Ministry of Health (Rwanda)

Transcription

This evening I'm just going to introduce our wonderful speaker, my friend and colleague Agnes Binagwaho. Put simply, she is Minister of Health for the Republic of Rwanda. But Agnes is so much more than a Minister of Health. So let me just explain why she is so much more, for a moment. First of all she's a paediatrician - it's not very common to have medical doctors as ministers of health. It's usually said that that's a bad thing. But I think there's something the UK could learn from having someone who actually knows about the subject as a Minister of Health [applause]. I think that-- I do think Nigel Crisps in the audience, that we really could turn the world upside and learn a lot, actually, from what's taking place in Rwanda right now. Agnes has had a distinguished career in her country. She led the National AIDS Control Commission, she was Permanent Secretary in the Ministry of Health and she has academic appointments at both Harvard and Dartmouth College. And that's where Agnes is even more unusual as a Minister of Health, because she takes research and evidence seriously. That is why she is here this evening. At the moment she's serving on two commissions that we have running. She's serving on a commission of women in health and one on a commission on investing in health. We had a meeting last year on the commission on women in health and it was held at another university in London which I wouldn't dare mention here, and we had a day or a couple of days of discussion and Agnes was invited, and quite honestly, we didn't think she would come. She's a Minister of Health, she has responsibilities elsewhere. And she came. We thought, well, she'll come for half an hour to an hour and then she must go and do other things that her embassy will instruct her to do. In fact, she spent the entire day with us, taking part vigorously in discussions about the direction that the commission should go. She is a serious intellectual and she seriously engages with issues that matter, and that's another reason why she's here this evening. In July, she invited us all to go to Kigali for a meeting of the Commission on Investing in Heath, and we were here guests there. And we witnessed firsthand a remarkable health transformation that's taking place in Rwanda. You're all fully aware that next year is the 20th anniversary of the genocide that took place in Rwanda during 1994. And quite literally, the country has had to be built from every community upwards, almost from scratch. And in one of the first slides that she showed of what she's doing as Minister of Health, it was entitled, "Building a Health System." And that is what she and her incredible team have been doing. It's a tough challenge and there are many challenges still to go. But if you look at the various measures of what's taken place in Rwanda under her leadership, PMTCT, vaccination coverage, preventing malaria, family planning and addressing the emerging epidemic of non-communicable diseases, she is literally leading a health transformation, one that the rest of the world needs to pay serious attention to. And she's not just a one minister show! She is concerned about building capacity in her country, and she has an amazing team that she has put together, and one of the requirements for her team is that they all have to pursue postgraduate studies in a particular discipline relevant to their role in the Ministry of Health. There's another thing we could learn from Rwanda in the way we construct our Ministry of Health! It's a real pleasure this evening to welcome Agnes Binagwaho, and her title already is provocative: Charity Does not Rhyme with Development, Let's Create a New Partnership: The Golden Age for Global Health. Please welcome Agnes Binagwaho. [Extended applause.] >>[Agnes Binagwaho] Good evening, everybody. So thank you for your kind words. It's my pleasure to be here. And why I'm in your commission is because I believe that history has to be written. And article in the Lancet, or report in the Lancet, and many other journals, influences politicians. And I want you to influence politicians in this part of the world to do better their job. It will help us to do better our job. [Laughter.] So, but I am very humble to be here this evening, and thank you, Richard, and Anthony Costello, to have invited me. Thank you also to your great team, because I was really welcome and helped. Today it's a general title. I guess that the majority of you are in the health sector, isn't it? But what I'm going to tell you it's about, it's in general, because health is just a piece of what concerns people. So I'm going of course to speak as a recipient of that aid, and also as somebody who is running the health sector. Yes. So this Rwanda, I think that you can Google it and have it, so I'm not going to spend many time on this. The only thing I want you to see is that we have increased life expectancy, more than doubled it. More than doubled it without really being more rich. The majority of our people still live under one dollar, but they have access to health. Meaning, money is not everything. In the-- what I have to tell you also, money is not everything, and if it's -- I don't present you my country, I think that I have to say that I have a lot of respect to be with you here today because as Richard says, less than 20 years ago, our country was totally destroyed, devastated. Doctors had been killed, nurses too, because I want to tell you that the genocide started by killing the intellectual so that they can not be a barrier between that. So we had a country that was totally destroyed and the fact, if somebody had said that 20 years ago we will be here talking about what we think the world should do with a lot of experience to talk about it, it's really not -- it was really not probable. So this is the money that went in the health sector. But if we want to talk about Africa in general now, more than one trillion dollars -- it's a lot of zeroes, I don't even know how much it is -- but more than one trillion dollars has been given, in general, to Africa, for its development over the last 50 years. In health also, this is only for health. But what we need to know is that the revenue per capita, people are more poor in parts of Africa than they were 50 years ago. So what happened that this massive influence of aid didn't bear fruits in Africa? There is something to think about. There is something wrong, because this money, guys, is your taxes. You are sweating for that, or if not yours because you are young, but not everybody is young here. [Laughter.] It's the money of your parents. If it's not producing revenue, better give that money to you so go to the pub Friday, isn't it? [Laughter.] So there is something we should think about: how come that this money didn't bear fruits? Too early. I want also to say something else: the majority of the countries in Africa have a growth between five and eight percent. A ha! On the one hand, a lot money and no result, and the other hand, those countries are growing. How come they are growing with a little investment in economic development, because there is less money invested in economic development than in health? But those countries are taking off whatever. There is little investment, there is a good return. And in the other hand, people are becoming poorer and poorer. Majority of African countries will not meet the MDGs, and the MDGs, what we say in Rwanda, was not the ceiling; it was the floor. And they are not going to make it. So, let's talk about why this money didn't work? And let's talk about, if you invest in Africa correctly, you have eight percent return systematically every year. Does your bank give that return? [Laughter.] No?So it's quite good. The majority of the money has gone like this. This is a slide showing what happened in Tanzania. But for Rwanda, Kenya, Uganda, Malawi, we have somebody from Malawi here, where are you? Is it correct? You recognise your country? So this is the international-Africa way to do business in the health sector when you talk about aid money, impossible to find your