Universal Health Coverage in Low and Middle Income Countries

In this video, I share my thoughts on the importance of the underlying principles that are key in building and implementing Universal Health Coverage (UHC). UHC is a crucial aim of social justice and the basis for each person to access equitable, quality, sustainable care.

The Quest for Universal Health Coverage in Low and Middle Income Countries

April 4, 2016

Johns Hopkins University, Maryland, USA (Filmed in Kigali, Rwanda)

I gave a guest lecture titled “The Quest for Universal Health Coverage in Low and Middle Income Countries” for Professor Afsan Bhadelia’s Johns Hopkins University undergraduate public health course.  This video displays a part of the rich discussion the students and I had during the Q&A following the lecture.  

Here is the link to watch the lecture Q&A:

Building Resilience for NCDs: Integration in basic care

March 28, 2016
Yale University, School of Public Health, Connecticut, USA (Filmed in Kigali, Rwanda)

On March 28, 2016, I gave a guest lecture titled “Building Resilience for NCDs: Integration in basic care” followed by a Q&A in Dr. Nicola Hawley’s Yale University School of Public Health course, “Global Non-Communicable Disease.”  The Masters-level students were from various departments across Yale University- including public health, epidemiology, infectious diseases, anthropology, and management. 

Accepting the 2015 Roux Prize from the Institute of Health Metrics and Evaluation (IHME)

Washington, DC, USA, October 21, 2015

On October 21, 2015, I was deeply grateful to represent Rwanda in receiving the Roux Prize from the Institute of Health Metrics and Evaluation (IMHE). We received this esteemed award for our health sector's use of Global Burden of Disease (GBD) data to make evidence-based decisions around improving neonatal health in Rwanda and, though this, decrease neonatal mortality and reduce suffering among the youngest in our population.  Read more about the Roux Prize and the

Guest on the Big Q (TV Station)

Kigali, Rwanda, October 1, 2015

On October 1, 2015, I was invited to be interviewed on the Big Q, a television show, to discuss health.  Watch the recorded videos above. 

Speaking about Health and Safety on Work Day in Bralirwa Gisenyi

Bralirwa Gisenyi, Rwanda, May 1,  2015 

On May 1, 2015, I spoke to the community of Bralirwa in Gisenyi, Rwanda about health and safety on the annual holiday Umunsi w'umurimo, or "Work Day" in our national language of Kinyarwanda. On this day, we take time as a community to discuss employment, workplace safety, and new innovative ideas.

Inauguration of Children's Week

Stockholm, Sweden, 19 April 2015

On April 19, 2015, I was honored to speak about the principals of building a system to promote child health in Rwanda, discussing how the future is in our hands. 

Featured on #1o1RW with Eugene Anagwe

Kigali, Rwanda, August 25,  2014

On August 25, 2014, I was invited to be a guest on "One on One" with Eugene Anangwe on 89.7 Contact FM here in Kigali to discuss Rwanda's position on Ebola related issues and other issues in the health sector. It was a fun experience and I hope many were able to listen in for the great conversation!

Dartmouth Lecture: "Building a Health Sector Alongside a Nation"

Dartmouth College, New Hampshire, USA, July 23,  2014

On July 23, 2014, I was invited to speak at Dartmouth College to give a presentation on how my Rwandan colleagues and I have built the health sector alongside the development of our nation, led by His Excellency President Paul Kagame of the Republic of Rwanda.  As I share in my lecture, a health sector must be integrated into the broader development of a country.  Here in Rwanda, we are guided by our national development plan, Vision 2020, and our Economic Development and Poverty Reduction Strategy.  Each of the strategic plans of the sectors within the government, including the health sector, are aligned with these overall, comprehensive national plans in order to ensure that we are all moving forward together in harmonized, complimentary efforts.

Giving the Inaugural Address at the 3rd National Food and Nutritional Summit

Kigali, Rwanda, February 18, 2014

On February 18, 2014, I was honored to give the inaugural address at the 3rd National Food and Nutritional Summit here in Kigali. Learn more about the Summit and the conversations we had here:

Voice of Africa Interview: Perspective on U.S. AIDS new initiative to increase research for a cure for HIV

Kigali, Rwanda, December 3, 2013

Here, on December 3, 2013, I was invited to be a guest on radio station Voice of Africa (VOA).  VOA's Vincent Makori interviewed me and asked for my thoughts on U.S. President Barak Obama's new initiative to increase research to find a cure for HIV.  Visit VOA here:

UCL-Lancet Lecture 2013: "Charity does no rhythm with development"

November 13, 2013

On November 13, 2015, I was invited to give a UCL-Lancet 2013 lecture.  In this presentation, I shared my perspective of Rwanda's experience in mobilizing partnerships to help us achieve universal health coverage, with a social-entrepreneurship-business mindset.  We discussed how open access research, "reverse innovation," and equitable global partnerships rooted in solidarity can reinvigorate the pursuit of health for all.  Read more about the UCL-Lancet lecture and other presentations here:

2013 Skoll World Forum: "Can It Be Replicated? A Look at Rwanda's Development Gains in Context"
August 2,  2013 

On August 2, 2013, I was invited to speak at the Skoll World Forum and present a discussion, "Can It Be Replicated? A Look at Rwanda's Development Gains in Context."  I was joined by the following social entrepreneurs: 

Former President of Ireland, President of Mary Robinson Foundation
Mary Robinson is President of the Mary Robinson Foundation -- Climate Justice. She served as President of Ireland from 1990-1997 and UN High Commissioner for Human Rights from 1997-2002. She is a member of The Elders and the Club of Madrid, and is the recipient of numerous honours and awards, including the Presidential Medal of Freedom from the President of the United States, Barack Obama. Mary served as Founder and President of Realizing Rights from 2002-2010.

