Comment
A call for international accountability—preserving hope amid false protection Today’s struggle to control the Ebola outbreak in west Africa is a reminder that trust within health systems is absolutely crucial to fight disease—not only locally, but also globally. We describe Rwanda’s experience with a breakdown of communication, accountability, and trust that threatened the great strides in malaria control made over the past decade. Rwanda has formalised a series of national strategic plans since 2005, all of which rely on evidence-based methods to combat the burden of malaria. A key component of this arsenal includes a commitment to achieve universal coverage of long-lasting insecticidetreated bednets, especially for the most vulnerable people (eg, pregnant women and children under 5 years of age).3 Coupled with robust policies on health-system strengthening, these plans have achieved dramatic reductions in malaria morbidity and mortality.2,3 Yet, Rwanda witnessed an unprecedented rise in malaria cases in 2012 (table). Rwanda’s Ministry of Health responded in accordance with its national strategic plan and with means approved by WHO. Millions of additional WHO-recommended long-lasting insecticide-treated bednets were distributed in districts with a high burden of malaria and to all children younger than 5 years of age. Unfortunately, unlike during previous upsurges, the number of malaria cases continued to rise, despite these efforts. The predictable reasons for this rise, such as the expansion of water bodies for rice cultivation, climatic anomalies, and increase in insecticide resistance,5,6 could not fully explain the sharp rise in malaria cases after these interventions, so Rwanda’s Ministry of Health actively investigated the issue. Results of national laboratory analyses completed in September, 2013, revealed that the distributed insecticide-treated bednets were impregnated with suboptimum concentrations of insecticide and thereby failed to meet WHO-required bioefficacy standards for prequalification.7 These results were later confirmed by the US Centers for Disease Control and Prevention.8 On learning of the substandard product, Rwanda’s Ministry of Health removed the bednets from circulation nationwide and had to identify an alternative www.thelancet.com/lancetgh Vol 3 April 2015
course of action to protect its people. Although even fully operational and effective bednets alone could not have prevented the rise in malaria, the ineffective product only exacerbated the challenging situation. To have invested in the purchase and distribution of a substandard product, only to have to subsequently remove it, was not only a waste of money but also of precious time that could have been devoted to other crucial development priorities. In October, 2013, 1 month after Rwanda had recalled and replaced the substandard bednets, Member States received notification8 from the WHO Pesticide Evaluation Scheme that this particular brand of bednets were no longer recommended for use, owing to their substandard performance in trials7 of their efficacy against malaria. Of particular concern, however, was that this recommendation had been made in July, 2013, nearly 4 months before Rwanda and several other countries were notified of these findings by WHO.7 Such an unnecessary delay serves as a sobering reminder that we must expect and demand greater international accountability in the global health arena. It is alarming that WHO did not alert Member States sooner, so that health authorities could make expedient and informed decisions to protect their people from malaria. Withholding information about substandard products erodes trust in the international normative agencies that are supposed to protect the interests and rights of vulnerable people. Moreover, concerns about the influence of non-state actors (eg, business interests) on international agencies are not alleviated by these types of incidents.9 Erosion of trust and perception of bureaucratic inefficiency might translate into budget shortfalls for entities such as the WHO, which would hamper its ability to manage global health challenges, such as the Ebola crisis, in the present and
Malaria cases Deaths due to malaria
Published Online February 24, 2015 http://dx.doi.org/10.1016/ S2214-109X(15)70014-8
2011
2012
2013
2014 (as of October)
208 498
481 868
934 484
1 081 028
380
459
412
352
Source: Rwanda Biomedical Center, Ministry of Health, 2014
Table: Malaria burden in Rwanda, by year
e188
Comment
the future. Profound reform, especially with respect to accountability, is needed of such an institution. Indeed, accountability is a two-way street. Too often, however, the emphasis on international accountability is directed unilaterally at aid recipients. Indeed, Member States and their leaders, politicians, programme managers, and health-care providers should be held accountable for being good stewards of limited funds and providing high-quality services to recipient populations. At the same time, international normative organisations should be expected to provide timely and accurate responses in alignment with their mission to improve health. International businesses should be liable for selling substandard health products when such negligence can have deleterious health consequences. When products for prevention of lethal diseases, such as malaria, are compromised, epidemics spread unnecessarily, and progress towards development can be halted. At the very least, international normative agencies should respond by coordinating themselves to develop coherent policies and regulations that can assist Member States to fulfil their duties and to ensure that private interests do not put lives unnecessarily at risk. Failing to do so comes at a cost, not only to health but also to the trust we place in these organisations to serve as partners in a quest to combat complex and challenging roots of human suffering.