way. It became so fragmented that it has no impact. Money is decided in London, Paris, Geneva, Washington, New York. Now it's starting in Beijing. But not in your capital, my capital, and the other capitals of Africa, where the people are living. So there is no match with the real needs of the countries and the amount of money that is coming. And if you have, let's say, one million dollars and you gave it to one person, one institution that is very good, to implement, they will have a coordinator, this coordinator will have a house, a car, et cetera, but if you gave that to this multitude of people, there is a multitude of coordinator, a multitude of cars, a multitude of houses, and you end with 60% of the money your parents or yourself are sweating for that make Toyota more rich, just to say a brand for a car, and what goes in the ground for people like my friend Tom for people to come and implement in how to save babies. What is remaining? If we are lucky, 40%. So there is a new way to do business we have to think about. This also gives another problem because you have so many people that are working for the same program and they all ask you to do the reports with all of them having specific indicators that have been decided, again in New York, Geneva, et cetera, and that has nothing to do with your real life. So in place of spending a lot of hours to run programs or to give cash, we have to give a lot of reports, and we have asked them, please, you are very intelligent people, you all go to great universities like this one. Could you come together and have one framework we can discuss with? 2007, I remember, December in Devon, all the people were dealing with monitoring and evaluation in Pepfar, Global Fund, WHO and many other institutions I don't even know, invited us and we went in Devon, I remember. And they decided to go and talk together to come--because PMCTC it's a mother whose HIV-positive with a baby in her body and the virus should not go to the baby. And for this we have a treatment that is very simple, it's the same everywhere, and the way to give it and the way to monitor how to give it should be simple. You agree with me? Ah, no. [Laughter.] You and me are wrong. In London, it's not the same than in Washington. They are going to find an indicator that is not totally different because it's the same woman, but that is different because in this part of the world, they will say okay, it's the number of women HIV-positive that go to treatment clinic: another three, another four, another going there is a mark of this. And you continue and you continue and you have to fill those reports. And the poor nurse in the health centre with a queue of people to treat have to fill this out, because if we don't fill it, they will say "lack of accountability; we don't know what to do with our money". Even if the baby is safe and we go and show the baby, this baby is safe, it's HIV-negative, "yes, but the mother; what was her mark?" etc., etc. So with those types of fragmentation it's impossible for country. We should make a Masters in NGO Management. Are you ready to do that? It will help us a lot. Because also, something, many of those who receive money got the money from the government, or from foundation like Bill Gates Foundation, Rockefeller Foundation, Skoll Foundation here in UK, SIF Foundation and those have also their own indicators. So there is the money but we in Africa and up till the example of Rwanda, we also don't know the amount of money they receive. We know the targets we have to reach but we don't know with how much. And it's not our business, but it's still your money people have sweated for, because even in Skoll Foundation there is somebody called "Skoll" one day who made a lot of money, put it aside and said this will serve for the good health of the people but I guess this one is dead, but the other one should inform us totally what is for Rwanda. It's another accountability area. We should know for how much you sweat for me. And so this is a problem. The other issue, this is Google Map, is just to show you that poverty, HIV, Malaria, infant death and we can continue all this, are linked. So if you really want to tackle HIV, you should go for comprehensive development. That's why I say what we think here, what we are talking about, is really the overall development process, fighting disease and fighting poverty have to go together. If we just come and give pills, we will never end disease. We need education and that's why we are ready to partner with you. We need factories. We need to know how to do those pills. And this is the only sustainable way to go. So talking about tackling all those disease, those infectious diseases and the majority of causes of death, is to take a journey for education. So that's why development, aid doesn't rhyme with charity because charity doesn't rhyme with sustainability. If you give me a coin because I'm starving today and I'm going to die maybe before tonight, you don't give me the capacity to eat tomorrow. And for an entire continent, we need the capacity of dealing with this tomorrow. Who remembers that? Hmm? This is the Marshall Plan. A massive aid given by the US to a portion of Europe to boost their development. And it works. So that means we cannot say that we don't know what to do. There were no conditionalities of UK ladies number for the health clinic - not it's not UK, sorry, German, hmm? There were no measurements and et cetera, the measurement was economic growth. The money was given and massively. The money was well used, and massively. And out of the taxes, with the industry were put back together, the countries bought education, health, social protection, built roads to go and get health, railway, bridge, diplomacy, universities, et cetera, et cetera. That's what we call now budgetary approach, in the language modern, because you know we have to change language. This is something we have Peter Piot in this room. He was the head of UNAIDS. He will tell you if every five years we don't change names we feel old. [Laughter.] So, but this mean that I give you money to boost your economy and I'm just asking you to prove that your economy is working. And not what we-- you know, when I started HIV/AIDS, do you know how many indicators I was supposed to sign off? 800. 800. On everything. People didn't lose their time on that. So this was working, with this Marshall Plan, we should see the quantity of health -- it's a good study -- Germany has brought to their people just through taxpayers generated domestic revenue. So I like this slide and it's a good point made last year. It's done by a certain Sidney Harris. I emailed him and I said how much I liked this slide. So in Rwanda, we managed to pull out of abject poverty one million people in the last ten years. We have managed to create a community health insurance that covers - we have universal coverage - and people are no longer dying with what we call [unintelligible]. We have also universal access to HIV drugs, universal coverage of malaria prevention with two bed nets per family. It's not that every family has two bed nets but on average there is two bed nights per family. We have decreased death due to HIV, due to TB, due to malaria, all for more than 80%. Our cohort of people living with HIV/AIDS have 90% survival with more than 60% virulent[?] depressed. Better than UK. Better than New York. Better than Paris. How we do that is because of the health sector we have. And why I put this, I like this, is because first of all, seven years ago when I was going in conferences like this, people were telling me propaganda. Propaganda, it's politics, I'm a minister but I don't do politics. My president today, it was my first day in cabinet, I was there with six other new ministers, he told us, 'Don't come and play politics. Go for results. You are there for the welfare of our people. Just go and work and make the lives of people better.' And when I was saying that, I come back and people were saying propaganda. Now that the measurements have been done by external bodies, not by us, people say, Oh it was true! My goodness! What