About : portable tv stands for flat screens uk
Title : portable tv stands for flat screens uk
portable tv stands for flat screens uk
this evening i'm just going to introduce ourwonderful speaker, my friend and colleague agnes binagwaho. put simply, she is ministerof 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 saidthat that's a bad thing. but i think there's something the uk could learn from having someonewho 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 andlearn a lot, actually, from what's taking place in rwanda right now. agnes has had adistinguished career in her country. she led
the national aids control commission, shewas permanent secretary in the ministry of health and she has academic appointments atboth harvard and dartmouth college. and that's where agnes is even more unusual as a ministerof health, because she takes research and evidence seriously. that is why she is herethis evening. at the moment she's serving on two commissions that we have running. she'sserving 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 anotheruniversity in london which i wouldn't dare mention here, and we had a day or a coupleof days of discussion and agnes was invited, and quite honestly, we didn't think she wouldcome. 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 doother things that her embassy will instruct her to do. in fact, she spent the entire daywith us, taking part vigorously in discussions about the direction that the commission shouldgo. 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 goto kigali for a meeting of the commission on investing in heath, and we were here gueststhere. and we witnessed firsthand a remarkable health transformation that's taking placein rwanda. you're all fully aware that next year is the 20th anniversary of the genocidethat took place in rwanda during 1994. and
quite literally, the country has had to bebuilt from every community upwards, almost from scratch. and in one of the first slidesthat she showed of what she's doing as minister of health, it was entitled, "building a healthsystem." and that is what she and her incredible team have been doing. it's a tough challengeand there are many challenges still to go. but if you look at the various measures ofwhat's taken place in rwanda under her leadership, pmtct, vaccination coverage, preventing malaria,family planning and addressing the emerging epidemic of non-communicable diseases, sheis literally leading a health transformation, one that the rest of the world needs to payserious attention to. and she's not just a one minister show! she is concerned aboutbuilding 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 postgraduatestudies in a particular discipline relevant to their role in the ministry of health. there'sanother 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 isprovocative: charity does not rhyme with development, let's create a new partnership: the goldenage for global health. please welcome agnes binagwaho. [extended applause.]>>[agnes binagwaho] good evening, everybody. so thank you for your kind words. it's mypleasure to be here. and why i'm in your commission is because i believe that history has to bewritten. and article in the lancet, or report
in the lancet, and many other journals, influencespoliticians. and i want you to influence politicians in this part of the world to do better theirjob. it will help us to do better our job. [laughter.] so, but i am very humble to behere 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'sa 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 apiece of what concerns people. so i'm going of course to speak as a recipient of thataid, and also as somebody who is running the health sector. yes. so this rwanda, i thinkthat you can google it and have it, so i'm
not going to spend many time on this. theonly thing i want you to see is that we have increased life expectancy, more than doubledit. more than doubled it without really being more rich. the majority of our people stilllive 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'tpresent you my country, i think that i have to say that i have a lot of respect to bewith you here today because as richard says, less than 20 years ago, our country was totallydestroyed, devastated. doctors had been killed, nurses too, because i want to tell you thatthe genocide started by killing the intellectual so that they can not be a barrier betweenthat. so we had a country that was totally
destroyed and the fact, if somebody had saidthat 20 years ago we will be here talking about what we think the world should do witha 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 africain general now, more than one trillion dollars -- it's a lot of zeroes, i don't even knowhow 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. butwhat we need to know is that the revenue per capita, people are more poor in parts of africathan they were 50 years ago. so what happened that this massive influence of aid didn'tbear 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 becauseyou 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 thismoney didn't bear fruits? too early. i want also to say something else: the majority ofthe 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 theyare growing with a little investment in economic development, because there is less money investedin economic development than in health? but
those countries are taking off whatever. thereis little investment, there is a good return. and in the other hand, people are becomingpoorer and poorer. majority of african countries will not meet the mdgs, and the mdgs, whatwe say in rwanda, was not the ceiling; it was the floor. and they are not going to makeit. so, let's talk about why this money didn't work? and let's talk about, if you investin africa correctly, you have eight percent return systematically every year. does yourbank give that return? [laughter.] no?so it's quite good. the majority of the money hasgone 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 recogniseyour country? so this is the international-africa
