ROTARY CLUB DE BRUXELLES NOUVELLES BREVES: ÉCOUTONS LES FEMMES
Publié par Rotary Club de Bruxelles, le 9 Mars, 2021
Pour célébrer la Journée internationale de la femme, le 9 mars, le Rotary Club Bruxelles a consacré notre réunion à l’écoute des femmes. Lors de cette réunion, aux côtés d’autres femmes leaders, en tant que membre honoraire, j’ai partagé mon expérience en tant que femme leader et co-fondatrice de l’Université de Global Health Equity au Rwanda…
“Agnès est pédiatre et a occupé de nombreuses fonctions dans le renforcement du système de santé pour les enfants au Rwanda. Elle a également été ministre de la santé et a cofondé l’université Global Health Equity afin que chaque personne ait droit au même niveau de soins (https://ughe.org/) Elle est membre de l’Académie Nationale de Médecine aux USA et membre de l’Académie africaine des Sciences. Également membre d’honneur du club depuis 1 an. Agnès est arrivée en Belgique à 3 ans, a vécu comme une petite belge et y a étudié la médecine. Lors d’un voyage au Gabon, elle a eu la chance de rencontrer un système philosophique et social différent dans une région où le matriarcat était en place et avait gardé des structures précoloniales solides. Les femmes y avaient le rôle de leader. Pour faire un pendant, il y a longtemps au Rwanda, le Roi dirigeait avec sa maman. Le Roi ne parlait pas à la population mais faisait passer ses messages à travers sa mère. Cela donnait un certain pouvoir à la femme. Après le génocide, ce sont les femmes qui ont remis le pays sur les rails. Les femmes des deux ethnies ont décidé de s’unir sur la voie de la reconstruction. Jusqu’en 1994, la femme n’avait pas de droit d’héritage et très peu de femmes faisaient des études. Les lois ont ensuite changé : droit de contracter différents régimes de mariage, droit à l’héritage, droit de posséder un compte en banque, puis est arrivée la discrimination positive : la constitution dit aujourd’hui que si 30% d’un genre n’est pas élu, les élections sont annulées. Les partis ont poussé leurs femmes à participer au monde politique et ce sont aujourd’hui 61% de femmes au parlement. Des études ont été faites : elles sont moins corrompues, possèdent moins d’égo, ont une plus grande propension à aller vers un consensus et leur gouvernance est empreinte de compassion.
L’attention aux plus vulnérables est meilleure et la mortalité infantile y est de 30% inférieure. Mais, à la lueur du passé et du fait de la culture, c’est toujours la femme qui fait tout dans les ménages ! Il y a encore beaucoup à faire dans les villages. L’homme a toujours la main mise sur l’avenir de la famille… Dans la culture rwandaise, il faut aussi que la femme se marie et ne fasse pas de trop longues études. En faculté de médecine, ce sont 10% de femmes qui sont diplômées. Dans son université, c’est le contraire. On ne prend que des personnes capables mais sur les 100 premiers étudiants, filles et garçons, 30% des places seront dévolues aux garçons et le reste sera pour les filles. Il existe à cet effet un système de mentorat car s’il y a grossesse, elle veut pourvoir leur donner les mêmes chances de réussir. Dans les instances internationales, ce sont 25% de femmes qui ont des postes de leadership. La meilleure façon de mener un combat intelligent est d’éduquer les filles, qu’elles aient confiance en elles et leur signaler qu’elles n’ont jamais à s’excuser d’avoir été sélectionnées ! Combien d’hommes n’engagent pas de jeunes et brillantes jeunes femmes car il y a risque de maternité ? Au Rwanda, une assurance grossesse payée par toute la population a été créée : chaque rwandais paie 0.003 % afin que le secteur privé n’ait aucune raison de ne pas engager de femmes ! Tout doit passer par la loi sinon ce sont des individus qui agissent et le risque est grand de régression. Il faut être une grande gueule, et surtout avoir une gueule qui parle juste car à la moindre erreur, on la met sur votre dos. Mais on y arrive, hein…”
Black History Month: Fueling our Future with the Pride of our True Past
Published by Medical News Today on February 5, 2021
By Dr. Agnes Binagwaho, Brianna Ngarambe, and Kedest Mathewos
“The idea of Black History Month was born out of Carter G. Woodson’s Negro History Week, launched in 1926 in an attempt to challenge the underrepresentation of Black people in United States history. It wasn’t until the Civil Rights Movement in the 1960s that this weeklong celebration was transformed into a month.
The United Kingdom followed suit, recognizing and celebrating Black History Month for the first time in 1987. Other parts of the world should do the same, even if the celebrations would involve diverse reflections, expressions, and events across countries.
We can’t change the past, but we can correct the systematic historical negationism and focus on a future based on equity by leveraging the momentum built around the celebration of Black History Month. We should focus on actions for change and use this month as a checkpoint to measure, year after year, our progress toward equity, in health and across society in general. Together, as a community of people guided by equity, we should set goals and actionable steps that challenge the representation and narrative around Black history, culture, and contribution to humanity, to continue the fight for social justice and equity.”
Lessons from Rwanda’s Fight Against COVID-19
Published by Project Syndicate on December 31, 2020
By Dr. Agnes Binagwaho
“Rwanda’s success in fighting COVID-19 should lead us to rethink many assumptions about what it takes to build a strong health system. For example, Rwanda does not have an abundance of ventilators or intensive-care-unit beds, but it does have a system built on equity, trust, community participation, and patient centrism. By making evidence-based decisions, learning from the lessons of our past, and following the example of other successful countries, Rwanda has defied expectations and shown that any country can keep its citizens safe with the right strategies and leadership.”
COVAX Initiative: The Solution for Equitable Distribution of COVID-19 Vaccines
Published by Australian Outlook on December 4, 2020
By Dr. Agnes Binagwaho and Kedest Mathewos
“Eleven months after the first reported case of COVID-19, the world is still scrambling to find a solution that brings an end to this crisis. We know that the solution can only be a vaccine. However, historically, the pursuit of life-saving public health interventions has disregarded vulnerable populations globally, especially those in low- and middle-income countries (LMICs).
Even the successful distribution of the smallpox vaccine prioritised the global North, with the virus first eliminated in North America and Europe in 1952 and 1953, respectively. Even when the World Health Organization (WHO) initiated a plan to eradicate smallpox in 1959, the dearth of financial resources and health professionals prevented an effective response in the global South. The virus was eliminated last in Africa – only in 1977, 25 years after its elimination in North America. This example is instructive of what we should expect if the distribution of COVID-19 vaccines is not managed equitably.
Twenty years ago, a global movement was established to reduce unnecessary deaths from the HIV/AIDS epidemic. Global solidarity was manifested through the Global Fund, a public-private partnership that required countries to submit project proposals to apply for and be accepted to receive the funding. Today, there is an initiative to equitably and systematically distribute the COVID-19 vaccine to people at risk worldwide, without obliging countries to spend time conceiving a proposal for approval. If the COVAX initiative successfully achieves its mission of equitable distribution, we will enter a new era of global health solidarity, with this initiative potentially serving as a benchmark for program development against future health threats.”
A Call for Equitable Distribution of Covid-19 Vaccines
Published by BMJ on December 2, 2020
By Dr. Agnes Binagwaho, Dr. Paul Kadetz, and Kedest Mathewos
“For the majority of health threats that humanity has faced these past three decades—be it Ebola, swine flu, HIV/AIDS or others—reflections on an equitable response have been an afterthought, and this has only happened solely thanks to the fight and advocacy for social justice by global health activists. Provision of life saving medical and public health interventions have often disregarded the most vulnerable in society, despite the fact that they are more likely to be disproportionately affected. A prime example is the HIV/AIDS epidemic, during which the delayed establishment of a life-saving antiretroviral (ARV) programme in South Africa—one of the first African countries to get access to ARVs—is estimated to have caused the preventable loss of 330,000 lives between 2000 and 2005.
The search for a vaccine should not cause divisions. Throughout the past few months, we have seen various nationalistic and protectionist moves in countries around the globe. In June, the US monopolized the market for Remdesivir, buying up stocks of this potentially life-saving drug for the following three months. Although Remdesivir is no longer recommended as a treatment for covid-19, at the time this monopolisation of the drug was widely criticised. Moreover, a competition ensued between the US and Germany over a biotech company, CureVac, to ensure that the production of vaccines occurs on their own soil. These examples of greed and the inevitable competition to reach the finish line will not help us end this pandemic any sooner.
Instead, we should come together as a human family, reinforcing values of international solidarity to prevent any more suffering and deaths from covid-19. Now more than ever, we have seen how interconnected we are, with the health, economic, and social impacts of this pandemic traversing nation states. Therefore, as we expectantly wait for the rollout of a safe and effective vaccine, we need to design equitable, global distribution mechanisms that include the vulnerable, keeping in mind that no country is safe until we all are. This is the only way that we can prevent the legacy of the HIV/AIDS epidemic from repeating itself in the 21st century.”
Read full article here: https://blogs.bmj.com/bmj/2020/12/02/a-call-for-equitable-distribution-of-covid-19-vaccines/
What Explains Africa’s Successful Response to the COVID-19 Pandemic?
Published by Medical News Today on 20 November 2020
By Dr. Agnes Binagwaho and Kedest Mathewos
“In 2019, the Global Health Security Index ranked countries according to their preparedness for pandemics. The United States was identified as the most prepared country, while most African countries were deemed to be least capable of dealing with any new health threat.
Further entrenching this perspective of Africa’s lack of preparedness, Africa as a continent was predicted to have 10 million COVID-19-related deaths.
In the past few months, scientists, global health professionals, and journalists have attempted to explain Africa’s unexpected response to the pandemic. However, these explanations often fail to recognize the reasons behind the prompt response of African countries to the pandemic.”
The Hamwe Festival Explores Arts in Mental Health
Published by the East African on 17 November 2020
By Dr. Agnes Binagwaho, Injonge Karangwa, Kedest Mathewos, Brianna Ngarambe
“For centuries, art has been used as an expression tool of the human soul – the emotions, the ups and downs, the disappointments, the joys and the sorrows of everyday life. The arts tell the story of human existence by exploring the mental and physical states of being. However, the arts not only reflect the soul of the artists but also touch the souls of those engaging with it. The arts initiate a critical self-reflection of an individual’s life, the society in which they live and the associated norms. This engagement with the arts makes both the creators and consumers of artwork happier and more satisfied with their lives, thereby supporting them to maintain their mental health.”
Opinion: Why Universal Health Coverage is the Key to Pandemic Management
Published by Devex on 28 October 2020
By Dr. Agnes Binagwaho and Kedest Mathewos
“Over the past nine months, COVID-19 has killed more than 1 million people. However, this is likely an underestimation; many countries do not count the deaths of older adults in nursing homes or individuals who may have survived if not for the disruption in health service delivery systems. For example, there have been instances in which people avoided care because of fear of contracting COVID-19, lack of transportation due to the lockdown, or lack of money due to partial or total job loss.
However, the COVID-19 pandemic has shed light on the systemic flaws within health care systems worldwide that have made these practices unachievable. In various countries, we have seen how the lack of resilient health care systems backed by policies, strategies, and programs centered on universal health coverage — or UHC — contributed to a failed pandemic response and a disruption in the delivery of existing health care services.
Achieving UHC during a pandemic requires strong political will, collaboration between stakeholders, and a health care workforce trained in the principles of equity and evidence-based decision-making. This is what we are teaching at the University of Global Health Equity where we equip our students with the knowledge and skills needed to design and manage quality, accessible, and affordable health systems. It is only when we achieve such UHC that we can ensure safety for all.”
COVID-19: A Global Survey Shows Worrying Signs of Vaccine Hesitancy
Published by The Conversation on 28 October 2020
By Dr. Scott C. Ratzan, Dr. Agnes Binagwaho, Prof. Heidi Larson, Dr. Jeffrey V. Lazarus, Dr. Kenneth Rabin, and Prof. Lawrence O. Gostin
“It has been nine months since the World Health Organisation (WHO) declared the outbreak of COVID-19, caused by the SARS-CoV-2 virus, a “public health emergency of international concern”. Since then, more than 44 million cases have been recorded and over one million lives lost. Economic costs measure in trillions of dollars. Global recovery will take years.
We recently surveyed 13,426 people in 19 countries. We included two of Africa’s most populous and visible nations, Nigeria and South Africa, which are among the most affected by COVID-19 on the continent.
Overall, we found that 71.5% of participants said they would take a “proven safe and effective vaccine” while 14% would refuse it outright. An additional 14% said they would hesitate to take the vaccine.
As scientists, we should help health leaders to prepare now with education and dialogue to set appropriate expectations for when a coronavirus vaccine may be available. We need to build vaccine literacy with effective communication and community engagement for acceptance country by country, village by village, taking into account community-specific issues, concerns or misconceptions and working with local religious and civil leaders and influencers.”
Training Can Improve Patient and Health Worker Safety in Sub-Saharan Africa
Published by The Conversation on 14 October 2020
By Dr. Paul I Kadetz, Dr. Abebe Bekele, and Dr. Agnes Binagwaho
“Medical technology has made great advances. Yet, patients are often harmed while receiving medical care. Globally four out of 10 patients are harmed in primary and outpatient care. Furthermore, 15% of total hospital activity and expenditure is a direct result of adverse events or irregularities in healthcare delivery.
The most sustainable and cost-effective way to protect patients’ lives is to reduce the causes of human error. Therefore, health providers must strive to practise in a ‘error-free’ environment. In order to achieve this goal, health workers need to be properly trained to reduce adverse outcomes.
The current pandemic has taught us several lessons. The importance of the health and wellbeing of the healthcare workforce is a lesson that can’t be underestimated. Without a mentally and physically fit health workforce, alongside increased investment in their training to improve patient safety and healthcare quality, patients may ultimately suffer.”
Communicating Public Health and Social Justice
Published by Project Syndicate on August 13, 2020
By Laura Wotton and Dr. Agnes Binagwaho
“KIGALI – As the COVID-19 pandemic has shown, communication is a double-edged sword. It is one of the most powerful tools for changing behaviors. It can create awareness of – and compassion for – the plight of vulnerable groups, which suffer disproportionately during crises. When paired with a strong equity agenda and credible leadership, it can drive positive and inclusive action. But when it is misused – distorted by false assumptions, shortsightedness, and narrow self-interest – communication can be a dangerous weapon.
A comparison between the COVID-19 response in United Kingdom and Rwanda illustrates this dichotomy. The UK’s response suffered from a lack of rapid coherent political engagement and action, and its population was initially less responsive to public-health messages. Communication failures played a significant role in this.
The way authority figures such as media and political leaders communicate with the public can save or endanger lives, and it can challenge or reinforce injustice. Rwanda and all too few other countries, most notably New Zealand, have shown that in combating COVID-19, innovative, inclusive, and science-backed communication is the most powerful tool we have.”
Opinion: We Need Structural Change to Enable Self-empowerment — not Empowerment by Others
Published by Devex on 31 July 2020
By Dr. Timothy Carey and Dr. Agnes Binagwaho
“There can be no question that vulnerable people often require assistance to live the lives they would wish for themselves and their families. What form this assistance should take and how it should be provided, however, are matters where there is much less agreement. A solution that has been increasingly discussed in recent times has been the so-called empowerment of vulnerable populations.
When decision-makers and people in positions of power report that they are empowering different individuals or groups, we should be very wary about their intentions.
For some decision-makers, the rhetoric of empowering the vulnerable is the fashionable tactic they have adopted for the purpose of self-promotion and perhaps also to secure another term in office. For others, while they might genuinely want vulnerable people to be empowered to live as they would wish, these decision-makers encounter a dilemma because they do not really want to share their power with the vulnerable.”
Africa: Greatest Global Challenge is Cooperation – Not COVID-19
Published by AllAfrica.com on 14 July 2020
By Dr. Timothy Carey and Dr. Agnes Binagwaho
“Kigali — Pandemics come and go. The tragic effect of plague in the Middle Ages reminds us that Covid-19 wasn’t the first, and it is clear that it won’t be the last…
…While large amounts of resources and tireless efforts are being dedicated to finding a vaccine, there is still no solution on the horizon. There are, however, some discernible patterns of what it means to address this problem effectively.
Where solidarity and compassion are cultivated, the penetration of SARS-CoV-2 is harder. A refusal to invest in cooperative and collaborative solutions is far more dangerous in the long-term than the fragility of our health systems or our own individual physical health. Comprehensive solutions to problems such as Covid-19 require genuine cooperation, both nationally and internationally, between governments and the private sector, and at all levels of the health system.”
Read the full article here: https://allafrica.com/stories/202007150001.html
Beyond Florence Nightingale: How African Nurses Have Decolonised the Profession
Published by The Conversation on 9 July 2020
By Timothy Carey, Agnes Binagwaho, and Judy Khanyola
“This year – 2020 – marks the 200th anniversary of Florence Nightingale’s birth. It’s therefore understandable that it’s being marked as the year of the nurse and midwife.
Nightingale is best known for her pioneering spirit and fearless approach to changing atrocious conditions and improving healthcare service delivery. These qualities still characterise the attitudes and habits of nurses around the world. They are often the only frontline healthcare workers caring for people – whether they are vulnerable and living in poor and isolated settings or well-off in rich parts of the world.
But Nightingale left two legacies. The other is less known.”
Opinion: ‘Silent Discriminator’- the Women Global Data is Leaving Behind
Published by Devex on 19 June 2020
By Agnes Binagwaho and Tsion Yohannes Waka
“We, as women, might be surprised at this time to see figures that suggest we are less vulnerable to COVID-19 than our male counterparts, with more male deaths reported globally than female. This data fills our screens, via live updates and situation reports. But look closely and you’ll find it is incomplete — and terrifyingly so.
This “silent discriminator” weaves a parallel web of destruction in its economic, political, and social burden on women. The reality is that COVID-19 has aggravated the preexisting inequities that women face in the division of labor, widespread gender-based violence, and hardship roles in front-line health care. While there is some sex-disaggregated data on coronavirus deaths among most-affected countries, there is still lack of sex-disaggregated data to support future interventions that tackle the long-term impacts of the pandemic.”
Read the full article here: https://www.devex.com/news/opinion-silent-discriminator-the-women-global-data-is-leaving-behind-97465
COVID-19 Shows the World Needs Physicians Who Can Look Beyond Medical Charts
Published by The Conversation on 3 June 2020
By Abebe Bekele and Agnes Binagwaho
“As modern medicine has advanced, so too has our understanding of what affects health. Over recent decades this has generated a number of new fields in medicine. One of the most important that has been born out of the latest generation is social medicine. It studies how social and economic factors help determine our health, specifically inequalities within societies that negatively influence health outcomes.
Similar to primary health care, social medicine prioritises health equity and promotes a broad view of health, multi-sectoral action and the participation of communities. Both significantly contribute to progress in improving health equity.
COVID-19 has placed a spotlight on the field of social medicine. It has done so by showing up inherent injustices in society. An example is the fact that African-American and Native American communities in the US are experiencing disproportionate COVID-19 deaths. The result is that more people are beginning to argue that social medicine should take centre state in the medical community. But the argument towards a more progressive approach to healthcare is also being met with criticism by those who still cling to the traditional model of medicine.”
Read the full article here: https://theconversation.com/covid-19-shows-the-world-needs-physicians-who-can-look-beyond-medical-charts-138460
The Difference Between Gender Equity and Equality—and Why It Matters
Published by Fortune on 25 March 2020
By Agnes Binagwaho
“The theme of this year’s International Women’s Day was centered around the notion that “[a]n equal world is an enabled world.” Indeed, there has been global progress toward a world that has gender equality; nearly 68% of the countries (101 of 149) included in the World Economic Forum’s latest Global Gender Gap Report showed improvements in their scores for gender parity for 2019.
But despite this progress, education is one of many areas in which men and women are still not equally enabled. So while the world is close to reaching gender parity in terms of access to primary education, girls still face more obstacles to their education than boys in low- and middle-income countries. Laws may enable girls to attend school, but in many countries there are still other barriers limiting girls’ education, such as families prioritizing boys’ education and cultural beliefs that girls should be limited to a future of raising children…
… Today, our global society still has 10 years left to reach the goal of gender equality set by the UN’s Sustainable Development Goals. To achieve this, it is time for all of us to shift from an equality to equity agenda and ensure that all are actively promoting and supporting women, in education and in all aspects of life. Only then can an equal and truly enabled world be achieved.”
Read the full article here: https://fortune.com/2020/03/25/gender-equality-and-equity-iwd-womens-education/
Lessons from Rwanda on How Trust Can Help Repair a Broken Health System.
Published by The Conversation on 30 September 2019
By Agnes Binagwaho and Miriam Frisch
“Seven countries around the world – three of them in Africa – have made faster than expected progress over the past 15 years in reducing deaths among children younger than five. These seven countries, Bangladesh, Cambodia, Ethiopia, Nepal, Peru, Rwanda and Senegal, were selected because they have all performed unexpectedly well in improving childhood health relative to their economic growth.
There are many factors at the root of their achievements, most notably, a strong integrated and coordinated health system built on primary health care. However, one cross-cutting factor stands out that we believe allowed them all to achieve significant health gains but which, so far, tends to be always overlooked: trust.”
Read the full article here: https://theconversation.com/lessons-from-rwanda-on-how-trust-can-help-repair-a-broken-health-system-124183
A Medical School for The Future that Africa Needs.
Published by Devex on 12 September 2019
By Agnes Binagwaho and Miriam Frisch
“The vision of achieving “health for all” by 2030 is gaining political support across the developing world. More and more leaders recognize the imperative of investing in health at a time when every $1 invested in health in developing countries can produce up to $4 in benefits annually.
But one of the challenges in realizing the goal of universal health coverage in Africa — which would ensure that everyone has access to quality, affordable health care — is the need to rapidly scale up the health care workforce.
Although Africa accounts for 24% of the global burden of disease, it has only 3% of the global health workforce. Shortages of health workers at the national level are exacerbated by severe imbalances in their distribution within countries, especially between rural and urban areas.”
Read the full article here: https://www.devex.com/news/opinion-a-medical-school-for-the-future-that-africa-needs-95527
The Road Ahead for US Foreign Aid to Africa
Published by the Aspen Ideas Festival Blog on June 18, 2018
By Agnes Binagwaho
In this blog post, I offer my recommendations for the US entities who provide aid to sub-Saharan Africa, as part of my speaking engagement in the Our Planet, Our Health track at Spotlight Health at the Aspen Ideas Festival.
“Africa was a continent once deemed “hopeless” by the US media. Sub-Saharan Africa, in particular, was condemned to an endless cycle of poverty, starvation, and tragedies. Yet in the past 10 years, the region has undergone major transformations thanks to home-grown solutions and outside support. Sub-Saharan Africa’s rise is due to interconnected factors including growing economies, efficient governments, and focused foreign development support, through both governmental and non-profit investment.”