e189
*Agnes Binagwaho, Corine Karema Ministry of Health, Kigali, Rwanda (AB); Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA 02115, USA (AB); Geisel School of Medicine, Dartmouth College, Hanover, NH, USA (AB); and Malaria and Other Parasitic Diseases Division, Rwanda Biomedical Center, Ministry of Health, Kigali, Rwanda (CK) [email protected] AB is Minister of Health for Rwanda. We declare no competing interests. Copyright © Binagwaho et al. Open access article published under the terms of CC BY-NC-ND. 1 2 3
4
5 6
7
8 9
Binagwaho A, Farmer PE, Nsanzimana S, et al. Rwanda 20 years on: investing in life. Lancet 2014; 384: 371–75. Farmer PE, Nutt CT, Wagner CM, et al. Reduced premature mortality in Rwanda: lessons from success. BMJ 2013; 346: f65. Karema C, Aregawi MW, Rukundo A, et al. Trends in malaria cases, hospital admissions and deaths following scale-up of anti-malarial interventions, 2000–2010, Rwanda. Malar 2012; 11: 236. Malaria and Other Parasitic Diseases Division (MAL & OPD Division-RBC, Rwanda) and ICF International. Rwanda Malaria Indicator Survey 2013. Rockville, MD: MAL & OPD Division-RBC and ICF International, 2014. http://www.dhsprogram.com/publications/publication-MIS16-MIS-FinalReports.cfm (accessed Dec 14, 2014). Ochomo E, Bayoh NM, Kamau L, et al. Pyrethroid susceptibility of malaria vectors in four Districts of western Kenya. Parasit Vectors 2014; 7: 310. Toé KH, Jones CM, N’Fale S, Ismail HM, Dabiré RK, Ranson H. Increased pyrethroid resistance in malaria vectors and decreased bed net effectiveness, Burkina Faso. Emerg Infect Dis 2014; 20: 1691–96. WHO. Report of the sixteenth WHOPES Working Group meeting. Geneva: World Health Organization, 2013. http://apps.who.int/iris/ bitstream/10665/90976/1/9789241506304_eng.pdf. Ministry of Health, Rwanda. MOH Reports. http://moh.gov.rw/index. php?id=99 (accessed Dec 21, 2014). Hawkes N. “Irrelevant” WHO outpaced by younger rivals. BMJ 2011; 343: d5012.
www.thelancet.com/lancetgh Vol 3 April 2015
A call for international accountability—preserving hope amid false protection Today’s struggle to control the Ebola outbreak in west Africa is a reminder that trust within health systems is absolutely crucial to fight disease—not only locally, but also globally. We describe Rwanda’s experience with a breakdown of communication, accountability, and trust that threatened the great strides in malaria control made over the past decade. Rwanda has formalised a series of national strategic plans since 2005, all of which rely on evidence-based methods to combat the burden of malaria. A key component of this arsenal includes a commitment to achieve universal coverage of long-lasting insecticidetreated bednets, especially for the most vulnerable people (eg, pregnant women and children under 5 years of age).3 Coupled with robust policies on health-system strengthening, these plans have achieved dramatic reductions in malaria morbidity and mortality.2,3 Yet, Rwanda witnessed an unprecedented rise in malaria cases in 2012 (table). Rwanda’s Ministry of Health responded in accordance with its national strategic plan and with means approved by WHO. Millions of additional WHO-recommended long-lasting insecticide-treated bednets were distributed in districts with a high burden of malaria and to all children younger than 5 years of age. Unfortunately, unlike during previous upsurges, the number of malaria cases continued to rise, despite these efforts. The predictable reasons for this rise, such as the expansion of water bodies for rice cultivation, climatic anomalies, and increase in insecticide resistance,5,6 could not fully explain the sharp rise in malaria cases after these interventions, so Rwanda’s Ministry of Health actively investigated the issue. Results of national laboratory analyses completed in September, 2013, revealed that the distributed insecticide-treated bednets were impregnated with suboptimum concentrations of insecticide and thereby failed to meet WHO-required bioefficacy standards for prequalification.7 These results were later confirmed by the US Centers for Disease Control and Prevention.8 On learning of the substandard product, Rwanda’s Ministry of Health removed the bednets from circulation nationwide and had to identify an alternative www.thelancet.com/lancetgh Vol 3 April 2015
