|Speech by former US President Clinton when he and President Kagame visited Eastern Province|
Rwamagana, 19 July 2012
Health Professionals Education in Rwanda: A Vision for the Future.
Thank you for the kind introduction Honorable Minister of Health.
Your Excellency President Kagame, Honorable Minister of Health, Governor of Eastern Province, Mayor of Rwamagana (THE W IS SILENT), Director of the Rwamagana School of Nursing and Midwifery, partners, honorable guests, colleagues and friends, first, let me thank you, for making me and our delegation feel so welcome here in Rwanda. We're all very grateful to be here. I'd also like to thank the students and health professionals who are here in the audience today. I especially thank the many health professionals who could not make it here today because of their commitment to taking care of patients in the hospitals and health centers right now.
I was last in Rwanda in 2008 where I visited the cassava fields in Rwinkwavu, the coffee farmers in Gisenyi and visited the district hospital in Burera, which I had the pleasure of going back to yesterday for the launch of Rwanda’s first cancer center of excellence. Four years ago, I noted the incredible progress of Rwanda under the leadership of President Kagame. Today, four years later, I continue to marvel at the incredible achievements that Rwanda has made and continues to make.
Since I have left public office in the United States, I have been working with my Foundation to help to improve the lives of those most vulnerable by supporting governments through long-term commitment and partnership. I have always been deeply committed to work here, in Rwanda. The Clinton Foundation started our work here by focusing on the fight against HIV, and in particular, lowering the cost of drugs and tests so that countries could afford to put more patients on treatment. Later on, we began to support economic development through our agricultural work with rural farmers and expanded our support for health programs.
Since the horrific events of the genocide 18 years ago, Rwanda has come a long way. Life expectancy has climbed from 28 years in 1994 to 55 years in 2010. 90% of Rwandan children ages 12–23 months have received all recommended vaccines. Maternal mortality has decreased from over 1,000 to 400 deaths per 100,000. In December 2002, approximately 800 people in need of antiretroviral therapy were receiving it. Today, more than 100,000 people living with HIV in Rwanda are receiving antiretroviral therapy, which is more than 90% coverage of the population in need, a better percentage than in the United States. Since 2007, malaria morbidity has decreased by half from 2.6% to 1.4% among children 6–59 months and from 1.4 percent to 0.7 percent among women between the ages of 15–49. Diarrheal diseases due to unsafe drinking water have also dramatically decreased since 2000. We heard yesterday that vaccination coverage to prevent cervical cancer is over 93%, while currently in the United States HPV vaccination coverage is still only 26%.
These successes are not accidental. They can be attributed to the strong national leadership in Rwanda from His Excellency President Kagame and the strong leadership in the health sector under the current Minister of Health Dr. Agnes Binagwaho, who has worked with us since we arrived in Rwanda ten years ago when she led the national HIV/AIDS committee. Globally, Rwanda’s tremendous successes are often considered to be a role model for other nations.
Rwanda has made immense progress in increasing access to primary care through its decentralized health model that places skilled professionals in over 40 district hospitals across the country. Since 2002, utilization of primary care services has increased more than four-fold. While primary care continues to scale-up, the need for specialized care is becoming more evident. Minister Agnes Binagwaho expressed her vision that through the development of a highly trained workforce, Rwanda will be able to stop having to seek advanced care outside of the country and will be able to provide specialized care in Rwanda.
My Foundation has been honored to play a role assisting the Government of Rwanda in fighting the AIDS epidemic since we assisted with the development of the first AIDS care and treatment plan beginning in 2002.
In 2004, under the leadership of the Rwanda Government, we brought Paul Farmer and Partners in Health to Rwanda to assist in developing model hospitals and care and treatment systems in rural areas. We then assisted the government nationally and district by district to develop plans for scaling up high quality primary care throughout the country.
Two and a half years ago, the Government of Rwanda asked us to assist them in their ambitions to become the first world-class health system in Africa that will be sustainable within the Rwanda GDP and not dependent on foreign aid. The key to accomplishing this goal is to educate enough Rwandese doctors, nurses and health managers in Rwanda, and to create a medical education infrastructure in Rwanda staffed by Rwandese professors that can continue to educate world-class health professionals. The Government asked my foundation to help them develop a Human Resources for Health (HRH) national strategic plan where ambitious objectives to increase the healthcare workforce would be clearly defined. Together with our colleagues from US CDC, CHAI led the Technical Working Group on HRH. Thanks to the contribution of all the various Rwandan institutions involved including: the school of medicine, professional associations, nursing schools, the Kigali Health Institute, the school of public health and others, the Government produced a very inspiring plan.