is that miracle? And unfortunately, and that's why we need to partner, we are so few and people are working so hard, we don't have time to write. If we say from a country where malaria was the biggest killer and now we are in the process of getting rid of it, how have we done it? Is it what we did with our government? Is it the spray? Is it the prevention? Is it the mosquito net? Is it, is it, is it? We didn't measure, we just saved lives. We were in the emergency period, now it's more calm. We better study. This is the life expectancy at birth how we'd claim, it claims with the revenue per capita, it's another proof that what we do in health totally depends on the socio-economic situation of the country. But it's not enough because we are not very far. Far from our target. Many people still have less than $400 per year. So those gains don't reflect money. And it's another good thing to study. What are the impacts of policies, what are the impacts of the financial plans? When many countries want to know, and even ourselves, we would like to know. This is the Institute of Health Metrics who have done it, London School and Washington University in Seattle. And you can see in blue the nutritional deficiency over time. In the year '90s beginning you see that up to 2000, we were not good. It was still the consequences of the genocide, infrastructure destroyed and people killed. And after that going down drastically. What I want to tell you with this, it is that we can see by studying those figures where the next problem is and we can start to work on it. As I told you, we have controlled HIV, TB, malaria, digestive diseases etc. We have the kids - I don't want here to say glory, but as a paediatrician I like that feeling - we have the kids the best vaccinated on earth. They have 11 vaccines. 90% have all those doses, of 11 vaccines. The six recommended by WHO: diphtheria, tetanus, polio, etc. Meningitis, rotavirus, hepatitis, pneumococcal and HPV. So we have already a decline in under five mortality, with the rotavirus and pneumococcal [gestures that it is gone], malaria control is going to be better. You can see what emerged. We'll see emerging non-communicable disease. I don't think I have that slide here. Yes, we can see emerging is the same principle but for non-communicable disease, injuries and neonatal condition. You see in the bottom, the neonatal deaths are going to have a bigger proportion because their cause of death aren't under control. It's not that children will die more, it's just the proportion of death due to that will be more important. So we are working on training our people, all along the chain of the care delivery, for this. But if I'm going to a big meeting and I show them this, and I say if we want to be efficient we continue to do what we do in TB, malaria, HIV, HPV, blah blah blah, but we should invest a bit in neonatology. They look at this and we see how difficult it is working together. They look at you like my goodness but okay it's a paediatrician, it's normal. But in fact it's the next programme. And you can see also those studies are talking a lot. Can you see the proportion of mental health increasing? This is Rwanda. Where this was a lot, in proportion, where people were dying more of infectious diseases. The epidemic of suicide etc is something across the world, and when you don't die of infectious diseases - in any case we will die, the later is the best - but you see the proportion is increasing. And this is what is done due to war. You can see that. So just to tell you that we need to partner to study our setting. This is the Demographic and Health Survey. I can talk about it because it's not us who's doing it. It's Macro Atlanta, and it's a partnership with [unintelligible] and also it's the slides that I like a lot. You know why? Because it just tells me that I'm doing my job. [Laughter.] You know why? This is the rate of decrease in child mortality. And you can see that the poorest have the biggest increase - these are the highest. That means that opportunities are well spread among the rich and the poor. And this is one of the reasons we are successful, because my target is not my grandchild. I have a grandchild I love, I have to talk about her. [Laughter.] My target is the child of the poorest woman in Rwanda. Because when she will be safe and the child will be safe, that means all the other will be safe also. And this shows us that it works. This is a national policy in Rwanda. Whatever you do, you have to tackle the most vulnerable. Tom, you are visiting Rwanda every two weeks, tell them if I'm wrong. But by doing so, it's so easy because when you tackle the most vulnerable, the others are following. I'm going to tell you, and also we had to twist the aid we had to reach that, because 2004, 2005, 2006, 2007, we were using drastically the money for HIV because the money that was available was HIV, TB and malaria, tried to say at that time that we want to save women. Nobody was listening. The woman at that time was only the prostitute, at risk of HIV. Other women don't exist. So we have with HIV money, we have built a natal clinic, paediatric, capacity to do vaccination and later on, money came and it was very efficient. And this is the result of that, because there is no global fund for under 5s. There is none. And they are dying, a lot. There is no global movement for neonataology, where the majority of deaths occur. I'm going to tell you another story about aid. Mutuelle de sante, it's our community health insurance. Mutuelle de sante, how we take off in Rwanda: we take off with the support of The Global Fund. There were very revolutionary people at Global Fund and we explained that it would strain the system, they let us try, we won the grant. The grant was done His Excellency, the First Lady and the Minister of Health. Me, I was internationally with a control commission. And we won the grant. And we won the capacity to give health insurance to the one million poorest Rwandans. So we did. And when the last poor saw that the poorest have better access than them to care, they all rushed and pay their two dollars. Yeah! Without a lot of movement, because people used to say, in Rwanda, people are on the line and do because it's a dictatorship. [Tsking noise.] Try to explain to people, you know, we are bad but we love you. We are very bad, we are dictators, but we will keep you alive. We are bad and dictators, but we put you at school. 96% of children are in school. Before the genocide, you know how many? The country was producing only 3000 high-level educated people a year. For ten million people. Can you imagine that? How many students you have in this university, Provost? How many students? [Provost] >>27,000. >>[Agnes] Ah, can you imagine! Now the country produces still not enough, but more than 100,000. And we have teachers, we try, we borrow teachers from the US. We have 100 US teachers on ground for a year. They come on the condition they do until the academic year. And you believe that people are going to hate such a government? They say yes, but there is no dialogue. No, I think that the way we use the aid and make it more efficient for the most vulnerable, this is the key, that I have transformed the way we have success with the money. So when everybody was rushing to pay two dollars per household, the rest were supported by a domestic fund. We just called a consultation and say okay, we have this money from Global Fund for the poorest, this money from Domestic Fund for what is missing, now if we want to give you more care, we need the two dollar no longer per household, but per capita. Our partners say, are you crazy? They are too poor! You know, those two dollars are the cost of one beer, isn't it? I have a colleague from around there. It's the cost of one beer per capita. So we told them, it's one beer for capita. They will drink a beer. And of course, the women drink less than the men so no problems, it's good for everybody. We did so, but we had a position in this country too. Many partners said no. People did it. They were very happy. And now let me tell you, one thing you become