way to do business in the health sector whenyou talk about aid money, impossible to find your way. it became so fragmented that ithas no impact. money is decided in london, paris, geneva, washington, new york. now it'sstarting 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 countriesand the amount of money that is coming. and if you have, let's say, one million dollarsand you gave it to one person, one institution that is very good, to implement, they willhave a coordinator, this coordinator will have a house, a car, et cetera, but if yougave that to this multitude of people, there is a multitude of coordinator, a multitudeof cars, a multitude of houses, and you end
with 60% of the money your parents or yourselfare sweating for that make toyota more rich, just to say a brand for a car, and what goesin the ground for people like my friend tom for people to come and implement in how tosave babies. what is remaining? if we are lucky, 40%. so there is a new way to do businesswe have to think about. this also gives another problem because you have so many people thatare working for the same program and they all ask you to do the reports with all ofthem having specific indicators that have been decided, again in new york, geneva, etcetera, and that has nothing to do with your real life. so in place of spending a lot ofhours to run programs or to give cash, we have to give a lot of reports, and we haveasked them, please, you are very intelligent
people, you all go to great universities likethis one. could you come together and have one framework we can discuss with? 2007, iremember, december in devon, all the people were dealing with monitoring and evaluationin pepfar, global fund, who and many other institutions i don't even know, invited usand we went in devon, i remember. and they decided to go and talk together to come--becausepmctc it's a mother whose hiv-positive with a baby in her body and the virus should notgo 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 agreewith me? ah, no. [laughter.] you and me are wrong. in london, it's not the same than inwashington. they are going to find an indicator
that is not totally different because it'sthe 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, anotherfour, another going there is a mark of this. and you continue and you continue and youhave to fill those reports. and the poor nurse in the health centre with a queue of peopleto 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 showthe 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 makea masters in ngo management. are you ready
to do that? it will help us a lot. becausealso, something, many of those who receive money got the money from the government, orfrom foundation like bill gates foundation, rockefeller foundation, skoll foundation herein uk, sif foundation and those have also their own indicators. so there is the moneybut we in africa and up till the example of rwanda, we also don't know the amount of moneythey 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, becauseeven 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 guessthis one is dead, but the other one should
inform us totally what is for rwanda. it'sanother accountability area. we should know for how much you sweat for me. and so thisis 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 wantto tackle hiv, you should go for comprehensive development. that's why i say what we thinkhere, what we are talking about, is really the overall development process, fightingdisease and fighting poverty have to go together. if we just come and give pills, we will neverend disease. we need education and that's why we are ready to partner with you. we needfactories. we need to know how to do those pills. and this is the only sustainable wayto go. so talking about tackling all those
disease, those infectious diseases and themajority 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 yougive 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 capacityof dealing with this tomorrow. who remembers that? hmm? this is the marshall plan. a massiveaid 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 conditionalitiesof uk ladies number for the health clinic - not it's not uk, sorry, german, hmm? therewere no measurements and et cetera, the measurement
was economic growth. the money was given andmassively. the money was well used, and massively. and out of the taxes, with the industry wereput back together, the countries bought education, health, social protection, built roads togo and get health, railway, bridge, diplomacy, universities, et cetera, et cetera. that'swhat we call now budgetary approach, in the language modern, because you know we haveto change language. this is something we have peter piot in this room. he was the head ofunaids. 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 youto 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. peopledidn't lose their time on that. so this was working, with this marshall plan, we shouldsee the quantity of health -- it's a good study -- germany has brought to their peoplejust through taxpayers generated domestic revenue. so i like this slide and it's a goodpoint made last year. it's done by a certain sidney harris. i emailed him and i said howmuch i liked this slide. so in rwanda, we managed to pull out of abject poverty onemillion people in the last ten years. we have managed to create a community health insurancethat 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 malariaprevention with two bed nets per family. it's
