
All of the above reasons show why the Government of Rwanda has put ICT as a top priority in our health development, 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 within Rwanda’s health sector. This approach will be crucial in enabling the sustainability of an integrated and coordinated healthcare system in Rwanda that will efficiently provide high-quality, gender, geographical and age balanced services.
The last advantage of using an ICT approach is that we save trees since we are saving the paper used for plans, reports, files, mails, etc… At this time when experts recognize the danger of global warming to the Earth, “saving CO2” environmental programs should also award the use of ICT by the Government of Rwanda!
Mental Health is a Basic Human Right to Fight For
13 December 2009
A few days ago the world celebrated Mental Health Day, and more recently it was the Human Rights Day, as such I have decided to post a reflection on the rights of all people to access mental health care as a part of the access to health care as a basic Human Right. I especially dedicate this reflection to the issues surrounding access to quality mental health care services for women.
Unfortunately, in the majority of the developing world, mental health is not an issue that is given adequate attention. However, if we take the definition of WHO, mental health plays as important part in overall health as the physical aspects do. To improve mental health, governments have to create a well-trained and well-equipped workforce to care for mental health and ensure that the funding and human and physical infrastructures are available. This will help to increase access to mental health care, but should be completed by making drugs available, like psychotropic drugs. Many of these medications are not so expensive and can be part of public essential drugs available at public health facilities. It is a matter of paying attention to the problem.
Also, the general population should be educated via mass media campaigns so that they will have less fear and a better understanding of mental health diseases and those who suffer from them, causing mental health patients to suffer from less isolation, stigma and discrimination. This can be done by partnering the government with civil society organizations to improve the public education on this issue through TV, radio, speeches, billboards and community events.
Both of these points are vital and necessary if we wish to improve the care of people who suffer from mental illness, because they will encourage the community to send people for care when mentally ill, and when the patient arrives, the health care providers will be ready to give proper care.
This is the system that the Government of Rwanda is creating by having one psychiatric nurse in each district hospital working in an integrated manner with hospital personnel, and by training general practitioners in the diagnosis and treatment of simple mental diseases and in the identification of severe ones so that such patients can be transferred to the national referral hospital for mental health. We also have some psychotropic drugs available as essential drugs, but we still have a long way to go to ensure that every Rwandan in need of mental health receives it.
An extremely important area of mental health care for women is trauma due to conflict situations, where many women are devastated because of rape and other sexual violence, as these health issues are often neglected. Mass rape has been used as a tool for war for centuries, and can be found in modern history as well: from the rape by German and Japanese armies during World War II, to the use of systematic rape and deliberately infect women with HIV during the Rwandan 94 genocide against Tutsis; this: from the rape of women during the Kosovo conflict, to the current use of rape to intimidate and humiliate women in the eastern regions of the Democratic Republic of Congo and through the devastation of their genital organs. For these women, international organizations should play a bigger role, since most of the conflicts are predictable and usual time for rape, sexual abuse and violence and psychological traumas.
In post conflict situations such psychological destruction needs specific attention to rebuild mental health and care for psychological reconstruction as a priority. Instead, the thousands of individual women suffering from this type of trauma are totally neglected and suffer in silence. Furthermore, in some countries these women additionally face stigma because of forced sex and pregnancy out of marriage, and are sometimes even forced to leave their households and villages because of that – doubling their trauma. In this manner, the communities who should be helping these women instead end up being on the same side of the perpetrators of this violence. For the prevention of mental health illness in women post wartime sexual violence, we must do massive behavior change campaigns for tolerance in countries recovering from wars. That was we did and still do in Rwanda. If not, these women will be denied their basic human rights to gender non-discrimination, to live without violence, and to access care for mental illness and other health issues like STIs, HIV, and genital organ damage.