addicted to is access to care. The more you access care, the more care you want. Isn't it? Did you see what happened in some of the countries called wealthy where the consumption of care is almost you want to say 'stop!' because it's too much. Now that the people were used - you know in the beginning they haven't got it and they live with it - after that they had malaria, we treat malaria, they feel better. Now sometime you have a pain without any reason, you take a paracetamol. And I say to them, listen, now the more you are used to care the more you use care, the more you are addicted to care and that is very good. But that means also you need to increase the contribution and the premium. So in 2011 there was another big - that one took two years of consultation. And we said, we are going to make people pay according to their revenue. And now people, like me, pay $12 per capita of people in their house. People who are like my secretary, middle-class, are paying $5 per capita. And people who are poor, 25% of the population, don't pay at all. Why do we pay their health insurance? You have 90% of the care supported. You pay 10%. For the people who don't pay the premium, we decided to pay at point of care, even if it's a high transactional cost, because we want everybody to understand that care has a cost. And we don't want to go for free. We want people to understand that somebody somewhere pays. So we receive the bill at point of care. But we have 92% of our people that are covered. So this is the story of one aid that was efficient because it entered totally in our view, and Global Fund is good for that. This is the child mortality decline, you see that here it was again around the distribution of the health centre, but after that you see the decline faster than ever, because even if we follow the natural curve, we should be here. You see? So there is something that I don't like. It's when people say, oh yes, you are good but it's because everything was destroyed. You can invent a new Rwanda. Don't say that. It's because, as Richard said, there is a lot of dedicated people that are spending sleepless nights to try to find step by step what is the best move for reaching even more. Because as my president have said, MDGs is not the ceiling; it is the floor. But we want to show you that because there is another slide I didn't bring because I didn't think I'd want to bore my friend Richard because we showed him that slide when he was in Rwanda. If we look, the number of lives saved by investment per capita of aid in addition to domestic funds, Rwanda is among the lowest. It's the maximum results. Same for women lives saved. Same for children. So there is something else that needs to be studied. This is my health sector. And this slide shows you - it is exactly the same as this but it's flat. This is the central level, this is with referral hospital and the ministry and agency that are working. This is the district hospital. We have 42 around the country. These are the health centres. We have almost 500 around the country. And these are the villages. In each village we have community health workers. In each health centre, we have nurses. Here start the doctors. Here start the specialists. In reference and in the ministry, Richard has said that all the staff have a Master's. They have got it at work. They enter with the degree and me, I challenge them and I say, I want you to have a Master's, we will find the money, we will pay it. Another way of good investment. And don't believe that the time they spend out of work is losing for me. They enter with the skills, they start to work and they get this one, now they go for a PhD, wow. We are going to have the Ministry of Health the most strong on health. Any tests change our way to do things because they know what evidence-based means. They know what research means. They know why you don't do a policy because you feel like that today. [Laughter.] No no no no. It's very important, you know. If I talk with somebody who is totally for elderly people, I'll do a policy for elderly people. So we go with the real needs and studies. Evidence-based. That is what has brought that for me. And at central level, up to here, district hospital, they are all doing a Master's or they have their Master's. And here I have already more than 20 people running for a PhD. And that's still at work. I don't let them come here. They can come to me, one month etc., not more. You help them where they are. By doing so we have all along the system a lot of quality data you cannot imagine. Rwanda is a very organised country. People are keeping the data very well. From here to here. You talked to community health workers. Those are people who don't have, they just know how to read and write. You cannot imagine how they run their business. And while I put that for aid, you see here, all the community health workers, there are 45,000 - three per village. Two women, one man. One man and a woman for common diseases. One man and a woman for following the maternal and child health. They all have a phone. And when they have an alert, here, immediately an SMS. We capture the SMS in the Ministry of Health, also the mobile emergency system, the ambulances get it, and the people are served almost immediately. Before having that, and we did so with the support of Global Fund, but it was a struggle because they don't see how this brings health. It has decreased by almost five, the death of women, because they were dying because we were there too late. Now we know the messages come from here, here, there, and we follow the ambulances and the ambulances come from somewhere here. Same for children. Here everybody in the health centre has a computer and reports in the health information system all the epidemiology. Same for this level and of course ourself. Now in the ministry, all ministries are reporting to the prime minister. We no longer send paperwork. We can have paper, but we don't - I always say that we are one for cupboard saving. Isn't it? It's very good. And having this, we don't have more personnel. We still have only 600 doctors for eleven million people, ten million point five. The number of specialists are very few, but it allows us to task shift and to do remote supervision to ensure that the care is well done. When we start to do all those things, HIV, TB, malaria, every time people were saying, "Not sustainable; don't go for that." Three years ago we started HPV vaccine. The HPV vaccine was so high but Merck was great to give us the vaccine for three years. Shall I say no? To save at least two cohorts of future women, to save them from cervical cancer? They say yes but this population doesn't know that they have a cervix, how are they going to-- ok, that's true! So we went and campaigned and we said to women, 'this is a uterus, this is a cervix, and the cancer blah blah.' And they say, 'Yes, but it's not sustainable. What are they doing to do after?' We say we don't care. We'll find a solution after. We don't lose that opportunity. They say, they will never do it, it's impossible; they will spoil your name. They say to Merck. And Merck, at a certain point hesitated. I had to call very influential former friends and say, 'Before you were in administration, you were part of the civil movement for IV aid to Africa.' You remember that? You are too young guys, but it was a fight. Peter, you remember? Saying that every African has the right to IVs. They say, not sustainable. They don't know how to read time. They will never follow the old prescription. They are singers, dancers, not serious. They will spoil the global epidemic credit resistance and we are going to be lost. Who remembers that period? Thanks to crazy people like Peter. He says no, we go for that. And now in our continent adherence is better than here for other reasons that are more linked to social cohesion. There is a nice study done that showed that for HPV the fight was starting again. I advised you to read some - I think it was published in the Lancet - saying that I was a criminal because I sell or sold - I don't know how you do that verb - I have given my young people to a pharmaceutical firm. Can you imagine that? Do their people think about that when there are vaccinated people here? You know, we vaccinate the entire cohort of girls age 11 because the demographic and health survey shows us that first intercourse doesn't start before 12. All the schools, because we decided to do school-based, it was more easy for us, they say: it's crazy, we never do that at national level, how are they going to do? We just partnered with Minister for Education, Minister of Local Government, the Minister of Internal Security. You know why? Not because people are going to steal the vaccines. But just because these ministries have a lot of power in everywhere in Rwanda, for the police. So we borrow their car. And in three days our vaccine leaves Kigali, go in a truck, go in every school with the help of the nurses here in health centres, they go in every school, they vaccinate the kids. With the help of community health workers here, community health workers during those three days watched the children that are not at school and proposed a vaccine at health centres. 