not that every family has two bed nets buton average there is two bed nights per family. we have decreased death due to hiv, due totb, due to malaria, all for more than 80%. our cohort of people living with hiv/aidshave 90% survival with more than 60% virulent[?] depressed. better than uk. better than newyork. better than paris. how we do that is because of the health sector we have. and why i put this, i like this, isbecause first of all, seven years ago when i was going in conferences like this, peoplewere 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 welfareof our people. just go and work and make the
lives of people better.' and when i was sayingthat, i come back and people were saying propaganda. now that the measurements have been done byexternal 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 workingso hard, we don't have time to write. if we say from a country where malaria was the biggestkiller and now we are in the process of getting rid of it, how have we done it? is it whatwe 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 emergencyperiod, now it's more calm. we better study. this is the life expectancy at birth how we'dclaim, it claims with the revenue per capita,
it's another proof that what we do in healthtotally depends on the socio-economic situation of the country. but it's not enough becausewe are not very far. far from our target. many people still have less than $400 peryear. so those gains don't reflect money. and it's another good thing to study. whatare the impacts of policies, what are the impacts of the financial plans? when manycountries want to know, and even ourselves, we would like to know. this is the instituteof 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 yousee 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. whati want to tell you with this, it is that we can see by studying those figures where thenext 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 onearth. they have 11 vaccines. 90% have all those doses, of 11 vaccines. the six recommendedby 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, injuriesand neonatal condition. you see in the bottom, the neonatal deaths are going to have a biggerproportion because their cause of death aren't under control. it's not that children willdie more, it's just the proportion of death due to that will be more important. so weare 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 efficientwe continue to do what we do in tb, malaria, hiv, hpv, blah blah blah, but we should investa 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 infact 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 wasa lot, in proportion, where people were dying more of infectious diseases. the epidemicof 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 needto partner to study our setting. this is the demographic and health survey. i can talkabout it because it's not us who's doing it. it's macro atlanta, and it's a partnershipwith [unintelligible] and also it's the slides
that i like a lot. you know why? because itjust tells me that i'm doing my job. [laughter.] you know why? this is the rate of decreasein child mortality. and you can see that the poorest have the biggest increase - theseare 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. ihave a grandchild i love, i have to talk about her. [laughter.] my target is the child ofthe 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 anational 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 soeasy because when you tackle the most vulnerable, the others are following. i'm going to tellyou, 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. sowe have with hiv money, we have built a natal clinic, paediatric, capacity to do vaccinationand later on, money came and it was very efficient. and this is the result of that, because thereis no global fund for under 5s. there is none. and they are dying, a lot. there is no globalmovement for neonataology, where the majority
of deaths occur. i'm going to tell you anotherstory 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 werevery 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 andthe minister of health. me, i was internationally with a control commission. and we won thegrant. 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 tocare, they all rushed and pay their two dollars. yeah! without a lot of movement, because peopleused to say, in rwanda, people are on the
line and do because it's a dictatorship. [tskingnoise.] 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 atschool. 96% of children are in school. before the genocide, you know how many? the countrywas producing only 3000 high-level educated people a year. for ten million people. canyou 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 notenough, but more than 100,000. and we have teachers, we try, we borrow teachers fromthe us. we have 100 us teachers on ground for a year. they come on the condition theydo 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 makeit more efficient for the most vulnerable, this is the key, that i have transformed theway we have success with the money. so when everybody was rushing to pay two dollars perhousehold, the rest were supported by a domestic fund. we just called a consultation and sayokay, we have this money from global fund for the poorest, this money from domesticfund for what is missing, now if we want to give you more care, we need the two dollarno longer per household, but per capita. our partners say, are you crazy? they are toopoor! you know, those two dollars are the cost of one beer, isn't it? i have a colleaguefrom around there. it's the cost of one beer
