Building back fairer in public health policy requires collective action with and for the most vulnerable in society

FUNDING: We acknowledge the University of Aberdeen for supporting the authors to conduct formative work on Strengthening Health Care Systems to Provide Care in the Community. Acknowledgements We acknowledge the University of Aberdeen for supporting the project. The authors gratefully acknowledge the inputs of Professor Tim Carey Director of the Institute of Global Health Equity Research at the University for Global Health Equity to earlier draftsPeer reviewedPublisher PD

Improving the world’s health through the post-2015 development agenda: perspectives from Rwanda

The world has made a great deal of progress through the Millennium Development Goals (MDGs) to improve the health and well-being of people around the globe, but there remains a long way to go. Here we provide reflections on Rwanda’s experience in working to meet the health-related targets of the MDGs. This experience has informed our proposal of five guiding principles that may be useful for countries to consider as the world sets and moves forward with the post-2015 development agenda. These include: 1) advancing concrete and meaningful equity agendas that drive the post-2015 goals; 2) ensuring that goals to meet Universal Health Coverage (UHC) incorporate real efforts to focus on improving quality and not only quantity of care; 3) bolstering education and the internal research capacity within countries so that they can improve local evidence-based policy-making; 4) promoting intersectoral collaboration to achieve goals, and 5) improving collaborations between multilateral agencies – that are helping to monitor and evaluate progress towards the goals that are set – and the countries that are working to achieve improvements in health within their nation and across the world

Mutual health insurance and its contribution to improving child health in Rwanda

Rwanda is among the few countries in Sub-Saharan Africa and the developing approaching universal health insurance coverage. To date, over 90 per cent of the population are enrolled in the Mutuelles de Santé - a system that started off from a number of stand-alone community based health insurance schemes and gradually evolved into a unified social health insurance plan. The country has also made remarkable progress in ameliorating child health, particularly since 2005, which coincides with the year when the Mutuelles de Santé was standardised and raises the question to what extent the insurance scheme did contribute to the observed improvements. In order to address this issue we conduct a quantitative impact evaluation using nationally representative micro-data from the 2005 and 2010 Rwandan Demographic and Health Surveys (RDHSs) and also consider potential channels from which improvements could originate. Our results suggest the following: The Mutuelles de Santé improves access to preventative and curative health services. Insured households are more sensitive to health issues, in the sense that they are more inclined to use bed nets and ensure safe drinking water. Despite a weak effect on health outcomes overall, the insurance scheme seems to have contributed to improvements in stunting and mortality, at the critical ages (before the age of two)

Paying primary health care centers for performance in Rwanda

Paying for performance (P4P) provides financial incentives for providers to increase the use and quality of care. P4P can affect health care by providing incentives for providers to put more effort into specific activities, and by increasing the amount of resources available to finance the delivery of services. This paper evaluates the impact of P4P on the use and quality of prenatal, institutional delivery, and child preventive care using data produced from a prospective quasi-experimental evaluation nested into the national rollout of P4P in Rwanda. Treatment facilities were enrolled in the P4P scheme in 2006 and comparison facilities were enrolled two years later. The incentive effect is isolated from the resource effect by increasing comparison facilities'input-based budgets by the average P4P payments to the treatment facilities. The data were collected from 166 facilities and a random sample of 2158 households. P4P had a large and significant positive impact on institutional deliveries and preventive care visits by young children, and improved quality of prenatal care. The authors find no effect on the number of prenatal care visits or on immunization rates. P4P had the greatest effect on those services that had the highest payment rates and needed the lowest provider effort. P4P financial performance incentives can improve both the use of and the quality of health services. Because the analysis isolates the incentive effect from the resource effect in P4P, the results indicate that an equal amount of financial resources without the incentives would not have achieved the same gain in outcomes.Health Monitoring&Evaluation,Population Policies,Health Systems Development&Reform,Disease Control&Prevention,Adolescent Health

University of Global Health Equity’s Contribution to the Reduction of Education and Health Services Rationing