93% compliance for three doses across a year. And over the three years, more than 98% completion for the vaccine. This is another aid effectiveness, because it was not government to government. It was a PPP: public-private partnership. And we didn't tackle enough in PPP. Now it has given me ideas and I'm going to dialogue with motorbike producer to create ambulances at community level. You know why? Because for this telephone we are now in agreement with Samsung to upgrade them so that the community health workers can follow and understand what we do, what they do, their job, and compare with others. And it is so important to give to the people the capacity to own their work. The capacity to understand what they do, so that they are the actor of their own development and not only followers and people that only execute. It changes everything. So there are the more also, there is something that creates another addiction: results. Those people are incredible. They didn't get salary in the beginning. Now we are paying them on their performance with another type of aid that is effective. It's a grant we get from World Bank and we create all along the country little businesses, so Ministry of Health has created little businesses, can you imagine that, little businesses - four hundred and something, about that, for the community health workers. And the result, the outcome, the profit of those businesses will allow us to pay them on a regular basis. Investing in health by creating little businesses. You understand? Those community health workers are so proud, isn't it, Richard? They are so proud of their life. They have created their own domain. They are serving the people, and what made them proud, they are elected by the people in the village. And our job, the Ministry of Health, is just to train those elected. Only terms of reference: to be elected, know how to write and read. You know that we had a cholera epidemic in Rwanda? In a refugee camp? A true cholera epidemic. I am very proud to say no deaths. No delay. Confinement, immediately. Why? Thanks to the phone. And distribution of stuff to clean the etc, etc. Thanks to the community health workers and the people all along the chain, thanks to ICT, the manager of health sector, we have good communication immediately. From here we can send an SMS to 45,000 people. One person here can alert us and we alert 45,000 people. So this is, let's say, good health investment. I don't know how much time I still have. So when people are telling us 'not sustainable,' now we are laughing because if we say 1966, the word 'sustainable' was pronounced, let's say, less than 10,000 times a day. At the present day it's a lot. In 2036 it will be in each pages. In that day, each sentence, and some time it will be only that. Don't laugh, you know. When we have a good idea and we sell it, it comes so often. So what we say, the word 'sustainable' is according to some people, unsustainable. But when you have a good idea, always go for it. Money is not the true barrier because if you can prove after that the delivery of health is less expensive with your new idea, you should go for that. It's investing in health. Another thing, it's not to please you, it's because it's a big debate. We have, and that's why we can partner, many people that are really implementers, experts. And nobody listens to them. By travelling around the world, Richard has done a very good piece of paper around it. Meaning, this part of the world should listen more to what our part of the world has as needs. And also, how we see and we envision to implement that. Don't come with solutions that are already drafted. Also if we have managed to have success, still there is a lot to do. Still there is too many dying for preventable things. Still, we still need to educate far more people for the health sector. But if we have managed that it's because the coordination was strong. We have learned with HIV. HIV has taught us three ones: one coordinating body, one action plan, one monitoring and evaluation plan. One way to educate. So that everybody has the same protocols and if somebody is sick in north, east, west, can be treated and go back home without discrepancy in treatment. Many of our country, I don't know how it is in my sister country Malawi, but for many people that's the issue. We try to have an understanding in east Africa for HIV treatment. And procure together. We don't have the same protocols. All the majority of protocols bring the same effect. We just have to decide what is the best for all of us. We know it but Geneva should listen more to all of us. And this was about - this is another story about aid effectiveness. One day we received from Canada a call. We have a dialysis machine, it was 2006, but Rwanda has to pay the shipment and we say oh dialysis machine, portable, that's genius because we have those people but we don't have the money to buy. So we pay the shipment. 18 machines. When we opened the container, you know what was written? [Something on the slide.] That's not a joke. They are still packed somewhere in Kigali because to destroy them is too expensive. Yes, effectiveness of aid. So did that person really know, because they contact our embassy in Canada, we agree to pay on tax of domestic funds, and the thing out there is if you want to destroy them it's too expensive so we, Ministry of Health, don't have the money, it's too expensive. I try to sell them to the veterans, because it's for cows, dogs, but they laugh at me and they are still there. It's also an example that aid should really mean that you are supporting and going a step forward. The rest is really criminal. It's not a joke. We had to find a place because they were packed in the vaccination institution compound and when we start to increase the number of vaccines from six to seven, eight, nine, now eleven, there were no more places so we scream in Kigali to say where to put them? So they are still there. I think we should bring them in a museum of nonsense. This is to show what we can do together. There are very good studies to do. So in red is the cost of IVs. In blue is the productivity gain. In green is the cost averted to have orphans. And in purple it's saving by delaying end of life. So you can see with such a graph, I can go everywhere, I show you that invest in IV brings economic growth and supports the development. Those are the types of studies that are interesting. There is no time so I don't know where I stand. It's okay, not, I'm going quickly. This is another thing. We can do good, even ourselves. We need to document, I told you. This is another area. It has been documented that we do the work but publications are elsewhere. The people about our job are publishing one thousand more than us, about our jobs. About how we are sweating for inventing it. That's what I call intellectual prostitution. So this is something also we can work on together. Of course, to do such a approach by listening, trust and do with us, we need a legal framework as well