per capita. so we told them, it's one beerfor capita. they will drink a beer. and of course, the women drink less than the menso no problems, it's good for everybody. we did so, but we had a position in this countrytoo. many partners said no. people did it. they were very happy. and now let me tellyou, one thing you become addicted to is access to care. the more you access care, the morecare you want. isn't it? did you see what happened in some of the countries called wealthywhere 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 theylive with it - after that they had malaria, we treat malaria, they feel better. now sometimeyou 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 tocare and that is very good. but that means also you need to increase the contributionand 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 atall. why do we pay their health insurance? you have 90% of the care supported. you pay10%. for the people who don't pay the premium, we decided to pay at point of care, even ifit's a high transactional cost, because we
want everybody to understand that care hasa cost. and we don't want to go for free. we want people to understand that somebodysomewhere pays. so we receive the bill at point of care. but we have 92% of our peoplethat are covered. so this is the story of one aid that was efficient because it enteredtotally 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 afterthat 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, ohyes, 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 arespending sleepless nights to try to find step by step what is the best move for reachingeven 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 ididn't think i'd want to bore my friend richard because we showed him that slide when he wasin rwanda. if we look, the number of lives saved by investment per capita of aid in additionto domestic funds, rwanda is among the lowest. it's the maximum results. same for women livessaved. same for children. so there is something else that needs to be studied. this is myhealth 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 thatare working. this is the district hospital. we have 42 around the country. these are thehealth centres. we have almost 500 around the country. and these are the villages. ineach village we have community health workers. in each health centre, we have nurses. herestart the doctors. here start the specialists. in reference and in the ministry, richardhas said that all the staff have a master's. they have got it at work. they enter withthe degree and me, i challenge them and i say, i want you to have a master's, we willfind the money, we will pay it. another way of good investment. and don't believe thatthe time they spend out of work is losing for me. they enter with the skills, they startto work and they get this one, now they go
for a phd, wow. we are going to have the ministryof health the most strong on health. any tests change our way to do things because they knowwhat evidence-based means. they know what research means. they know why you don't doa 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 elderlypeople. so we go with the real needs and studies. evidence-based. that is what has brought thatfor me. and at central level, up to here, district hospital, they are all doing a master'sor they have their master's. and here i have already more than 20 people running for aphd. and that's still at work. i don't let them come here. they can come to me, one monthetc., not more. you help them where they are.
by doing so we have all along the system alot of quality data you cannot imagine. rwanda is a very organised country. people are keepingthe data very well. from here to here. you talked to community health workers. thoseare people who don't have, they just know how to read and write. you cannot imaginehow they run their business. and while i put that for aid, you see here, all the communityhealth workers, there are 45,000 - three per village. two women, one man. one man and awoman 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 capturethe sms in the ministry of health, also the mobile emergency system, the ambulances getit, and the people are served almost immediately.
before having that, and we did so with thesupport 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 becausewe were there too late. now we know the messages come from here, here, there, and we followthe ambulances and the ambulances come from somewhere here. same for children. here everybodyin 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 reportingto the prime minister. we no longer send paperwork. we can have paper, but we don't - i alwayssay that we are one for cupboard saving. isn't it? it's very good. and having this, we don'thave more personnel. we still have only 600
doctors for eleven million people, ten millionpoint five. the number of specialists are very few, but it allows us to task shift andto do remote supervision to ensure that the care is well done. when we start to do allthose things, hiv, tb, malaria, every time people were saying, "not sustainable; don'tgo for that." three years ago we started hpv vaccine. the hpv vaccine was so high but merckwas great to give us the vaccine for three years. shall i say no? to save at least twocohorts of future women, to save them from cervical cancer? they say yes but this populationdoesn't know that they have a cervix, how are they going to-- ok, that's true! so wewent and campaigned and we said to women, 'this is a uterus, this is a cervix, and thecancer blah blah.' and they say, 'yes, but
