A conversation with the Assistant Clinical Professor of Public Health, Columbia University.
Card: How has Rwanda improved health care outcomes?
Josh Ruxin: There are still enormous challenges for public health. There are many health centers in the country which lack running water, which lack electricity, and perhaps most importantly which lack the management that’s required to deliver good quality health care.
Let me just give you one quick example of that. There are health centers which I frequently visit where there might only be three or four staff with a little bit more than high school education who are expected to provide health care for a population of 25,000 people. That would be hard for any three or four professional staff anywhere in the world to do. But in Rwanda where the training has been relatively light and where the resources are also less than ideal this is an enormous challenge, and pretty much unbearable and impossible to really improve the overall quality of health.
What can you possibly do in order to change that situation? There are different diagnoses of it. A lot of people who will say, “Let’s bring in more nurses. Let’s bring in more doctors.” Others will say, “Let’s bring in new drugs. Let’s help to make sure that there’s a good drug pipeline.”
In my work in Rwanda, we’ve actually made a related but slightly different differential diagnosis of the situation. Our diagnosis is it’s really about the management. If you’ve got a couple of people who are running a health center, the first thing that they need is access to private sector-type strategies for implementation.
Do they know QuickBooks? Do they know basic accounting? Do they know how to get the job done, how to schedule their human resources, how to stay on top of the physical infrastructure? Do they have all of those skills first? Because everything else ends up following.
Our experience so far is that we can actually go into a health center which is in disrepair working with the staff to improve those skills over the period of six months to a year, really get the health center on its feet, move up from seeing perhaps 15 or 20 patients per day, to a hundred patients per day, increase the income, increase the quality of services, and ultimately increase the outcomes, improve the outcomes for the poorest people perhaps in the world, certainly some of the poorest people in Rwanda.
The big challenge today isn’t so much on the drug procurement side, but rather on the management side. Are there good systems in place for anticipating what type of drugs are going to be required and in what quantities? Do the health centers and the hospitals have good systems? Do they have good checks and balances? Are they able to ensure that they’re procuring the right drugs and they’re not getting counterfeit drugs? These are the types of questions which can be handled best by good health management leadership, and that’s an area that terribly demands new investment today.
Question: How is technology improving health care?
Josh Ruxin: I think the most important technologies that we have are those that we’ve had for decades. One small example of that would be Oral Rehydration Therapy which is a simple solution of sugar, salt and water which can save the lives of severely dehydrated people, people dehydrated by cholera or intestinal worms which has resulted in severe diarrhea.
I’ve actually seen kids who actually come back from death. They’re literally hours from dying, you give them the simple solution, in the right quantity, of Oral Rehydration Therapy, and they’re up running around playing soccer.
Why isn’t that being used everywhere in the world? The answer is that the management, the wherewithal and the overall unity of focus on public health does not currently exist in so many countries. Instead, they might be trying more complex solutions, sophisticated antibiotics, and other interventions such as intravenous drips which can’t be administered in all resource-poor settings.
It’s really a mixed perspective. There’s a lot to be said for new portable EKGs and also electronic medical records. But overall, first we have to figure out: How do we roll out the technologies that we’ve got a lot of practice with which we know are extremely effective? Those are technologies like insecticide-treated bed nets or combination therapy for malaria or anti-retro viral therapy for HIV/AIDS. These are all very basic interventions which have been with us at least a decade, if not decades more than that, and yet they’re not currently being implemented across the board.
There are actually some new vaccines which have just come to market and are starting to be used in developing countries, including a vaccine for pneumonia, pneumococcal vaccine, which we just piloted in Rwanda. That’s going to save 6,000 lives. It’s just one shot in the arm that kids need periodically, and they’re going to be good. It’s going to end up saving more lives than lots of more sophisticated intervention.
Question: In global health, what diseases need special attention?
Josh Ruxin: Non-communicable diseases are the diseases that you and I are most familiar with. They are things like diabetes and heart disease.
Unfortunately if you run your hand over the planet, you’ll see that in the poorest countries there’s extremely little that’s being done across these dimensions. These diseases are not getting the attention that they deserve. And yet they are becoming a larger and larger piece of the puzzle of public health.
In Rwanda, Kenya and Ethiopia and a number of countries where I’ve worked over the years, we’ve seen large numbers of new type I and type II diabetes coming through the door.