as doing research in Rwanda then the way we manage. Because we cannot put the blame on the developing world only, for not following what we agreed at an international level, the way to proceed. We need a strong legal framework. A strong law of finance, also procurement, also a manual of aid policy, so that everybody knows what to do and follow. And also a zero tolerance for corruption. So also aid should really promote reverse elevation. There is a lot we can invent and if I go to the community health workers and say this is the problem we want to solve, how should you do that, they have a lot of ideas. That's how we can invent the way to implement or the way to do things or the way to do something else. Don't believe that global health doesn't concern you and you just come and help us. You come to me, I come to you, for us to have a good journey together for better health for the world. Because if people, if diseases like that are spreading, you are not safe. We better work on it when it starts to spread, because all the world is concerned. Also I told you, health is fundamentally social, so it needs to be tackled as a - we need to tackle also the social determinant of health. And if health is a human right, tackling the social determinant is also in that category. I'm going to pass quickly on the example of MDR-TB. This is the example of investing the money right to produce more health per dollar invested. And I would like you to think about dealing with humanitarian as a business. Where do you put your energy to produce the more health? Just to show you that more result and decline per investment. Also it's important to know that we manage that because we govern by cluster. The social clusters are all those ministries. And when I decided to do something in the health sector, I consult all my colleagues to see how we can work together. This is the comprehensive governance. So we have this, the solution is ownership. It is equity. You go for the more vulnerable. It is also science. You give evidence on what you are doing before taking decisions. Participation: never do something without the other people concerned as beneficiary or as implementers. And if we can have those principles applied to the global - to the money that is outside for health, we will succeed. Those are the places where the decisions have been made to respect countries. There was Rome, there was Paris and after that we change continent. We went to Accra! Still, status quo. The burden of this is still on the countries that have to report differently but HP+ plus never take off. Accountability of donor country is very, very low. I want to show you that hospital, it's a hospital that was not sustainable because it was built in the middle of nowhere. [Laughter.] And it's a beautiful hospital. I just want to tell you, it doesn't cost more to do beautiful things than to do bullshit. [Beautiful.] It's the same cost. But the difference is this: and also, this now we are working to make it a medical campus. We are going to have a new Faculty of Medicine, new faculty in the middle of nowhere. We create cities etc., of course there will be a market, and of course there will be a cinema, because students need to relax, and also the teachers, etc. So build a school, etc. I am ending because I see that my friend is nervous. I talk too much. [Laughter.] I'm very talkative. But I want to end on this, because this is the philosophy. It's from Martin Luther King Jr, and there is a word that they told me how to pronounce but I'm sure I'm going to pronounce it badly. "True compassion means more than - fledging? flading? - a coin to a beggar; it comes to see that an edifice which produces beggars needs restructuring." You can change now, by the international aid and you have the solution. Thank you Martin Luther King. [Applause.] >>[Richard] Now it wasn't that I wanted to cut you off, it's just that I know our audience might want to ask you some questions because it's not every day that you will be coming here to UCL. So now the timetable was that we were going to finish at 7:00pm so that you could go across and have a drink but I'm going to steal a little bit of that time unless somebody waves violently at me from the back to give you a chance to make some points. So let's take three or four points from people from the audience. >>[Agnes] Can I have a pen? >>[Richard] Oh yes. >>[Agnes] Thank you. >>[Richard] So, who'd like to start? Yes please, and if you could say who you are. The microphone will come and find you. >>[Audience member] Hello, I'm Jian Lee, studying currently at the London School of Hygiene and Tropical Medicine, but I used to be part of the charity community because I worked with World Vision for five years, and I deeply sympathise and agree with crazy indicators, the fact that economic development is a sustainable solution, but because there is always going to be some charity people who take sustainability seriously, would you actually give suggestions or some good cases you've seen of NGOs, external players, collaborating with community and government in making this development sustainable. I think it would be wonderful to hear from you. >>[Richard] That's great. Let's take a few comments. Yes please. >>[Audience member] Hello, I'm Andrew Tompkins, and I work in this Institute. I think we've been absolutely astounded to have such a clear vision of inspiration leadership and you've shown what very, very strong and clear and excellent leadership gives and a health service delivery like no other country. Could you say something about the other side of the coin, which is the community. What movements were there within the community that possibly contributed to the remarkable reduction in mortality? The reason I ask is that certainly in Africa many other countries are looking not just at service delivery but they're looking at ways in which social development and community participation can make a big difference, and it would be really helpful to have your comments on that. Thank you. >> [Richard] Okay there are two comments down here. Man in the blue jumper and then the gentleman behind in a scarf. And I'm looking for gender equity here. >>[Audience member] Thank you very much. Michael Heinrich, School of Pharmacy. I'm the head of Pharmocognosy. But a very different question: governance. i think the big challenge for me after your talk is how can we develop a governance structure which facilitates all this and finds the place between community and NGOs and governments where things went grossly wrong in many cases. >>[Richard] Very good, thanks. Just behind you. >>[Audience member] Hi, I'm Chekwe, I'm a public health physician and I blog on Nigeria Health Watch. Quick question simply on leadership: Every African here today we are exceptionally proud of your presentation, but a question: what seems to be holding back your colleagues, ministers of other African countries in having the same type of vision, inspiration and drive that you have demonstrated this evening. Simple question on leadership. >>[Richard] That's a great question, thank you. Agnes, we'll go to you on some of those. >>[Agnes] So this one is... so the first question on NGOs. Madame or Mademoiselle. I think we need to be clear. In Rwanda the government coordinates. The government should never implement. We implement when there is nobody to implement correctly, because we need to go forwards. Our objective is to have nationally the capacity. So NGOs international groups have a lot to do. But first of all, not to come into business forever. Come and train Rwandan to do business forever. And also what we do, I think, if we are here, we can learn to be here, with the NGOs. And when you are here, you learn to be here, and so on. We're always partners, and that's how we have implemented the human resourcefulness. It's not that it was against NGOs, we want our society to come at the stage we were. We want universities. So we implement the aid program ourself. We save some money -- we contract American universities because it's American money, to come and teach our people. You see? So we always need these civil