Founder and, BRIDGE2RWANDA
Dale Dawson is Founder and CEO of Bridge2Rwanda, a social enterprise that facilitates business development in Rwanda and creates opportunity for Rwandan students to study abroad. He serves on President Paul Kagame's Presidential Advisory Council and the Urwego Opportunity Bank, Rwanda's largest micro-finance bank. In the first half of his career, Dale was an investment banker, entrepreneur and KPMG partner.

Co-Founder, Partners in Health
Paul Farmer, MD, PhD, is Kolokotrones University Professor and Chair of the Department of Global Health and Social Medicine at Harvard Medical School, Chief of the Division of Global Health Equity at Brigham and Women's Hospital in Boston, and Co-Founder of Partners In Health. He also serves as UN Special Adviser to the Secretary-General on Community Based Medicine and Lessons from Haiti.

US Business Editor, The Economist
Matthew Bishop is the US Business Editor of The Economist. He is the author of several books with Michael Green, including 'Philanthrocapitalism: How Giving Can Save the World', 'The Road From Ruin' and 'In Gold We Trust? The Future of Money in an Age of Uncertainty'. Mr Bishop is also the author of 'Essential Economics'. Mr. Bishop chaired the World Economic Forum's Global Agenda Council on Philanthropy and Social Innovation, and was a member of the Advisors Group to the United Nations International Year of Microcredit in 2005

The Skoll World Forum on Social Entrepreneurship aims to "accelerate the impact of the world's leading social entrepreneurs by uniting them with essential partners in a collaborative pursuit of learning, leverage and large scale social change."  Learn more about the forum here:

The Skoll Foundation brings together social entrepreneurs and other innovators to solve pressing problems across the world.  Learn more about the Skoll Foundation here:

International Society for Neglected Tropical Diseases Meeting

London, UK, July 15, 2013

On February 12, 2013 I spoke at the International Society for Neglected Tropical Diseases Meeting in London about the global healthcare implications of co-infections with NTDs and with other diseases. Watch videos of additional presentations here:

Commenting on Lancet Publication "Redefining global health-care delivery:" Reflections on Global Health Delivery

Kigali, Rwanda, May 23, 2013

World Bank President Jim Yong Kim, Dr. Paul Farmer, and Professor Michael Porter recently published a paper in the Lancet, titled "Redefining global health-care delivery."  The publication, which analyzes health care delivery in the heart of the intersection of poverty and serious illness, can be found here: In this video, I offer my comments on my colleagues' paper.  This video was recorded by Daniel Murenzi. 

Discussing the Importance of Priority Setting in Health

Kigali, Rwanda, May 1, 2013

In this video, filmed on May 1, 2013, I share my perspective on the importance of priority setting in health.  Planning is an integral tool in any sector, and priorities and timelines must always be set in order to move forward effectively and efficiently.

2010 Global Burden of Disease Study: Country-level data launch

Kigali, Rwanda, March 5,  2013

On March 5, 2013, the Institute of Health Metrics and Evaluation (IHME) in Seattle, Washington launched their data findings from the Global Burden of Disease (GBD) 2010 Study.  The GBD Study is the largest and most comprehensive effort to date to measure epidemiological levels and trends worldwide. More than 1,000 GBD collaborators from 108 countries participated in the study.  I strongly believe that health decisions must be evidence-based and driven by sound, culturally sensitive data.  My Rwandan colleagues and I use the IHME's GBD data often as we make our evidence-based data-driven decisions for the Health Sector.  Learn more about the IHME, the GBD Study and to access data here:

Delivering Open Remarks at the Susan G. Komen International 2013 Global Women's Cancer Summit

Washington, DC, February 19, 2013 

On February 19, 2013, I was very honored to deliver the opening remarks at the  Susan G. Komen International 2013 Global Women's Cancer Summit in Washington, DC. This Summit brought together leaders from across the world to discuss the growing burden of women's cancers, an important issue as we each face the growing burden of non-communicable disease on national levels.  Learn more about the Susan G. Komen International Global Women's Cancer Summit here:;-Worldwide-Collaboration-Aims-to-Tackle-Breast,-Cervical-Cancer.html

Presentation for the the International Society for Neglected Tropical Diseases Co-infections 2013 Meeting

London, UK, February 11, 2013 (Filmed in Kigali, Rwanda)

On February 12, 2013, I spoke at the International Society for Neglected Tropical Diseases (ISNTD) Coinfections Meeting, which took place at the Wellcome Trust in London, UK.  This society aims to create multidisciplinary partnerships with NTD specialists, development professionals, research scientists, governments, donor & philanthropic organization and the private sector in order to improve healthcare outcomes globally.  