Read the full article here: https://www.aspenideas.org/blog/road-ahead-us-foreign-aid-africa
GCSP Hosts the Event “One Health, One Planet. Environment and Health in the Human Security Agenda.”
Published by Geneva Center for Security Policy on May 31st, 2018
“On 22 May 2018, the Geneva Centre for Security Policy (GCSP), in partnership with the University of Global Health Equity (Rwanda), organized an event under the title: ‘One Health, One Planet. Environment and Health in the Human Security Agenda’.The panel was moderated by Mr Bruno Jochum, former director of Médecins sans Frontières (MSF) and an Executive-in-Residence within the GCSP. The panelists included Dr Stephane de la Rocque, Head of the One Health Team in the Health Emergency program of WHO, Dr Desiree Montecillo-Narvaez, Programme Officer in UN Environment Programme (UNEP) as well as Dr Agnes Binagwaho, Vice Chancellor of the University of Global Health Equity, former Minister of Health of Rwanda.”Read the full article here: https://www.gcsp.ch/News-Knowledge/News/GCSP-hosts-the-event-One-Health-One-Planet.-Environment-and-Health-in-the-Human-Security-Agenda
Landmark Studies in Rwanda, Madagascar Show Success for Universal Care Model
Published by Partners in Health on May 16, 2018
“BOSTON (May 16, 2018): Deaths of children under 5 have dropped by nearly 20 percent in just two years in a poor, rural district in Madagascar—despite the island nation’s lowest health spending in the world. This transformation echoes the strength of results charted across the last decade in rural Rwanda, where under 5 mortality dropped 60 percent between 2005 and 2010 in Southern Kayonza and Kirehe districts. Both sets of results were products of a grassroots health system movement founded on principles of public partnership, data science, and universal access to care for all. … Professor Agnes Binagwaho is senior author on the Rwanda study, having served as the Rwanda Minister of Health from 2011 through 2016. “Through Rwanda’s commitment to a universal right to health, we have continued to witness transformation that has rendered our country’s health system an example for not only Africa, but for the world,” she said. “We embrace the shared vision and work of our partners in Madagascar. Together, we can pave the way to inclusive health systems that advance equity and health for all people.” Prof. Binagwaho is currently on the faculties of both Harvard and Dartmouth Medical Schools, and is the Vice Chancellor of the University of Global Health Equity, a new Rwanda-based university that trains global health professionals from across the globe.”
Read the full article here: https://www.pih.org/press/landmark-studies-rwanda-madagascar-show-success-universal-care-model
New Management Training for Immunization Leaders Launches in Rwanda
Published by Yale News on May 15, 2018
“This is an unprecedented opportunity,” said Erika Linnander, director of the Yale Global Health Initiative (GHLI), during her opening remarks at the recent launch in Kigali, Rwanda of a new immunization program. “I see such an exceptionally diverse group here today to help support this program — nurses, managers, policymakers, government officials, development partners, physicians, and educators. This coming together in support of improved management and leadership is fundamental to the achievement of global health targets.” …“Thoughtful leadership and effective management practices are necessary to strategically and equitably improve health systems, including making sure vaccines reach children in every corner of the world,” said UGHE Vice Chancellor Dr. Agnes Binagwaho. “By hosting this forum in Rwanda, participants will train in an environment that prepares them to both address delivery challenges, as well as inspire them to improve access to high quality care.”
Read full article here: https://news.yale.edu/2018/05/15/new-management-training-immunization-leaders-launches-rwanda
Words of Wisdom from African Women Moving the World Forward
Published by MasterCard Foundation on April 9th, 2018 By Shona Bezanson
“When African women come together to discuss transformative leadership, one can’t help but feel amazed, inspired and energized. The African Women’s Leadership Conference recently hosted by Wellesley College provided seasoned African women leaders with an opportunity to share their leadership journeys with the continent’s emerging young women leaders….
Dr. Agnes Binagwaho, a pioneer and activist in the global public health sector shone a light on gender inequity at all levels of global health. She also shared her newest project — the University of Global Health Equity, in Rwanda — a revolutionary model of health care provision that puts equity at the center. She told us: ‘find your passion. Fight for it. Be ready to die for it. It gives you life.’”
Read the full article here:http://www.mastercardfdn.org/words-of-wisdom-from-african-women-moving-the-world-forward/
African Women on Top
Published by Project Syndicate on March 8th, 2018By SHONA BEZANSON, PETER MATERU
“TORONTO – Africa has a long history of female leadership. Yet leadership can be a challenging aspiration for the continent’s young women, owing to enduring barriers to success. If African countries – and Africa’s women – are to meet their potential, this must change… Former Rwandan Minister of Health Agnes Binagwaho has dedicated her career to achieving equitable access to health care in her country and beyond”
Rwanda has Universal Health Care – and it’s Working
Published by BLKHLTH on February 28th, 2018By Paulah Wheeler
“‘It gives relief to people knowing that if you get sick, you don’t need to have a lot of money,’ said Dr. Agnes Binagwaho, the former Minister of Health who turned health in Rwanda around with her belief that health care is a human right for all. ‘It gives you psychological stability so you can concentrate on something else. The money can be used for other things – this is very important in trying to stimulate economic development.’”
Read the full article: https://www.blkhlth.com/blog/2018/2/28/defining-moments-and-figures-in-the-history-of-black-health
2017: The Year in Quotes
Published by Partners In Health on Dec 18, 2017
A view of Chiapas, Mexico. Photo by Cecille Joan Avila / Partners In Health.“Inspiration in a sentence—that’s what we were looking for as we sifted through our stories about Partners In Health in 2017. Like any round-up, this collection of quotes falls short of conveying the breadth and depth of all that was accomplished this year. PIH staff saw 1.5 million patients in clinics and hospitals, never mind the hundreds of thousands consulted in their homes. But hopefully these few quotes, chosen for their pithiness, hint at one important aspect of the work: our deep gratitude for the chance to serve such amazing people.…‘The more our students are spread across the world to serve vulnerable populations, the more we will be able to change the world.’—Dr. Agnes Binagwaho, vice chancellor of PIH’s University of Global Health Equity in Rwanda, on her hope for graduates”
Read the full article here:https://www.pih.org/article/2017-year-quotes
Vice Chancellor Agnes Binagwaho Inducted to the National Academy of Medicine
Published by the University of Global Health Equity on October 19, 2017
“Washington, D.C. (October 14, 2017) — Vice Chancellor of the University of Global Health Equity (UGHE), former Minister of Health of Rwanda and global health champion Agnes Binagwaho, MD, M(Ped), PhD has been inducted to the National Academy of Medicine (NAM), an esteemed society of over two thousand distinguished contributors to the advancement of health and medicine.”
Read full article here: https://ughe.org/national-academy-medicine/
Bending the Arc, Partners in Health Documentary
October 6, 2017
This is a documentary that I was a part of along with Paul Farmer, Ophelia Dahl and Jim Kim Yong which talks about the work of Partners in Health, using Rwanda as an example and looking at the progress that has been made in health.Directed by: Kief Davidson and Pedro Kos Produced by: Cori Shepherd Stern, Executive Producers – Matt Damon and Ben AffleckScreened at: Sundance Film Festival, Miami International Film Festival and San Francisco Film FestivalAwards: Best Documentary Feature Film at the Greenwich International Film Festival (2017)
Find the documentary trailer at: https://www.youtube.com/watch?v=OjJmWZrmpcEFor more information on screenings please visit: http://bendingthearcfilm.com/screenings/
Social Media Saves Lives and Makes the World Better
Published by Techonomy on September 18th, 2017
By Agnes Binagwaho
“Social media is not just for fun, socializing, and commerce. Recent innovations, such as how conversations on Twitter have advanced the debate about global health, the use of Twitter and Facebook to register the satisfaction of medical patients, and many others, should change our preconceptions. More and more, these digital platforms are showing their value as vital agents in communication, saving lives, and serving as vehicles for advocacy and campaigning. It is leading to more efficacy and efficiency in human development and in global health. Such platforms facilitate health management, the exchange of ideas on a global scale, and improve the outcomes of actions as practitioners, experts, and ordinary people share experiences.”
Read the full article here: https://techonomy.com/2017/09/social-media-saves-lives-makes-world-better/
The Secret Behind Rwanda’s Successful Vaccination Rollouts
Published by The Conversation on August 10, 2017
By Agnes Binagwaho
“The best medical treatment option in the world can’t save a single patient unless it is delivered at the proper time, with the proper plans and processes in place. That’s why implementation science for health matters.”
University of Global Health Equity’s Contribution to the Reduction of Education and Health Services Rationing
Published by International Journal of Health Policy and Management on July 9th 2017
This is a video summary made by the International Journal of Health Policy and Management (IJHPM) in which I explain what the University of Global Health Equity brings to health education and how we aim to help the poor and those living in rural areas.
Read the full article here:http://www.ijhpm.com/article_3371.html
Watch the video here: https://www.youtube.com/watch?v=Yq1ngoa0zUE
Dr. Agnes Binagwaho Appointed Commissioner for the Task Force on Global Advantage
Published by the University of Global Health Equity on June 30th, 2017
“Over the last decade, Rwanda has seen significant advances in economic growth and population health. Developments in mobile health technology, household-administered rapid diagnostic tests, and support systems that integrate information and communications technology (ICT) are transforming not just how care is delivered – but where. By delivering high-quality health care and social services in some of the country’s poorest communities, Rwanda has developed a strong brand in global health delivery.”
Read the full article here:https://ughe.org/task-force-on-global-advantage/
Training the Next Generation of Global Health Leaders in Africa
Published by Devex on May 31st, 2017 by Catherine Cheney
“At this time of year, students around the world are putting on their caps and gowns for graduation ceremonies. Among them are 23 students from Rwanda and one from the U.S. who graduated as the first class of the University of Global Health Equity in Kigali, Rwanda, on Saturday.…Agnes Binagwaho, vice chancellor of the university and a former minister of health in Rwanda, calls UGHE ‘both exceedingly ambitious and urgently needed.’”
Read the full article here: https://www.devex.com/news/training-the-next-generation-of-global-health-leaders-in-africa-90037
Former Rwandan Minister of Health to Lead Partners In Health’s Groundbreaking University
Published by the University of Global Health Equity on March 31st, 2017
“Kigali, Rwanda (March 31, 2017)—The University of Global Health Equity (UGHE) announces the appointment of Professor Agnes Binagwaho, MD, M(Ped), PhD, former Rwandan Minister of Health and a champion for health equity, as its new Vice Chancellor.”
Read the full article here: https://ughe.org/former-rwandan-minister-health-lead-partners-healths-groundbreaking-university/
The Heart of Africa’s New Medical School
Published by Project Syndicate on February 1st, 2017 by Michael Fairbanks
“SAN FRANCISCO – Rwanda has achieved some of the most dramatic gains in health and poverty-reduction in the world. This small, landlocked African country (the size of Massachusetts, but with twice the population) has developed a primary health-care system with near-universal access to clinical care and insurance. Rwanda has reduced both economic and health-care inequality, and demonstrates how ‘health equity’ helps to build strong societies.…In 2015, the government of Rwanda and the Boston-based Partners In Health (PIH), with the help of the Bill & Melinda Gates Foundation and the Cummings Foundation, established the private, not-for-profit University of Global Health Equity (UGHE). The university is founded on the principle that every member of a community deserves the same care and opportunity, and focuses on the delivery of quality health care to those who need it most. Agnes Binagwaho, a co-founder of UGHE who is a former minister of health and an adjunct professor at Harvard Medical School, once said to me, ‘Why would I want to raise my children in a nation where all children don’t get the same medical care as they do?’”
Read the full article here: https://www.project-syndicate.org/commentary/rwanda-universal-health-care-ughe-by-michael-fairbanks-2017-02?barrier=accesspaylog
Published by the University of Utah on January 26th, 2017
I was invited to speak with students and staff from the College of Social Work, School of Medicine, and the College of Architecture and Planning at the University of Utah. Find the full article here:
Read the full article here:https://thc.utah.edu/lectures-programs/talks-at-the-tanner/
Construction on UGHE Paves Way For The Next Generation of Leaders
Published by the University of Global Health Equity on December 11th, 2016
“Kigali, Rwanda – The University of Global Health Equity (UGHE) will break ground on its Butaro campus, initiating the first phase of construction on a facility that will support over 1,000 students and faculty and convene the world’s leading minds in health care delivery.…‘More than a shift in higher education, UGHE represents a shift in opportunity,’ says Dr. Agnes Binagwaho, Professor of the Practice of Global Health Delivery at UGHE. ‘The university will serve as an intellectual hub for the world’s best and brightest; many of whom will come from Rwanda and, as graduates, drive the success of our health system.’”
Read the full article here: https://ughe.org/construction-ughe-paves-way-next-generation-leaders/
The Evolution of the Physician Role in the Setting of Increased Non-Physician Clinicians
Published by the International Journal of Health Policy and Management on September 13th 2016
In this video, I give a commentary about a paper I worked on explaining the evolution of the physician role published in the International Journal of Health Policy and Management (IJHPM)
Title of paper: The Evolution of the Physician Role in the Setting of Increased Non-physician Clinicians in Sub-Saharan Africa: An Insistence on Timing and Culturally-Sensitive, Purposefully Selected Skill Development;
Video Comment on “Non-physician Clinicians in Sub-Saharan Africa and the Evolving Role of Physicians”
Authors: Agnes Binagwaho; Gabriela Sarriera; Arielle Eagan
We Need to Bring Mental Illnesses out of the Shadows
Published by the World Bank on April 13, 2016
By Agnes Binagwaho
“In an act to survive and rebuild, we turned to our communities for healing. Giving a voice to the people and collectively finding a solution to the mental health challenges that we faced at that time has helped Rwanda to resiliently move forward on a path toward recovery.”
Deutsche Welle Interview on Non-Communicable Diseases
June 10, 2016
Here, I am interviewed by Deutsche Welle, the German Broadcast Service for foreign countries, during the 2016 World Economic Forum, which was held in Kigali. This discussion was around the impact of non-communicable disease on development and the need to create health systems and sustainable partnerships to support the delivery of quality care. I share my perspective on how a multi-sectorial approach and teamwork is essential to reach each patient at the right time.
The full interview with all participants is available at:
Taking Stock on Malaria in Rwanda
Published on June 15, 2016 in The New Times by Dean Karemera
Rwandans have been urged to ensure that their homes and surroundings are kept clean at all times and clear bushes or stagnant water which are breeding grounds for mosquitoes. Dr Agnes Binagwaho, the Health minister, made the call, yesterday, at a news conference at the ministry headquarters.
She warned that, due to the warm season ahead, malaria cases could shoot up again if caution is not undertaken by homes to supplement government efforts to ensure that no person dies of malaria again.“In the fight against malaria, we’ve realised that there’s a portion that is still not fully done, and that is the maintenance of sanitation in homes and our environment.
The government can provide bed nets, train community health workers, offer medical insurance but if we ignore the simple things such as cleanliness in our homes and environment, we won’t succeed in the fight against malaria,” she said.The minister urged the public to seek quick medical attention whenever they fall sick and people without insurance cover to get it.She added that, in a research conducted two years ago, they found out that people without medical insurance accounted for more than 3 times the deaths resulting from malaria.“Most people who die from malaria are those without medical insurance because they fear seeking medical care without it. I urge them to get medical insurance because it’s likely that malaria is going to increase. We have trained community health workers to handle cases and they are fully equipped,” she added.
During the implementation of the malaria contingency plan in highly affected areas, the ministry increased the number of effective long lasting insecticidal nets (LLINS), targeted indoor residual spraying and improved the levels of malaria and behavioural management and inspection of insecticides, drugs and malaria commodities.The number of houses sprayed stands at 453,320 representing 99 per cent in five out of eight highly affected districts.Also, 2.6 million LLINS have already been distributed and an additional 6 million will be distributed by the end of this year.
Malaria cases have significantly reduced from 2,456,091 last year to 1,353,861 cases this year.On the issue of bed nets that were once procured and later found not to be effective, the minister said they now conduct their own testing of bed nets even after the World Health Organisation has done its own testing.This, she said is to ensure that the bed nets are up to the standards as required by MOH.“Although government is employing different methods to fight against malaria, what is most important is that we embark on maintaining cleanliness in our houses and communities. Hygiene is very important in this fight,” she said.
For inquiries on the above article, please contact email@example.com.
American Medical Association Journal of Ethics Feature on Rwanda’s Health Sector
In July of 2016 the AMA Journal of Ethics featured a podcast, which gives an accurate view of our current health sector. The link to the podcast is here:
Rwanda: Using Innovation through Drones to Save Lives
Africa: Govt Closer to Using Drones in Medical Supplies Delivery
Published on May 15, 2016 at 7:32 pm in All Africa by Julius Bizimungu Article retrieved from:http://allafrica.com/stories/201605160346.html
Zipline Inc, a California-based robotics firm Friday announced details of a partnership with Government to make on-demand deliveries of life-saving medical products using drones.
This follows a deal signed in February, between the government and the firm to build infrastructure for unmanned aerial system (UAS) to ensure efficient logistical transportation of medical supplies in the country.
Speaking during a press briefing, the Minister for Youth and ICT, Jean-Philbert Nsengimana, said that Rwanda is ready to receive the first delivery of drones.
“We have had a fruitful and a fun-filled week talking about the forth industrial revolution at the World Economic Forum (WEF). I think it’s very significant for people to know that what they might think will be achieved in future, is already here in Rwanda. We already have the technology that people think we will have in the future. Rwanda is ready to receive the network of drones, and I truly believe this is going to shape the future,” Nsengimana noted.
Often, essential health products don’t reach the people who urgently need them.According to the World Health Organisation (WHO), millions of mothers and children die every year due to conditions that could be prevented or treated with access to simple, and affordable medical interventions.
However, in the developing world, access to these interventions is hampered by what is known as the last-mile problem: the inability to deliver needed medicine from a city to rural or remote locations due to lack of adequate transportation, communication and supply chain infrastructure.The distribution of blood products is particularly challenging given the strict temperature requirements and short shelf life. Africa has the highest rate of maternal deaths in the world, mainly due to post partum hemorrhaging, which makes access to lifesaving blood transfusions critically important for women across the continent.
In Rwanda, rural hospitals have struggled with supplies in the past due to their isolated locations. Most life-saving supplies are currently delivered via motorcycles. According to Dr Agnes Binagwaho, the Minister for Health, the initiative is truly a life-saving technology. “We have established that if we manage to use this technology, it will be a life-saving initiative. There are a lot of advantages, but I’m also hopeful that as pioneers we learn by doing. Although, I can’t predict how many lives will be saved, even saving one life is crucial,” she said.
What Zipline is bringing
According to Keller Rinaudo, Zipline Chief Executive Officer, the company is working with the government of Rwanda to create a network of delivery drones that will ferry medical supplierding to the World Health Organisation (WHO), millions of mothers and children die every year due to conditions that could be prevented or treated with access to simple, and affordable medical interventions.
However, in the developing world, access to these interventions is hampered by what is known as the last-mile problem: the inability to deliver needed medicine from a city to rural or remote locations due to lack of adequate transportation, communication and supply chain infrastructure.The distribution of blood products is particularly challenging given the strict temperature requirements and short shelf life. Africa has the highest rate of maternal deaths in the world, mainly due to post partum hemorrhaging, which makes access to lifesaving blood transfusions critically important for women across the continent.
The network will have capacity to make 50 to 150 deliveries per day, using a fleet of 15 drones, each with twin electric motors and an almost eight-foot wingspan. The unmanned drones will use GPS to navigate, and will airdrop supplies before returning to the landing strip from which they were launched.
“The inability to deliver life-saving medicines to the people who need them the most causes millions of preventable deaths each year. Zipline will help solve that problem once and for all. We’ve built an instant delivery system for the world, allowing medicines and other products to be delivered on-demand and at a low-cost, anywhere,” said Rinaudo.
Starting July, the government will begin a public-private partnership with Zipline for the last-mile delivery of all blood products throughout the country. A team of Rwandan and American engineers will set up and operate Zipline’s first Hub in Muhanga District. From this Hub, Zipline will deliver life-saving blood to 21 facilities located in the Northern, Western, and Southern Provinces.Zipline plans to expand services to Eastern Province in early 2017, putting almost every one of Rwanda’s 11 million citizens within range of lifesaving medical product deliveries.
The partnership will strengthen ongoing efforts by the Ministry of Health to deliver a high standard of health care.
First Lady Urges Action to End Neglected Tropical Diseases
Published on May 14, 2016 in New Times by Athan Tashobya
Article retrieved from:http://www.newtimes.co.rw/section/article/2016-05-14/199872/
First Lady Jeannette Kagame addresses the meeting on NTDs in Kigali yesterday. (Courtesy)
Africa needs stronger commitment from both public and private sectors to tackle Neglected Tropical Diseases (NTDs) on the continent, First Lady Jeannette Kagame has said. Mrs Kagame made the remarks, yesterday, at a World Economic Forum-sanctioned event convened by the END Fund on ending neglected tropical diseases on the continent. The event intended to shade more light on the continent’s health issues, and particularly called for increased investments in NTD control in sub-Saharan Africa. The event was attended by Her Royal Highness the Queen of Buganda Kingdom of Uganda, Sylvia Nagginda; the Chief Executive of the END Fund, Ellen Agler; the Minister for Health, Dr Agnes Binagwaho, among other officials and health experts.
Buganda Queen Sylivia Nagginda delivers her keynote address at the meeting. (Courtesy)
A study conducted by Erasmus University, and released at the End Fund event, indicates that Sub-Saharan Africa could save up to $52 billion by 2030 if the region meets the World Health Organisation’s 2020 control and eliminations target for the five most common neglected tropical diseases, such as Elephantiasis, River blindness, Bilharzia, Intestinal worms and Trachoma.The study was conducted with support from the Bill and Melinda Gates Foundation.
Mrs Kagame said this kind of events bring more light to some of the health issues still affecting the region, calling for stronger partnerships in bringing an end to the NTDs. “In a world fast evolving and creating new solutions to various health, environmental, socio-economic problems, while connecting people through technology, it comes as a sad irony that such a large population of our planet still struggles with diseases that should have been eradicated a long time ago,” the First Lady said. Figures indicate that 1.6 billion people have had at least one tropical disease, while 500,000 die each year from complications linked to the diseases. Mrs Kagame said “the figures of the number of people affected worldwide each year, by these various tropical diseases are indeed alarming.”“I believe that, for our communities to pave the way to a future free from these health issues, we must continue educating our populations on how to protect themselves, but also further invest in strengthening institutions for more efficient health care systems, able to respond rapidly to this kind of crises,” she said.
Discussing the role of traditional and cultural institutions to end NTDs, Queen Nagginda said NDTs have been recognised as a health challenge “yet little attention have been paid to this challenge.”She said NTDs are mostly found along the Rift Valley side of Uganda and urged cultural leaders to be part of the campaign to end the diseases. “Cultural institutions have a role to play in fighting NTDs through partnering with health institutions to promote healthcare programmes. Cultural leaders have the ability to mobilise, modernise communities towards health care and development matters,” Through her Nnabagereka Foundation, the Queen of Buganda has been involved in several health advocacy and women empowerment efforts in Buganda region in central Uganda.