societies but it's different according to the society. But I also want to remind that the systems are not created by NGOs. This is a big mistake. People come to create a country - no. You are there to help people to create their own country. Then it works. For the second question: it was about, I don't know, it was about what was the role of communities. Fantastic. There is something that makes us all shivering, you know, because you believe that we are very popular. Uh uh. My merger is given by my community. Every year they rate us, satisfaction, and this study is done by local government and reported directly to parliament. If I can do the best, if the people are not happy, they will put me in red. So that means whatever we do, we need to explain. And we make them part of the things and don't do that without them. I'm going to give you an example. An African here will understand me. Normally, an African man thinks about talking to a child when the child is reasonable. Isn't it? That was the tradition. It's the tradition, before it was the matter of the woman. What came with PMCTC? When we need the men to go and test for a baby he has even not seen? There is a lot of cultural revolution in the health sector. It is the first time men in Africa are concerned with the baby that is even not born. Going and giving his blood for something that have no existence in our, we don't consider traditionally, not now, now a pregnancy is considered as a child. Just to say that community, don't think that what I ask you to do is me. I can do that with the community. For the other question, the governance, it's very simple. When people are corrupt, why do you give them money? Corruption has two hands: you give me, I steal me, you have given me and you know, you are as guilt as me. So the traditional way the north and the west give money to corrupt governments is what has killed us. And I say to my colleagues, when you steal money, you damage my program because you remove trust from the world and Africa. That is the other thing we have to say. Africa, for the majority of people, is a black box, very damageable, full of microorganisms, dirty, etc. And that's true. You know. [Laughter.] You know, that's true that you think so and that's not true. There is a lot of hope in Africa. I can give you an example. In the morning there is a street full of black shit, some with blood etc. If it was in Africa none of you will cross that corridor. Because it's in London, you will just cross. The image of things have a different signification according to the place of the world where we are. In Africa, somebody serve you a glass like that, you don't drink it because there is a lot of microbe, was it clean, etc. Here, we just drink and we don't ask question. Mindshift, guys. We need to shift minds. So that's what I want to say for the leadership. How to stop it, stop fund it. Or ask accountability. Why you don't ask accountability? And why my colleagues are not like me? Many are like me, it's just that I'm very talkative. [Laughter.] [Applause.] >>[Richard] Okay, let me go back and ask for a few more. Yes please. The microphone will find you. >>[Audience member] Yvonne Madesi from Malawi, by the way of the University of Southampton, and thank you so much for a very interesting presentation, and I really admired everything you said and I admire you very much, and I echo what my Nigerian colleague said about how we wish we had more of you. But I was interested in what you said about giving telephones to the community health workers and getting them to actually learn what's happening in other places. And I wondered about the power of information for the communities and what role that plays. Does it help, for example, in terms of accountability, but does it also help change mindsets in the ways they actually deliver care and so on? >>[Richard] We'll take another one. Joy... >>[Audience member] Thank you so much Agnes. As a fellow African woman, I was born in the bush of northern Uganda, I just collected the wrong skin. I think it's fantastic not just to see an African woman on the platform but to talk about the hope and the power and the reality of Africa today, not what people often see, which is the Africa of previous decades, and you've shown us that change can happen. But I particularly want to point back to your slide about the burden of disease in Rwanda. And you highlighted the increasing proportion of neonatal deaths. And what you said is what we hear from ministers all over the world, that this is now our burden, and yet when they're saying to donors, that isn't what the donors are funding. Donors are saying no we don't do that. So I would like to hear how you've answered that and how you think your fellow African ministers. And I'd just like to point out that Rwanda has shamed Britain because you had about four times as many female MPs as you do so maybe that's your secret. [Applause.] >>[Richard] There was a question down here as well, I think. Just here down the front. Second row. >>[Audience member] B. Roshodende, paediatrician, Nigerian. Thank you for your lecture. You've addressed the collaboration that takes place, or that is meant to take place, between what is often referred to as the north and the south. What I'd like to ask you is what are your thoughts in terms of how best to go about collaboration between south and south. That's one. The second question -- oh >>[Richard] No, go on, go on. Very quickly, go on. >>[Audience member] Okay. The second question I wanted to ask is in terms of the if you like, the details of interaction between the various parties, how do you engage the local community in determining what needs doing? I'm not just talking about the research processes that, for example, in response to someone who says you should build a bridge rather than give treatment? >>[Richard] Okay, very good. Just there. >>[Audience member] Thank you. Cam Stocks, I'm the national director of medicine which is the UK's global health network. You very astutely identified at the beginning of your talk that this is a room full of young faces, and so I just wondered first of all what was the contribution to this incredible change that happened in Rwanda and how are you including people in the developments you're making in the future, and secondly, to this room full of future global health leaders, what is your one key message? >>[Richard] That's great, okay. >>[Agnes] Okay, so, it started with the telephone. How the telephone has changed mindsets. It's incredible how the telephone changes mindsets. The power of communication. That means, the world became a little village. But Rwanda became a little portion of a village. Meaning, by knowing they can communicate with us, they are, they take more risks. They know how to ask advice, they feel empowered to do their job. By people also knowing they have that power, they go more to them, to seek services. But it's not the only way that it works. It gives also more accountability to people like me because we have, I was supposed to but it's too long, we have what we call a national dialogue day. It's two days, where we are like you, sitting in the parliament, chaired by His Excellency, co-chaired by the Prime Minister. In the room we have all the heads of the army, the police, all governors, all the mayors, all people who have a decision. We are more than 800. And people, there is a screen, communicate with SMS, there is Facebook, there is Twitter, and there is a phone. And let me tell you, it's soon. And it's my two hard days. You know why? Because everything can be asked. And that's good because if I mistreat, it is there. Because on Twitter, it doesn't disappear. And there is a Twitter for that and His Excellency and other people are reading those tweets. So if I am a bad lady, it will transpire. If somebody's bad some way, it will transpire. And you have people who just as I told you, we have three phones per village, that's for health suddenly. We have also a phone for anti-corruption, we have also a phone for other sectors. So those are there, communication is there, it's good. You know why? One day people