Just a couple of months ago, I was out at a health center where a man who is suffering with type I diabetes was actually living at the health center because he didn’t have the authority to provide himself with daily injections of insulin. Of course, this would never happen in the US or in rich country. He’d get his needles and insulin and he’d inject himself at home. But where there is care that’s given, it’s given without very much instruction or very much knowledge of these diseases.
One of the best interventions that we can make as a world today, in the area of public health, is around these non-communicable diseases.
We’ve actually got a start taking a look at heart disease in poor countries. I know that in China for example, heart disease has become one of the top killers. In Rwanda and Sub-Saharan Africa, heart disease is the major killer, but it’s a bit of a silent killer because people haven’t tracked it over the years. It hasn’t been as interesting nor has it attracted as much donor dollars as something like AIDS, tuberculosis or malaria. And yet it’s still claiming a huge number of lives and a lot of productivity.
Even though we don’t have the best of baseline data, we do know that the impact is enormous and that with changing diets in poor countries, with urbanization, with increase in smoking and basically bad, rich country habits, people are going to be getting sicker and sicker, earlier and earlier. Now is the time to really prevent this disease which is going to be the next wave of pandemic that hits the world.
Question: What leads to the proliferation of neglected tropical diseases?
Josh Ruxin: The neglected tropical diseases are diseases which you can tell by their name are terribly neglected. It means that they have not received the level of interest, investment or intervention that they deserve over the years, and yet by some estimates they actually the largest disease burden on the planet today.
One of the most common neglected tropical diseases are intestinal worms. These are worms which embed themselves in the bowel. They can result in malnutrition, vitamin deficiencies, diarrhea, and ultimately making children and adults as well more susceptible to other diseases.
This is really important take away on the NTDs as they’re called, the neglected tropical diseases. Some of them appear to actually be linked to other diseases. Recent data just out in the past couple of months shows that one of these NTDs, schistosomiasis, can raise the rate of HIV/AIDS infection by threefold in women.
How does that happen? Schistosomiasis is a particularly pernicious disease carried by snails and the parasite can actually result in vaginal lesions which make a woman more likely to contract HIV/AIDS during sexual intercourse.
Preventing these diseases and treating these diseases is critical. What does it take to treat them? We already know that. It cost between 35 and 50 cents for well known treatments, many of which are available by donation, to treat kids and to treat adults for these diseases. But treatment alone is not the answer. What else is needed is actually access to clean water, basic hygiene and sanitation and basic hygienic practices in order to avoid the transmission of these NTDs in the first place.
This is probably one of the areas of global health where we can have the most bang for a buck. A lot of people are extremely critical of vertical solutions, just focusing on one disease or another disease. But in the case of neglected tropical disease, this is something that can be done through schools. It can be done through existing health centers. There is not a massive incremental cost. It doesn’t take a lot more time to do. And yet it actually has a domino effect on taking out other diseases downstream and overall improving lives and improving productivity.
Question: Which developing countries are doing the best job with health care delivery?
Josh Ruxin: One of the greatest successes in global public health, particularly in Sub-Saharan Africa over the last decade, is Rwanda. It’s no coincidence that I moved there with my family three years ago to help make a contribution. It was one of the countries where I never faced corruption and where I saw the government really took a firm lead in making a vision of good health for all a reality.
They’ve done this a couple of different ways. They’ve actually made use of financing from the Global Fund to Fight AIDS, TB and Malaria, from the Presidential Emergency Plan for AIDS Relief, and other donors in order to really improve the quality of overall health care. Unlike other countries which get thrown money and just focus on AIDS, and all the resources suddenly scrambling and look at AIDS, Rwanda has been very smart about it and they’ve actually said, “We’ve got to take a look at our burden of disease. We’ve got to improve overall health care at the health center level, at the health post level.” And they’ve gone out and slowly but surely really ramped up the overall level of care for the average Rwandese.
What does that actually look like on the ground? One of the major plans for Rwandan health care is called Health Mutuelle. Rwandans are expected to spend about $2 per capita per year for a suite of services. If they show up with their Health Mutuelle card, they’re provided malaria care, basic infection, immunizations, all the basics actually get done for them. They’ve essentially bought into an insurance fund.