On Rwanda’s case, according to the Ministry of Health, there were no large scale NTDs control efforts in place and data on the burden of the diseases until 2007. However, over the last eight years, the Government, with support of partners such as The End Fund, has taken steps to reduce the burden of NTDs. Dr Binagwaho said Government has since mapped the prevalence of intestinal worms, bilharzia, elephantiasis and Trachoma, adding that it is now “implementing a comprehensive approach to improve hygiene, mass drug administration, among other NTDS case management campaigns.”
Health minister Dr Agnes Binagwaho addresses the question of NTDs with Agler. (Courtesy)
“The Government has tripled the budget to curb NTDs in the last three years, and it seeks to double the budget in the next two years,” she said. End Fund’s Agler said NTDs control efforts “offer a return on investment unparalleled in global health.”
“Ending these debilitating diseases will help reduce poverty at all levels,” Agler said.Mrs Kagame said, over time, Rwanda has seen a decrease in the number of people affected by these infections and the country now considers only two of the five NTDs to be a public health problem.
“I trust that such a conversation, will help create a stronger sense of our shared responsibility in fighting these diseases, while implementing strategies that can significantly empower our communities to fully thrive, to live the kind of dignified lives, we all so rightfully deserve, irrespective of our cultural or economic backgrounds.”
Rwanda Army Joins Battle Against Malaria
Published on April 22, 2016 at 7:32 pm in KT Press by Patrick Bigabo
Article retrieved from:http://ktpress.rw/2016/04/rwanda-army-joins-battle-against-malaria/
Rwanda’s Army has joined the fight against malaria that is increasingly claiming more people both in the country and in Africa.
The Military is currently engaging different players in the health sector to harmonise efforts against the killer disease. The Army is coming in to utilize its resources which includes, doctors, logistical muscle and the human resource distributed across the country.
The Ministry of Health is championing the campaign. A symposium was organised together with the military to define strategies and interventions that can be implemented at different levels of the health system.
The head of internal medicine at Rwanda Military Hospital, Lt. Col. Dr. Jules Kabahizi said at the symposium that the army is keen on contributing significantly to reduce malaria cases with a long term objective of eliminating the disease.
Health Minister Dr. Agnes Binagwaho said during a one-day Malaria symposium at Serena Hotel that, “am glad our army has joined the battle field. ”
“Malaria is a threat, malaria is a problem, and it’s not only for Rwanda alone but for the whole region and it is affecting even the economies,” she said.
According to Binagwaho, Rwanda had pushed malaria to the edge and “we had started the elimination phase but it’s increased ten times more.”
Statistics from the ministry of health indicate the country has managed to reduce incidence of malaria by 86%, Mobility by malaria by 87% while mortality was reduced by 74%.
Dr. Binagwaho said that mosquitoes are now able to fly between 4 to 22 kilometers a day and survive to up to a month and are able to fly higher altitudes. This implies they can now easily fly across borders.
“Now they have leant to fly high because of global warming, it’s no longer cold up there and in less than a month they can cover the country,” she noted.
The movement of mosquitoes facilitated by several factors makes it difficult for one country to lay strategies to eliminate Malaria and thus suggests joint strategies for regional governments.
Malaria experts said drug-resistant malaria is not spreading across eastern region, but is developing independently in isolated pockets.
For Dr. Binagwaho with this new knowledge on drug-resistant malaria, there is need for regional member states to collaborate on a new strategy for combating the potentially fatal parasite.
Prof Zulu Prenji, chair-pathology in Aga Khan university Hospital told KTPress that Malaria fight needs political support. He explained that in countries where there are problems such as corruption, the fight becomes challenged.
Dr. Olushayo Olu, World Health Organisation Representative in Rwanda says despite remarkable increase in malaria cases, countries still have room to eliminate Malaria deaths through early detection and prevention.
Meanwhile, in a rare breakthrough, an international team of scientists has discovered that a mutation that makes parasites resistant to a key anti-malarial drug winds up killing them.
“The resistant parasites die before they can infect another person,” said Christopher D. Goodman of the University of Melbourne, a member of the research team.
Read more at KT Press: http://ktpress.rw/2016/04/rwanda-army-joins-battle-against-malaria/
Medics Tipped on Professionalism
Published on March 28, 2016 in The New Times – Rwanda By: STEVEN MUVUNYI
Medics have been urged to improve their profession by prioritising the common good of the medical practice.The call was made by the Minister for Health, Dr Agnes Binagwaho during the election of the National Council of the Rwanda Medical and Dental Association.Minister Binagwaho told the medics to positively brand their profession, despite the shortage of doctors and teachers’ in the country.“We need to consider how we want the population to perceive us. We have to prove that we are the right people at the right place, with the right knowledge, right ethics and the right morale,” she said.
Binagwaho asked medics to be humble in order to deliver correctly. “The improvement of our profession is a continuous process. Gone are the days a doctor did and knew everything. A good doctor has to learn every day since science is an evolution,” she added.The elected national board that will serve a four-year term is composed of DrEmmanuel Rudakemwa, the chairman, Dr Jean Claude Byiringiro, the vicechairperson, Dr Albert Nzayisenga, the secretary as well as Dr Kaitesi Mukara Batamuriza, the treasurer.The national board also includes representatives of the public medical and dental schools, dental and private practitioners among others.The voters were twenty nine provincial representatives.
Prof. Emille Rwamasirabo, the outgoing chairman of the council was pleased by the progress made during his tenure and advised the new committee to work hard to impact Rwanda’s medical future.“Many professional malpractices were solved, but we still need to work on the improvement of uncaring doctors and increase the training,” he said. Dr Rudakemwa, a radiologist, newly elected chairman of the council said the new committee will work hard for quality improvement in medical practices.“With the partnership and cooperation with the Ministry of Health and the out going committee, we hope to take this institution to greater heights,” he said.Established in 2003, Rwanda Medical and Dental Council is responsible for the regulation of medical and dental practice in Rwanda.It is in charge of registering and licensing all medical and dental practitioners.
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Experts Discuss Health Financing
Published in The New Times -Rwanda on March 31, 2016 by HUDSON KUTEESA
Local and international experts on health financing are meeting in Nyamata, Bugesera District to discuss the desired health financing modifications and how they can be aligned with the Sustainable Development Goals.The two-day conference that opened yesterday is held under the theme: “Health financing reforms in the eve of sustainable development goals.”The conference attracted over 150 participants, including experts from Senegal, Sierra Leone and Ethiopia, deliberating on how current health financing policies can be a stepping-stone toward achieving the SDGs.The national and international experts, especially those who have contributed in the design and implementation of health financing reforms in Rwanda are sharing current state of health financing policies and brainstorming about the future directions.
Dr Agnes Binagwaho, the Minister for Health in an interview with journalists said the conference would come up with ideas on how to generate finances for the health sector and look at ways of using it efficiently.“Rwanda has achieved the SDGs, but to us, it is not enough. We want more achievements and it needs money.
So these health financing experts are gathering to come up with innovations of financing the health sector and how we can use the finances efficiently.We need innovation for example electronic medical records which use ICT linked with diagnostics. Such innovations reduce the money spent or bring efficient spending. We hope to come up with solutions for the future in the global architecture of health.”Claver Gatete, the Minister for Finance and Economic Planning emphasised the importance of financing the health sector which he described as the foundation of all development in Rwanda.
“The health sector is an area that we can’t avoid because it will come back and haunt us. It is the foundation of all development in Rwanda.The topic of health financing is very timely. It comes at a time when we are looking at what we have achieved in vision 2020. So, it will help us to see ways of financing the health sector and how we can work with the other financing institutions to contribute to the sector,” he said.“Investing in health sector is very important.For instance if we invest in health equipment, there will be no more going to India for surgeries and other complex medical processes.And this can save a lot of money and even bring in forex when neighbouring countries send their patients for treatment here.”He also called for innovation that will see Rwanda be able to finance such institutions without depending on support from outside countries, citing an example from last year’s budget where 66 per cent was from domestic resources, 14 percent borrowed and 20 per cent from grants.“We should think differently.
We cannot expect that money will always be coming from outside all the time.We have to think innovatively towards health financing by working with partners, tapping into the private sector institutions and most importantly engaging the population.”He expressed hope that by working together, the health system can change for the better and thanked the financing partners working with the ministry of health including Global Fund, the US government, Bill Gates Foundation, Rockefeller Foundation and bilateral donors like the Belgians among others.
The Rwanda Vision 2020 considers health financial accessibility as a key priority among its strategic directionAmong the anticipated outcomes of the meeting are understanding the current status of global health financing reforms in the areas of universal health coverage and quality assurance approaches; reviewing of different approaches to ensure sustainable quality improvement and exploration of ways to link financial reforms with quality assurance and improved initiatives.The discussions from the meeting will feed into the current government process of developing a health sustainability plan for the whole health email@example.com
Undergrad Interns for Rwanda Minister of Health
Published on March 29, 2016University of Vermont University Communications by Amanda Kenyon Waite
As one of six kids, Gabriela Sarriera ’17 is practiced in the art of speaking up and asking for what she wants. So when the microbiology major heard the Rwandan minister of health deliver a moving talk at the Global Health and Innovation Conference at Yale last year, she waited patiently in the long line after the keynote — not to ask for a photo as others had done — but to ask for a job.“I want to know how can I help,” she remembers telling Dr. Agnes Binagwaho, a pediatrician who returned to her home country after the genocide and has helped recover a ravaged health system. Sarriera, who attended the conference as a member of UVM’s global health club, MedVida, also has plans to pursue medical school and become a pediatrician. But beyond just a career role model for Sarriera, Binagwaho is an inspiration.The minister is the 2015 winner of the Roux Prize for her work to rebuild trust in the Rwandan health system and her contribution to initiatives that have increased the country’s life expectancy by 20 years, drastically dropped the maternal mortality rate, and, now that people are living longer, is expanding care for non-communicable diseases, as well. The Atlantic has called it a historic recovery — one the U.S. could learn from.Sarriera promised the minister that if she accepted her help, she would find a way to get to Rwanda. FaceTiming from Kigali nearly 12 months after the Yale conference, Sarriera makes clear the gratitude she has for Binagwaho, who, amazingly, took a chance on the undergrad by offering her an internship, exposing her to work normally reserved for graduate students.
Healthcare for all
For three months now, Sarriera’s been immersed in learning the history of the Rwandan legal system. Why law when it’s medicine she wants to pursue? Her project expands on Binagwaho’s doctoral research, which uncovered troubling limits the colonial-influenced legal system puts on ensuring all citizens have the same access to healthcare. The path forward in the health sector means fully understanding policy that’s been shaped by a complex history. Sarriera’s work began Christmas day with a flight to Europe, where the English minor began her internship with a document search, trying to trace the history of the book of laws that’s the basis for Rwanda’s legal system.
Vaccines in Rwanda
September 25, 2015
Please see this piece on vaccines in Rwanda recently published by Vaccineswork. It was a pleasure working on this article with Anisha Hedge, a medical student at the University of Virginia who spent the past summer in Rwanda. Here, we provide an overview of the benefits of vaccines in our efforts to improve the health and well-being of Rwanda. Please see the entire article here: http://tmblr.co/Z_c1Ou1tXdTN1
Rwanda’s Sustainable Strategy for Saving Lives
Agnes Binagwaho, Ministry of Health Rwanda and Anisha Hedge, University of Virginia School of Medicine.
“Rwanda has demonstrated the value of vaccines over the past 15 years, as the rollout of new and underused vaccines has helped us reduce under-five mortality by two thirds, and achieve the fourth Millennium Development Goal (MDG) along the way. This year, as the world transitions to the Sustainable Development Goals (SDGs) and partners aim to end poverty by 2030, immunisation must remain at the core of the health agenda. As well as saving lives, the benefits of vaccination programmes stretch beyond immunisation to improving health services and promoting social integration, and Rwanda is the case study to prove it.”
1. VACCINATION CAMPAIGNS AT THE CENTRE OF SOCIETAL DEVELOPMENT
Rwanda has increased basic vaccine coverage (DTP3) from 77% in 2001 to 99% in 2014. In the last seven years Rwanda has introduced new and under-used vaccines against pneumococcus, rotavirus, rubella and human papillomavirus (HPV), and maintained high rates for traditional vaccines. Vaccination campaigns present the opportunity to reach out to the population with a range of other health services. During the pneumococcal campaign in 2009, advice was given on causes and symptoms of pneumonia to facilitate early detection and access to treatment. Community health workers also educated parents on good health practices such as breastfeeding and wholesome nutrition.
2. ACHIEVING EQUALITY IN HEALTHCARE
To encourage equal access to health care, Rwanda holds a Mother and Child Health Week twice a year. It offers a range of health services; vaccination campaigns such as rubella and HPV for adolescent girls, the provision of iron tablets for pregnant and lactating women to prevent anaemia, vitamin A supplements for all children under five years and a family planning campaign for women of reproductive age.
3. FORGING NATIONAL PARTNERSHIPS
Vaccination programmes have fostered new working relations between different governmental and non-governmental organisations. This was evident with the rollout of the HPV vaccine in schools in Rwanda which involved a partnership between the Ministry of Health, Ministry of Education, Ministry of Gender and Family Promotion and the Ministry of Local Government in order to reach adolescent girls in schools and communities.
4. STRENGTHENING HEALTHCARE INFRASTRUCTURE
Adequate health system infrastructure is essential for the effective rollout of vaccines. In Rwanda this has included improved waste disposal facilities for contaminated materials, new cold rooms for temperature-controlled storage and increased medical storage capacity.
Currently, the Rwandan government self-finances all traditional vaccines, such as the tuberculosis vaccine BCG, and co-finances with international partners to provide new and under-utilised vaccines. This trend has been demonstrated with the pneumococcal vaccine and is currently unfolding with the HPV vaccine, which protects against major causes of cervical cancer. Looking ahead, we hope that as demand increases, vaccine prices will be driven down, thereby creating a sustainable future for vaccine provision. Globally, there is still a way to go. One in five children in Gavi supported countries still miss out on the basic package of childhood vaccines; around the world about 1.5 million children die from vaccine-preventable diseases each year. But as our country has shown, immunisation can sustainably address this inequity, and so much more besides. With immunisation as part of the next set of development goals, we can help all countries make the most of these vital tools, and we should — because life, whether lived in the remote areas of Rwanda or the suburbs of London, deserves a fighting chance.
Angus Deaton’s Cartoonish Moral Calculus
By Agnes Binagwaho, August 30, 2015
In July of 2015, I posted this article in the Boston Review to address not only the absurd comments from Angus Deaton, but also the shocking, pervasive racism that is so often expressed by intellectual yet arrogant people.
I spend a lot of time explaining and promoting Rwanda’s record on public health to audiences around the world. Together with our research and funding partners, Rwanda has made unprecedented strides on almost every health measure. We are one of the few developing countries that will meet all MDG targets. All Rwandans have access to health insurance, and maternal mortality has fallen at historically unprecedented rates.
For Angus Deaton, these gains only served to entrench dictatorship and repression in Rwanda. How? By threatening to let our children die unless altruistic and gullible Westerners pay our government to keep them alive.
Deaton believes that we ‘provide health care for Rwandan mothers and children’ in order to ‘insulate ourselves from the needs and wishes of our people’. I can’t tell if he means that Rwandans don’t wish for good health, or that our country would be more democratic if we neglected basic needs.
As a Rwandan, and as a physician, I have heard a lot of outrageous statements in my life. But Professor Deaton has invented an entirely new level of absolutism.
How does one begin to reply? More facts and figures about Rwanda’s progress would only reinforce Deaton’s grotesque logic. Testimonials from the donors and researchers who know Rwanda best would be dismissed as compromised.
Moreover, Rwanda is not the issue here, and I would feel no satisfaction if Deaton apologized to Rwanda and then went to pick on a different country that better exemplifies his stereotypes.
The issue is moral, and it concerns all of us. Deaton’s theory rests on the assumption that Africans don’t feel love for their children. It follows that President Kagame, being an African, sees children as a commodity, like copper or sweet potatoes, to be sold to people in the West who value their lives more highly.
Angus Deaton doesn’t know Paul Kagame from Kunta Kinte. The president is just a cartoon character he uses to argue against foreign aid. Deaton isn’t referring to the real Paul Kagame or the real Rwanda, but to a generic ‘other’ whose moral inferiority is so self-evident that it requires no elaboration.
In other words, Deaton knew his readers would share in the contempt. In point of fact, Paul Singer replied complaining about Deaton’s criticisms of his work; but he made no mention of the scandalous libel of President Kagame.
This is neither ignorance or carelessness. It is an ideology of moral superiority, a form of racism that is all the more pernicious because it has no name and leaves no marks on its victims. Eventually the victims internalize it and come to despise themselves.
By dropping the mask a little, perhaps Angus Deaton has done us all a favor. We need to have more honest conversations about the assumptions implicit in judgments we make about each other.
Rwanda’s story is tragic and hopeful in equal measure. Maybe the first step is for Angus Deaton, Paul Singer, and anyone else who feels concerned by this exchange, to visit Rwanda and see for themselves what kind of people we are, and how we care for our children. They would not be the first visitors to Rwanda who left with a deeper appreciation for our common humanity.
Read article here: http://bostonreview.net/blog/letter-editor-agnes-binagwaho-angus-deaton
Rwanda’s Quest for Universal Health Coverage
July 9, 2015
The following essay on Rwanda’s Quest for Universal Health Coverage was featured in the Commonwealth Health Partnerships annual booklet, which is now available online: http://www.commonwealthofnations.org/wp-content/ebooks/CHP15/#/102/
I encourage you to look over the various essays on topics related to UHC, ageing, governance, NCDs, and much more throughout this publication.
Preserving Hope Amid False Protection
Published by the New Times on May 1, 2015
Below is an Op-Ed I composed for the New Times that was published on Labour Day in Rwanda. May we continue to “ignore detractors”. “Today, as we celebrate the International Labour Day, I reflect upon the great challenges that Rwanda faced 21 years ago and then consider the great progress that has been made by all the workers in Rwanda; I am so proud to call Rwanda my home.”
“Today, as we celebrate the International Labour Day, I reflect upon the great challenges that Rwanda faced 21 years ago and then consider the great progress that has been made by all the workers in Rwanda; I am so proud to call Rwanda my home. However, when I read news articles suggesting that our progress is somehow “following in the footsteps” of other countries, I find this argument wanting. Though it may not be intentional, such a characterization of our progress has the insulting implication that workers in Rwanda are incapable of seeking out innovative solutions to improve their lives on their own.My conclusion is that some of the people who make such claims, many of whom have never set foot in Rwanda, believe that a country of black people in the heart of Africa is incapable of achieving the kind of progress they only read or hear about.On the contrary, under the visionary leadership of President Paul Kagame, workers in Rwanda have demonstrated great will and ability to plan and deliver substantial improvements on our economy, health, education and governance sectors.After 1994, much of the world viewed Rwanda as a failed state. They expected us to stay disorganised. That has always been their expectation of black Africans, a pre-judgment that is not immune to racism. Indeed such analysis unveils a pernicious double standard.Thus, for those who have observed Rwanda’s progress, they have been surprised. According to the World Bank, Rwanda still only has a GDP per capita of $638. Yet, we have made progress that exceeds this level of development.We have managed to do more with each available dollar.The world does not expect that workers in Rwanda keep streets clean, and that the country is governed according to the rule of law. A population full of energy and hope, a police force that protects and services the people without asking for a bribe, an army that protects civil rights and uses its personnel to promote the health, education and wealth of the citizens under its protection. And yet this is the reality here.And still, today, 21 years after the Genocide, people are astonished that we used our own energy and forward looking minds to get out of the dark hole that characterised our past, and even more so, that we have done this in one generation. Their surprise is due to the unwarranted low expectations of us. They cannot deny the undeniable evidence that such progress has been made, they only argue that it is because we have followed in the steps of others. Often, they suggest that we are mimicking Singapore, as opposed to building our future based on our own Rwandan values.The desire to strive for excellence is universal. To simplify the pursuit of excellence in Rwanda to an effort to “mimic” or copy another’s success undermines all the Rwandan workers who have made Rwanda’s journey possible. We do not need other countries to inspire us to work for the good for our people.We have had our own innovations that have contributed to Rwanda’s development. These include Gacaca courts, the One Cow per Family programme (Girinka), the national dialogue (Umushyikirano) during which leaders are held accountable by the electorate, and the conception of global partnerships such as Rwanda’s Human Resources for Health Programme, which is creating high quality physicians to improve our nation’s health.Other examples include community participation to facilitate vaccination of 90 per cent of our children with 11 vaccines, a record rate of coverage. Another example is the community empowerment of people in villages to select 45,000 dedicated voluntary health workers.I could also talk about the national policy to ensure equity in human development and access to health opportunities even for the most vulnerable – a pillar of our national policies – which has allowed Rwanda to have community-based health insurance (Mutuelles de Santé) a health centre staffed by nurses in each sector (except 18, to be covered soon), a district hospital in each district, and a provincial hospital in each province. In addition, three new referral hospitals are planned to ensure that Rwandan citizens are equitably served.We certainly have had the accompaniment and support of tremendous partners since 1994 and we are absolutely grateful to them, but it is the Rwandan people who, with their relentless efforts, have fundamentally driven this progress.I am grateful for the transformative leadership that holds us accountable to ensure we meet the highest expectations, that does not accept actions that would promote double standards, and promotes the fulfillment of human rights as we carry forth on this path towards a better tomorrow. Happy International Labour Day!The writer is the Minister for Health.”*Published in Rwanda New Times – 1 May 2015 – http://www.newtimes.co.rw/section/article/2015-05-01/188367/
Ministry of Health Commemoration Event
Published by the New Times on April 25, 2015
I was honored to participate in the commemoration events in Nyanza where we commemorated our brothers and sisters killed during the 1994 genocide against the Tutsi. Afterwards, we held an event for 35 Ministry of Health colleagues who were killed during the genocide against the Tutsi 21 years ago.
Read more here: http://www.newtimes.co.rw/section/article/2015-04-25/188184/
Reflections on Kwibuka 21
Published by the New Times on April 11, 2015
Below is my Op-Ed on Kwibuka 21 that was published in New Times in April 2015. I hope you will take a moment to read through these reflections on what happened in Rwanda 21 years ago and where we are today.