Watch videos of additional presentations here:

ISNTD Coinfections brings together experts in NTDs, other diseases and associated conditions of poverty - including HIV/AIDS, TB and malaria - who will be addressing the latest developments in these fields and their impact on NTD control with a view to effectively impacting poverty and development in the long-run. The Aim of this Coinfections group is to improve the delivery of healthcare and poverty alleviation among the most vulnerable by integrating resources across research, funding and advocacy with a focus on disease prevention and cure programmes.

Learn more about the International Society for Neglected Tropical Diseases here: 

Learn more about the International Society for Neglected Tropical Diseases Coinfections group here:

Presentation for 2013 GET-Health Summit

New York, NY, USA, February 7, 2013 (Filmed in Kigali, Rwanda)

On February 2013, I shared this video message at the Global Education and Technology (GET) Health Summit in New York City, hosted at the United Nations. My remarks were part of the Ministerial Forum and were shared on February 7th. The summit was convened by the Johns Hopkins Center for Clinical Global Health Education and by the Global Partnership Forum.

Learn more about the Global Education and Technology Health Summit here:

Presentation for 6th World Congress on Pediatric Cardiology and Cardiac Surgery

Cape Town, South Africa  Published: February 5, 2013 (Filmed in Kigali, Rwanda)

For the 6th World Congress on Pediatric Cardiology and Cardiac Surgery, that took place 17-22 February, I offered a video remarks. My presentation titled "Uniting to address pediatric cardiac disease in Africa: A message from Rwanda" provided insights into the principles leading health care delivery in Rwanda. 

Presentation to US National FACE AIDS 

Leadership Summit

Boston, MA, September 30, 2012 (Filmed in Kigali, Rwanda)

On 30 September, I spoke to leaders of FACE AIDS student groups at universities across the US about the continued global activist movement to fight HIV/AIDS. FACE AIDS currently works in Rwanda (among many other countries) to build awareness among youth around prevention, care, and social support for HIV/AIDS.

Interview with Dr. Agnes Binagwaho

New York, NY, September 26, 2012 (Filmed in Kigali, Rwanda)

On 26 September, I spoke about the importance of participation, consensus, evidence-based health science, accountability, decentralization and governance, and the role these factors have played in moving Rwanda forward. 

A Talk for Harvard University's Conference, "Universal Health Care: Challenges, Measurements, and Evaluation Strategies"

Boston, MA, September 13, 2012 (Filmed in Kigali, Rwanda)

On 13 September 2012, Harvard University hosted a conference on Universal Health Care. I participated via video-lecture and a video-Skype discussion with economists and public health professionals from around the world.

A Video Clip from Dartmouth College, 

"The World is a Little Village" 

Hanover, NH, August 1, 2012

On 1 August 2012, I gave a brief interview on Rwanda's new Human Resources for Health Program in collaboration with the consortium of universities in the United States.

A Talk at Dartmouth College, "Time for a Paradigm Shift in Global Health: Equity, Science, Participation, Sustainability"

Hanover, NH, July 30, 2012

On 30 July 2012, I gave a public lecture in partnership with The Center for Health Care Delivery Science at Dartmouth College on how Rwanda's experience can inform a paradigm shift in global health and why there is an urgent need for global solidarity.

Global Health Corps Fellows Orientation 2012

New Haven, CT, July 10, 2012

On Tuesday, 10 July 2012 I spoke via YouTube at the Orientation for the 2012-2013 Global Health Corps Fellows. This message can also can be applicable to students and young people interested in global health issues.

Wilton Park Conference: "The new era in HIV/AIDS treatment and prevention: science, implementation and finance"

Geneva, 27-28 June 2012

During the 2012 Wilton Park Conference titled "The new era in HIV/AIDS treatment and prevention: science, implementation and finance," I spoke via YouTube with Dr. Sabin Nsanzimana, Head of the HIV/AIDS, STIs and Other Blood Borne Infections Division in the Rwanda Biomedical Center, on Rwanda's country perspective on treatment as prevention for HIV. 

Salzburg Global Seminar - Strengthening Leadership and Policy for Improving Care in Low and Middle Income Economies

Salzburg, Austria, 24 April 2012

This week, I spoke at the Salzburg Global Seminar on "Strengthening Leadership and Policy for Improving Care in Low and Middle Income Economies." I was invited to speak on a panel during the seminar's fourth day, and discussed improvements in system-wide procurement and infrastructure development as an example of Rwanda's approach to quality improvement. You can view the video of my speech above, and a program description at the Salzburg Global Seminar website.

Harvard College Course Video Presentation: Health Systems Strengthening and Social Justice

Cambridge, Massachusetts, 22 November 2011

I delivered these remarks via Youtube for a course taught at Harvard College called "Case Studies in Global Health: Biosocial Perspectives." This video presentation on Tuesday, 22 November 2011 was aired in conjunction with a lecture by Partners In Health - Rwanda Country Director, and Chair of the Rwanda Biomedical Center, Dr. Peter Drobac. My video presentation and Dr. Drobac's lecture were accompanied by a discussion with Professors Paul Farmer and Arthur Kleinman.