it's not sustainable. what are they doingto do after?' we say we don't care. we'll find a solution after. we don't lose thatopportunity. they say, they will never do it, it's impossible; they will spoil yourname. they say to merck. and merck, at a certain point hesitated. i had to call very influentialformer friends and say, 'before you were in administration, you were part of the civilmovement for iv aid to africa.' you remember that? you are too young guys, but it was afight. peter, you remember? saying that every african has the right to ivs. they say, notsustainable. 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 resistanceand 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 forother reasons that are more linked to social cohesion. there is a nice study done thatshowed that for hpv the fight was starting again. i advised you to read some - i thinkit was published in the lancet - saying that i was a criminal because i sell or sold - idon'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 peoplehere? you know, we vaccinate the entire cohort of girls age 11 because the demographic andhealth 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 ministerfor education, minister of local government, the minister of internal security. you knowwhy? not because people are going to steal the vaccines. but just because these ministrieshave a lot of power in everywhere in rwanda, for the police. so we borrow their car. andin three days our vaccine leaves kigali, go in a truck, go in every school with the helpof 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 thosethree days watched the children that are not at school and proposed a vaccine at healthcentres. 93% compliance for three doses across
a year. and over the three years, more than98% completion for the vaccine. this is another aid effectiveness, because it was not governmentto government. it was a ppp: public-private partnership. and we didn't tackle enough inppp. now it has given me ideas and i'm going to dialogue with motorbike producer to createambulances at community level. you know why? because for this telephone we are now in agreementwith samsung to upgrade them so that the community health workers can follow and understand whatwe do, what they do, their job, and compare with others. and it is so important to giveto the people the capacity to own their work. the capacity to understand what they do, sothat they are the actor of their own development and not only followers and people that onlyexecute. it changes everything. so there are
the more also, there is something that createsanother addiction: results. those people are incredible. they didn't get salary in thebeginning. now we are paying them on their performance with another type of aid thatis effective. it's a grant we get from world bank and we create all along the country littlebusinesses, so ministry of health has created little businesses, can you imagine that, littlebusinesses - four hundred and something, about that, for the community health workers. andthe result, the outcome, the profit of those businesses will allow us to pay them on aregular basis. investing in health by creating little businesses. you understand? those communityhealth workers are so proud, isn't it, richard? they are so proud of their life. they havecreated their own domain. they are serving
the people, and what made them proud, theyare elected by the people in the village. and our job, the ministry of health, is justto 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 choleraepidemic. i am very proud to say no deaths. no delay. confinement, immediately. why? thanksto the phone. and distribution of stuff to clean the etc, etc. thanks to the communityhealth workers and the people all along the chain, thanks to ict, the manager of healthsector, 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, goodhealth 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' waspronounced, let's say, less than 10,000 times a day. at the present day it's a lot. in 2036it 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. sowhat we say, the word 'sustainable' is according to some people, unsustainable. but when youhave a good idea, always go for it. money is not the true barrier because if you canprove after that the delivery of health is less expensive with your new idea, you shouldgo for that. it's investing in health. another thing, it's not to please you, it's becauseit's a big debate. we have, and that's why
we can partner, many people that are reallyimplementers, experts. and nobody listens to them. by travelling around the world, richardhas done a very good piece of paper around it. meaning, this part of the world shouldlisten more to what our part of the world has as needs. and also, how we see and weenvision to implement that. don't come with solutions that are already drafted. also ifwe have managed to have success, still there is a lot to do. still there is too many dyingfor preventable things. still, we still need to educate far more people for the healthsector. but if we have managed that it's because the coordination was strong. we have learnedwith hiv. hiv has taught us three ones: one coordinating body, one action plan, one monitoringand evaluation plan. one way to educate. so
that everybody has the same protocols andif somebody is sick in north, east, west, can be treated and go back home without discrepancyin 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 forhiv treatment. and procure together. we don't have the same protocols. all the majorityof protocols bring the same effect. we just have to decide what is the best for all ofus. we know it but geneva should listen more to all of us. and this was about - this isanother story about aid effectiveness. one day we received from canada a call. we havea dialysis machine, it was 2006, but rwanda has to pay the shipment and we say oh dialysismachine, portable, that's genius because we
have those people but we don't have the moneyto buy. so we pay the shipment. 18 machines. when we opened the container, you know whatwas written? [something on the slide.] that's not a joke. they are still packed somewherein kigali because to destroy them is too expensive. yes, effectiveness of aid. so did that personreally know, because they contact our embassy in canada, we agree to pay on tax of domesticfunds, 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 tothe 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 stepforward. the rest is really criminal. it's
