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The health science missing in Rwanda, South Africa

The next step for how science can boost healthcare in Africa is ‘implementation science’ — working out how best to apply research findings and provide services — according to Rwanda’s former Minister of Health and a senior policymaker in the South African government.

To find out more, Scidev.Net caught up with Rwanda’s Agnes Binagwaho, and Melvyn Freeman, head of the non-communicable diseases branch at South Africa’s Department of Health, who have both put forward their ideas during residencies at the Rockefeller Foundation Bellagio Centre in Italy. 

Agnes Binagwaho: ‘The science of implementation is neglected’

Agnes Binagwaho is a paediatrician and Rwanda’s former Minister of Health, widely credited with transforming the country’s health system during a five-year term that ended in the summer of 2016.

She implemented a set of measures, such as universal health insurance and networks of community workers, which added up to a system bringing impressive gains in indicators from AIDS life expectancy to malaria treatment rates.

Binagwaho spoke to SciDev.Net this month in Kigali, where she is now vice-chancellor at the University of Global Health Equity, about the role of science and technology in bringing about the transformation.

How has science helped transform the health sector in Rwanda?

Health is a key pillar of the Rwandan government’s Vision 2020 strategy for economic development and poverty reduction. Science has helped in many ways. Research helps prevent diseases. Rwanda is using technology to help improve the capacity of health service providers. We adopt telemedicine.

There is also the science of service delivery, which is how to make sure you can reach a person more efficiently, with more efficacy. This is what we call implementation sciences — the way you provide services for more equity, for making the most out of your actions, to make sure you don’t leave anybody behind, make sure you extend treatment to even people with financial difficulties, or geographical difficulties to reach you.

To reach the country’s poorest, the Ministry of Health trained 45,000 community health workers, sending them into the homes of people who often don't receive care. It has given community workers cell phones that allowed patients to contact doctors through social media platforms.

What is behind Rwanda’s success in using evidence and technology?

Rwanda has achieved a lot as a team, and the community workers have achieved a lot — because these are the people who sensitise the families.

What we have applied in Rwanda, and I had the chance to accomplish, is doing everything with an evidence base — knowing your objectives, what is the disease, what are the causes of the disease — so that you don’t waste money treating something you don’t know.

You can also make things sustainable by working with civil society. This is something we have done very successfully, starting with the fight against HIV. It’s very important that we give the message about the disease across the country, and there are NGOs everywhere.

I think the best thing we have achieved is this kind of organizational structure, where the country uses community leaders, civil society, women’s groups, and youth organisations as a vehicle to deliver medical services to people in every corner. This structural agenda for the common good has been successful.

Where does science now need to have more input in shaping health policy?

Where science should be is in education — better education, to prepare health professionals at all levels to deliver care with quality but also with another mind set. Health professionals are sometimes at a distance from their patients, yet patients want to feel confident to speak about their problems.

Science should not only take care of bacteria, the disease; it should also be applied in a holistic manner about the patients. The technology is now available and should be used more so that people you are treating get educated about the diseases affecting them.

Where science can do better is the prevention of the disease. A good example is the cook stove, where the woman and the child inhale the smoke. We have modern cook stoves that can help reduce the risk.

Science also [comes into] finance and the science of implementation, which is neglected. If there is strategic thinking, and the principle of implementation of science, you provide more services using the same money and with more benefits for patients.

Melvyn Freeman: ‘We need research to cope with the information we’ve got’

At the same Bellagio residency, a health official from a different African nation, grappling with a different set of challenges was, in fact, coming to similar conclusions.

Melvyn Freeman heads the non-communicable diseases branch of South Africa’s Department of Health. Three decades of experience have helped him formulate what he believes is a crucial question: “If you are looking at improving the mental health of a population or group, where do you invest your money to have the best outcomes?”

SciDev.Net spoke with Freeman in Pretoria about the role of research in finding answers to some of these difficult questions.

In which areas do you think science and research can play a role in shaping mental health policies? 

There are many kinds of sciences. Let me give you just one example [that relates to the question of] where do we invest. [At Bellagio] I actually came out with an answer of saying, well, unless we have such severe social determinants undermining what we want to do, like apartheid, investing in mental health is critically important — because research shows interventions do change behaviour and are workable solutions.

I also found research which shows that investing in mental health is actually good for development; that your outcomes are favourable for your investment. Some research recently showed that when you are dealing with depression in particular, for every dollar invested, your return on it is four dollars. So you say, no brainer — invest in your mental health services.

What are some successes and challenges in using evidence?

There are many examples of where science is informing policy in mental health. Let me give you one from a health systems perspective.

Many people who have mental health problems also have other health problems — there is strong co-relationship between chronic diseases and mental health, HIV and mental health, substance abuse and so on. Now, mental health is [often] regarded as something quite different from other health areas. This has led to quite a lot of stigma — because people must go to that clinic over there, and everybody knows that they have mental health problems because they are standing in that queue. Then they must come one day for mental health problems and the next day for diabetes, the next day for HIV. We have been doing quite a bit of science to determine the extent to which one can integrate mental health within primary care. We are now using that evidence to change the way we do it in South Africa.

In another programme within South Africa, they have trained lay people — not people with a lot of experience in mental health — to do basic counselling at relatively cheap cost. Research shows that the outcomes are actually very positive.

Are there areas where scientific input is still missing?

Well, we have more research than we can cope with. I think we need research to help us to cope with the information that we’ve got. And that is very important — it’s a different kind of research, what one might call implementation research or translational research. We probably need more of that because the services are lagging quite a lot behind the research.

But this doesn’t mean we don’t need all the different kinds of research. We need to start looking at every aspect of treatment, of care, of human rights, of social determinants — and then we got to be wise.

What are some successes and challenges in using evidence?

There are many examples of where science is informing policy in mental health. Let me give you one from a health systems perspective.

Many people who have mental health problems also have other health problems — there is strong co-relationship between chronic diseases and mental health, HIV and mental health, substance abuse and so on. Now, mental health is [often] regarded as something quite different from other health areas. This has led to quite a lot of stigma — because people must go to that clinic over there, and everybody knows that they have mental health problems because they are standing in that queue. Then they must come one day for mental health problems and the next day for diabetes, the next day for HIV. We have been doing quite a bit of science to determine the extent to which one can integrate mental health within primary care. We are now using that evidence to change the way we do it in South Africa.

In another programme within South Africa, they have trained lay people — not people with a lot of experience in mental health — to do basic counselling at relatively cheap cost. Research shows that the outcomes are actually very positive.

Are there areas where scientific input is still missing?

Well, we have more research than we can cope with. I think we need research to help us to cope with the information that we’ve got. And that is very important — it’s a different kind of research, what one might call implementation research or translational research. We probably need more of that because the services are lagging quite a lot behind the research.

But this doesn’t mean we don’t need all the different kinds of research. We need to start looking at every aspect of treatment, of care, of human rights, of social determinants — and then we got to be wise.