Salzburg Global Seminar - Concluding Remarks

Salzburg, Austria, 30 September 2011

On the concluding day of the Salzburg Global Seminar: "Innovating for Value in Health Care: Better Cross-Border Learning, Adaptation, and Adoption,” I delivered remarks via teleconferencing technology.

Seeing and hearing the presentation and ideas on innovation delivered by the Salzburg participants on both individual and group levels throughout the week, I found the type of community created in such a short time to be one that has great potential to continue in several important ways.

In my remarks, I shared four key ideas on my perspective on the importance and concept of having a vision: (1) the creation of a vision, (2) the measurement of the progress to reach this vision, (3) the strategy in order to attain targets, and (4) the ability and prioritization of documenting the vision and the process taken to achieve. Every person and Health System must have a vision; we must know where we want to go. We need to know where we are now and how to get where we want to go in order to achieve our mission. We need to document how we did each step so that we can learn from our efforts.

The first part is the vision is identifying where we want to go, no matter whether other people find it too ambitious. It is our vision, and we need to stick to it. In doing so, we assure that all of our actions will be according to our own priorities. I believe that this vision must be shared because alone we cannot accomplish much. But when everyone is together, we can design together a national strategy and plan that is country-owned and community driven, because communities should be a part of the design from the beginning.

This participatory process brings together communities with the public and private sectors. It is then easy to be morally sound because, from the start, no one is left out and the vulnerable people are taken care of. This is the essential human rights concept behind access to care.

The second part of the vision is measurement – we need to effectively measure the health of our population, the quality of our health care system, our people’s to access to care and treatment, and the utilization of health services across our country. This is useful, on one hand to provide a baseline for evidence-based planning but also, on the other hand, to set targets according to the financial, human, and infrastructural resources that we have. This means that we can design results-oriented strategies and plans. If we do such assessment periodically, they will show us over time where we stand compared to our vision and our plan.

In my presentation, this brought me to the third category: how to reach our targets. We do this by designing good strategy, good action plans, and by creating good tools. We reach our targets by thinking outside of the box – with creativity, with flexibility, by learning as we are doing, and by being always being ready to question how we can do better. Innovation, of course, includes the pursuit of new partnerships, such as North-South partnerships like that between Dartmouth and Rwanda as well as South-South partnerships like that between Haiti and Rwanda.

The final fourth part of the vision is documentation of how we build our health sector. We need to learn from our progress and, more importantly, from our mistakes. To facilitate this learning, we need to conduct research for better policies, better strategies, and better ways to implement. This is implementation science, which teaches us to reduce to gap between what we know from clinical research and what we actually deliver to our population. Today, implementation science requires as much research as clinical science because improving policies, strategies, and delivery allows us to produce better health with the same resources. Sometimes, improvement of our strategies and implementation produces even greater results when it is about public health by teaching us how to bring things to scale using opportunities in a synergistic way that makes the money go farther. We need to see health care delivery as a social business where the units to produce are health, enjoying life, and wealth.

Friends, good intentions, innovations, creativity, flexibility, and clinical science are not enough because poor planning and bad procurement can undermine health just as much as bad will, business as usual, bad clinical services, and laziness. For example, in 2008 in Rwanda, we had an argument with the Global Fund on mosquito net procurement that delayed distribution for twelve months. Because we were not allowed to use the Global Fund money before an agreement was reached, we were obliged to redo the entire process. In the end, the money we received was the same, because we had been genuine and had indeed done the procurement honestly; yet as a result of this delay, Rwandans died of malaria. This can be understood by health care delivery science: the Global Fund should be held responsible for system outcomes in the same way that the health professional is held responsible for the death of patients because of his or her bad practice.

Another example is the bad decision not to vaccinate Haitians against cholera during the country’s cholera outbreak because the vaccine was said to be too expensive. This decision has cost thousands of Haitian lives. The development partners who made that decision should be held responsible for this, as it has cost the lives of innocent, vulnerable Haitian people. Health care delivery science teaches us how to attain the best outcomes with the resources we have while making us totally responsible for the principles upon which we  implement and for the results that come from our actions.

Salzburg Global Seminar - From HIV to HPV

Salzburg, Austria, 27 September 2011

This week, I spoke at the Salzburg Global Seminar on "Innovating for Value in Health Care Delivery: Better Cross-Border Learning, Smarter Adaptation, and Adoption." You can view the full program description here.

I was asked to present on Rwanda's experience of integrating funding and programming for HIV into a comprehensive national strategic plan for quality basic health care. The talk was entitled: "From HIV to HPV: Same Principles in Building an Accessible, Affordable, and Equitable Health Care System in Rwanda."

I started by discussing how, the week prior, I was in New York City for the United Nations High Level Meeting on Non-communicable diseases. It was intended to be a turning point in the global approach to tackling NCDs.