“This year, for the first time, I spent the entire first day of Kwibuka in my village. It was a moving way to begin the 21st commemoration of the Genocide against the Tutsi. As I spent the day alongside my neighbours, many of whom suffered so much from the Genocide, I found myself moved by the courage of the great people of Rwanda.For the survivors who chose to seek reconciliation as opposed to revenge, you have allowed this country to move forward to where it is today. I am deeply humbled by your courage to forgive.By doing so, you have offered your hand to lift Rwanda from the ashes it once was.Today, we are a peaceful and strong country. We are proud of what we have become. As His Excellency President Paul Kagame has said, “this country has changed for the better and for forever”. I am thankful for this transformative leadership that has guided and inspired us all along this difficult but meaningful journey.Immediately after the Genocide against the Tutsi, 21 years ago, much of the world viewed Rwanda as a lost cause. They expected us to fail if we were left to our own devices. They believed, as usual, that it was a place that required a hero from the outside. But they were mistaken. Our heroes are you the survivors and you our great President, Paul Kagame, who led us to our journey of recovery.Mister President you are a true hero for leading those who ended the 1994 Genocide. You are a hero for continuing to lead us in our quest for stability, peace, development and prosperity.My other heroes are those survivors who have faced unimaginable suffering, trauma and pain and yet are striving daily for a better future for all Rwandans – for both survivors and perpetuators and the generations to come. I salute the values that have guided you, including the spirit of self-determination and ownership. Agaciro. Because of you, Rwanda has shown that poverty, savagery, revenge and terror are not acceptable destinies.
Our story since 1994 has also helped to show how misguided and harmful opinions can be when it comes to false global solutions to assist nations that are trying to overcome great obstacles.For instance, some justified withholding life-saving health interventions from Rwanda’s children because it will add “man-years of human misery”, (The Lancet)[i]. There are some in this world that promote such failures to humanity. I could provide many other examples of international organisations that essentially did the same in so many areas.The world failed to imagine that Rwanda could be where it is today. We have thus proven these dangerous skeptics wrong. We have shown that we can break dangerous cycles of despair through forgiveness, reconciliation, and standing united for a brighter future.Many describe Rwanda’s transformation over the past two decades as nothing short of a miracle. And yet this discredits the intentional and participatory processes that we have developed as a country to overcome these formidable obstacles.Under the guidance of our President, a leader who knew that a brighter future would only be possible if Rwandans internalised and worked towards this vision collectively. We trusted him and he leads this movement to be innovative in our collective thinking. We have refused to leave the most vulnerable behind and held strong to our commitment to equity.We have created policies that are relevant and responsive to the community at the grassroots level. We have sought out partners who share in our Vision 2020 and beyond. And so much more. Such innovations have translated into consistent economic growth and unprecedented health improvements, among others. Thank you Mister President.While we have come so far, we all know that we have a long way to go under your guidance. Our journey has only begun. But this promising future for our beautiful land of a thousand hills would not be possible without the critical, challenging first steps that our beloved survivors took to pursue real and lasting reconciliation.To each of you, I hope you know how deeply I admire your courage and thank you for the opportunity to learn from you and be with you in this journey towards a brighter future for all Rwandans.”
Read more here: http://www.newtimes.co.rw/section/article/2015-04-11/187761/
Interview with European Times
Published by European Times on March 5, 2015
I had the opportunity to meet with a team from the European Times and share reflections on the progress we have made in the health sector and a number of our goals to further this progress
A link to the full article is available here: http://www.european-times.com/sector/government/dr-agnes-binagwaho-rwandas-minister-of-health/
**Minister of Health Highlights Impressive Progress and Future Goals
Dr. Agnes Binagwaho, a paediatrician, has been Rwanda’s Minister of Health for the past four years. She discusses the efforts Rwanda is making to bring high-quality, affordable healthcare to its people and outlines current and future projects.
European Times: How has the Rwandan healthcare sector evolved over the past decade?
Dr. Agnes Binagwaho:Rwanda has achieved more progress in its healthcare sector than expected, in spite of limited funding. Great improvements have been made in access to services, financing, equipment and human resources. The Ministry of Health is working with high synergy across sectors to use funding as efficiently as possible. Rwanda has reduced death rates from AIDs, malaria and TB, and now offers universal access to HIV treatment. Around 90% of Rwandan children have been vaccinated with ten different vaccines. We are steadily increasing the number and quality of our healthcare professionals and we have implemented an advanced electronic information system for the healthcare network.
European Times: What are your current goals for the healthcare sector?
Dr. Agnes Binagwaho:The ministry’s mission is to bring good health to all Rwandans. Having made great progress in combating communicable diseases, Rwanda now needs to tackle non-communicable diseases. The ministry has launched preventive campaigns concerning protection from HIV infection, the need to wear seatbelts and helmets, and the risks of smoking. We will continue to expand the healthcare network and will upgrade existing hospitals to three more referral and four provincial hospitals. The ministry is promoting private-sector participation, public-private partnerships, education and investment in healthcare infrastructure. Public-private partnerships are already very important in the healthcare sector, since around 40% of the country’s hospitals are privately owned but benefit from government support.
European Times: What are the main challenges the healthcare sector faces?
Dr. Agnes Binagwaho:We need more healthcare professionals and more specialists in different medical fields, including oncology. Rwanda now has nine nursing schools which will graduate a total of around 900 nurses per year. We need to quadruple the number of Rwanda’s healthcare professionals so Rwanda welcomes private universities offering healthcare training. Expanding the healthcare infrastructure is one of the Ministry’s goals.
European Times:What are the opportunities for foreign investors?
Dr. Agnes Binagwaho: In addition to investment in healthcare training, the Ministry of Health wants to attract investment in private healthcare facilities and high-quality pharmaceuticals, and may outsource the management of public hospitals. Investors should keep in mind that Rwanda is well placed to become a regional healthcare hub.
Beyond MGD’s: Why We Need to Strengthen Our Institutions
Published in the New Times on February 18, 2015
I hope you will take a moment to read my OpEd published by the New Times on 18 February 2015 regarding the need to strengthen our institutions to assure a better health system for Rwandans.
“We know how far we have come to be where we are today. As I reflect upon several achievements attained not only as the health sector but the entire nation, I am also reminded of the long journey ahead to meet the set goals in the interest of all Rwandans.A good example is the positive outcomes we have witnessed following the decentralization of our health system. Decentralization in Rwanda has translated into real and meaningful empowerment, placing critical responsibility in the hands of the local leaders.This empowerment has grown in parallel with the increasing capacity of the central government to monitor, evaluate, and strengthen its auditing role. This has helped improve accountability across all levels to ensure we are doing all we can to better the healthcare system.For instance, by applying the fiscal decentralization with the national budget, hospitals have been assigned their funds through the district budgeting process. Also, other health financing strategies for the country are based on decentralization.This includes the community-based health insurance known as Mutuelles de Sante, which serves as a useful example to demonstrate how the local and central governing structures work together. It also shows how we are continually learning and adapting to improve the program.
Mutuelles was created about 15 years ago and it is now undergoing its third major reform. The first reform involved changing the amount that each household paid for their health insurance premiums.At first, each household paid for a single household, but the reform ensured that each household would contribute the amount appropriate to reflect the number of people in their domicile to improve fairness of the contributions across the country as well as financial access for all.The second reform involved the implementation of the stratification system, so that each person would pay in accordance with their income as opposed to a flat fee per person. The third reform is ongoing.The government is transitioning the management of Mutuelles to the financial professionals at the Rwandan Social Security Board which has the mission to provide quality management of health insurance. This will ensure the sustainability of the programme.All of these reforms have relied upon an effective decentralization of responsibility and authority to the local governments that also oversee Mutuelles starting at the district level; the direct management of the Mutuelle staff by the local administration puts the Mayor in charge of this programme in that district.In general, this decentralization structure has been working well. Having local leadership overseeing the local implementation of Mutuelles has been helpful. These local leaders have, on the whole, been loyal, trustworthy and hardworking, and are dedicated to their mission vis-a-vis their administrees.
Unfortunately, however, there have been a handful of local leaders who have been dishonest – acting as though they were more powerful than Rwandan institutions. They did so by stealing the hard-earned money that people had placed to get their health insurance locally.And such dishonest acts were discovered through the complementary, central auditing system in place through the Ministry of Internal Affairs, the Ministry of Local Government, Ministry of Finance and Economic Planning, and the Ministry of Health.In Rwanda, we have a zero tolerance for corruption. Thus, at all levels, we create institutions, such as the auditing system noted above, that reinforces accountability and discourages dishonest actions by making the cost of corruption high. In this case, those local leaders who unjustly took money from the health insurance pool for their own personal gain were appropriately identified by this system. These individuals will be held accountable for their criminal actions and will reimburse up to the last penny of what they have taken, even if this means that they have to sell their assets.Rwandans should rest assured that their investment into their health insurance will not be lost. We have learned from this experience that we can be even more vigilant in our fight against any form of corruption, nepotism, or any crime moving forward.
Creating systems that reinforce honesty and accountability is very vital to protecting our integrity, our rights, and development as a country, especially as we strive to reach our Vision 2020 goals.Yet this experience has taught us that we need to foster the growth of honest local leaders coupled with improved central level institutions that bolster accountability and reassure the people that their interests are being protected.I am grateful to live and work in a country where systems are strong enough to identify and correct problem areas or loopholes. Our effort to learn from both our successes and mistakes allows us to continuously improve every day in our efforts to protect public goods, community assets and people’s rights.
The writer is the Minister of Health “*Published in the New Times on 18 February 2015. Available at: http://www.newtimes.co.rw/section/article/2015-02-18/186076/
Securing Health for the Next Generation
Published by New Vision on December 14, 2014
An Op-Ed that I recently wrote on ways to improve healthcare for the next generation was featured in Uganda’s newspaper New Vision on 12 December. “Today, as Rwanda’s Minister of Health, I can attest to the great progress our country has made to improve the health of everyone living in the “land of a thousand hills.” But I also recognize how critical it is to keep pressing onward, not only as a country, but also as a continent.”
“When I served as a pediatrician in Rwanda’s public hospitals, I devoted myself to building a future where children could reach their full potential without fear of disease.
Today, as Rwanda’s Minister of Health, I can attest to the great progress our country has made to improve the health of everyone living in the “land of a thousand hills.” But I also recognize how critical it is to keep pressing onward, not only as a country, but also as a continent.
Africa is home to some of the fastest growing economies in the world, but the benefits of this progress have not been felt equally. For far too many, basic health care remains out of grasp. Millions of Africans simply do not have access to health facilities staffed with trained workers, or even to experienced community health workers. Even for those fortunate enough to live in close proximity to a health facility, many cannot afford to pay for basic healthcare services.
The time has come to commit to making affordable, quality health care the cornerstone of Africa’s development. Several African countries have taken a stand on providing health services to all their citizens, and their efforts are already paying off through healthier communities.
Twenty years ago, Rwanda was a nation devastated by genocide and war: Nearly eight in ten people lived in poverty, our health system was all but destroyed, and one in four infants didn’t make it to his or her fifth birthday.
Today, even though we still have a long way to go, Rwanda is flourishing. This is due to many factors, including a collaborative governance structure that aims to extract the most value for our people from the money spent.
Rwanda’s visionary approach to prioritizing the nation’s health has also been instrumental in achieving this progress.
Combining national resources with international donor support, we have developed a system to improve both geographic and financial access to quality basic care for all Rwandans.
Through our community-based health insurance scheme, called Mutuelles de Sante, approximately 90 percent of the population has health insurance, with another 7 percent reached through civil, military, or private insurance.
Even in the most remote villages, Rwandans can rely on local community health workers to deliver 80 percent of the preventive and primary care services and connect them to advanced care when needed. Under this system, Rwandans can access care without fear of financial ruin.
The results of this approach, driven by a deep commitment to health equity, have been striking: Since 2000, infant mortality has decreased by 66 percent, child mortality has decreased by more than 70 percent, and deaths from HIV, malaria, and TB have fallen by nearly 60 percent. Rwanda’s children were the first in sub-Saharan Africa to receive the vaccines for pneumonia and the human papilloma virus (HPV).
Other African nations are also making important strides towards universal health coverage. Each country is developing its own model to provide coverage for its people—informed and influenced by our distinct cultures, histories, populations and settings. For example, in Uganda, the government has committed to establishing mandatory health insurance for all citizens by 2025. Going forward, it is necessary that each country feel ownership of both the successes and failures of the approach they opt to take.
Whatever the approach, health systems should be participatory in nature, ensuring that communities provide “buy in” to the value of having health insurance, as well as a sustained political commitment to scale up these efforts. This will help ensure that no one remains beyond the reach of efforts to provide affordable, quality care.
The need for universal health care has never been greater throughout the world, and especially in Africa. Despite commendable progress in health over the past decades, Africa still faces the highest burden of disease, and continues to have far too many weak health systems. The recent Ebola epidemic has highlighted what is at stake for all of us if we fail to invest in both strong health systems alongside good governance.
Health coverage is also a major financial challenge. Millions of Africans suffer financial hardship due to catastrophic expenditure whenever they are sick. According to the World Health Organization, about half of health care expenses in our region are paid out-of-pocket, and a 2009 study in Health Affairs found that one in every three households in Africa must borrow money or sell their possessions just to pay these fees.
No family should have to choose between getting well and going bankrupt, especially when we’ve witnessed what a powerful force national health care can be for stability and economic growth. When governments invest in affordable health care, the whole population is healthier. There are real economic benefits: there is less absenteeism at work, and the money saved by avoiding these consequences of poor health can be invested in building stronger futures for families and communities. School fees can be paid, new business can be started, and households can build savings.
Politically, there has never been a better time for us to invest in universal health coverage. Two years ago today, the United Nations unanimously endorsed universal health coverage. Global institutions such as The Rockefeller Foundation and, more recently, The World Bank, have elevated the benefits of UHC globally, and to date more than 80 countries have asked the World Health Organization for assistance in implementing universal health coverage.
Today, we mark the anniversary of this landmark decision with the first-ever Universal Health Coverage (UHC) Day, a global call-to-action that has garnered unprecedented support from more than 500 organizations.
As we look beyond the 2015 Millennium Development Goals, African leaders face an incredible opportunity: If we invest in our health systems now—which we know yields an impressive return for the investment—we can build an Africa where individuals, families, and entire nations reach their full potential.
Together, we can chart a course for a stronger, more resilient Africa and world.”
How Can Design Health
October 4, 2014
Please take a moment to watch this video by our friends in architecture – the MASS Design Group – who helped to construct the Butaro hospital.
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.”**See full article on this web link: http://ic2030.org/2014/09/grand-convergence/
World Health Organization and UNICEF Accountability: We are not there yet
Published by the New Times on 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.”
Please see my OpEd that was published in today’s New Times: http://www.newtimes.co.rw/section/article/2014-09-15/180939/
PhD Life and Reflections
Published by the New Times on September 9, 2014
Given my background as a paediatrician 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. 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. I’ve also included a picture from the special graduation day 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 aDoctorate 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
September 4, 2014
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.
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 http://www.lancet.com.”
The above text and figures are from http://www.globalhealth2035.org/sites/default/files/policy-briefs/overview-english.pdf
Let’s Use Evidence-Based Interventions to Save Lives of Children and Mothers
Published by the Huffington post on June 25, 2014
The 06/25/2014, I had the great pleasure to publish in Huffington Post, this article with Mark Shriver, the Senior Vice President for Strategic Initiatives, Save the Children.
“If 18,000 preschool kids and 800 moms were attending a World Cup game and they all died, no newspaper around the world would be silent. But that’s exactly what happens every day around the world: 18,000 kids die before they reach the age of five and 800 moms die during pregnancy or childbirth. The biggest tragedy is that in both of these cases, most of these deaths are preventable.”
Today, over 500 representatives from governments to non-governmental organizations to the private sector are gathering in Washington, DC to take on this challenge and discuss how we are “acting on the call to end preventable maternal, newborn and child deaths” — a pledge that 176 governments and over 450 civil society organizations and faith-based organizations signed two years ago.This is an opportunity not only to reflect on the tremendous progress made on improving maternal and child survival around the world, but also to double-down on our success and demand more attention and resources. Imagine how many lives could be saved if we coupled political will with sufficient resources focused on key interventions.Over the last two decades we have nearly halved the number of children dying annually and reduced the number of maternal deaths by 45 percent. Twenty-five countries, including Rwanda, have reached Millennium Development Goal Four (reducing child mortality by two thirds) and a number of other countries are on track.In fact, according to “Countdown to 2015 modeled data in 2013,” Rwanda not only had already achieved an under-five-year mortality rate (U5MR) reduction of more than 70 percent, but it has the fastest rate of decline in child deaths of any country, ever.
Rwanda’s success, while remarkable, is not a mystery. Investments were based on the evidence, tackling the biggest threats to child survival by increasing effective interventions such as vaccinations and breastfeeding rates. The government has put equity at the core of efforts to strengthen the health system from putting community health workers in villages and ensuring appropriate care facilities at the sector, district and provincial levels, as well as referral hospitals across the country. This approach to bring care and prevention near where the people are living has drastically improved the geographic accessibility for all. And this commitment to reach all Rwandans has been mirrored in the Vision 2020 strategy that will improve socioeconomic conditions.Rwanda is a success story but much remains to be done: no country should stop before ending the last preventable child death. Many countries in Africa are experiencing success, but the risk of a child dying before five is still highest in the African Region — about six times higher than that in the Americas. Today, a woman’s risk of dying from childbirth in sub-Saharan Africa is more than 47 times greater than in the United States.Rwanda proves that it doesn’t have to be this way. A recent study by the World Health Organization noted that an additional $8 per capita per year investment in Africa could prevent up to four million maternal deaths, 90 million child deaths within a generation in the region. And the benefits can transform not only families, but also economies: investments in maternal and child health yields economic benefits including higher per capita incomes and increased labor force participation.To end preventable maternal, newborn and child deaths globally, we must increase attention and resources in Africa.
Today, USAID is releasing a report, Acting on the Call: Ending Preventable Child and Maternal Deaths that lays out a roadmap for dramatic progress over the next five years. The US and African Presidents will come together in August to talk about investing in future generations. Together, we have an opportunity to use this Summit to accelerate action in Africa to end preventable maternal, newborn and child deaths worldwide. Our hope is that this summit will increase collaboration between the U.S. and African partners to promote and deliver the most effective interventions and identify new and innovative resources.
There is no more important goal we can share, no more important investment in the future health and stability of the continent, than saving the lives of mothers and children.
We Must Work Hard to Own Our Liberation
Published in the New Times Rwanda on 7th July 2014
Twenty years after the end of the 1994 Genocide against the Tutsi, this July fourth makes me reflect on what the events we remember today have brought to me as a Rwandan, as an African, and as a woman, a mother, and a daughter. First and foremost, I have come to understand that, to truly honor the sacrifices of our RPF’s brave soldiers—who laid down their lives so that Rwandans might live in a country free of discrimination, free of the fear of violence based on one’s background, and free to pursue lives they value—we must work to own our liberation.
Thanks to our heroes, I now live in a country where all have an equal chance, whether you are the nation’s newest baby girl in the most rural district, or whether you are the head of Parliament. Thanks to this foundation, we have the opportunity to build the future we want through dialogue and transparency.
In this reborn Rwanda, our society is far from homogenous; this is such a blessing, because it is our diversity that fuels the engine of innovation behind recent progress. Certainly, many serious challenges lie ahead, and we have so much more to achieve in order to give all of our brothers and sisters the opportunities that they deserve. But we are continuously progressing each day to achieve that vision, and on this July fourth, I hope we do not take these efforts for granted.
In today’s Rwanda, every citizen inside our borders or living all around the world—whether they support the government’s efforts or hold different views—identify themselves as Rwandans with pride. Today, we celebrate the blessing of our shared identity as Rwandans, and pursue with renewed purpose our mission to accelerate the journey to shared development by transforming our Vision 2020 into our daily reality.
Many of our international friends see Rwanda’s recent achievements as a miracle of humanity, compassion, forgiveness, inclusivity, and progressive thinking that some claim could never be replicated elsewhere. But on this July fourth, as we reflect on a journey spanning twenty years, it is clear that this is no miracle. Anything that we have achieved has been through the determination and shared efforts of millions of Rwandans to liberate our country from the spirit of division, from fear, from ignorance, from the consequences of bad leadership, and from the oppression of poverty.
If we still have a long way to go, we are proud of what has been built to date. In this spirit of reflection, I feel a strong sense of gratitude to the Rwandan Patriotic Front for having halted the Genocide, and for protecting our people and our nation these past two decades. By helping more than two million refugees and displaced citizens to return home to peace and security, by making our communities free from discrimination of any kind, and by building the foundations of a democracy based on human rights, the sacrifices of our countrymen and countrywomen and the leadership of our President Paul Kagame have brought us here today. The liberation of 1994 recovered our dignity; the daily work to liberate our minds is making us proud Rwandans and proud Africans.
With this legacy, the Rwandan people can address the greatest challenges we have face by owning them, working to take full responsibility in the face of complexity, and harnessing the creativity of our people to find the solutions our nation needs. If we carry this spirit forward, we will truly own our future for the next 20 years and beyond.
Read more here: http://www.newtimes.co.rw/news/index.php?i=15776&a=78193
Towards Sustainable Health Care: From Community To Medical Tourism
Published by Ubuzima Magazine, of the Rwanda Health Communications Center and the Rwanda Biomedical Center on December 11, 2013
Ultimately, our strategy is to tap into medical tourism but this can only happen if we first secure the health of our own people and build the soft and hard infra- structure – people, facilities and a quality regime assurance to provide a world class health product.
Rwanda has the ambitious but achievable vision of building a self-sustaining state. To achieve this, the country must accelerate and sustain economic growth at 11.5 percent annually for the next two decades.Every sector must play its part in contributing towards the realisation of that vision. The health sector is an integral part of the journey to economic self-sustainability and our contribution will be measured by the extent to which we are able to provide the preventive, palliative and curative care, using the best quality state of science to each and every Rwandan at an affordable price with the idea of equity in mind. That would mean that wherever one happens to be in the country, they will have the same rights and enjoy access to what we can offer to each and every Rwandan.Ultimately, our strategy is to tap into medical tourism but this can only happen if we first secure the health of our own people and build the soft and hard infrastructure – people, facilities and a quality regime assurance to provide a world class health product.
Over the past five years, we have been putting in place the building blocks to a sustainable healthcare delivery system. We have already made good progress towards making the first point of contact with the health system, the Community Health Worker (CHW) self-sustaining. We have three CHW’s per village. These are people that are elected by the community members and the Ministry of Health gives them six weeks training and an annual refresher course which equips them with skills to provide quality care with a community-centric approach. They are supervised by the health centers and the doctors at district level.They provide care at village level diagnosing and treating pneumonia, bronchitis, and malaria. With the exception of implants and IUD, they provide the full range of family planning services from condom, pills, and injections. They also treat diarrhoea and they provide counseling for HIV. One of the CHW’s is a maternal health assistant who follows up pregnancies in the community and children under one year. They follow up children ensuring that everyone is vaccinated.CHW’s now take care of around 80 per cent of the disease burden and the cost of this care will soon be covered by cooperatives with money mobilised by the Ministry of Health for this purpose. We now have more than 470 cooperatives and our target is to reach 500.The profits generated by the cooperatives are used to grow businesses for the Community Health Workers and to sustain them. The business opportunities are identified by the CHW’s in their own communities and some have started hostels, shops, farms while others have gone into agribusiness. The profits from those cooperatives have created a pool of funds from which care at the community level can be paid for through performance based financing. A percentage of the profits from the cooperative belong to the health sector and are used to pay for the services of community care. This means nothing is free, everything has a cost and no one works for free in Rwanda even though we have to generate the money to pay for healthcare.We have been paying CHW’s since 2008 but the difference now is that instead of the resources coming from outside the community, they will be paid from revenue generated within the community with clear management and financial guidelines.