not a joke. we had to find a place becausethey were packed in the vaccination institution compound and when we start to increase thenumber of vaccines from six to seven, eight, nine, now eleven, there were no more placesso we scream in kigali to say where to put them? so they are still there. i think weshould bring them in a museum of nonsense. this is to show what we can do together. thereare very good studies to do. so in red is the cost of ivs. in blue is the productivitygain. in green is the cost averted to have orphans. and in purple it's saving by delayingend of life. so you can see with such a graph, i can go everywhere, i show you that investin iv brings economic growth and supports the development. those are the types of studiesthat 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 todocument, i told you. this is another area. it has been documented that we do the workbut publications are elsewhere. the people about our job are publishing one thousandmore than us, about our jobs. about how we are sweating for inventing it. that's whati 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 frameworkas well as doing research in rwanda then the way we manage. because we cannot put the blameon 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 zerotolerance for corruption. so also aid should really promote reverse elevation. there isa lot we can invent and if i go to the community health workers and say this is the problemwe want to solve, how should you do that, they have a lot of ideas. that's how we caninvent 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 cometo me, i come to you, for us to have a good journey together for better health for theworld. because if people, if diseases like that are spreading, you are not safe. we betterwork 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 alsothe social determinant of health. and if health is a human right, tackling the social determinantis also in that category. i'm going to pass quickly on the example of mdr-tb. this isthe example of investing the money right to produce more health per dollar invested. andi would like you to think about dealing with humanitarian as a business. where do you putyour energy to produce the more health? just to show you that more result and decline perinvestment. 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 thehealth sector, i consult all my colleagues
to see how we can work together. this is thecomprehensive governance. so we have this, the solution is ownership. it is equity. yougo for the more vulnerable. it is also science. you give evidence on what you are doing beforetaking decisions. participation: never do something without the other people concernedas beneficiary or as implementers. and if we can have those principles applied to theglobal - to the money that is outside for health, we will succeed. those are the placeswhere the decisions have been made to respect countries. there was rome, there was parisand after that we change continent. we went to accra! still, status quo. the burden ofthis is still on the countries that have to report differently but hp+ plus never takeoff. 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 beautifulthings 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 havea 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 needto relax, and also the teachers, etc. so build a school, etc. i am ending because i see thatmy 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 wordthat they told me how to pronounce but i'm sure i'm going to pronounce it badly. "truecompassion means more than - fledging? flading? - a coin to a beggar; it comes to see thatan edifice which produces beggars needs restructuring." you can change now, by the international aidand 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 audiencemight want to ask you some questions because it's not every day that you will be cominghere to ucl. so now the timetable was that we were going to finish at 7:00pm so thatyou could go across and have a drink but i'm going to steal a little bit of that time unlesssomebody 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 willcome and find you. >>[audience member] hello, i'm jian lee, studyingcurrently at the london school of hygiene and tropical medicine, but i used to be partof the charity community because i worked with world vision for five years, and i deeplysympathise and agree with crazy indicators, the fact that economic development is a sustainablesolution, but because there is always going to be some charity people who take sustainabilityseriously, would you actually give suggestions
or some good cases you've seen of ngos, externalplayers, 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'vebeen absolutely astounded to have such a clear vision of inspiration leadership and you'veshown what very, very strong and clear and excellent leadership gives and a health servicedelivery like no other country. could you say something about the other side of thecoin, which is the community. what movements were there within the community that possiblycontributed to the remarkable reduction in
mortality? the reason i ask is that certainlyin africa many other countries are looking not just at service delivery but they're lookingat ways in which social development and community participation can make a big difference, andit 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 thegentleman 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 headof pharmocognosy. but a very different question: governance. i think the big challenge forme after your talk is how can we develop a governance structure which facilitates allthis and finds the place between community