In that same UN hall, 10 years ago, we met to discuss how to make access to HIV prevention, care and treatment services a global priority. The 2001 UN summit on HIV/AIDS changed the conversation about HIV around the world.

At that time, we were told that we did not have the roads, the infrastructure, the cold chain, and the procurement capacity for drugs, consumable and reagents. We were told that we did not have the specialists, or even enough general practitioners and nurses, as many were killed during the 1994 Genocide Against the Tutsi. On top of all that, the so-called “experts” of health implementation said that our population was illiterate.  They said that our people did not wear watches, so they could not read and know the time when they would have to take ARVs and could thus not adhere to therapy. They claimed that we should concentrate on prevention and not try to introduce ARVs to save the lives of those already infected, as it was too costly and dangerous for the health of the rest of the world –they expected our people would be non-adherent and said that this would create deadly resistance. But what they did not into account for was the cost of inaction, a cost that Rwanda would not tolerate.

Today, despite all of the barriers, we are proud to say we now have universal coverage for antiretroviral therapy and one of the lowest prevalence rates in Africa at 2.8%.

We are also proud to say that we just completed our second dose of the HPV vaccine for girls aged 11 in Rwanda through our national comprehensive cervical cancer prevention and screening program. The coverage rate was 95% for the first dose and 97.4% for the second.

These two achievements, scaling up access to HIV care and launching the developing world’s first national HPV vaccination program, are not unrelated. Rwanda was able to vaccinate all of its girls aged 11 against HPV because we have strategically built upon the foundation of advances made in HIV care and treatment, among other communicable diseases.

We moved from a destroyed health sector after the war and the genocide to tackling and managing HIV and other infectious diseases.  We moved to tackle and manage non-communicable and chronic diseases while not dropping our advances in infectious disease control.

Health in Rwanda in general is understood as an important element of development. The HIV program needed to be coherent with the overall development vision of the country. And, just as our HIV plan, our overall health plan is evidence-based and results-oriented. The strategy of the health sector must follow national priorities and be linked to the national development vision (in Rwanda this is our Vision 2020 as well as our plan for the MDGs). The results must be monitored and used for planning and programming. Implementation and adaptation must be results-oriented.

When a massive influx of new HIV treatment resources was made available after years of effort by activists and people living with HIV around the world, we immediately made the choice to apply to access these funds. We used them to save the maximum number of lives in the most sustainable manner. This meant building a system that provided the best possible care for all Rwandans.

This was also a political choice, as it was rooted in the principle of assuring that the plan left no one out of the benefits. During our needs assessment in 2001, we realized that women use less health services than men. We acknowledged this disparity and the Government issued a Ministerial instruction to assure that if one member of a family is on ART there would be no additional cost for all additional members of the family to be put on treatment. A unit cost for the family with the objective to assure women and children access to prevention, care, and treatment was the first step in implementing an equitable health program based on gender, age and geographic equity. This is also why we made PMTCT the key family entry point to treatment.

Furthermore, we needed to assure in the beginning that people from higher socioeconomic levels would not be served more than poor, vulnerable patients, as we only had medicine for 3,500 people compared to the high volume of people in need of ARVs in order to survive. We assured this by putting civil society at the heart of the fight to regulate the selection of beneficiaries in health facilities.  We also put civil society on the board of coordinating bodies for the fight against HIV. While we no longer face these problems today, as we currently have enough treatment for all, this principle still guides us to fight discrimination and segregation.

Our strategy is based on national ownership and responsibility. We have strong national leadership. In order for the government to be in the driver’s seat from A to Z, we coordinate our development partners in committees chaired by a Rwandan civil servant. We developed national tools, which meant developing a policy, a strategy, and a plan.

Our institutions are responsible for normative functions (e.g. clinical standards, site accreditation) on performance. These are results-based contracts that do not allow delay. Once this national framework was in place – development partners were, and are still today, given a framework to which they can integrate.  Partners align their programs to the national plan. If they don’t want to align with our plan, they can go to another country. Parents are also asked to align with us and follow our lead around the location of their work. Many development partners come and want to be in the city, or they go to a country and want to be by the beach to do their work.  We realized quickly that we needed to be careful about this type of coordination with partners as well.

To assure the alignment of partners, we needed a participatory process. Partners need to participate in the design of the policies, strategies, and plans. They also need to sign their commitment of clear actions to be taken to support the process and clear indicators to be rigorously evaluated over time. This has allowed us to succeed with innovative approaches, including our common basket of procurement for ARV and consumable procurement and activities.

We assure also an equitable geographic coverage through strong coordination of our partners and with the political will to move resources out from the capital city. Another strategy we promote to assist with equitable distribution of human resources is performance-based financing, which helps incentivize nurses and doctors to continue working in remote areas as well as to increase and maintain the quality of the care they provide.

The other tool developed was the community-based health insurance (called Mutuelles de Sante), which aids in eliminating financial barriers to basic health care.  One pillar of our strategy is to provide systematic health insurance for civil servants through a program called RAMA. For the rest of the population, we began Mutuelles. This health insurance scheme aims to protect every Rwandan citizen from all common diseases. Since some very poor people cannot afford the 2 USD co-pay per year, there is also a free health insurance paid by the government for the poorest percentage of the population.