say, I was entitled to receive a cow with this program. I didn't receive it because I don't have land, but I was receiving that cow to increase my economic growth. Immediately in that very setting, which sector you come from, which mayor is the sector, governor mayor, tell u what happened? So police, tell the police to go and see if it's true. It's true. Bring the cow back to the guy. Now are there many other cases like that? Immediately, we receive the Minister for Agriculture and the police receive one month to track all the cows that get to the wrong person. You understand? This is what we call accountability day. People like me, I had to inform-- to explain, I was PS at the time, there was another minister, this is Vera, who had to explain why we have closed all the A2 nurses' school. And we had to explain that it's because we opened A1. We upgraded. That's what I call, let's say, direct democracy. But it's good so phones are key. Also how we engage communities, there was another question. How we engage the communities, I think, people are good. They just need to understand have to be explained. But also sometime we need to make them feel uncomfortable, leaving your comfortable zone. What we did for maternal death, for example, we have the maternal death thing. Before we did not know what happened, why the women were disappearing. For the woman who dies in hospital or health centre, there is a professional autopsy. We have to say what happened. For those who die in the village, there is what we call a community autopsy. Meaning, there is a committee created with villages, private sector, local leaders, etc. who go in that house and say, what happened to that lady. She was not supposed to die, did she complain before, etc. Everybody knows that. So men don't want to be asked. So now when a woman say "ah!" [in pain] they say, "let's go to the health centre!" [Laughter.] And that's the best way to do it. You do moral pressure for the good. So that's how we engage, an example to engage community. For the collaboration. You are a very good country. We have a collaboration with you. You bring some health professionals for two years in Rwanda. But I think that we need to collaborate for better understanding our health sector. We have differences but we have similar populations. Also we should start to collaborate in production. That mean that today if all the houses of the health want a mosquito net, there is not enough production. Is that it? How can we start production in the continent to serve the continent if we don't have it. Don't forget, but we don't have it. This country can do this. This country can do that. And together we don't replicate and we create economic growth also. Also, the new born, how we engage, I don't -- the question is what we say exactly to get money, or? >>[Richard] Why aren't we supporting new born health despite the fact that-- >>[Agnes] Because they don't understand. And they are in their comfortable zone, again in New York, Geneva, and London, and they don't know that we can save children with little actions that doesn't cost a lot. And they are not interested. I think we need a new mindset. The charity should be in the heart and removed from aid. But if people tell you that this is my problem, believe them! Believe them. And if we tell them we'll be accountable with this, we will save this number of children, just come and see. And saving neonatal is the best family planning tool. Because people have children because they don't trust that you will keep them alive. When I came back in Rwanda in 1996, I had only two girls. My family just say, "two girls, are you crazy? First of all you need a boy." [Laughter.] Then we bring boys. And after that they say, "Only two! Me, I had eight! Only one is alive. You will die alone. You understand that?" The best family planning tool is keeping the children alive in a peace land where people have access to care. The key message for youth, and the role of youth. Youth are fantastic because they are not yet spoilt. So I think that exchange is good, I love that. And also the youth before coming, just teach them how to be humble. We have so much knowledge, life knowledge, in people that don't know how to write and read. You know, our people are very polite. Why I am saying all of those things is because, probably, my siblings education was somehow wrong. In Rwanda, like in many African country, they are not telling what they think, but they don't like arrogance. And this slow collaboration. You go with humility to those people and just learn about them. I have learnt so much. They know so much; they don't know who is [a person] but they know how to serve their life better than you do. So these are the messages: come with humility, and also young people of the world, know that you can do the revolution peacefully. You are the one who will change. And they are the future. >>[Richard] Very powerful. The Provost has given us a few minutes more. So I'm going to go top left there, yes please. >>[Audience member] Hello, I am the industrial partnership manager for UCL Enterprise, and I was thinking about the public/private partnership. I was just wondering if you could give some examples that you've used in Rwanda and it was very successful, that could be used in other places. Than kyou. >>[Richard] Okay, and Tom. >>[Audience member] Tom Nissau, paediatrician in Rwanda, and I'm pleased to say have done a lot in terms of health partnership with you in Rwanda. I was going to ask something a bit different, and that is, here we're at a university and we've heard about the great universities we have in the UK. What would you most like from our universities? >>[Richard] Let's take those two questions and then we'll finished. >>[Agnes] So, the public/private partnership. The telephone I show you. It's really a public/private partnership. The host is a company. The provider is a company. The government have found the money and also paid for those. You can do nothing now in a country like mine if the government doesn't give the seats something. We don't have a private sector that will grow, we will go nowhere, because a backbone of a country is the private country. Even though I believe that the backbone of quality care and well distribution should be coordinated by the government, but my dream is private sector strong in Rwanda, they pay a lot of taxes so that we can build hospitals. So another example of public private partnership, there is public-private community partnership. You saw the 42 hospitals. These are called district hospitals. PPCP. 40% of them belong to churches or to NGOs. We treat them the same. They have the same advantages and they have 50% of the health professionals. In exchange, the have our health system and they have the same category of prices and they accept everybody if it's a muslim hospital, they don't have to be muslim. It has two advantages. We don't have to build all those 40%, we can concentrate on something else, and also it brings the community together. You saw the village and the health centres. In between there is a bag called the cell. We have almost five, seven to ten cells belonging to one health centre. We want to propose a PPCP there by having a nurse, A2, running a health post, we don't pay her salary, she makes her own money by reimbursement of the care by health insurance and selling things in drug store. The community give the place. The community elect the nurse. We recognise and we train her. I think PPCP is the future, at least in Africa. The other thing is what I like in university - I like the rigour, I like academics, and I like education. Under the condition that you don't delay saving life. Don't go for doing study only, go for -- your best motivation should be saving lives as soon as possible. But doing it with rigour, with good documentation, allowing young people to do research, make the brain of young people more smart, etc. That's great. That's what I like. >>[Richard] Okay, now we could listen to you all evening, but there is a reception outside. I'd like to thank you, Agnes, on behalf of everyone in the audience. [Applause]