Rwanda's Bold Focus on Cancer Starts With HPV

A recent WHO assessment of Rwanda's capacity to address non-communicable diseases (NCDs) found that country failed on every measure.
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A recent WHO assessment of Rwanda's capacity to address non-communicable diseases (NCDs) found that country failed on every measure. Except for having a branch in the Ministry of Health that addresses NCDs. In between the lines of the assessment, and captured within the Ministry of Health, is a major push by Rwanda to take on cancer.

The Rwandan Ministry of Health is implementing preventative structures to reduce the incidence of cancer. For women, that means improving access to breast cancer screenings and a national HPV plan. Cancer is responsible for 5 percent of deaths in Rwanda each year. As a point of comparison, cancer accounts for 23 percent of all deaths in the United States.

Major Development Gains

Rwanda has experienced a relatively rapid growth rate over the past few years. It was revealed earlier this year that 16 of 20 surveyed African countries by World Bank researchers are experiencing falling child mortality rates that are equal to or greater that what is set of the Millennium Development Goals. Rwanda's 8 percent annual reduction stands at twice the rate of what is needed.

The gains are not limited to health. Roughly one million Rwandans are no longer living in poverty. The gains are a testament to the government, said Paul Collier, director of the Center for the Study of African Economies at Oxford University, at the time. "Basically, [President Paul] Kagame built a culture of performance at the top of the civil service. Ministers were well paid, but set targets. If they missed the targets there were consequences," said Collier to the LA Times. "Each year, the government holds a whole-of-government retreat where these performances are reviewed: good performance rewarded, and poor performers required to explain themselves."

All Eyes on NCDs

One of the focal points during the U.N.'s annual general assembly (UNGA) in September of 2011 was the rising global burden of NCDs. A resolution adopted by the General Assembly recognized the global problem and urged governments to work together, with donors and the WHO to support measures that will prevent and treat NCDs.

"Addressing NCDs is critical for global public health, but it will also be good for the economy; for the environment; for the global public good in the broadest sense," said U.N. Secretary General Ban ki-Moon in his remarks to the UNGA in 2011. If we come together to tackle NCDs, we can do more than heal individuals -- we can safeguard our very future."

"According to the World Health Organization, deaths from NCDs will increase by 17 percent in the next decade. In Africa, that number will jump by 24 percent," said Ban. The burden of NCDs will increase in low income countries like Rwanda as development gains eliminate avoidable child and maternal deaths.

Tackling HPV

HPV is almost entirely responsible for cases of cervical cancer. The three shots during adolescence will provide protection against HPV and all but eliminate the chances of developing cervical cancer when they get older.

"We are a government that is evidenced based and result oriented," asserted Minister of Health Dr. Agnes Bingawaho. That is why Rwanda implemented one of the first widespread HPV vaccination campaigns for young girls in a low-income country.

For Rwanda's older population, health clinics will undertake systematic screenings of women between the ages of 35 and 45 years old for cervical cancer. The solutions dominated approach has shaped the Rwandan cervical cancer program and the way that it developed. Bingawaho explained, "We always go for a policy first - the science in front of everything. We develop a strategy plan, followed by an implementation plan and then fundraise."

Rwanda began working with pharmaceutical giant Merck as far back as 2009 to develop a partnership that led to the signing of a three year memorandum of understanding in December 2010 to provide the vaccine at no cost. A paper authored by Dr. Bingawaho covered the rollout of the vaccines for over 90,000 schoolgirls in April 2011. The researcher report over 90 percent coverage for all three vaccine rounds.

The authors answered questions regarding the allocation of resources towards the campaign by making a rights-based argument for vaccinating against HPV. They write, "High-level leaders are committed to ensuring the long-term integration of a rights-based cervical cancer prevention, care and treatment programme into the basic package of health services." Prices will continue to fall, argue the authors, as more countries follow the lead of Rwanda and implement HPV vaccination campaigns.

Merck announced in June of 2011 that it would provide the GAVI Alliance, a global organization dedicated to improving access to vaccines, its HPV vaccine at two-thirds its market price of $15. GAVI followed up in November by officially announcing its intention to support that introduction of HPV vaccines in developing countries with the goal of vaccinating as many as 2 million girls in nine countries by 2015. "The HPV vaccine in particular is critical to women and girls in poorer countries because they usually do not have access to screening to detect cervical cancer and treatment available in richer nations," said GAVI Alliance CEO Dr Seth Berkley in announcing the organization's goals.

The Ministry of Health relies heavily upon community health workers to reach its citizens. Dr Bingawaho considers them to be the 'echo' of the ministry and an integral connection point to communities. There are three community health workers per village and they are selected by the village members. Doing so, explained Dr Bingawaho, engenders greater trust. That in turn leads to better health outcomes. "When people are given the opportunity to have better health, they are very responsive," she said.

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