Minister Binagwaho told us that foreign assistance for health education as traditionally carried out had serious limitations. Many times, expatriate health professional trainers would come to Rwanda to provide trainings in hospitals and Rwandan schools, but only for short amounts of time; sometimes 3 months and sometimes for just one week. This model of training was not sustainable for the beneficiaries, the Rwandan students and educators, and the costs of such short-term programs are not an efficient use of donor funding. What Rwanda needed was a true long-term sustainable partnership with a shared sense of responsibility that would bring the most highly-trained faculty of medicine, nursing and health management to Rwanda to be based here, in-country, for an extended period.
The HRH Program’s goal is to establish the critical mass of highly skilled Rwandese doctors, nurses and health managers needed to train the next generation of Rwanda health professionals. The Ministry of Health identified specialty areas such as: internal medicine, pediatrics, obstetrics & gynecology, anesthesiology, surgery, pathology and emergency medicine. The HRH Program will help to train over 500 specialist doctors in these areas to ensure a robust specialized workforce.
The Ministry of Health has made great strides in increasing the skills levels of nurses and midwives. The HRH Program will additionally provide the opportunity for 5,000 nurses to upgraded to the A1 training level. Over 2,000 nurses will be trained in nursing specialties such as nurse educators in critical care, oncology and pediatrics. E-learning strategies will be used to help upgrade a major portion of nurses. Ultimately, Rwanda’s nursing schools will be strengthened to increase the uptake of new students producing more highly-skilled nurses than ever before.
At the request of the Ministry of Health, CHAI began to establish academic partnerships with top-ranked US schools to provide medical, nursing and health management faculty to Rwanda for long-term one-year minimum assignments. In this model, nearly 100 US faculty will be based in Rwanda each year to work hand-in-hand with Rwandese faculty. The US faculty’s main role will be teaching and mentoring. Each US faculty member will be paired with a Rwandese faculty member for a year to transfer training capacity.
The Government of Rwanda also wanted to tackle the current inefficient foreign aid model where too much money was spent on high costs for overhead and administration that is paid to institutions to implement programs. In the current aid model, often less than 50% of foreign assistance dollars are actually spent directly on programs with the rest being taken as overheads in the US or spent on project administration.
CHAI approached a number of the leading medical, nursing and health management schools in the United States on behalf of the Rwanda Government, and the response to this visionary program was overwhelming. Harvard, Yale, Brown, Dartmouth, Duke, Columbia, and University of Virginia medical schools all agreed to participate. New York University, University of Illinois at Chicago, Howard, Duke and University of Maryland nursing schools, and the Yale School of Health Management will also participate and send nearly one hundred professors per year to Rwanda for the next several years.
Further, they agreed to waive the 25-30% overhead they would normally charge for their work and to contract directly with the Rwanda Government which because of economies of scale will mean that the program can operate with a 7% administrative cost.
Whereas on many aid projects, administrative and overhead costs consume half or more of total dollars spent, on this project, 92 cents on the dollar will go directly to program expenditures.
This will be by far the largest medical education project ever undertaken in the history of foreign aid and it will be the first time that so many universities will work together and put themselves under the leadership of a developing country government and work according to its plan to transform the health system of a nation.
In order to be able to implement this plan and achieve the country’s vision, The Government of Rwanda had to convince some of the largest donors, mainly the US Government, to support this plan. To do this, they offered to give up certain existing programs funded by the US Government and repurposed the money for the HRH Program. The US Government agreed and the Global Fund also agreed to provide support to fund the program.
I would like to thank Ambassador Koran and colleagues here in the audience from USAID and CDC for understanding the critical importance of health education and for supporting the Rwandan Government in this program that will commence next month. The US Government has been a strong partner to this HRH Program.
Today, we have in the room Rwandese students, doctors and nurses that will be participating in the HRH Program and I would like to say that you are going to be part of a historic program that within 7 years will create the first world class health system in Africa. Your schools will receive assistance from some of the best universities in the world over the next seven years. By the end of this program I expect that you will continue your relationships with these US universities, but by then your schools will do this as equals. This program will also help pave the way for a new paradigm in foreign aid and global health partnerships. Rwanda is going to again lead the way and define how meaningful country ownership and leadership of aid programs can be the most efficient and effective way to bring strong results.
I would like to thank President Kagame and Minister Binagwaho for their great leadership. I am convinced that Rwanda will succeed in developing an independent world-class health workforce and health system that will serve not just Rwanda but the whole region and that within seven years it will be able to do this without the need for foreign assistance. I would also like to thank the 13 US schools that will be part of the academic consortium for the HRH Program. Additionally, I would like to thank Dr. Paul Farmer, Partners In Health and Harvard Medical School for their leadership and commitment to committing a great number faculty to the HRH Program.
It is the students and teachers in the room today that will ensure the success of Rwanda’s tomorrow. Through the partnership with US schools and their faculty members, I am confident that over the course of the seven-years, Rwanda will become a health education hub in Africa that will train world-class professionals not only from Rwanda but from all over Africa.
I look forward to formally launching the HRH Program with the Rwanda Government and with our partners from the US Government next month.