The percentage that is not secured for the health sector will go directly to CHW’s. Weighed against the diseases burden, that means that 100 percent of the cost of care at village level will be paid for by the community itself so we provide sustainable health care. This approach will be scaled up to cover the different levels of the health system.Above the village we have the cell. A cell is made up of about ten villages and we plan to have a health post in each cell. The community will provide the space – 4 rooms – one for examination, a reception area, observation room as well as a storage room and pharmacy. From here patients can either be referred for hospitalization at a health center or district hospital or get discharged to return home after treatment.Those posts will be headed by nurses trained to A2 level. They will provide services that will be reimbursed by Mutuelle de Sante. They will have no salary and will be paid directly in return for the services they provide, just like any private practitioner. They will also operate a drug shop. That means they will be offering services under a frame- work dubbed public-private –community partnership.We are also going to create a national cooperative for these A2 nurses and in a couple of years, the proceeds from that cooperative combined with Mutuelle de Sante and the proceeds from selling drugs at the drug shop will pay for the care at cell level. They will also be supervised by the health center and the leadership at the sector level. Once we are through with this arrangement, we should have completed the loop of providing health care at the community level in a sustainable manner. We are close to our target of having one health center in each sector.
Less than 50 health centers remain to be built.Under this arrangement, the sector will be the first point of interface between a patient and a public sector health facility. The system starts with a CHW at village level on to the public-private-community partnership at cell level and then the public health facility at sector level. Next are the district hospitals and then referral hospitals.Forty per cent of health facilities in sectors and district hospitals (we have 42 district hospitals) belong to Non- Governmental Organizations (NGOs), associations and Faith Based Organizations (FBOs). We have an agreement with FBOs and NGOs. In return they offer treatment to each and every Rwandan in need. This has allowed us to have the same number of health centers and district hospitals in each part of the country rather than wait until the public sector can build its own.The government through its budget pays subvention to each health facility or hospital. Mutuelle de Sante reimburses 90 percent of the cost of care but also there is a10 percent out of pocket which patients pay directly to the health unit when getting care. We are creating an e-system for better administrative and financial management of the health sector because we have private health facilities that for now do not get this contribution from the government but may be able to benefit of the e-system. We are therefore going to make the financial management more rigorous and private sector oriented.Each district hospital will also become a teaching site with a director in charge of education for doctors and a director in charge of education for nurses. They will report directly to the College of Medicine and Allied Sciences that the Government of Rwanda is creating under the single university system. The same approach to self-sustenance will be employed when it comes to referral. Because all referral hospitals are also teaching hospitals that means they will have income from both the health and education sectors.If we come to the ministry of health and the role of the Rwanda Biomedical Center; this center has been created to generate income to help the health sector become self- sustainable. We are now going into a phase of intensive business creation through RBC. PPP’s to create factories for consumables and drugs and goods for sale to the health sector are some of the options we are considering to decrease importation of what we bye anyway. We already have Labophar which has a unit for manufacturing infusions. Its capacity will be expanded; and we are going to build on that. The proceeds generated by these businesses will be reinvested to make the health sector self-sustaining at health center and hospital level. Because the systematic community up to cell level will be self-financing, the money generated from these activities will pay for services at sector, district and central level.
TAKING ON NCD’s
With a 50 percent decrease in acute malnutrition, we have made progress but our goal is to eliminate malnutrition all together. There is hope after the Clinton Foundation and World Food Programme teamed up with the Ministry of agriculture and the Ministry of commerce to set up a factory for nutritious foods.
This will help the health sector fight malnutrition by providing children and pregnant women with all the nutrients that they need. Malnutrition starts during pregnancy with malnourished mothers giving birth to malnourished children.Sensitization to improve the nutritional status of children and mothers continues and the one cow per family programme has helped increase the consumption of milk. We now envisage a situation where we can use all those health posts we are creating to facilitate distribution of milk. We are progressing in creating systems, sensitization and what it takes to deliver the service. As we make progress against infectious disease; non- communicable diseases are gaining prominence. It isnot because these are new diseases, it is just that we are not dying of infectious diseases as we used to. Due to improvements to the health system we have doubled life expectancy and reduced the mortality of children. Life expectancy in Rwanda is now around 63 years at birthand the profile of disease is beginning to be different asa result. So we are beginning to see more cases of heart disease and lung disease that are related to longevity because the population is aging. We are now educating medical personnel to manage this new challenge and we have introduced a diploma course in emergency medicine. We need 42 graduates to cover the 42 district hospitals. We have also created a residence of emergency medicine in provincial and referral hospitals. The school of medicine has almost completed the curriculum for a bachelor’s in cardiology so that we can have at least one medical doctor with special skills in cardiology in each district hospital. This is intended to accelerate the diagnosis and referral of patients to a full specialist if need arises and also do the follow-up of the people who have been treated.We have already conducted more than 300 successful cardiac surgeries in Rwanda and those people are living in the villages. It is therefore necessary to have a doctor with the relevant skills living near them to keep them in good health through follow-up and ensuring they take their medicine. That way, they will not need to come back to Kigali because it is far and sometimes they come when it is already too late. The diploma in emergency medicine has already started and we hope to commence admissions to the bachelorof cardiology next academic year. With these incremental steps, in five years, we hope to have a good referral system and fully functioning center of excellence for cardiology. We are also working on creating a residency in oncology and a diploma in oncology that again will allow us to have in each district, somebody with skills in oncology and who through specialists, can follow up, seek advice via telemedicine and be available to see the patient on regular basis since we are equipping all our districts with telemedicine capacity over the next 3 years. Routine specialised care will be offered at district level. So renal disease, cardiac disease, cancer and other complications will be taken covered by system we are creating now to serve all the population in an equitable manner.
We see medical tourism as a spinoff of care that will first and foremost be available to our own people and this is how we shall provide care for Rwandans. We are working with 23 institutions of higher learning in the United States that every year second 100 high level faculty members from their ranks who come to mentor their Rwandan counterpart’s under a twinning program. The aim is to create highly qualified and skilled clinical staff for both medical and nursing as well as lab technicians.We are reinforcing high education in the health sector through the coming school of medicine and allied sciences. There are 60 A0 nurses to be trained to be tutors in specialised areas such as nephrology, theatre, neonatology, emergency, ICU, paediatrics and mental health. So we shall have highly qualified teachers for both the nursing and medical school. Through this twinning programs we hope to create very good educative tutors with a university that will be one of the best in Africa and attractive to students from outside Rwanda.Once we have those highly qualified tutors, the system should produce highly qualified service providers. We have are sending to India, 16 people – surgeons, cardiologists, anaesthetists, nurses, and lab technicians to train in cardiac surgery to help create a center of excellence for cardiac surgery here.We are searching for the same opportunities for renal transplants. We have entered a partnership with the Chinese to transform Masaka hospital into a huge public teaching hospital and a separate partnership with the Japanese to have another high level public specialised hospital.We are also promoting partnerships with anybody who may want to come do fair business in the health sector because we have a beautiful country where one can create set up a beautiful hospital for the discerning patient who may want to combine a medical checkup in a high quality facility space in serene and scenic surroundings to mix tourism and reinvigoration of their health.And just as we are doing cardiac and renal surgery, we will do the same in neurosurgery so that we can attract here people who will, come to pay for quality care in Africa asit is done in other other parts of the world. That is how we will come to medical tourism. But before serving in such a segment you need to have first secured the care for your own people.Community care is already on track, and RBC has begun the next phase of its evolution or the first steps to turn this institution into a business oriented entity. For medical tourism, the paperwork is in progress at RDB and a project proposal is already with the African Development Bank and other development partners for analysis. We are off to a good start and all we need to do is pull in the same direction to get to our destination. Medical tourism results into regional centers of excellence and good medicine is generally a good business.
© RBC/Rwanda Health Communication Centre 2013
VOA’s News Programme, Africa 54, Minister of Health Agnes Binagwaho’s interview
Health Agnes Binagwaho discusses how Rwanda managed to lower its rates of deaths and new infections of HIV, TB, and malaria in the past 10 years.
HER INTERVIEW STARTS AT THE 16:20 MARK.
A Win for Global Health
The following text has been partially published on November 29, 2013; in the section Opinion of the US News & Report
While Sub-Saharan Africa bears 24 percent of the global disease burden, it’s served by only 4 percent of the global health workforce. As the World Health Organization just announced, the global health worker shortage stands at more than 7.2 million today and is expected to grow to 12.9 million by 2035.
Over the past decade, humanity has made extraordinary gains in the struggle against the world’s deadliest communicable diseases. International solidarity and financing mechanisms such as the US President’s Emergency Plan for AIDS Relief (PEPFAR) and The Global Fund to Fight AIDS, Tuberculosis, and Malaria are saving millions of lives every year. But low-income countries still face a seemingly insurmountable obstacle in addressing these and other public health challenges: a critical shortage of highly-trained health professionals.
While Sub-Saharan Africa bears 24% of the global disease burden, it’s served by only 4% of the global health workforce. As the World Health Organization announced last week, the world’s health worker shortage stands at more than 7.2 million today, a gap expected to grow to 12.9 million by 2035.
A report that my colleagues and I published this week in the New England Journal of Medicine offers compelling new evidence about the power of partnership to overcome this obstacle. This new program financed by PEPFAR and The Global Fund provides an example of how we can create a better environment for battling current and future global health challenges in aid-reliant countries.
It’s about moving from the condition of dependence to interdependence.
In my country, Rwanda, the Human Resources for Health (HRH) Program is creating a solid infrastructure over the next 7 years to ensure that we are equipping enough health professionals in Rwanda to meet the pressing health challenges facing our people.
Announced in 2012 by Rwandan President Paul Kagame and former US President Bill Clinton and followed by a launch by former US Global AIDS Coordinator and US Ambassador for Global Health Diplomacy, Dr. Eric Goosby, the HRH program deploys nearly 100 American faculty members each year —including physicians, midwives, nurses, dentists and management experts—from a consortium of 25 leading American medical institutions, to partner or “twin” with their peers at Rwandan institutions for at least one year to transfer invaluable skills and knowledge.
This “twinning” enables better curriculum development, teaching, and clinical research that will ultimately empower Rwandan clinicians and educators to take charge of all instruction and healthcare delivery. By 2018, Rwanda’s specialist physician capacity will have more than tripled, and the proportion of the country’s nurses with advanced training will have increased by more than 500%. An additional 550 physicians, 2800 nurses and midwives, 300 oral health professionals, and 150 health managers will have been newly trained in Rwanda—all of whom will have signed contracts to work in the country for a certain number of years based on the degree they obtain. Thereafter, the Rwandan government plans to fully finance the health workforce and medical education system on its own.
By improving the quantity and quality of Rwanda’s health workforce, this innovative program will help us better serve the needs of all Rwanda’s people—from our vulnerable children through improved neonatal services, to our HIV patients who are living longer now that they are on therapy but face a growing burden of chronic diseases like cancer due to their weakened immune systems.
Rwanda is not the only country to benefit from this program, which breaks sharply from old models of foreign aid. This partnership is also a win-win for our American colleagues, who are learning more each day about what it takes to deliver care in resource-constrained settings. Such experiences are already enriching global health programs at universities throughout the United States and opening new doors for research collaboration between our two countries. Overall, this partnership—in both the clinical and research settings—will help the global health community better understand how we can collectively overcome health challenges in a more sustainable way.
Interdependence in global health is not just an abstract idea. In an age in which a single airplane flight can turn a drug-resistant pathogen into an international public health emergency, better-trained health workers in the developing world will improve prevention by bolstering our first-line of defense against serious global public health threats.
On December 3rd, the world has a critical opportunity to harness the power of partnership, when international leaders gather in Washington D.C. to pledge support for the Global Fund’s work over the next three years. The event provides an opportunity for people to call upon these leaders to continue the fight against the devastating scourges of AIDS, TB, and malaria, but also to sustainably strengthen health systems and reduce the need for foreign aid in the future as countries advance in their journey of development.
Each and every nation—rich and—must do its part to think “out of the box” and create new ways of supporting our common fight against these health challenges. If this creativity or spirit of collaboration fails on December 3rd, we will see a chilling number of preventable deaths around the world.
We would also immediately see a projected $47 billion in additional costs to treat HIV infections that would otherwise have been prevented, an estimated $20 billion in lost global GDP due to malaria, and increases in the number of cases of multi-drug resistant TB, each of which costs tens of thousands of dollars to treat—and each of which poses risks that transcend borders.
Infectious diseases have shown us time and time again that the world is just a little village. The achievements of PEPFAR and the Global Fund, and the launch of new initiatives such as the Human Resources for Health Program, show us how much is possible with true solidarity. As my friend Dr. Paul Farmer, co-founder of the nonprofit Partners In Health, likes to say, we live in one world—not three. The time is now to renew our commitments to one another.
Dr. Agnes Binagwaho, the Minister of Health of Rwanda, is a pediatrician, Senior Lecturer at Harvard Medical School, and Clinical Professor of Pediatrics at the Geisel School of Medicine at Dartmouth College.
Can It Be Replicated? Look at Rwanda’s Development Gains in Context
August 6, 2012
This session of the Skoll 2013 Forum in Oxford was an interesting moment to review the progress of the health sector in Rwanda in service delivery. The discussion were done in the framework of Rwanda’s goal to grow GDP at 11% in the coming years, up from the current rate of 8%, by decreasing the number of people in poverty and with a spirit of change using the principle of social entrepreneurship for development. The human rights were also evocated and discuss against right to health to development and decent life. The discussion tried to understand the principles behind Rwanda recovery in 19 years after the 1994 genocide against the Tutsis; questioning the signification of democratic, the difference in the South, between people members of communities that are generaly poor and civil society that are generaly rich. The lack of accountability of a certain bad prototype of NGOs
I advise to see this video:
4 days ago – Uploaded by Skoll World ForumA Look at Rwanda’s Development Gains in Context 2013 Skoll World Forum.
Honorary Degree to Agnes Binagwaho (Doctor Of Science)
The 13 June 2010, I had the tremendous honor of being welcomed to Dartmouth by my friend Jim Kim to receive an Honorary Doctor of Sciences. This is the video from the ceremony.
Honorary degree citation to Agnes Binagwaho (Doctor Of Science)by Jim Kim President of Dartmouth
Agnes Binagwaho, you are a healer for whom healing alone is not enough. In your life’s work as a pediatrician and leader in public health, you have never rested in trying to make today better than yesterday and tomorrow better than today.You believe that any problem can be solved if we work hard enough to find solutions within our culture and within ourselves. Your tenacity demonstrates the power of that belief.You trained as a doctor in Belgium and France. But rather than remaining in Europe for a successful and comfortable career, you returned to your native Rwanda, where you rose to the herculean task of rebuilding a country devastated by genocide.In the process, you helped to create a health care system that has become a model for all of Africa. Malaria mortality in your homeland has been reduced by two thirds. Seventy percent of Rwandans with HIV/AIDs now have access to antiretroviral drugs. And, more than 90 percent of Rwandans now have health insurance.Today, as Rwanda’s Permanent Secretary of the Ministry of Health, yours is a clarion voice in support of women’s rights and you are an eloquent champion of participatory health care. You are empowering adolescents to make choices that will lead to better health outcomes. You are a savior to them and an inspiration to us all.And for all the seriousness of your life’s work, you have never let it weigh down your spirit or drive the joy from your soul. For all this and all of your accomplishments, the Dartmouth community is proud to confer on you the honorary degree, Doctor of Science.
Setting Course for 2012
Posted in Ubuzima Journal first quarter 2012
By Dr. Agnes Binagwaho
As we embark on yet another year, it is time to check our bearings and determine the direction we want events in the health sector to take during 2012.
While there is no fault in celebrating our achievements in the past year, maintaining those gains should be the overarching priority for 2012. The gains in the health sector are always fragile and could easily be lost if we are not focused. Ten years ago, infectious diseases were killing us. Now those are contained but because they are still there we should not relax our vigilance. The gains made against HIV can be lost in as short a time as one year if we relax our guard.
We shall continue to see progress in the areas where we have done well and this is translating into reductions in the incidence of malaria, HIV/AIDs and TB. For children we are introducing the rotavirus vaccine this year. Two and half years ago we introduced the vaccine for pneumonia and as a result pneumonia has decreased.
We have made good progress across all the infectious disease profile and people are living healthier and longer. According to the National Institute of Statistics, the average Rwandan can now expect to live as long as 55 years.
It is a modest number that is at the same time significant in our setting. This year we need to begin focusing on the long term by anticipating health problems that are likely to arise in the not too distant future and preparing solutions now. As the health of our population gets better, they will start to experience health problems related to longevity. So we shall need to focus on those new problems that are changing our epidemiology. Simply by people beginning to live longer we are starting to see cancer and other non-communicable diseases emerge as public health issues.
This means that we have to be prepared to tackle the new diseases that are beginning to emerge in the population such as hypertension, heart disease, metabolic diseases etc. We are also beginning to see that deaths from motor accidents or other injury are beginning to overtake other causes. This is not necessarily because there has been an increase in the rate of accidents but there has been a reduction in other causes of mortality and morbidity.
The simple message from this trend is that we need to focus on non-communicable diseases since communicable diseases are now under control.
There are many areas where we can act on non-communicable diseases and others where we cannot act immediately. An area where we can act immediately and where we have already started is cancer. And even in cancer, it is not all cancer as the initial focus is on women and children. It is not that we are neglecting men but because affordable solutions targeting these cancers happen to be available on the market at this material time. On the other hand we cannot work on everything at the same time.
For women we are taking action against cervical and breast cancer by detection and early treatment. A vaccine against cervical cancer is also available providing an affordable and sustainable solution.
We are also going to act on a series of cancers affecting children. We are finalizing the protocols, the guidelines and policies.
We are taking on those cancers against which we can act immediately and which are also the most frequent. For example Lymphoma affects mainly children and there is something that can be done about it. We are not going to wait for big infrastructure but handle whatever we can within the present means. We shall then create facilities for cancer care knowledge. For those for whom it may be too late to offer successful treatment, we shall opt for palliative care.
The guiding philosophy is that Rwanda will always prioritize the most acute problem. So we can now focus on the next major killers and go on like that until such a time as we reach the level of the developed world.
Quality and value for money
The other area of focus this year will be improved management of the health sector to achieve more value with fewer resources as global fund resources are decreasing. Quality of care will come under increased scrutiny as we seek to maximize value from our resources.
Quality care has two sides – the science and the way to implement that science. After that you have the human dimension, the customer care. Already there is progress. When a population is healthy and when you empower them on their rights, they are more demanding. Before, expectations were low because it was the time when you had just two doctors per district hospital. But now we expect quality because the numbers have started to be significant and on the other hand we have pushed the people to demand quality care.
At one time, many people who were visiting our health facilities would find a good doctor with skills who was critically short on customer care. Today people are legitimately complaining because they expect both quality care and customer care. I may be a good and highly skilled doctor but if am rude that undermines the quality of my overall output.
On the other extreme you could have someone who may not be even be qualified but has great customer care and people actually prefer to consult him or her just because of that. This happens a lot in our country and potentially creates dangerous gaps in our health system if people choose to seek care from non-professionals. So doctors in the formal sector need to provide the full package of knowledge, science and customer care.
Malnutrition is another priority for this year. The government has committed itself to eradicating the causes of malnutrition before the next Umushyikirano. Looked at objectively, malnutrition is not insurmountable. We have malnutrition not because we cannot produce food but rather because we are using it wrongly. You find families that say they don’t have food but they can grow the food. Others say they don’t have land but the local government can provide collective land for people to grow food. Malnutrition should not occur in this country, eradicating it is just a matter of organization.
Two percent of children under five years suffer severe malnutrition but that malnutrition can not be linked to disease since hunger per se is almost non-existent. There are also cases where malnutrition is a result of mothers not knowing how to feed their children. In the same age bracket we also find 11% that are underweight and 44% that suffer chronic malnutrition.
We have learnt that the primary cause of malnutrition is related to what children and pregnant mothers eat. Most of those children are born malnourished because the mother did not take enough micro-nutrients, vitamins etc when pregnant. The solution lies in increasing the knowledge to fight the habit of not eating some sources of protein. It requires a revolution in the way we are feeding children.
Human Resource for Health
Another frontier during this year will be developing the Human Resource for Health. Because we have made good progress with what we have now and have achieved reasonable levels of basic care, people are going to get diseases that are related to age. Yet we don’t have the specialists to care for them.
At the district level at a minimum we need one surgeon, a pediatrician, one anesthetist, one internal medicine specialist and an oncologist to deal with cancer and related complications. We also need to develop the capacity to treat or manage metabolic diseases.
It will take us decades to achieve desired staffing levels if we were to continue producing health professionals at the current rate. To mitigate this, we have partnered with 18 American universities that will bring here hundreds of experts to mentor Rwandans to be teachers, teach residents to be good specialists and teach graduates to be good medical directors. Over the next seven years, we shall have attained the capacity to produce our on workforce and we will produce the minimum we need that are capable of giving the care we need.
We are planning to have radio-therapy facilities and oncologic wards at CHK, Kanombe and Butaro hospitals where we shall provide specialist care for cancer patients. We will have a facility for radiotherapy and places where we shall hospitalize people that need special care.
We are also going to produce an accompanying complement of Medical Directors with specialist skills in oncology within two years. We plan to create full specialists who will train and supervise others so that we have someone with these skills in every district hospital. The missing gap in the training of our human resource has been mentorship and bedside training.
Mutuelle de Sante
Making progress against infectious diseases does not necessarily free us from spending money because the cost of prevention is also high and that is why the health budget has been increasing year after year in the national budget. On the other hand even as we have increased the national budget for health, the international contribution to that budget is uncertain so the future lies in what we shall be able to do under the national budget and health insurance.
Fortunately even the out of pocket expenditure is increasing because of the improving economic welfare of Rwandans. We have one million Rwandans who have transitioned from poverty to a better income status. As a result, they have more money out of pocket and are capable of paying for their health insurance. Additional resources for health may come by way of savings made by individuals against future sickness through health insurance and Mutuelle de Sante.
However Mutuelle de Sante is a national institution that is still growing and maturing. If we are not strict in its management we are going to pull it down yet it is a good system.
We have so many sectors and to ensure that all are managing the system properly is a fight that requires day and night vigilance. Because you have money there for healthcare that may seemingly be lying idle, some leaders at the local level may want to use this money for other things. We need to sensitize and convince them that is not right to diverting that money to other priorities and that this constitutes a financial crime. We need to get that message down to the sectors.