All this is done to protect people living with HIV, as well as those who are HIV free, against the most common diseases. It is not effective to save a child through antiretroviral therapy, costing more than one hundred dollars a year, and then to lose that same child to treat diarrhea or malaria, for lack of five dollars.  It is also not right to improve only the life of a small portion of our people.

The government
s financial support for Mutuelles for the poorest people in the population provided the opportunity to show to those who have to pay for themselves, that the poorest people with Mutuelles have better access to care than them. The result is that, last year, 98% of Rwandans had health insurance. We created both the demand and a new mentality among the rural population, who saw people poorer than themselves having access to health care. It created a revolutionary demand for pre-payment in a country where paying prior to needing care no longer existed.

In the area of capacity building we accomplished many goals that improve the health of all Rwandans, including the training of health staff at different levels and the provision of solar panels, computers, ambulances to the health centres. “AIDS money” has allowed the country to train health workers and to improve overall care. We have used it to provide incentives to improve human resources, allowing health workers to serve the poor.  When you train a lab technician for HIV testing, you also train him/her to test for syphilis, other diseases and even pregnancies. The lab infrastructure and microscope he uses serves all diseases. Almost half of HIV/AIDS funds in Rwanda were directed to strengthen the general health system and to support non-health, multi-sector development. 

Plans need to be community-driven if we want to solve the real problems at the community level. Because HIV is a disease linked with poverty, integration of HIV and AIDS programs needs to be part of a larger strategy for economic development and poverty reduction for the achievement of MDGs. I believe that this notion of health as a basic right is critical, and that this right must be protected and promoted by everyone.

We must have zero tolerance for vertical programs. This means we must consider an individual as a whole, not tackling one disease but instead tackling all public health issues by using the same service structures for the same communities with the same health workers.

Here is a concrete example of how, with “AIDS exceptionalism,” we strengthened the entire health system: to provide ARV services, we need to be able to first test for VCT and PMTCT to know if a person or pregnant women is HIV-positive. That means we need a laboratory for the testing. Before building or improving an existing laboratory, we need to provide common basic care to the clients of the sites where HIV treatment will be given. That means basic care for all, not only for PLWHA, and there is no site aimed only at HIV but, rather, aimed at comprehensive health facilities that treat the entire population for all diseases. Integration of HIV services in the health system is a prerequisite to provide ARVs in a safe manner while taking into consideration the needs of the entire population.

In Rwanda, we managed to use the influx of AIDS money to strengthen all sectors of the health system. We know that HIV is a cross-cutting issue. Within the health sector, AIDS money was used to rehabilitate or build infrastructures from scratch, such as health centers, delivery wards, laboratories, and consultation facilities. We have bought materials for communications, including telephones, computers, and ambulances.

Another key requirement for building a system is ensuring accountability from both sides, including countries and donors, through enforcement of transparency and anti-corruption measures. The greatest challenge that Rwanda and many other African countries face is that the health sector is largely externally financed. We have solved that partially by making the funds country-driven and directed them to meet community-defined needs.

However, many interventions remain under-funded, such as programs to address the link between food insecurity and health. Sustainability issues for interventions like ARV therapy remain beyond the financial means of most developing countries. We face the challenge of maintaining balance between our investments, by addressing the human resources deficit, while providing necessary services today. Development requires long-term support, and we face difficulties in firming up long-term donor commitments to projects focused on health systems strengthening. Partners must bring a spirit to plan for achievement and results, not simply a limited and arbitrary timeframe – what is not achieved in a sustainable way it will be lost one day.

While we face significant challenges, we also have a lot of opportunities. These include clear political and technical vision, strong government leadership, broad community and civil society participation, goodwill from all partners that results in global solidarity put into action, strong foundational programs on which to build, and motivated teams of health workers with the right skills.

By dedicating ourselves to making the new resources for HIV work to meet our vision, we have seen remarkable progress in the health of our population. Over the last five years, malaria morbidity has been reduced by 60% and under-five mortality has dropped by 50%. We have increased the proportion of infants receiving all basic WHO recommended immunizations from 75% to over 90%. Maternal mortality has dropped by nearly two-thirds. 98% of Rwanda’s 11 million people have health insurance. We have 45,000 community health workers and have successfully implemented our performance-based approach in the health sector.

So, on the shoulders of these advancements, we decided to tackle non-communicable diseases, which we saw as an important investment. The fight needed to start somewhere, and it is clear that for women we can mitigate cervical cancer with a vaccine, and breast cancer with self-detection or clinical detection. This is the place our government wanted to start. So on April 26th and 27th of 2011, 128,000 young Rwandan girls received their first shot of Gardasil – with no out-of-pocket payment – and Rwanda became the world’s first low-income country with a national HPV vaccine program.