and ngos and governments where things wentgrossly wrong in many cases. >>[richard] very good, thanks. just behindyou. >>[audience member] hi, i'm chekwe, i'm apublic 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 havingthe same type of vision, inspiration and drive that you have demonstrated this evening. simplequestion on leadership. >>[richard] that's a great question, thankyou. agnes, we'll go to you on some of those. >>[agnes] so this one is... so the first questionon ngos. madame or mademoiselle. i think we
need to be clear. in rwanda the governmentcoordinates. the government should never implement. we implement when there is nobody to implementcorrectly, 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 businessforever. come and train rwandan to do business forever. and also what we do, i think, ifwe are here, we can learn to be here, with the ngos. and when you are here, you learnto be here, and so on. we're always partners, and that's how we have implemented the humanresourcefulness. it's not that it was against ngos, we want our society to come at the stagewe 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 ourpeople. you see? so we always need these civil societies but it's different according tothe society. but i also want to remind that the systems are not created by ngos. thisis a big mistake. people come to create a country - no. you are there to help peopleto create their own country. then it works. for the second question: it was about, i don'tknow, it was about what was the role of communities. fantastic. there is something that makes usall shivering, you know, because you believe that we are very popular. uh uh. my mergeris given by my community. every year they rate us, satisfaction, and this study is doneby local government and reported directly to parliament. if i can do the best, if thepeople are not happy, they will put me in
red. so that means whatever we do, we needto explain. and we make them part of the things and don't do that without them. i'm goingto give you an example. an african here will understand me. normally, an african man thinksabout 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 weneed the men to go and test for a baby he has even not seen? there is a lot of culturalrevolution in the health sector. it is the first time men in africa are concerned withthe baby that is even not born. going and giving his blood for something that have noexistence in our, we don't consider traditionally, not now, now a pregnancy is considered asa child. just to say that community, don't
think that what i ask you to do is me. i cando 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 giveme, i steal me, you have given me and you know, you are as guilt as me. so the traditionalway the north and the west give money to corrupt governments is what has killed us. and i sayto my colleagues, when you steal money, you damage my program because you remove trustfrom the world and africa. that is the other thing we have to say. africa, for the majorityof people, is a black box, very damageable, full of microorganisms, dirty, etc. and that'strue. 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 astreet full of black shit, some with blood etc. if it was in africa none of you willcross that corridor. because it's in london, you will just cross. the image of things havea 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. weneed 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 colleaguesare 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 willfind you. >>[audience member] yvonne madesi from malawi,by the way of the university of southampton, and thank you so much for a very interestingpresentation, and i really admired everything you said and i admire you very much, and iecho what my nigerian colleague said about how we wish we had more of you. but i wasinterested in what you said about giving telephones to the community health workers and gettingthem to actually learn what's happening in other places. and i wondered about the powerof 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 actuallydeliver 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 thebush of northern uganda, i just collected the wrong skin. i think it's fantastic notjust to see an african woman on the platform but to talk about the hope and the power andthe reality of africa today, not what people often see, which is the africa of previousdecades, and you've shown us that change can happen. but i particularly want to point backto your slide about the burden of disease in rwanda. and you highlighted the increasingproportion of neonatal deaths. and what you said is what we hear from ministers all overthe world, that this is now our burden, and yet when they're saying to donors, that isn'twhat the donors are funding. donors are saying
no we don't do that. so i would like to hearhow you've answered that and how you think your fellow african ministers. and i'd justlike to point out that rwanda has shamed britain because you had about four times as many femalemps 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 thesouth. what i'd like to ask you is what are your thoughts in terms of how best to go aboutcollaboration 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 youlike, the details of interaction between the various parties, how do you engage the local community in determiningwhat 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 veryastutely 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 changethat happened in rwanda and how are you including people in the developments you're making inthe future, and secondly, to this room full of future global health leaders, what is yourone key message? >>[richard] that's great, okay.>>[agnes] okay, so, it started with the telephone. how the telephone has changed mindsets. it'sincredible how the telephone changes mindsets. the power of communication. that means, theworld 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 toask advice, they feel empowered to do their job. by people also knowing they have thatpower, they go more to them, to seek services.
