The Fierce Urgency of Now…
in Rwanda

Dr. Agnes Binagwaho – Rwanda’s Minister of Health and 2010 recipient of an Honorary Doctoral degree from Dartmouth – was recently at a high-level meeting of all African Ministers of Health. A lengthy discussion arose about donor coordination and high overhead among some development partner organizations. Dr. Agnes, as she is known among friends and colleagues, took the floor. “Let’s tell the truth,” she stated seriously, with a pause. “The children of my children will be at this same meeting in fifteen years and they will be having the exact same discussion unless we address it now.”

A community support worker under the support of Socios En Salud (SES) staff.
Rwandan Minister of Health, Dr. Agnes Binagwaho, enjoying time on the porch of the Hanover Inn with TDC Director, Dr. Al Mulley, during her most recent visit to Dartmouth this past summer.
Hope Delivered

Compared to the exacting standards in Rwanda’s health sector, a deadline of “now” was actually quite generous (yesterday is more like it in the Ministry of Health). Many Americans know the country primarily for the 1994 genocide during which about one in every seven Rwandans was killed. The less widely known history and ongoing narrative concern the unprecedented speed with which Rwanda has progressed in the struggle against poverty and inequity. Emerging from the devastation of 1994, the new government focused on sustainable, equity-based rebuilding efforts to create lasting institutions, restore dignity, and strategically dedicate resources for securing basic human rights – medical care, education, jobs, housing, security, and so forth – to all Rwandans. Indeed, more than one million Rwandans lifted themselves out of poverty within the last five years according to the latest data validated by the World Bank.

The Ministry of Health is aligned with the public sector’s drive toward sustainable development and is constantly moving forward to ensure value and timeliness in the delivery of all health interventions. Since 2005, Rwanda has achieved 50% reductions in both maternal and child mortality, a nearly 90% drop in malaria morbidity, and a 450% increase in family planning uptake. Compared to other sub-Saharan African nations, Rwanda has the highest coverage of antiretroviral therapy to treat HIV/AIDS (88%) despite remaining among the lowest in GDP per capita. These achievements are not realized by chance, but rather by the Ministry of Health’s strategic approach to the coordination of aid, the pursuit of value, and prioritization of equity.

As the Minister of Health, Dr. Agnes has been a vocal participant in global debates around scaling up the provision of antiretroviral therapy in Africa, the feasibility of availing novel health technologies in resource-poor settings, the need to fairly compensate health workers in the public sector, and the importance of integrating “vertical” interventions with efforts to strengthen entire health systems. From her publications detailing the scale-up of community-based health insurance to her testimony at the United Nations High-Level Meeting on Non-Communicable Diseases, she has exhorted policymakers to act with what Martin Luther King Jr. termed “the fierce urgency of now” without sacrificing any attention to detail.

Rwanda’s achievements in the health sector are evidence that many debates in global health policy about the possibility of providing proven interventions in settings of extreme poverty are driven more by narrow understandings of cost-effectiveness rather than by robust understandings of potential value and impact. Time and again, Dr. Binagwaho has reminded the world to account for the tremendous costs of inaction against killers like HIV and cervical cancer.

She and her colleagues have repeatedly backed these calls to action with unimpeachable results. Just six years after it was said that ART could never be provided at scale in sub-Saharan Africa because “Africans do not know what watches and clocks are” and thus could not adhere to therapy, Rwanda achieved universal access to treatment and adherence rates that far exceed those in the United States or Western Europe. In the same decade that international health authorities had deemed multidrug-resistant tuberculosis “impossible to treat” in Africa, Rwanda’s program reached and sustained an 88% second-line success rate. When it was argued that attempting to roll out the human papillomavirus vaccine with its three-dose requirement would be unmanageable in rural nations with limited cold-chain capacity, Rwanda achieved 93.2% coverage for all three doses among eligible girls in the program’s first year (the United States’ most recent figure was 20%).

Each of these successes was made possible at least in part by Dr. Binagwaho’s tenacious leadership and ability to rally together incredibly diverse stakeholder groups around a common vision that conceptualizes bold efforts to improve the health of the poor not only as morally imperative, but also as eminently possible.

One of the core missions of the Dartmouth Center for Health Care Delivery Science (TDC) is to study how each individual patient can receive the best care possible at that time, and that the whole health system can simultaneously function to create value. To focus on both the lived experience of the individual patient and the complexity of a dynamic system in parallel is a tremendous and important task – and this is where the synergies between Dr. Agnes and Dartmouth have taken off.

In September 2011, Dr. Agnes collaborated with TDC Director Dr. Al Mulley on the Salzburg Global Seminar, “Innovating for Value in Health Care Delivery: Better Cross-Border Learning, Smarter Adaptation and Adoption.” The Seminar drew on the expertise of fellows from 26 countries, bringing together scholars, policymakers, and providers for a week spent sharing lessons from around the world and charting a course towards common understandings of patient-centered and value-based health care.

Dr. Agnes contributed to two sessions during the Seminar: “From HIV to HPV: Principles in Building an Accessible, Affordable, and Equitable Health Care System in Rwanda,” and a panel titled, “How Do We Recognize Success: Can We Measure What Is Most Important to Innovate for Value in Health Care?” During the final moments of her first talk, she reminded fellows that “advances in combatting communicable diseases and strengthening health systems have created both an opportunity and a challenge – they reflect at the same time our progress and the tall mountains we still have to climb to provide the necessary services to our populations.”

Indeed, there are many tall mountains to climb as Rwanda aims to build on past successes in confronting the global health delivery challenges of the twenty-first century. The evolving partnership between TDC and Rwanda’s health sector through Dr. Agnes’s work is a key step on this journey, and we look forward to seeing it bear fruit in 2012.

Cameron Nutt ’11 is a Fellow at the Dartmouth Center for Health Care Delivery Science, and Claire Wagner ’10 is a Research Assistant in the Department of Global Health and Social Medicine at Harvard Medical School. Cameron and Claire work in Rwanda to support Dr. Agnes Binagwaho’s research agenda.Back to top