The inadequate supply of health workers and demand-side barriers due to clinical practice that heeds too little attention to cultural context are serious obstacles to achieving universal health coverage and the fulfillment of the human rights to health, especially for the poor and vulnerable living in remote rural areas. A number of strategies have been deployed to increase both the supply of healthcare workers and the demand for healthcare services. However, more can be done to improve service delivery as well as mitigate the geographic inequalities that exist in this field. To contribute to overcoming these barriers and increasing access to health services, especially for the most vulnerable, Partners In Health (PIH), a US non-governmental organization specializing in equitable health service delivery, has created the University of Global Health Equity (UGHE) in a remote rural district of Rwanda. The act of building this university in such a rural setting signals a commitment to create opportunities where there have traditionally been few. Furthermore, through its state-of-the-art educational approach in a rural setting and its focus on cultural competency, UGHE is contributing to progress in the quest for equitable access to quality health services

Shared Learning in an Interconnected World: Innovations to Advance Global Health Equity

The notion of reverse innovation --that some insights from low-income countries might offer transferable lessons for wealthier contexts--is increasingly common in the global health and business strategy literature. Yet the perspectives of researchers and policymakers in settings where these innovations are developed have been largely absent from the discussion to date. In this Commentary, we present examples of programmatic, technological, and research-based innovations from Rwanda, and offer reflections on how the global health community might leverage innovative partnerships for shared learning and improved health outcomes in all countries

We Need Compassionate Leadership Management Based on Evidence to Defeat COVID-19

The current pandemic of coronavirus disease 2019 (COVID-19) has had unprecedented reach and shown the need for strong, compassionate and evidence-based decisions to effectively stop the spread of the disease and save lives. While aggressive in its response, Rwanda prioritized the lives of its people – a human right that some governments forget to focus on. The country took significant steps, before the first case and to limit the spread of the disease, rolled out a complete nationwide lockdown within one week of the first confirmed case, while also providing social support to vulnerable populations. This pandemic highlights the need for leaders to be educated on implementation science principles to be able to make evidence-based decisions through a multi-sectoral, integrated response, with consideration for contextual factors that affect implementation. This approach is critical in developing appropriate preparedness and response strategies and save lives during the current threat and those to come

Convergence of Mortality Rates among Patients on Antiretroviral Therapy in South Africa and North America

Agnes Binagwaho and colleagues explore the narrowing gap between South African and North American cohorts in survival on HIV treatment, described in the study by Andrew Boulle and colleagues. Please see later in the article for the Editors' Summar

The Role of Social Capital in Successful Adherence to Antiretroviral Therapy in Africa

Agnes Binagwaho and Niloo Ratnayake discuss the implications of a new ethnographic study that explores the reasons for the high rates of adherence to antiretroviral medicines in Africa

The Future of Global Health Education: Training for Equity in Global Health

Background: Among academic institutions in the United States, interest in global health has grown substantially: by the number of students seeking global health opportunities at all stages of training, and by the increase in institutional partnerships and newly established centers, institutes, and initiatives to house global health programs at undergraduate, public health and medical schools. Witnessing this remarkable growth should compel health educators to question whether the training and guidance that we provide to students today is appropriate, and whether it will be applicable in the next decade and beyond. Given that “global health” did not exist as an academic discipline in the United States 20 years ago, what can we expect it will look like 20 years from now and how can we prepare for that future? Discussion: Most clinicians and trainees today recognize the importance of true partnership and capacity building in both directions for successful international collaborations. The challenge is in the execution of these practices. There are projects around the world where this is occurring and equitable partnerships have been established. Based on our experience and observations of the current landscape of academic global health, we share a perspective on principles of engagement, highlighting instances where partnerships have thrived, and examples of where we, as a global community, have fallen short. Conclusions: As the world moves beyond the charity model of global health (and its colonial roots), it is evident that the issue underlying ethical global health practice is partnership and the pursuit of health equity. Thus, achieving equity in global health education and practice ought to be central to our mission as educators and advisors when preparing trainees for careers in this field. Seeking to eliminate health inequities wherever they are ingrained will reveal the injustices around the globe and in our own cities and towns