but it's not the only way that it works. itgives also more accountability to people like me because we have, i was supposed to butit's too long, we have what we call a national dialogue day. it's two days, where we arelike you, sitting in the parliament, chaired by his excellency, co-chaired by the primeminister. in the room we have all the heads of the army, the police, all governors, allthe mayors, all people who have a decision. we are more than 800. and people, there isa screen, communicate with sms, there is facebook, there is twitter, and there is a phone. andlet me tell you, it's soon. and it's my two hard days. you know why? because everythingcan 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 peopleare reading those tweets. so if i am a bad lady, it will transpire. if somebody's badsome way, it will transpire. and you have people who just as i told you, we have threephones 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'sgood. 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 myeconomic growth. immediately in that very setting, which sector you come from, whichmayor is the sector, governor mayor, tell u what happened? so police, tell the policeto go and see if it's true. it's true. bring
the cow back to the guy. now are there manyother cases like that? immediately, we receive the minister for agriculture and the policereceive one month to track all the cows that get to the wrong person. you understand? thisis what we call accountability day. people like me, i had to inform-- to explain, i wasps at the time, there was another minister, this is vera, who had to explain why we haveclosed 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 phonesare 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 alsosometime we need to make them feel uncomfortable,
leaving your comfortable zone. what we didfor maternal death, for example, we have the maternal death thing. before we did not knowwhat happened, why the women were disappearing. for the woman who dies in hospital or healthcentre, there is a professional autopsy. we have to say what happened. for those who diein the village, there is what we call a community autopsy. meaning, there is a committee createdwith villages, private sector, local leaders, etc. who go in that house and say, what happenedto that lady. she was not supposed to die, did she complain before, etc. everybody knowsthat. 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 moralpressure 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 professionalsfor two years in rwanda. but i think that we need to collaborate for better understandingour health sector. we have differences but we have similar populations. also we shouldstart to collaborate in production. that mean that today if all the houses of the healthwant a mosquito net, there is not enough production. is that it? how can we start production inthe continent to serve the continent if we don't have it. don't forget, but we don'thave it. this country can do this. this country can do that. and together we don't replicateand we create economic growth also. also, the new born, how we engage, i don't -- thequestion 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, againin new york, geneva, and london, and they don't know that we can save children withlittle actions that doesn't cost a lot. and they are not interested. i think we need anew mindset. the charity should be in the heart and removed from aid. but if peopletell you that this is my problem, believe them! believe them. and if we tell them we'llbe accountable with this, we will save this number of children, just come and see. andsaving neonatal is the best family planning tool. because people have children becausethey don't trust that you will keep them alive.
when i came back in rwanda in 1996, i hadonly 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 planningtool is keeping the children alive in a peace land where people have access to care. thekey message for youth, and the role of youth. youth are fantastic because they are not yetspoilt. 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 peoplethat don't know how to write and read. you know, our people are very polite. why i amsaying all of those things is because, probably,
my siblings education was somehow wrong. inrwanda, like in many african country, they are not telling what they think, but theydon't like arrogance. and this slow collaboration. you go with humility to those people and justlearn 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: comewith humility, and also young people of the world, know that you can do the revolutionpeacefully. 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 goingto go top left there, yes please. >>[audience member] hello, i am the industrialpartnership 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 itwas very successful, that could be used in other places. than kyou.>>[richard] okay, and tom. >>[audience member] tom nissau, paediatricianin rwanda, and i'm pleased to say have done a lot in terms of health partnership withyou in rwanda. i was going to ask something a bit different, and that is, here we're ata university and we've heard about the great universities we have in the uk. what wouldyou most like from our universities? >>[richard] let's take those two questionsand 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 provideris a company. the government have found the money and also paid for those. you can donothing 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 ofa country is the private country. even though i believe that the backbone of quality careand well distribution should be coordinated by the government, but my dream is privatesector strong in rwanda, they pay a lot of taxes so that we can build hospitals. so anotherexample of public private partnership, there is public-private community partnership. yousaw the 42 hospitals. these are called district hospitals. ppcp. 40% of them belong to churchesor to ngos. we treat them the same. they have
the same advantages and they have 50% of thehealth professionals. in exchange, the have our health system and they have the same categoryof 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 somethingelse, 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 belongingto one health centre. we want to propose a ppcp there by having a nurse, a2, runninga health post, we don't pay her salary, she makes her own money by reimbursement of thecare 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 savinglife. don't go for doing study only, go for -- your best motivation should be saving livesas soon as possible. but doing it with rigour, with good documentation, allowing young peopleto do research, make the brain of young people more smart, etc. that's great. that's whati like. >>[richard] okay, now we could listen to youall evening, but there is a reception outside. i'd like to thank you, agnes, on behalf ofeveryone in the audience. [applause]