Finally, we need to create regional; reflections on how to treat diseases. We have started by seeking to create high efficiency programs for controlling malaria with our neighbours. Half of our problem with malaria is around the border areas and 45% of that burden is in just three sectors of this country meaning we need to work with our neighbours. Rwanda cannot be an island of welfare in a region of desperation. We are proposing common procurement and harmonisation of policies and fighting together against counterfeit medicines. We shall tackle these problems jointly by agreeing on the best policies based on the best science of the moment.
Rwanda’s Approach Proves Perfect Antidote to Counterfeit Drugs
Posted in the Guardian by Agnes Binagwaho and Amir Attaran
July 3, 2013
Rwanda’s integrated solution to combating fake drugs could inform a global treaty on medical safety
Globalisation has brought people many wonderful things, but occasionally it brings them death, thanks to the growing international trade in bad medicines. At least 100,000 people each year succumb to medicines that are negligently made, or sometimes deliberately faked with bogus ingredients. The solution demands local and global measures to improve regulation and make penalties tougher for medicine criminals. We simply cannot afford the cost of inaction.
This week, we published research in Public Library of Science Medicine showing that tuberculosis drug quality is variable in low- and middle-income countries. Of 713 samples of the tuberculosis medicines isoniazid and rifampicin collected in 17 countries, 9.1% contained insufficient quantities of the active pharmaceutical ingredient, and failed basic quality control tests. The situation is even worse in some African countries, where 16.6% of medicines failed; 7% were outright fakes, containing no active ingredient. These failing medicines won’t cure tuberculosis infections and could even fuel drug resistance, which makes the disease much more difficult and expensive to cure.
Yet one encouraging result stood out: no fake tuberculosis drugs were found in the sample from Rwanda. This is consistent with other recent studies, which found that the east African state has few substandard and no obviously falsified malaria medicines. So what is Rwanda doing right?
First, over the past decade the government has taken legal and technical steps to secure the whole of its medicine supply chain. It buys high-risk drugs, such as those for tuberculosis, exclusively from manufacturers certified by the World Health Organisation (WHO), and distributes them in a dedicated, controlled supply chain to hospitals and clinics.
Second, the Rwandan government has trained the healthcare workers who handle the medicines how to spot and report substandard and falsified products.
Third, a task force of health regulators and customs officials inspects all medicines entering the country at the border, notifying the police (who in turn notify Interpol) when something is amiss. The Rwandan approach is holistic, and draws on resources from across the government.
It is tempting to say that Rwanda does all this because – unusually for Africa – it has a strong publicly funded health system to treat tuberculosis. Yet, without a holistic approach, the system would be undermined by criminal activity and collapse. It is not just the healthcare workers and the quality of programme management that make the system function; in terms of medicines, it is the police and regulatory officials too. “Health is too important to leave to doctors,” people say around Rwanda’s health ministry.
Unfortunately, there is opposition to fighting fake and substandard medicines in this holistic way. Some countries, such as India, vocally oppose commingling public health and policing at an international level. Setting up that conflict seems a tactical mistake, because, as we know from many examples – food safety, airline safety, road safety – regulation and policing are necessary to prevent accidents and protect wellbeing. In fairness, India’s parliament now acknowledges (pdf) the country has medicine quality problems that “can harm patients”.
But for Rwanda to fix problems outside its borders, it needs the co-operation of other countries. A global treaty is needed to make medicine safety a priority, both by building the capacities of drug regulators and by making medicine falsification an international crime.
One perspective on the problem is that the world has done a dangerously imbalanced job of globalisation. Starting with the WTO agreements in 1995, free trade in legitimate medicines has helped patients who have access to quality drugs at affordable prices, but free trade in falsified and substandard medicines is hurting and killing many others. Without reversing the good half of this equation, countries need to clamp down on criminal activity. An international law that sets standards for medicine quality and safety in international trade – which, today, it does not – is essential.
Precedents abound: you can board an aircraft in country X and land safely in country Y because there are treaties on flight safety to which all countries agree. Likewise, you cannot print the banknotes of country X and pass them off in country Y without being arrested, because there are treaties criminalising counterfeiting. If international law can promote safe flights and criminalise fake money, surely it does not take too much imagination to negotiate and agree a treaty to promote safe medicines and criminalise fakes to protect people in low- and middle-income countries.
Agnes Binagwaho is Rwandan health minister, senior lecturer at Harvard Medical School, and clinical professor of paediatrics at the Geisel school of medicine, Dartmouth University. Amir Attaran is Canada research chair in law, population health and global development policy, and professor in law and medicine at the University of Ottawa
Uniting to Combat Both Hunger and Undernourishment
Ahead of the G8-sponsored summit on Nutrition for Growth on 8 June, I published an op-ed in Project Syndicate entitled “Diet and Growth” on 31 May.
You can read it on their webpage: http://www.project-syndicate.org/commentary/stepping-up-the-fight-against-childhood-undernourishment-by-agnes-binagwaho
Exchange About Entrepreneurship and Transformational Leadership Skills.
By Agnes Binagwaho
The 21st May, I met with a delegation of 31 bright students from the Wharton School of Business of the University of #Pennsylvania. They came in #Rwanda as part of the #Wharton’s Global Modular Course (GMC) program. This team of Masters of Business students came in Rwanda to learn about entrepreneurship and transformational leadership skills in emerging markets. This MBA course aim to learn “in country” and on the ground, about these practical subjects.We had a interesting interactive session in a panel between them, Honorable Minister of Agriculture; Agnes Kalibata and the DG RSSB; Angelique
The students got the approach right, since they met with us after they had visited several activities at community level; among them was a visit to beneficiaries of the project one cow, one family, one to a health center and another to a school. Following these field trips, it became easier for to explain how wealth and health of each and every citizen is at the center of our sustainable development plan.
We debated the Rwandan approach to gender equity, what were the next steps to take in that area. We discussed how our agriculture had brought food security; contributed in the fight against malnutrition and in the economic growth. We also explained how we sustain community health programs and generate economic growth at village level, with the community health workers cooperatives. These were examples of the ways in which all sectors contribute to the national journey in making the country a mid income nation.We discussed the principle of the country’s ownership and consensus approach in regards to the decisions taken after wide consultations and vertical and horizontal people’s participationThey asked us how we prepare the next generation to sustain the gains made and how in the future we intend to maintain the highly positive mood and energy of Rwandan and carry our development forward. We explained that we still have a long way to go and that every passing day, we prepare our future, this is part of everything we do, to create an enabling environment of peace, security and a climate for financial stability. For example we explained the requirements of the Human resources for Health since we will educate the doctors and specialists nurses we need as we use more health services than ever before as our population ages, because of the reduction in premature deaths, and also because the profile of our epidemiology and morbidity is changing.
We also had exchanges on how we built the Community Health Insurance, which based on social solidarity, in order to reduce financial barriers to health services and how solidarity has helped mental health care recovery, in a country with too few mental health specialists. More over we are proud that for the majority today Rwanda is no longer associate only to 1994 genocide but to quick progress, attaining the MDGs, to promotion of universal access to basic rights such as education, and health, to home grown innovative solution, using our culture to find solution for who we want to be etc.… The students asked us what we would like them to take away from their visit in Rwanda we proposed to them to contribute to our social change to invest or having projects in Rwanda.As they asked why the image in the northern press of our country is bad and don’t reflect the reality we told them to keep their critical analytic mind and not always to believe what is the written by press and to develop an evidence based judgment.
Judge the democracy of a country on what are the outcome a for its people while harming no one on earth and not on rigid inappropriate scholar definitions.
Specialised Medical Education: A Necessary Tool for Development and the Right to Health in Rwanda
Below is my contribution to Ubuzima Magazine, published by the Rwanda Health Communications Center and the Rwanda Biomedical Center.
I recommend you to read the full magazine! Lots of great updates on our health sector from the MOH and RBC. July 2012,Vol.69(2)
By Dr. Agnes Binagwaho Minister of Health of Rwanda
In Rwanda, equity is a principle written into our Constitution, and is found throughout Vision 2020, our roadmap for development. As in all sectors in Rwanda, the health sector has conceived policies, strategies, and plans based on equity that are aligned to the national development plan. Vision 2020 provides clear and flexible directives for achieving health and wealth in the framework of social justice for all. As such, we are wholly dedicated to ensuring that the fruits of science are beneficial to all – both providers and patients alike.
This approach has driven the gains made over the past decade by Rwanda in improving the health of its population, particularly in the area of infectious diseases. Mortality due to HIV disease decreased by nearly 78% between 2000 and 2010, and malaria mortality decreased by 76% between 2005 and 2011. , The utilisation of primary health care interventions has increased dramatically, and we have seen rapid declines in both maternal and child mortality rates of approximately 50% in recent years. Rwanda offers ten vaccines at no cost to all children; coverage rates for these vaccines range between 90-96%.4 Life expectancy in Rwanda has increased from 30 in 1995 to 55 in 2010. This gain has given ground for degenerative and chronic illnesses to commonly be expressed whereas in the past the Rwandan population had not survived to the age where those pathologies existed regularly enough to make them public health priorities. These achievements are due in part to equitable policies, evidence-based interventions, continuous adoption of scientific innovation, with a focus on community-based approaches. By virtue of the work of Rwanda’s 45,000 community health workers who receive constant training in preventive, diagnostic, and curative skills to be able to address 80% of the disease burden at the village level. In light of these achievements, it is time to take the health sector’s progress to the next level. To do this, we must educate current and future professionals in medical specialisations and sub-specializations enabling them to prevent, diagnose, and treat pathologies common and new to our population, including chronic care for HIV positive persons, and side effects of antiretroviral therapy.
In 2009, the President of the Republic of Rwanda spurred the Ministry of Health to find an inventive way to increase the number of highly specialized health professionals practicing in Rwanda in order to accelerate Rwanda’s pace toward becoming a middle-income country. After deep reflection within the health sector, we identified a way to increase the quality and quantity of health professionals who not only can maintain gains since 2000 in their capacity to tackle infectious diseases, but who can also address new pathologies and adaptations in the epidemiological landscape in Rwanda.
We decided to conceive a plan to improve human resources for health by building a knowledge base and increasing Rwanda’s capacity to provide academic and clinical training to the next generation of highly skilled health care providers who will then become the teachers and trainers themselves. The training program, coupled with purchasing new medical equipment and improving the health infrastructure, will certainly increase access to high quality care and advance Rwanda’s overall development.
The result is the National Human Resources for Health Strategic Plan 2011 – 2016 and its implementation plan: the Human Resources for Health (HRH) Program. The HRH program has been conceived within the framework of using the “3 Ones” principle of having one governance body (the Government of Rwanda), one action plan (National Human Resources for Health Strategic Plan 2011 – 2016), and one monitoring and evaluation plan.By repurposing existing bilateral and multilateral donor funds from development partners including PEPFAR, USAID, the Global Fund, GIZ, BTC, DFID, and the Swiss Cooperation, the Ministry of Health has been able to secure enough funding for a successful launch of the HRH Program in August 2012. The Government of Rwanda has also contributed greatly to the resources available through the Capacity Development Public Secretariat.
The HRH program seeks to address Rwanda’s critical gap of skilled specialized health workers and the inadequate amount and caliber of equipment available in health facilities that presently hinders clinical training and service delivery. The program was designed to increase the quality and quantity of physicians, nurses, and hospital managers through partnership and mentorship. The Ministry of Health has established a partnership with over a dozen top American universities, including five schools of nursing, seven schools of medicine, and one school of public health. These schools comprise the US Academic Consortium, which has been working with Rwanda to develop more than 15 specialty and sub-specialty areas including: anaesthesiology, surgery, internal medicine, obstetrics and gynaecology, paediatrics, critical care and traumatology nursing, surgical nursing, healthcare administration, and more.
For this seven-year program starting in August 2012, ever year 100 US faculty members will be deployed to Rwanda for one year at minimum. They will be paired with Rwandan educators in the Faculty of Medicine and Faculty of Nursing Sciences at the National University of Rwanda as well as all schools for A1 Nursing. US faculty will work together with their Rwandan counterparts to increase local training capacity and the quality of clinical teaching offered to students. As each year of the program progresses, Rwandan faculty will obtain increased capacity in teaching and training, and will eventually assume full responsibility for specialised medical education in Rwanda.
The investment of American, European, and Rwandan taxpayers for the development of Rwanda’s health sector in this novel and unprecedented model will be sustainable in the long-term because all residents who benefit from this training will sign a contract with the government to serve in the public sector for several years upon completion.
This new initiative for human resources for health in Rwanda is included in the legal framework, in the Health Sector Strategic Plan III, and in the development of the new Economic Development and Poverty Reduction Strategy that is currently underway. The planning and execution of this major program have been truly multi-sectoral and reflect the commitment and collaboration of leaders in across the health, finance, education, and justice sectors, in addition to medical professional associations. We have worked as a team to revolutionize the way Rwanda can train its health professionals in such a way that guarantees equity in the quality of an increased quantity of services to all Rwandans no matter where they live or who they are. Our fellow Rwandan citizens deserve nothing less than the best.
 Ministry of Finance and Economic Planning, Government of Rwanda. (2000). Vision 2020. Kigali, Rwanda. World Health Organization. (2012). World Health Statistics 2012. Geneva, Switzerland: World Health Organization. Karema C. (2012). Personal Communication. National Institute of Statistics of Rwanda and Macro International, Inc. (2012). Rwanda Demographic and Health Survey 2010. Calverton, MD: Macro International, Inc. World Bank. (2012).
DataBank: World Development Indicators and Global Development Finance. Available: http://databank.worldbank.org/ (Accessed 21 June 2012).
Rwandan Health Minister Hits Back at Critics Of Drug Company Deal
Published in the guardian.co.uk, Tuesday 21 May 2013
A hero of mine wrote from prison that “human progress never rolls in on wheels of inevitability; without hard work, time itself becomes an ally of social stagnation.” Dr. Martin Luther King Jr.’s words have long resonated with Africa’s struggle against global cynicism in the fight against AIDS. At the turn of the millennium, while I practiced as a pediatrician in Rwanda, international experts brandishing computer-generated prescriptions of cost-effectiveness told us then that the time just wasn’t right to provide access to the effective treatment widely available in their own countries. In short, African lives were worth less than American or European lives. Costs were just too high, they said (never mind that activists soon drove AIDS drug prices down from $12,000 to $100 per year). African governments and patients simply weren’t prepared, they cautioned (never mind that studies show Africans have far higher adherence to treatment than North American counterparts).
Dr. King’s words came to mind again last week, when I read with interest a recent commentary in The Guardian on pharmaceutical company donations in Africa. As an example of the pitfalls of corporate philanthropy in global health, author Adam Green cited Rwanda’s partnership with Merck to provide universal access to the human papillomavirus (HPV) vaccine for the prevention of cervical cancer. He echoed claims made two years ago by some experts that Rwanda jumped the gun, allowing itself to be used as a pawn by a predatory multinational corporation.
Most in global health have moved on from this debate, as the world came to recognize the mounting burden of cervical cancer in Africa, as the price of the HPV vaccine dropped from $16.95 to $5 per dose by mid-2011, and as the GAVI Alliance added the vaccine to its portfolio of support. And despite skepticism from some about the feasibility of nationwide HPV vaccination in Africa, Rwanda reached more than 93% of eligible girls with all three doses through a school-based program in 2011. When Rwanda already had 90% or higher coverage for vaccines against 10 other diseases, when cervical cancer now rivals HIV and maternal mortality as a leading killer of our women, and when GAVI’s budget grew 42% last year, it is difficult for me to see this as some kind of dangerous precedent.
Yet such arguments keep recurring (for HIV, drug-resistant tuberculosis, cancer, cholera, and so on) because of a larger divide in global development. Many who advance or tacitly endorse the claims echoed in Green’s piece often do so because they believe ideological purity (that is, the view that drug companies often pursue only self-interest) is a moral imperative, and that cost-effectiveness (that is, poor people should get cheap things) should always trump other considerations.
But do we truly live in such a zero-sum world that a win-win outcome from a public-private partnership for health is unimaginable? Certainly, competition is better for promoting access to medicines than voluntary donation programs. Yet there are already two companies making the HPV vaccine, and generic versions are not so far off. Furthermore, the historical gap between new vaccine introduction in rich and poor countries is two decades; by working with Merck, Rwanda reduced it to four years and showed the world one possible strategy for reaching universal coverage. Just this past week, GAVI made international news by announcing even lower prices for the HPV vaccine (down to $4.50 per dose) through agreements with two manufacturers, and approved a grant to continue Rwanda’s national program after Merck support stops in 2014.
So much can be achieved in global health with shared commitments to teamwork and humility, a willingness to grapple with complexity, and a big dose of imagination. Indeed, for the very health issues that Green argued should rank higher than the HPV vaccine, Rwanda (and many other nations) are already engaged in novel collaborations to address. On top of the HPV vaccine rollout, we are working with groups around the world to build synergistic screening and treatment programs for cervical and many other cancers. In tackling maternal and child mortality, we’re strengthening health and sanitation systems in addition to teaming up with development partners on a mobile-based notification system for community health workers. With the support of GAVI, we’ve rolled out three new childhood vaccines against pneumonia, diarrhea, and rubella nationwide since 2009. With two-dozen American schools, we are training hundreds of nurses and specialist physicians.
And it seems to be working: while spending less than $60 per capita on health, Rwanda is now on track for the Millennium Development Goals. Indeed, to those interested in working here, we like to say, “Don’t come for charity. Come for partnership.”
Adam Green’s piece voiced concerns about programs like those described above serving as “market priming to create the conditions for adoption.” From Rwanda’s view, the jury is in: with more women dying of cervical cancer than in childbirth worldwide, the market is quite primed and demand readily apparent. Supply of the HPV vaccine and many other tools of modern medicine, on the other hand, remains in doubt for those who need them most. But with no global solidarity fund for cancer today, how else should we get started but to forge smart new partnerships? One lesson from AIDS is that if the world stalls, you just need to act and show that it can be done.
As Dr. King said, in the face of challenges like growing global health inequalities, “We must use time creatively, in the knowledge that the time is always ripe to do right.” Let’s use our time and talents—as health workers, researchers, and journalists—to work together towards a future in which where a patient lives doesn’t determine if they live.
My Impressions on the Commemoration Anniversary of the 1994 Genocide Against the Tutsi
Commentary published in New Times – Rwanda 29 April 2013
On 25 April, hundreds of health professionals and partners in the health sector came together to commemorate our colleagues who were victims of the 1994 Genocide against the Tutsi.
We undertook a remembrance walk in the spirit and communion with what Rwanda has put in place for the remembrance month, during which the Nation, the sectors, communities, families come together, to reflect on what has happened and what can happen again any place in the world when bad leadership takes over a country. This was the case in Rwanda with leadership during the post independence up to June 1994, that was sectarian and imposed tribalism in a country that ironically never had tribes.
This year our driver; Abdu Ndayisaba gave a moving testimony, as a survivor, he wisely started with the story at the time of our great grand fathers and gave a very vivid portrait of the genesis of the 1994 Genocide against the Tutsis, followed by Rwanda’s liberation as well as the stopping of the genocide by RPF Inkotanyi, without forgetting the country’s recovery that His Excellency President Paul Kagame lead in the aftermath.
Now we are 19 years later and it is true that many of our brothers and sisters are still traumatized by what happened during the 1994 Genocide against the Tutsi. However, with time, slowly, wounds are mitigated by the better lives Rwandans have today due to the economic growth our peace and stability that promote health and wealth of Rwandan people.
Another highlight of the commemorations was the testimony of two children whose father Abdallah was killed in the horrific events of April 1994. Their dignity and pride as they stood testifying in front of us, describing what they did with their lives since then, symbolized the expression of a unified Rwanda’s renaissance. They demonstrated that those who planned to finish the Tutsis have failedMy advice to my colleagues, the health professionals, is that we work tirelessly for the health of our brothers and sisters and carry out our work with a smile and good customer care as we contribute to take our country forward. The joy we will have as we work that way will be for 365 days the celebration of the new Rwanda where all Rwandan are equal.
Abdu’s voice broke with emotion and shock as he engaged us with his testimony and I admire him because he still remained a sensitive human being when he was talking about his fallen sisters and brothers. Every year I pay tribute to the millions of Rwandans killed during the Genocide against the Tutsi by visiting a memorial. I wish that for the next forty years, if God gives me the chance, I will have the same tears and emotions when in memorials, I will be passing through the rooms dedicated to the children fallen in the Genocide, because I feel that this is the pillar of my humanity.
But I have a message for all perpetrators of the 1994 Genocide against the Tutsi both outside, or hidden inside our beloved country, I warn them not to misinterpret our tears and sadness dedicated to the good people they killed. We are using them as energy to spur us to work harder for a brighter and sustained future for our people and our country.
Uniting to Uproot Malnutrition in Rwanda
I published the following article in December 2012 in The New Times.
The full text is available online, and you can also read it below
Uniting to uproot malnutrition in Rwanda
Dr. Agnes Binagwaho, Minister of Health of the Republic of Rwanda
While Rwanda has made dramatic progress in decreasing child mortality over the past ten years, reducing the rate of deaths from 183 per 1,000 live births in 2000 to 54 in 2011, chronic height-for-age malnutrition (or stunting) has remained too high among children under the age of five. Earlier this year, His Excellency President Paul Kagame challenged the nation to eliminate the root causes of stunting by working together through a multi-sectorial approach from the community to the central level and across sectors.
The rate of stunting among children under the age of five years was found to be 51 per cent in 2005; by 2010, it was still far too high at 44 per cent. Over the same timeframe, the prevalence of underweight had declined by roughly 30 per cent, from 18 per cent to 11 per cent of children. Based on this and numerous studies by the Ministries of Health and Agriculture, it was clear that the driver of persistent malnutrition was not a lack of sufficient food, but a complex set of social, cultural, and economic factors interacting to prevent many children from accessing a healthy diet.
This challenge necessitated a multi-pronged approach to identify and combat the fundamental causes of malnutrition with significant emphasis on prevention. The most important strategies identified as priorities for action were the diversification of food sources, systematic growth monitoring of children at the community level, early detection of malnutrition, access to clean drinking water, and, most importantly, widespread awareness about the kinds nutritious diets children need and how to prepare them.
Existing programmes to promote access to a balanced diet among the most vulnerable have been strengthened, and new initiatives have been launched to fill gaps. The Ministry of Agriculture has continued to provide leadership in the national Girinka (One-Cow-per-Family) programme, Akarima k’igikoni (kitchen gardens), and One Cup of Milk per Child programs, and the central government has supported these initiatives by doubling the agriculture budget between 2006 and 2011.
More than 200,000 cows have now been distributed to families categorized as ubudehe socioeconomic 1 and 2 (equivalent to the poorest households), and these animals have begun to bear offspring which recipient families then pass along to their neighbors who have yet to receive a cow.