Several early decisions were crucial to the success of our HPV vaccine initiative. First, we decided to vaccinate the girls at age 11, because at this age they are ready to receive and understand messages on reproductive health. We decided to vaccinate them in schools because 96% of girls in Rwanda go to school. Accordingly, we decided to widen our technical working group on vaccinations to include the Ministries of Education and Gender and Family Promotion, the Center for Treatment and Research on AIDS, Tuberculosis, Malaria, and Other Epidemics (TRAC Plus), and health workers engaged in the provision of cancer care. At the same time, throughout Rwanda, a sensitization campaign was done months in advance of the HPV vaccination. Many were involved in this, including health care professionals, local government officials, clergy, and the First Lady.

Second, the committee decided on a multi-phased vaccination strategy spanning three years. It started for girls in primary 6. After this first year, we planned to have two years of vaccinating girls in the second year of secondary school to assure that all girls aged 14 are vaccinated. After the third year, we planned to continue to vaccinate only in primary 6.

Looking at the central considerations of our decision to roll out the HPV vaccine, it is clear that an effective HPV vaccine program has to build on a national vaccination program. The HPV vaccine in Rwanda is also based on public-private partnership with Merck, which we see in reality as a public-private-community partnership, since our community health workers have helped us to identify the children that were not at school on the day of the vaccine. When you vaccinate at school, universal access to education is key to health equity.

I should note that the same accusations made against antiretroviral therapy and MDR-TB, as Jim Kim and Jaime Bayona have publicly spoken about, were raised against our HPV vaccine program. Researchers said that it was too expensive for Africa and that the HPV vaccine would take away from other vaccination programs (which already have nearly universal coverage in Rwanda). Also, they alleged that Africa’s high HIV prevalence would make the vaccine dangerous. But what they did not consider again was the cost of inaction and the danger to women, who would die of cervical cancer without the vaccine. Rwanda and its health sector leaders would not tolerate this cost. 

The HPV vaccine in Rwanda relied heavily on government leadership and support, as well as a community health system that reaches all rural and urban persons. To provide timely, quality services without stock-out, the supply chain, distribution systems and cold chain have to be in place and monitored extremely carefully.

Integration was, and is, key to our approach to non-communicable diseases. Detection should be integrated with family planning, with life skills, and with economic development. The point is to be cost-effective while providing health care in an equitable manner that ensures accessibility and affordability to all individuals.

Historically, there has always been a 15-20 year lag between the introduction of a vaccine in rich and poor countries. But in Rwanda, thanks to the good partnerships we have and our human rights-based approach to development, we shortened that lag time in delivering the HPV vaccine to less than 2 years. This is something that can and should be done in many other poor countries – those who bear the brunt of the burden of disease are generally the last beneficiaries of advances in science and medicine.

Rwanda’s richest resource is its population. For this reason, all of the policies and strategies in our health sector are rooted in the pursuit of health equity and social justice. These advances in combatting communicable diseases and strengthening the health system have led to increased life expectancy, which now exceeds 50 years, leading to our people living longer and now showing an increased prevalence of NCDs later in life.  This is an opportunity and a challenge, reflecting both our progress and the immense mountains we still have to climb to provide the necessary new services to our population.

Fighting diseases needs to start by good policies, strategies, and plans and needs to be integrated across sectors with the goal of strengthening the entire health system.

Global Health Principles: A focus on Health 

System Strengthening

Cambridge, 7 April 2011

This talk was given to undergraduates and graduate students at Harvard University, and hosted by the Harvard Institute for Global Health in Cambridge, MA. Prior to a Question and Answer session, I spoke to the students about how it is important to develop a health care system based around national programs and ownership. I discussed the example of HIV programs, the fight against cancer, care of people living with handicaps, and issues of human resources for health including professionals and community health workers. Students posed terrific questions about accountability, national ownership and challenges to scale-up.

Global Health Financing, Panel at Harvard 

Kennedy School

Cambridge, 7 April 2011

A panel hosted by the Harvard Kennedy School; the Program in Global Public Policy and Social Change, in the Department of Global Health and Social Medicine of Harvard Medical School; the François-Xavier Bagnoud Center for Health and Human Rights, of Harvard University; and Partners In Health.  Several panelists participated in a discussion concerning the payment for health services and access to essential services in resource-limited settings. Dr. Binagwaho spoke on the panel with other scholars including Paul Farmer, Kolokotrones University Professor, Harvard University; Cristian Baeza, Director for Health, Nutrition and Population, Human Development Network, World Bank; Robert Yates, Senior Health Advisor, DFID; and S.A.S. Kargbo, the Director of Reproductive and Child Health in the Ministry of Health in Sierra Leone.  Each explained different models of health care financing and payment for services in various countries in Africa and other parts of the world. Dr. Binagwaho insisted on home grown solutions to payment schemes and on the sustainability of financing. After the panelists shared their views on payment for health care (e.g. individual payer, insurance provider, government as the payer), there was a designated period of Question and Answer with the audience. To conclude the event, the panelists agreed on the need for universal access to basic care with a shared understanding of health care as a human right.