Rwanda is one of the few countries in Sub-Saharan Africa that has a plan quite like it and has the percentage of participants that Rwanda has got today. So this is actually been one of the key ingredients to their success.
I’ve had some concerns of my own about reaching the very poorest of the poor who don’t have that $2 but the government of Rwanda and some of the donors have actually stepped in and said, “For those who are extremely poor, we will cover your health care because we recognize for you to be productive, you’ve got to have access to health care.”
What they’re striving for of course is universal health care. They want to make sure that there’s health care for all, and that no one’s discouraged from showing up at a hospital or a health center if they’re terribly ill, if they don’t have health insurance. This is a really tricky political football in Rwanda right now, but over all they’ve been doing a really good job figuring out how to get this online.
One for the original challenges that one of my teams noticed was that the Health Mutuelle card required a photograph, and a lot of people didn’t have a photograph, so one of the very simple solutions that my Access Project team rolled out was putting webcams in the health centers, on the Health Mutuelle computers. A 1995 webcam ended up taking these digital photographs for free and removing this barrier to accessing Health Mutuelle. We saw the uptake increase dramatically at the sites that started using these webcams.
Topic: Success stories in public and private health partnerships.
Josh Ruxin: The Access Project, which is a project that I’ve led in Rwanda for several years and actually which is currently completely led by Rwandese, is a huge success story because when I started up this project we had a fully expat team. So, we had a lot of Americans who were over living in Rwanda, working with the government side by side, literally at the desk with the Minister of Health, as the scaling up began in Rwanda. But over time we managed to build the capacity of Rwandese to take over the project.
Today, the entire project is led by Rwandans, and the private sector is actually taking notice. Pfizer, for example, the pharmaceutical company, has a Global Health Fellows Program and every year they are sending the Access Project some of their key personnel in management, accounting and strategy who are working with this Rwandan team in order to further make improvements to the health care system in Rwanda. That’s a great example of public/private partnership.
Another key partner that we have in Rwanda in the field is General Electric. Through the GE Foundation, GE has done some amazing things in Rwanda and across Sub-Saharan Africa in places like Ghana as well.
They’ve actually said, “We’re not going to give away our worst product. We’re not going to give away our cheapest products. We’re not going to give away last year’s products. We’re going to take our top of the line products, we’re going to send experts out to the field and figure out what are the needs in health centers, in hospitals, and if those countries and those health centers and those hospitals can demonstrate that they are competent and conscientious, and if they can manage and maintain the hardware that we’re willing to put in place, we will send out teams, we will train them in the utilization of this hardware and we will put it out there in the field.”
I’ve seen GE already pour millions of dollars this way into Rwanda and it literally has changed the quality of health care for hundreds of thousands, if not millions of people.
Topic: Investing in global health.
Josh Ruxin: Investments in global health aren’t just good for poor countries. Investments in global health are something that’s actually good for the world. When people scratch their heads and wonder, “We’re not spending perhaps enough money on health care here in America, what are we doing spending money on helping health care improve in a poor country like Rwanda?” The answer is that it’s an interconnected world, as we saw with swine flu and with SARS.
By improving surveillance and treatment, by improving what happens to emerging diseases and existing diseases in poor countries, we’re actually improving the overall health of the world. Moreover, we’re also improving productivity to levels where countries can finally climb out of poverty and not become countries that are dependent on our aid, but rather become countries that are improving their tax base, starting to pay for more of their public services, and ultimately become bigger consumers of American products.
An investment in health is a key step to ensuring that the world does not have the same problems that it’s had for hundreds of years, and finally getting over that incredible hump, and providing us with a world in which kids don’t die when they’re less than less than five years old of preventable and treatable diseases, when mothers don’t die in childbirth.
These are health issues which don’t just impact the communities in which they are occurring, it impacts the whole world. It makes everybody more susceptible to diseases, which we really don’t want to see at the levels of pandemic that we’ve seen just in the recent past.
Take a look at something like HIV/AIDS. It looks like it originated in Central Africa, perhaps as much as a hundred years ago, perhaps even longer ago, but we didn’t know about it until the early 1980s because that’s when it came up on our radar screen. If we’d been investing in health care systems more effectively in Central Africa and Sub-Saharan Africa, we probably could have picked up on that emerging epidemic much earlier, and we could have done more to stave off that epidemic from reaching our shores.
Recorded on: June 3, 2009.