With the support of local communities through monthly umuganda communal work days, kitchen gardens consisting of nutritious vegetable and fruit plants have continued to be scaled up across the country among ubudehe 1 and 2 families. Schools in 14 of 30 districts now receive one liter of milk per 3 each week, and this programme will be expanded to cover every school in the nation in the near future.
To ensure that children who do become malnourished – whether through severe or moderate growth shortfalls, underweight, or stunting – are linked to the health system and provided with appropriate treatment (from Plumpy’nut Ready-to-Use-Therapeutic Food to multivitamin supplementation), the Ministry of Health has incorporated monthly growth monitoring into the national community health system.
The country’s 45,000 community health workers (responsible for child health, reproductive health, and health promotion) now make regular household visits and can report children found to be malnourished to their local health centre, district hospital, and the central level via the cell phone-based RapidSMS system. Referrals of malnourished children have begun to occur much more rapidly than in years past, and preliminary data from the Ministry’s community health information system (SISCOM) show that moderate malnutrition has fallen by half between January and November 2012 – from 1.2 per cent to 0.6 per cent at the community level.
To contribute to improving the population’s access to potable drinking water, in addition to the work done by the Ministry of Infrastructure, the Ministry of Health has worked with partners to provide water filters to nearly 2,000 households in ubudehe1 and 2 across the country, with plans to scale up to the 600,000 poor households across the entire country
In addition to existing forms of filtration and purification (such as chlorination tablets), these filters help to improve hygiene and hence minimise children’s exposure to pathogens that cause diarrheal disease. Furthermore, recent international data from the United Nations project Rwanda to be on track for Millennium Development Goal 7, which includes key indicators for access to water and sanitation.
These developments are crucial to the fight against malnutrition, as persistent diarrheal disease prevents children from absorbing the nutrients they need and makes them feel sick so that they do not eat enough. This is another reason why the Ministry of Health worked with the GAVI Alliance to roll out the rotavirus vaccine for the prevention of one of the most dangerous causes of diarrhea this May, and preliminary data show nearly 95 per cent coverage among infants.
All of these interventions will be essential if Rwanda is to succeed in our goal of dramatically reducing the prevalence of all forms of malnutrition. With the bounty of agricultural resources our land provides and the wisdom of the Rwandan farmer, we have all the tools we need to keep every child healthy and growing.
But ensuring that improved availability and diversity of food sources translates into better health outcomes for the most vulnerable children requires more than accelerating production – it necessitates a revolution in the way that families prepare their children’s food and understand the importance of their children receiving nutritious diets for a brighter future.
For this reason, the government has started a massive educational campaign on “how to cook,” and pamphlets have been distributed across the country detailing the kinds of foods that children need, how to cook them, and the importance of proper hygiene and exclusive breastfeeding for children under the age of six months.
Demonstration kitchens are being rolled out in districts across the country, to show families recipes that make use of local foods in such a way as to maximise their nutritional value to children using traditional cooking methods.
Each umudugudu will hold a meeting to strategise on ending malnutrition on December 27 of this year, and these meetings will result in the publication of comprehensive local plans.
To conclude, Rwanda has made great progress this year towards the goals we have set as a people under the leadership of our President. But our job will not be finished until every single child is assured a healthy and balanced diet, until no mother worries about how to feed her baby, until no household goes without a clean water source or a hygienic and sustainable toilet.
From scaling up drugs for HIV to reducing child mortality, our nation has proven that we have what it takes to achieve what some have called impossible, and I have absolute faith that together we will successfully apply this same sense of purpose to the fight against malnutrition.
I can guarantee you that your public servants in the Ministries of Agriculture, Gender and Family Promotion, Local Government, Education and Health are spending sleepless nights working with our colleagues and partners to devise, scale, and monitor solutions to the root causes.
If you have specific complaints about the response to malnutrition or suggestions on how to improve, I urge you to engage with us via Twitter through @RwandaMOH and my personal account @agnesbinagwaho. Be specific –name names, share exact locations, and we will explore every claim. Furthermore, the next #MinisterMondays Twitter and SMS (via 0788386655) discussion on Monday, December 17 will address the state of the malnutrition response, and I look forward to your participation.
The Future of Innovation in Rwanda’s Health Sector: Equity, Participation, Science, Sustainability
I published the following article in October 2012 in Andrew Mwenda’s East African journal The Independent. The full text is not available online, but you can read below.
The world has begun to pay increased attention to Rwanda’s rapid rate of progress in the health sector, particularly as we approach the 2015 deadline set for the health-related Millennium Development Goals. Our country has likely already achieved goals of reducing the 1990 child mortality figure by two thirds and halting the spread of HIV/AIDS, tuberculosis, and malaria; we are on track to achieve the goal of reducing maternal deaths by three quarters by 2015.
What Rwanda has managed to achieve has been the subject of much dialogue (and much debate); I do wish to repeat what has been covered better elsewhere or to make it seem as if our health sector is resting contentedly for even one second when more than 22,000 of our children will die this year. Instead, I want to focus on the why, and to reflect on what must come next for our country and our region if we are to sustain, exceed, and spread this progress.
I firmly believe that the secret ingredient to Rwanda’s recent successes is something very simple in principle that requires a very serious commitment to implement effectively: the absolute insistence that nobody is left out of benefitting from our collective progress. This understanding forms the core of our national development plan, and all from the central level to the community realize that when we tackle the needs of the most vulnerable first, we are sure to also reach all the rest. Moving equity from the realm of the political into the realm of practice and policy has been a true force multiplier for everything that we do.
Rwanda has learned from our long history of segregation and division – due to sources both external and internal – that the only way forward is through complete inclusion. Therefore, before any single policy is implemented in the health sector (or any other), all stakeholders are invited to participate in a process of true consultation. The often complex task of implementation and dissemination is rendered simple when all are engaged to participate from the beginning.
But even policies that are formulated in the most open and inclusive manner will not succeed if they are not based on the highest quality of scientific evidence. It is often said that “you cannot improve what you cannot measure,” and one of Rwanda’s most important innovations has been the establishment of robust systems of monitoring and evaluation focused primarily on actual health outcomes. By implementing a national maternal death audit program, whereby health workers and communities analyze all dimensions of every situation where a pregnant woman dies in childbirth, we have been able to chart a reduction in the number of deaths from 8 women per day in 2004 to less than 3 per week today. By giving a name and a face to every lost mother has sparked each person’s innately human determination to stop this tragedy all the way from the most rural health post to the highest levels of the central government.
Putting evidence into practice requires more than just good tracking tools, however. It means bringing science to bear on both the root causes and the immediate causes of preventable suffering and death. Rwanda has prioritized increasing access to both essential health services (such as safe deliveries through a community-based SMS notification system for ambulances) and to the fruits of medical progress (such as new vaccines against pneumonia, the virus that causes cervical cancer, and the virus that causes many cases of diarrhea in infants). We are particularly proud to see our Ugandan sisters and brothers also scaling up access to the human papillomavirus vaccine this year, which will prevent thousands of young women from developing cervical cancer in the future.
The final building block of success, in my experience, is the honest pursuit of sustainability. I do not mean sustainability as a buzzword, in the way it is so often tossed around and how it comes to fill up a third of the word count for bureaucratic reports. Instead, I mean a sense of deep accountability and responsibility to ensure that programs are built to last and designed with an eye towards continual improvement.
We have a saying in the Ministry of Health that pilot projects are not a solution in Rwanda – the only pilots here are in the sky, working for RwandAir! When negotiating about a new opportunity for our population, we insist that we go national as soon as possible, or we go nowhere. This is not a reckless strategy that makes the perfect and enemy of the good. We simply know that as policymakers and citizens tasked with improving the health of the entire population (not a catchment area or capital city), we must strive for the most robust and long-lived programs possible.
When we designed our new pediatric cancer center of excellence in Butaro near the Rwanda-Uganda border, for instance, it was not only for that one district – it was as a referral center for the nation. When we rolled out the national community-based health insurance scheme, mutuelles de santé, we began by subsidizing the annual contributions and copayments for the poorest one million citizens; soon enough, the middle-class and others bought in because they saw that the most vulnerable were indeed enjoying the best access through this new program. If we had attempted to move from an experimental mutuelles program in one or two cities to nationwide rather than this phased strategy, we would certainly not be able to count 92% of our population as enrollees today.
Underlying all of these principles, and ensuring that they are collectively translated into results, has been innovation in partnerships. To harness synergies and maximize value, we mobilize each and every willing partner according to the framework and timeline of our national plan. This has fostered national ownership of our programs and our success, but it has also led to novel collaborations that simultaneously encourage service delivery, teaching, and research. Rwanda’s Human Resources for Health Program, launched this year with 13 American universities, is a great example.
The lesson for me, then, from Rwanda’s experiences in the health sector has been that anything is possible when you apply the principles of equity, participation, science, sustainability. To better do so, we require constant out of the box thinking, and a commitment to solidarity and shared improvement. My colleagues and I look forward to fruitful cross-border collaborations, and we know that we can make it together.
Congratulations, Dr. Mark Dybul
By Agnes Binagwaho on November 15, 2012
I am delighted to share that US Ambassador Mark Dybul, former leader of the US President’s Emergency Plan for AIDS Relief (PEPFAR), has been announced as the next Executive Director of the Global Fund to Fight AIDS, Tuberculosis, and Malaria. Mark is an inspiring choice by the Global Fund’s Board of Directors. I have believed in his candidacy for this position since the outset, and have great faith in what he can bring to one of global health’s most vital institutions.
Mark has long understood that global health must fundamentally be about equity and the fulfillment of the human right to health – not simply about addressing infectious diseases in far-off places. During his work to launch and expand PEPFAR, he demonstrated time and again that he believes in a person-centered approach to health care delivery and that he knows how to build strong systems that do not leave any among the most vulnerable out of benefits. Mark’s leadership in the global HIV/AIDS response helped to set a new paradigm for global health partnership, transitioning the world towards a long-term approach to tackling the most deadly pandemic in centuries while strengthening systems that have increased access to primary and specialty care for a wide range of diseases.
I am hopeful that Mark’s appointment to lead the Global Fund will help to usher in a new era of results-oriented programming that builds on the legacy of his predecessors, Michel Kazatchkine and Gabriel Jaramillo, while ensuring that the Fund stays true to its roots as an instrument truly of the people. I look forward to fruitful future collaborations with Mark and the Global Fund, and believe that the time for an integrated, solidarity-driven, and country-owned response to global health challenges is within our grasp. There is much work ahead, but the future is bright. Congratulations, Mark!
The Importance of Using Accurate Data: Case Study of Hunger in East Africa
On Saturday, 3 November, I published an op-ed in The East African responding to a recent article describing the findings of the “Global Hunger Index 2012,” a European report analyzing the state of food insecurity around the world. The report’s authors used extremely outdated data for Rwanda in their calculations, skewing their conclusions. My response attempts to call attention to the importance of using the latest and most accurate data in such global assessments.
Hunger Index Used Outdated Data for Rwanda
By Dr. Agnes Binagwaho
As with many international reports derived from complex and non-transparent methodologies to assess relatively straightforward challenges, the Global Hunger Index of 2012 represents an outdated and poorly designed approach to quantifying progress towards Millennium Development Goal 2. -As recently reported in The East African, the Index report ranks Rwanda behind only Burundi for food insecurity in the East African Community.
Based primarily on inputs of child mortality rates and chronic malnutrition or stunting among children under age five, the Hunger Index calculation could not possibly be using updated data for Rwanda, as the child mortality rate has declined by fully 50 per cent between 2005 and 2010 according to both our own internationally-validated Demographic and Health Surveys (DHS) and the World Health Organisation’s modelled estimates. The latest WHO figure shows that Rwanda’s child mortality rate is 54 deaths per 1,000 live births. Yet the Global Hunger Index report cites Rwanda’s child mortality as 91 deaths per 1,000 live births – using an old Unicef report from 2009 that is based on the 2008 DHS.
If child mortality has been falling so much but Rwanda’s Hunger Index has not, then malnutrition must be paradoxically skyrocketing despite increased access to all other child health interventions? But one look at DHS or WHO data shows otherwise: Chronic malnutrition among children under five years old decreased from 51 per cent to 44 per cent between 2005 and 2010. The proportion of children underweight plummeted from 18 per cent to 11 per cent over the same timeframe. But the Global Hunger Index report the 18 per cent figure from seven years ago.
How does Rwanda’s progress across broad socioeconomic indicators stack up to the assertion that its people are among the hungriest in East Africa? Fully one million Rwandans pulled themselves above the poverty line between 2005 and 2010 according to the latest Household Living Conditions Survey, and access to electricity, potable water, adequate sanitation have all improved dramatically since 2000. While Rwanda’s population has increased by nearly three million over the past decade, its Food Production Index compiled by the World Bank has increased by two-thirds over the same timeframe and climbed to the highest in East Africa. Finally, cereal yield in kilogrammes per hectare nearly doubled between 2007 and 2010, and is likewise the highest in East Africa.
While Rwanda is on track to meeting or exceeding all eight UN Millennium Goals in advance of the 2015 target, we are not resting on our laurels. We are acutely aware that still we have far to go in eradicating malnutrition and improving health outcomes, especially among children. In order to achieve our goals, however, we are obliged to develop and implement policies based on accurate data along with astute analysis.
In a country and region changing so rapidly, it is the responsibility of institutions such as the International Food Policy Research Institute, Welthungerhilfe, or Concern Worldwide to concern themselves with facts, not conjectures or models when robust and current evidence is easily accessible. If such “watchdog” agencies and the reports they produce are to serve a useful purpose (and I do believe they can when designed well and disseminated transparently), they must hold themselves to the same standards of accountability they seek from countries like Rwanda. No one more than the Ministry of Health knows that Rwanda has a long way to go until chronic malnutrition is not a massive health challenge, but it is our responsibility to base our approach on solid evidence and sharp analysis.
Recommendations based on the latest data can help public sector institutions to improve policies, strategies, and implementation of programmes to tackle challenges like malnutrition, but when they are conducted sloppily, one wonders whether the money spent on consultancies for such a document might be better invested in helping to grow food for improved nutrition of children around the region than using large amounts of overheads to create metrics that are out of date before they are even published.
Country Ownership to Strengthen Synergies Between Global Health Initiatives and Health Systems
On Thursday, 8 November, colleagues in the Ministry of Health and I published a brief Comment in Journal of the Royal Society of Medicine: Short Reports responding to a review of interactions between global health initiatives (like the Global Fund and PEPFAR) and country health systems. We shared Rwanda’s perspective on the importance of true country ownership in promoting integration and maximizing synergies.
Country Ownership to Strengthen Synergies Between Global Health Initiatives and Health SystemsAgnes Binagwaho, Sabin Nsanzimana, Corine Karema, Michel Gasana, Claire M. Wagner, and Cameron T. Nutt
As policymakers and researchers in Rwanda’s health sector, we applaud Josip Car and colleagues’ review of interactions between Global Fund investment and country health systems.1 Their trenchant analysis may not close the door on confidently advanced claims about the dangers of global health initiatives that are not based upon rigorous evidence, but it has helped to raise the bar for the debate.Several recent studies focused on Rwanda (that either did not fall within Car et al.’s timeframe or did not specifically investigate Global Fund programs and were thus not included in the review) together provide robust support for the argument that interventions explicitly designed to combat HIV/AIDS, tuberculosis, and malaria can be implemented in such a way as to strengthen the overall health system.2-4
In fact, Rwanda’s reductions of greater than 75% in mortality due to AIDS and tuberculosis between 2000 and 2010 were accompanied by a 70% decline in child mortality and a 60% decline in maternal mortality over the same timeframe.5 This was not a fortunate accident, but due to collaborative planning with civil society and development partners, and true country ownership of program implementation and evaluation.
From the beginning of Rwanda’s AIDS response, the public sector has been committed to constructing platforms of care able to address multiple chronic and acute conditions. When a clinic is built and staffed to offer HIV services to women, the same woman trying to prevent vertical HIV transmission to her unborn child will also require a safe place to deliver as well as a trained birth attendant. So will her neighbors, whether HIV- positive or not.
As is often said in the Ministry of Health, “if you give Rwanda money to help the youngest child born today, we will ensure that it also helps the oldest person by tomorrow.” When implemented according to principles of authentic partnership and when investing in public infrastructure and human resources, disease-specific global health initiatives can not only achieve positive spillover effects, but can also catalyze the development of comprehensive and equitable primary care systems in the poorest countries.The time has come for scholars and policymakers to move past unfounded worries about whether to invest in the pandemics of AIDS, tuberculosis, and malaria; what we must now devote our full attention to is the question of how best to harness synergies and maximize impact in the pursuit of health as a human right.
1 Car J, Paljarvi T, Car M, Kazeem A, Majeed A, Atun R. Negative health system effects of Global Fund’s investments in AIDS, tuberculosis and malaria from 2002 to 2009: systematic review. J R Soc Med Sh Rep 2012;3:70.
2 Price J, Leslie JA, Welsh M, Binagwaho A. Integrating HIV clinical services into primary health care in Rwanda: a measure of quantitative effects. AIDS Care 2009;21:608-614.
3 Kalk A, Groos N, Karasi JC, Girrbach E. Health systems strengthening through insurance subsidies: the GFATM experience in Rwanda. Trop Med Int Health 2010;15:94-97.
4 Shephard D, Zeng W, Amico P, Rwiyereka AK, Avila-Figueroa. A controlled study of funding for Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome as resource capacity building in the health system in Rwanda. Am J Trop Med Hyg 2012;86:902-907.
5 WHO: World Health Statistics 2012. World Health Organization, Geneva 2012.
Global Health Solidarity at a Crossroads
On 5 July 2012, I published an op-ed in Project Syndicate about the importance of fully funding The Global Fund to Fight AIDS, Tuberculosis, and Malaria.
You can read the full text below, or access the piece on Project Syndicate’s website here.
KIGALI – A decade ago, the global community stood together to declare that where people live should not determine whether they live or die when confronted by the scourge of AIDS, tuberculosis, or malaria.
This act of solidarity – unprecedented in human experience – led to revolutionary advances in promoting health care as a human right. The Global Fund to Fight AIDS, Tuberculosis, and Malaria, along with the United States President’s Emergency Plan for AIDS Relief (PEPFAR), quite literally changed the course of history. Programs directly supported by the Global Fund have saved nearly eight million lives since 2002 – an average of more than 4,400 lives every day.
But, while much has been accomplished, much more remains to be done – and the Global Fund needs at least $2 billion to reverse a funding freeze that is in place through 2014. So the world now plays a waiting game to see whether governments will step up and fill the gap.
To be blunt, many of the world’s largest economies are not fulfilling their financial pledges to the Fund. Their politicians cite budget constraints and the need to prioritize domestic programs over fighting diseases that disproportionately kill the world’s poorest.
My country, Rwanda, has been a recipient of Global Fund grants since 2002. Just 18 years ago, our society was torn apart by a brutal genocide that killed more than one million people. Today, Rwanda is a peaceful country full of promise and hope, with one of the world’s fastest-growing economies.
With Global Fund support for our national institutions, we have achieved universal access to lifesaving antiretroviral therapy for people living with HIV, and we have stabilised HIV prevalence at around 3% of the population. Similarly, Rwanda’s tuberculosis program has become a model for Africa, and all Rwandan families now have access to insecticide-treated bed nets to prevent malaria, contributing to an 87% drop in cases during the last seven years.
Integration of services for infectious diseases and primary care has contributed to some of the steepest declines in child and maternal mortality ever observed. And, as life expectancy in Rwanda continues to climb (from below 30 in 1995 to 55 in 2010), we are now taking action against non-communicable diseases such as heart disease, cancer, and diabetes. The flexible, country-owned support provided by the Global Fund has been crucial to our success.
My country is living proof that investing in health is not only the right thing to do, but that it can also create virtuous cycles that promote security and development. In fact, after receiving Global Fund support for years, Rwanda recently made its first donation of $1 million to the Fund.
Unfortunately, infectious diseases are far from under control around the world. Less than a quarter of the world’s children living with HIV have access to treatment, and up to a million people still die of malaria each year. And, alarmingly, only one in six patients with drug-resistant tuberculosis currently receives proper treatment. Moreover, reports of “totally drug-resistant tuberculosis” have recently emerged from India.
Policymakers would do well to remember that it only takes one airplane flight for such a pathogen to go global. Infectious diseases neither respect national borders nor conveniently follow economies into recession. History has shown that retreating from the fight against an epidemic can lead to a renewed plague that is immune to our best drugs, requiring far more expensive measures to control.
Our choice could not be clearer: either we resolve to answer the call of history and provide the Global Fund with the resources that it needs, or we allow political lassitude to undermine a decade of progress and consign untold thousands to preventable deaths. Investing now, on the other hand, would pay off in the long term: just $6 billion more per year for the AIDS response today would save more than $40 billion in averted treatment costs alone over the next decade.
Today, the Global Fund stands at a crossroads. The international community’s regard for the health of the world’s poorest in the face of financial uncertainty will be a standard by which history measures not only our ability to stand together in weathering economic upheaval, but also our capacity for justice.
Now is the time for donor countries, including middle- and low-income countries, to rise to the challenge and ensure that the Global Fund has the resources needed to accept new grant applications as soon as possible. The costs of inaction are morally – and economically – untenable.