Innovations to Improve the Quality of Health 

Care in Resource-Limited Settings

Boston, 31 March 2011

Lecture given in Boston, MA on 31 March 2011 on Innovations to Improve the Quality of Health Care
This lecture concerned innovations to advance the quality of health care in resource-limited settings with a focus on current programs and projected opportunities for improvement. In order to reach the Millennium Development Goals, especially those for health, countries must invest in innovations - both technological and political. We must agree that the responsibility to provide health care belongs to all people including the Government, the private sector and the general population. Improving access to prevention, care and treatment especially for those who are most vulnerable such as women and children, we need to have targeted innovative actions. Generally speaking, the world has come far since the MDGs were set in 2000. And yet we have a big push ahead of us. In order to advance as quickly as we need to - a big shift toward technology and communication must be made. 

If health care is taken as a basic human right - something I believe strongly - these innovations must reach all persons within a country, with a focus on those who are most vulnerable. In Rwanda, there are four examples of such innovation: (1) the new non-surgical male circumcision device that does not require a sterile environment, PrePex; (2) the alert system called Rapid SMS whereby community health workers can alert the district and central levels of, for example, a woman who needs an ambulance to take her to the hospital to give birth simply by sending an SMS; (3) mUbuzima, another cell phone technology that allows the community to send a set series of indicators on the MDGs within their communities; (4) and the system of governance in Rwanda wherein the population is given a strong voice in policy, action and major decisions.

With innovative tools and new ways of managing them with enhanced ownership and accountability, countries will be able to accelerate providing access to health services for all.

The Cycle of Poverty and HIV Infection

Boston, 8 July 2010

With Dr. Paul Farmer giving a lecture in the Harvard Medical School Course: Introduction to Social Medicine
This lecture explores the role poverty plays in preventing access to health care and discusses the vicious cycle of poverty and HIV infection. This is well illustrated by maps by of HIV distribution and poverty distribution worldwide.

Countries have to break the cycle of disease and poverty in order to achieve good health. The fight against HIV is one of the clearest examples of how the lack of access to care and treatment is a death sentence for the poor. And, beyond the affects of HIV/AIDS, a poor country in sub-Saharan Africa will not be able to reach development goals efficaciously without addressing the burden of other infectious diseases like malaria. Malaria claims millions of deaths in addition to debilitating tens of millions through chronic anemia. There is a need to promote prevention and, at the same time, improve case finding and treatment at the community level. This will lower the number of patients hospitalized for malaria and thus lower absenteeism among workers and students.

To fight HIV infection and malaria we need to link improvement in both prevention and care. We have to avoid choosing between one approach or the other given that both prevention and care are vital. Why does Africa face the vicious cycle of disease? By losing skilled people due to diseases, including doctors and nurses, rates of death among the population from other common diseases will rise since fewer professionals would be there to treat them.

In hospitals, beds occupied by those suffering from HIV-related diseases are limiting the space for patients sick with other treatable diseases. Thus, we see that AIDS kills even non-HIV infected patients because of lack of heath practitioners and lack of hospital spaces. In the education sector, the lack of teachers decreases the quality of education for the next generation (and a loss of investment for governments that have disbursed funds to trained teachers).

Most importantly, parents are dying in their productive and reproductive years and leaving orphans behind. As it is in the tradition, extended families and communities struggle to absorb these orphans.  T times there have been no parents left and children without adults alive at home struggled to organize themselves into new families. But extended families, and even moreso child-headed households, cannot afford school and health care for their children, brothers, and sisters without solidarity—locally and nationally and internationally. The orphaning of all of these children makes people even poorer and more vulnerable. Without appropriate action we have feared that Africa would become more and more poor, with diminished capacity to defeat poverty.

So, thinking beyond the examples of AIDS and malaria, what is needed to break the cycle of disease and poverty? Good health increases production capacity, which in turn leads to economic growth and poverty reduction. This leads to better health for the overall population as they have more money to pay for health services.

Taking examples of Rwanda, this lecture indicated the importance of developing a national policy framework, coordinating partners, proactively promoting gender-equity, mobilizing funds, integrating vertical programs in public health facilities, assuring sustainability and breaking down geographic and financial barriers.

We cannot ensure the basic human right of access to care for all without this battle. In breaking the vicious cycle of poverty, no one is exempt: no government, no sector, no agency, no NGO, no part of civil society, no multilateral organization, no individual – no expert, no scientist, no public health professional. All must join the fight.

Health and Human Rights: Creating an Open Forum to advance Global Health and Social Justice

Wednesday, September 17th,2008

HumanRights Journal Launch, Here the link:  - Part 1
HumanRights Journal Launch, Here the link:  Part 2

The Right to Health and the Right to Information are linked. Open Access Journals are good entry point to access to information and improve access to health care.

Rwanda’s history, and particularly, before 1994, the role of state-controlled radio stations in the genocide, had demonstrated that the right to information was critical to protecting individuals. The Rwandan government sees Information and Communication Technology as a top priority, and is working tirelessly to increase Internet access nationally.

This lecture reflected also on the irony of research done in developing countries that can’t never been available to the study subjects, without them paying for it. This is why the efforts of open access Journal in promoting access to a wider audience should be applauded as it increases access to education, information, and health all necessary for fighting against the cycle of poverty.