Rebuilding Confidence in Rwanda’s Future
My latest article in Rwanda’s New Times is below. To visit the website where the article is printed, click here. On all levels of a health care system, it is critical that there is real trust. This is true for the patient-provider relationship on a case-by-case basis, and between colleagues but also true on a larger scale. The population of a country must be assured that they can trust their health sector to make choices that are in the best interest of the people, and to avail technologies and services equitably and safely. The only way to gain this trust is by actually providing the promised services and technologies guided by the principle of equity as is written in our constitution.When I returned to Rwanda in the mid-1990s to work as a pediatrician in Centre Hospitalier Universitaire de Kigali (CHUK), alongside all the team of clinicians, we struggled day-to-day to keep children alive and healthy despite the lack of equipment and supplies to apply the best clinical practice. We saw so many unnecessary deaths during those years – we knew what it would take to save a life, but simply did not have the health professionals, the drugs, nor the technologies available to us to do so.During my first week at CHUK, I saw more avoidable deaths than I had seen unavoidable deaths over the course of the five previous years when I was working in a pediatric ward in Europe. It is no wonder, then, that the population did not trust the health sector. To lose a child results in unbridled pain for the parents – and this is what was happening in Rwanda every day, unnecessarily, for so many parents.At that time in Rwanda, the impact of the ethnic tensions – planted by the colonial enterprise and exacerbated by the bad governance based on divisionism during the first three decades of independence that ultimately resulted in the 1994 Genocide against the Tutsi – made it even more important that we start a new chapter in terms of providing services to our population in the framework of equity and rights.When I started to work in CHUK, distrust in health professionals was not only due to the fact that clinicians had limited tools to save lives, but distrust was also due to those that used their position in heath facilities to shorten the lives of Tutsi patients during the 1994 Genocide against Tutsi. Immediately following the Genocide, some patients were afraid of being victims as were their relatives during the 1994 Genocide against Tutsi, and others were afraid of possible revenge. We knew it was absolutely necessary that the public sector’s health system change drastically in the framework of development in order to provide good quality care and regain the trust in parents and the entire population.This difficult working environment almost pushed me to return to Europe, but I decided to stay with my colleagues to be part of the movement to change the medical environment in Rwanda. This was the most important decision I’ve made thus far in my professional and social life.The organised, peaceful return home of more than a million Rwandan refugees from the Democratic Republic of Congo had great impact to the peace, and the security process, and has affirmed for ever my trust in the future of my country, as did the Gacaca courts for justice and reconciliation. These decisions, among many others, have aided Rwanda in planning and creating a better world for our children so they can live in peace, security, prosperity, and good health.Last week was the closing of the Gacaca courts – close to two million people were tried in this homegrown judicial system, compared with the 60 cases tried by the International Criminal Tribunal for Rwanda (ICTR), which shows that it would have taken at least two centuries to process all cases through ICTR.Gacaca’s detractors who claim that there is nothing good in Gacaca offer polemic arguments unsupported by evidence. Gacaca has allowed Rwanda to harness its tradition to reach a grassroots solution to ensuring we can dissolve our fear of insecurity, recover from wounds and pain, collectively hold criminals accountable, give victims reparation, and build a foundation for truth and forgiveness. This has and will continue to allow us to design the roadmap for Rwanda’s future together as one nation, and promote a cycle of peace, development, health and wealth, instead of poverty, revenge, crime and distrust.As President Paul Kagame has said Gacaca is not perfect but no system would be perfect in such an extraordinary situation. Yet those who criticize propose no alternative to it. I have asked myself if those who criticize Gacaca prefer to see a poor and forever destroyed Rwanda without hope in its future instead of our vibrant nation which wants the best of peace and development for its populationIn my primary and secondary schooling in Europe, teachers taught us a concept called “enemies hereditaires” and explained it during many history lessons – the concept denotes a relationship wherein you inherit enemies from birth only because you are born in one place. This mindset is dangerous and gives false rationale that enables persistent regional and social divisions. In our new Rwanda, we have gone for the opposite of this term – we have gone for justice, recovery, and development through reconciliation and the understanding that every human being deserves respect and has fundamental rights to be protected, healthy and the right to be educated.All sectors of Rwanda continue working together in the promotion of this virtuous cycle. We, in the health sector, do so by providing services to our population that can be accessed anywhere in the country and that can be afforded by all. The number of health centres has risen drastically over the past 18 years, to now 438, and soon 476, distributed evenly across the country.Our trained community health workers (45,000 in total, three per village) provide preventive, diagnostic and curative services for some of the biggest killers equally in each umudugudu (village).Nearly 70 per cent of new mothers in Rwanda now deliver in health facilities – this also has been facilitated by the confidence in each other, in part rebuilt by the Gacaca justice system, and is proof of a solid foundation of a trusting relationship between patient and provider. If parents wish to choose the size of their families, they must be able to trust that the health system will provide the needed services to keep their children alive. Between 2000 and 2010, uptake of modern family planning methods has increased by over 450 per cent from 10 per cent to more than 45 per cent and we expect within a year to increase access by availing this service in each of our villages. We, in the health sector, would not be able to achieve this in a country struggling with distrust and not focused on developmentThere are multifaceted processes, systems, policies, and interventions that have enabled Rwanda to be an example to the world. Showing, for example, fast improvement in provision of health services in low-income countries we can also provide hundreds of other examples. I can cite our education sector with the primary and secondary school enrollment increased for both boys and girls, and completion rates that continue to improve. Our country has also been highlighted in newspapers and journals around the world illuminating the fact that the percentage of Rwandans living below the poverty line has decreased from 57 per cent to 45 per cent between 2006 and 2011 – accounting for one million Rwandans who have lifted themselves out of poverty. In this area, Rwanda is one of the world’s best achievers.All this dramatic progress in a country destroyed 18 years ago has been made possible only because of good leadership, good governance, zero tolerance to corruption, a vision focused on the wealth of our people and a spirit of accountability developed through processes including the Gacaca.The Gacaca courts have directly and indirectly allowed Rwanda to advance as a nation toward prosperity, security, increased wealth and better health. Even though some in the world will criticize Gacaca, I know from being like the millions of us a witness and a part of Rwanda’s development, how important reconciliation is to building a public sector that can be trusted to provide services in the best interest of the people. I see a bright future in front of us and I am proud of my country.
Rwanda’s Pursuit of Shared Wealth through Health for All
June 7, 2012
My latest article in Commonwealth Health Partnerships journal is below. To visit the website where the article is printed, click here.
Rwanda is determined to join the ranks of middle-income nations by the year 2020. This determination is largely driven by one thing: the demand for what Rwandans call ‘agaciro,’ or ‘dignity’ for our people. In pursuit of agaciro, the Rwandan people are continuously compelled to find better ways of doing things. Our economy must be vibrant and more independent; our politics must be inclusive and founded on consensus building; and our people must live a decent and dignified life, able to fulfill basic social needs.
To achieve these ambitious goals, the Government of Rwanda has adopted a number of innovative approaches to policymaking and implementation, including both universally applicable and home-grown solutions that effectively account for context in addressing Rwanda’s most pressing challenges.
Indeed, seeds sown since the 1994 genocide against the Tutsi are beginning to bear fruit. The recent publication of the countrywide household survey indicated that Rwanda has reduced poverty levels by 12 percent over the past five years, from almost 56 percent of the population in 2005 to 44 percent in 2010.
The understanding underlying this success is that for a nation to be successful, it must invest in and rely upon the human asset or capabilities of its own people. Rwanda’s philosophy for growth starts with a shared vision that a well educated and healthy population is the starting point for any economic development.
This is why the health sector been a key priority for the country’s Government; 18 years down the road to recovery after 1994, the achievements in this sector speak volumes.
Documenting Recent Progress
The recently released Demographic and Health Survey (DHS) of 2010 revealed several areas of dramatic progress in health outcomes since the last survey in 2005. Across the spectrum, the findings demonstrate significant progress in combating infectious diseases, improving child and maternal health, and addressing both financial and geographical barriers to accessing health care.
A Rwandan child born today has more hope than ever before of living to celebrate his/her first and then fifth birthdays. Between 2005 and 2010, the infant mortality rate dropped from 86 to 50 per 1,000 live births, while the under-five child mortality rate plummeted by fully 50% from 152 to 76 per 1,000 live births.
Rwanda remains dedicated to surpassing the Millennium Development Goal targets for infant and child mortality by 2015, but as a result of our deeply rooted conviction that our children must enjoy the right to life and hence a right to adulthood, we know that we can drive these figures down even further.
These declines have not come as a surprise; they are partially attributable to the fact that more and more of Rwanda’s mothers are enrolled in and retained by antenatal care programs throughout their pregnancy. This has led to an increase in the number of women giving birth at a health facility from just 30% in 2005 to 69% in 2010.
To adequately address issues concerning maternal and child health (MCH), Rwanda has employed many synergetic interventions along the continuum of care, but all of these are built upon the foundation of a strong community health system driven by Community Health Workers (CHWs) deployed in all villages across the country. These community health workers have bridged crucial access gaps in the health system and have brought prevention, treatment, and care services closer to the people.
One clear result of CHW’s effectiveness can be seen through Rwanda’s active immunization campaign, which has achieved over 90% coverage of all children and ensured the provision of new vaccines targeting emerging diseases to the population. In 2009, Rwanda was the first country in Africa to roll out the pneumococcal vaccine, and in 2010 became the first low-income country in the world to roll out the human papillomavirus vaccine. Both initiatives have attained over 90% coverage by building on the country’s pre-existing robust vaccination program.
Investing In Our Population
It is well known that Rwanda does not have major natural resources like oil, gold, and diamonds; but our Government knows that our greatest asset is our people themselves. To ensure that we deliver appropriate services in an equitable way that allows each Rwandan to reach their full potential, we have continuously worked to educate our people on the need for smaller families.
Rwanda needs a population whose growth does not outpace that of our economy. Declines in birth rates over recent years are not as dramatic as those that will be needed in the future, but they do show that we are achieving concrete results. Between 2005 and 2010, total fertility rate (the number of children a woman is expected to have throughout her entire life) dropped from 6.1 to 4.6. Uptake of modern family planning methods jumped by 450% during the same period, from just 10% in 2005 to 45% in 2010. Taken in the context of other socioeconomic indicators discussed earlier, we can see a strong relationship between improving child survival and declining birth rates – as fewer children die premature deaths, families feel the need to have fewer children.
Combatting Infectious and Non-Communicable Diseases
With the support of our global partners, Rwanda has made substantial gains in the fights against HIV/AIDS, tuberculosis, and malaria. HIV prevalence has fallen from 13.9% in 2000 to 3% today due to an integrated approach to tackling the pandemic with urgency and equity.
As of December 2011, fully 100,656 patients at 390 health facilities across Rwanda were receiving antiretroviral therapy for free, accounting for 84% of all patients clinically in need of treatment. When compared to the 870 patients at just 4 facilities who had access to these lifesaving drugs in 2002, it is clear that we have come very far.
A combination of effective policies for malaria prevention and control have likewise contributed to a reduction in prevalence and mortality associated with malaria by almost 50%. This is largely due to an increase in the usage of mosquito nets from 56% of households in 2005 to 82% in 2010, but also tied to the provision of effective diagnosis and treatment at the community level by CHWs.
However, Rwanda and its leaders will not be complacent following progress against the major infectious killers: we recognize well the need to turn our attention to the growing burden of non-communicable diseases such as heart disease, cancer, diabetes, and respiratory diseases. As more Rwandans live longer, we must focus on the long-term needs of the population by anticipating health problems that are likely to arise and preparing solutions now.
There are many areas where we can begin to act immediately on non-communicable diseases, such as the prevention and treatment of pediatric and female cancers where the market and partnerships have made new opportunities available today. The Ministry of Health is currently in the process of planning for comprehensive national early detection and treatment programs for breast and cervical cancer for women, who will also benefit from access to the human papillomavirus vaccine to prevent cervical cancer in the first place.
We are currently in the final stages of assembling protocols, guidelines, and policies for pediatric cancers, beginning with those that are most prevalent and most amenable to immediate action. Non-Hodgkin’s Lymphoma, for example, affects many children in Rwanda, and there is something that can be done about it now even as we work to build the capacity to address more complicated cancers.
While we understand the urgency of obtaining sufficient infrastructure, Rwanda will not wait for the last brick to be laid or the last road to be paved before we act – we will handle whatever illnesses we can within our present means while striving for a stronger system at the same time. For those who it is too late to offer successful treatment for cancer or other non-communicable diseases, we shall ensure the provision of palliative care.
As we take pride in Rwanda’s achievements, we are also mindful of the challenges ahead. Much as the DHS 2010 results provide a roadmap for further improvement of infectious disease control programs, we need to adopt innovative new approaches that will provide quick solutions for transforming our sector across all initiatives.
Through our Community-Based Health Insurance scheme, known as Mutuelle de Santé, we have addressed the issue of financial accessibility in the health system. More than 80% of Rwandans today are enrolled, guaranteeing them access to quality services. However, gaps persist in geographic accessibility that can be addressed by constructing more health facilities across the country. The Government’s aim is to have one health center serving each local government sector population of 20,000 to 25,000 people, meaning that significant further investment in infrastructure will be needed.
The Ministry of Health and health providers around the country understand that access alone is not enough – we must also strive to provide the highest possible quality of care to our population. Rwanda aspires to become a hub of exemplary services for the entire East African region, and we will need to continue improving quality if this vision is to be achieved. Such efforts will include not only the acquisition of newer and better equipment, but also bridging the ratio of providers to population.
Today, the ratio of physicians to population remains unacceptably high at 1 per 17,000. Our target is to reduce this figure to 1 per 10,000 in the near future. The Ministry of Health seeks to have at minimum a surgeon, a pediatrician, an anesthetist, an internist, and an oncologist at each district hospital.
To this end, we have reached an innovative $34 million agreement with the United States Government that will bring more than 100 senior medical faculty from American universities to Rwanda over the next seven years to train and work with our physicians to build specialty capacity and create new residency programs. This program will begin in July 2012; with sustained commitment and sufficient vision from all involved, it has the potential to affect a massive paradigm shift in global health partnerships and medical education around the world.
Looking to the Future
As a core element to Rwanda’s Vision 2020 national strategic plan, the Government of Rwanda has established ambitious targets for the health sector that must be realized by the end of the decade. The under-five mortality rate, for instance, should be reduced to 30 per 1,000 live births from the current 76 and current prevalence of severe malnutrition must be reduced six-fold. These and many other goals will require concerted efforts from every stakeholder, including our development partners.
In assessing our current situation and where we want to go, we can see that the good news is that Rwanda has built the basics of a dynamic and equitable health system. In order to take the health sector to the next level, we must build upon our solid foundation and continue to seek out ways to improve the value, quality, and compassion of services we deliver.
It is written in Rwanda’s Constitution that “the human person is sacred and inviolable.” The Ministry of Health could not possibly take this declaration more seriously; the quest for improvement is a civil, moral, and human duty that we accept with great humility and determination.
Time to Take Hygiene Issues Seriously
I published the following opinion piece in The New Times on 21 May 2012.
Around the world, it is well understood that catastrophic medical expenditures are a leading cause of destitution, driving some families from stability into poverty and preventing others from pulling themselves up.
One of the most common causes of hospitalization and mortality for young children in Rwanda is diarrhea and associated digestive diseases, causing tremendous suffering among the most vulnerable and hindering national development. Many of all of these cases are the result of poor hygiene and inadequate sanitation, a set of issues that we have all the tools and knowledge to solve. Vision 2020 and the Millennium Development Goals, toward which Rwanda has made strong progress in recent years, identify improved hygiene as a top priority for very good reason.
Digestive diseases pose both immediate and long-term health risks to children and families in Rwanda. Not only do the acute symptoms of diarrhea and dehydration threaten the child’s health, but these can lead to malnutrition before long when the child is unable to eat. Acute malnutrition is compounded by severe diarrhea, and chronic malnutrition exacerbated by recurrent diarrhea can lead to developmental delays.
Diarrhea leads to more hospitalizations among children than any other individual cause, and is responsible for a significant portion of out-of-pocket expenditure by families in both rural and urban areas. While mutuelle de santé covers 90% of all medical costs for enrolled families, even the 10% contribution can add up very quickly with lengthy or repeated hospitalizations. Families have had to borrow and draw on help from neighbors in order to manage these expenses due to diarrhea, but sometimes this is not enough.
Through the payment of 100% of medical bills when families in Ubudehe category 1 and 2 are unable to pay, the government spends a significant amount of both the domestic and development budget to provide care for multiple hospitalizations for children with digestive diseases. This money should be used for the economic development of the nation – to build more hospitals in remote areas, to construct high quality schools to educate our youth, and to provide families with greater opportunities to build better lives for themselves and for the next generation.
Furthermore, the opportunity costs of having a parent accompany and remain with a child to the hospital are enormous. Other children who stay at home are often neglected (not by parental irresponsibility but because they must give their full attention to the sick child), placing them at risk for poor school attendance, malnutrition, and depression. Additionally, that parent cannot perform their usual income-generating activity, rendering their family more vulnerable to catastrophic medical expenditure and making it less likely they will have the resources to continue improving hygiene and sanitation at home, so all of their children are at even higher risk for future digestive diseases. A vicious cycle of poverty and disease is perpetuated, undermining development and trapping families in a state of constantly trying to respond to the next health or financial crisis.
Our most powerful tool in the struggle against digestive diseases among children in Rwanda would be a widespread change in mindset around the importance of better hygiene. The hygiene committees that already exist at the district and umudugudu levels should be sensitized around the threat poor hygiene poses to local and national development. Communities should be supervised by local leaders for the construction of adequate toilets that follow sanitation guidelines from the Ministry of Health. Families across the country must be remind by all of us at all occasions about the importance of washing hands after using the toilet and before cooking or eating. Each man, woman, and child must use potable water – whether from an improved water source or through boiling or filtering or using pharmaceutical. Every household should take pride in maintaining a clean home, with separate safe places for clothing, cooking, and eating. Finally, families must serve children food that is well prepared – not cooked too little so that dangerous bacteria remain, but not so much as to remove important vitamins.
These actions are simple and urgent. The Ministry of Health and our colleagues across the Government Institutions are availing resources for continued scale up of behaviour change communication, improved water and sanitation infrastructure, and prevention and treatment of diarrhea (including the new rotavirus vaccine), but these will mean nothing if not accompanied by a major shift in day-to-day hygiene practices by the population. As a nation, we must stand together ready to confront poor hygiene as a serious but solvable threat to our development.
Global Health Delivery in Rwanda Course Featured in New York Times
The New York Times published an article today about the Global Health Delivery in Rwanda course, which resulted from a collaboration between Harvard Medical School and the Rwandan Ministry of Health. You can read it by clicking HERE or reading below.
Harvard Offers New Global Health Program
The success of Rwanda in providing health care to its poor has drawn the attention of the international community and has inspired a new program at Harvard University.
Rwanda was one of the poorest countries in the world in 1994, after a genocide claimed more than 500,000 lives and left the country with little or no access to medical services. In 2005, it began to rebuild its infrastructure. Now, according to the Rwandan Ministry of Health , the country provides health care and insurance to more than 90 percent of its population, inspiring medical leaders from around the globe to visit the African country to study its transformation.
Now, the Harvard School of Public Health is working with the Rwandan Ministry of Health to teach a course called Global Health Delivery in the village of Rwinkwavu twice a year.
“Rwanda is honestly starting to change the face of global health,” said Dr. Paul Farmer, one of the founders of Partners in Health , a nongovernmental organization that works in Rwanda and other poor countries. He is also the chairman of Harvard’s Department of Global Health and Social Medicine and one of the faculty members for its course in Africa.
In February, 30 African medical leaders met with Harvard faculty at the training and research center in Rwinkwavu to discuss the challenges of delivering health services in resource-poor settings. Six of these students were trained to become faculty members who will teach future classes, with the next sessions scheduled for July.
During the weeklong course, students and professors discussed case studies and conducted field visits throughout Rwanda. Because all the students are currently health workers — most are employees of the Rwandan Health Ministry — they are able to immediately apply what they learned in the Harvard course to their daily work.
Initially, the course was held only on Harvard’s campus, where students would discuss case studies on the difficulties of delivering medical services internationally.
But the course changed in February. A world away from Cambridge, Massachusetts, health professionals in Rwinkwavu discuss the same case studies. They also participate in live cases, in which students and faculty members interview doctors, nurses or other health workers, like the head of an organization working to deliver AIDS medications to the poor in Rwanda, to ask them about the challenges of their work. Visits to Rwandan clinics and hospitals allow students to see health care in action, and give them the opportunity to collaborate with other professionals to discuss solutions.
“To be a good global health provider, it’s good for students to see what others have done,” Dr. Agnes Binagwaho, who is both the Rwandan health minister and a Harvard faculty member, said by telephone.
Seeing potential for the course outside of Massachusetts, Dr. Binagwaho worked with Partners in Health to bring the Harvard curriculum to her home country.
“We hope to have students come from around the world and learn from them as well, and also have the students learning from each other, because they are all coming from countries where there are things ongoing,” she said.
There is now also a new Harvard degree, a Masters in Medical Sciences and Global Health Delivery, which will begin this autumn. Plans to offer a similar degree in Rwanda are under way.
“Above all, you need people who actually do the delivery to tackle the problems,” Dr. Farmer said. He stressed the importance of working not only in Africa, but also with African health care leaders. “Not everyone has the privilege to make it to Harvard — and we needed to reach out,” he added.
The Harvard course is one of the first that focuses exclusively on the challenges of delivering health care. It encourages students to think about how politics, economics and other social factors affect health.
“I don’t know many other groups that are looking at health care delivery as a field of study and bringing that to collaboration with African ministries of health,” said Dr. Joseph Rhatigan, the director of the Global Health Equity residency program at the Brigham and Women’s Hospital, a teaching hospital affiliated with Harvard in Boston.
Partnerships between medical schools and the developing world are increasingly common, but the majority focus on practicing medicine as opposed to delivering care and understanding the effect of social factors, he said.
Dr. Corine Karema, director of the programs for malaria and neglected tropical diseases at the Rwanda Biomedical Center and one of the students in the Harvard course who trained to become a faculty member, said the course made her change the way she looked at medical treatment.
“I’ve been working for a long time in public health, and we used to decide on intervention and strategies if they were cost effective without looking at how the strategy will best affect the patient,” she said.
She said she now had higher expectations. The course taught her to advocate the best treatment available, regardless of cost.
“Too many people in public health have been socialized for scarcity, the idea that we just have to make do with less,” said Dr. Farmer. “That socialization for scarcity has prevented innovation. That’s really what the course is about: confronting the socialization to scarcity and combating it.”
Dr. Farmer and other faculty members drew on their experiences at Partners in Health. For more than 20 years, the organization has worked in Haiti, Lesotho, Mali, Peru and other countries to make once-costly treatments for medical conditions like H.I.V. and tuberculosis available to the poor.
Although professors bring Harvard expertise to the table, they say they take as much away from the course as the students.
“I learn a lot more when I teach experienced people,” said Dr. Joia S. Mukherjee, the medical director of Partners in Health and a Harvard professor who helped organize and teach the course. “They are all saying, ‘Well, this is what we did here, this is what we did in Haiti.’ The students are learning more from one another than from professors.”
Dr. Farmer recalls students saying in a group discussion, “‘You mean that happened to you, too? Well, we had the same problem in Burundi.”’
“Within five minutes you had five people discussing a very specific problem that they had all faced,” he said. “That kind of exchange you can’t get out of a classroom, textbook or article. Watching hard-working African health care professionals sharing experiences, just for that hour session alone would have been worth the course.”
The students from Rwanda stay in contact via an online portal , and the case studies are available online as open source information.
“We agreed that in six months, we will all have a case study about something we have done in our daily work and use them as new materials for the Harvard lectures,” Dr. Karema said.
“It’s an outstanding initiative because it relates what is being done in the States to what the needs are overseas,” said Eldryd Parry, founder of THET Partnerships for Global Health, a British organization that works to improve health care in Africa and Asia. “There is so much in international aid and health that is decided in Washington, and that’s not the mind behind this program. It’s a catalyst for further interest.”
Faculty members have said that the main challenge will be maintaining funding, which is currently supported by Partners in Health, Harvard and philanthropies.
Dr. Pat Lee, who teaches at Harvard but is not affiliated with the course, said, “We have some interesting work to do as educators to adapt to the needs of different learners and tailor the curriculum so that it can be accessible to a variety of audiences.”
That will be critical if Dr. Binagwaho’s vision comes to light. In the future, she hopes to invite health professionals from around Africa and other developing countries to participate.
“We can be the example,” she said, “not teaching in theory, but teaching in practice. If you want the developing world to develop, you have to develop teaching. Courses like this have to grow.”