course of action to protect its people. Although even fully operational and effective bednets alone could not have prevented the rise in malaria, the ineffective product only exacerbated the challenging situation. To have invested in the purchase and distribution of a substandard product, only to have to subsequently remove it, was not only a waste of money but also of precious time that could have been devoted to other crucial development priorities. In October, 2013, 1 month after Rwanda had recalled and replaced the substandard bednets, Member States received notification8 from the WHO Pesticide Evaluation Scheme that this particular brand of bednets were no longer recommended for use, owing to their substandard performance in trials7 of their efficacy against malaria. Of particular concern, however, was that this recommendation had been made in July, 2013, nearly 4 months before Rwanda and several other countries were notified of these findings by WHO.7 Such an unnecessary delay serves as a sobering reminder that we must expect and demand greater international accountability in the global health arena. It is alarming that WHO did not alert Member States sooner, so that health authorities could make expedient and informed decisions to protect their people from malaria. Withholding information about substandard products erodes trust in the international normative agencies that are supposed to protect the interests and rights of vulnerable people. Moreover, concerns about the influence of non-state actors (eg, business interests) on international agencies are not alleviated by these types of incidents.9 Erosion of trust and perception of bureaucratic inefficiency might translate into budget shortfalls for entities such as the WHO, which would hamper its ability to manage global health challenges, such as the Ebola crisis, in the present and
Malaria cases Deaths due to malaria
Published Online February 24, 2015 http://dx.doi.org/10.1016/ S2214-109X(15)70014-8
2011
2012
2013
2014 (as of October)
208 498
481 868
934 484
1 081 028
380
459
412
352
Source: Rwanda Biomedical Center, Ministry of Health, 2014
Table: Malaria burden in Rwanda, by year
e188
Comment
the future. Profound reform, especially with respect to accountability, is needed of such an institution. Indeed, accountability is a two-way street. Too often, however, the emphasis on international accountability is directed unilaterally at aid recipients. Indeed, Member States and their leaders, politicians, programme managers, and health-care providers should be held accountable for being good stewards of limited funds and providing high-quality services to recipient populations. At the same time, international normative organisations should be expected to provide timely and accurate responses in alignment with their mission to improve health. International businesses should be liable for selling substandard health products when such negligence can have deleterious health consequences. When products for prevention of lethal diseases, such as malaria, are compromised, epidemics spread unnecessarily, and progress towards development can be halted. At the very least, international normative agencies should respond by coordinating themselves to develop coherent policies and regulations that can assist Member States to fulfil their duties and to ensure that private interests do not put lives unnecessarily at risk. Failing to do so comes at a cost, not only to health but also to the trust we place in these organisations to serve as partners in a quest to combat complex and challenging roots of human suffering.
e189
*Agnes Binagwaho, Corine Karema Ministry of Health, Kigali, Rwanda (AB); Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA 02115, USA (AB); Geisel School of Medicine, Dartmouth College, Hanover, NH, USA (AB); and Malaria and Other Parasitic Diseases Division, Rwanda Biomedical Center, Ministry of Health, Kigali, Rwanda (CK) [email protected] AB is Minister of Health for Rwanda. We declare no competing interests. Copyright © Binagwaho et al. Open access article published under the terms of CC BY-NC-ND. 1 2 3
4
5 6
7
8 9
Binagwaho A, Farmer PE, Nsanzimana S, et al. Rwanda 20 years on: investing in life. Lancet 2014; 384: 371–75. Farmer PE, Nutt CT, Wagner CM, et al. Reduced premature mortality in Rwanda: lessons from success. BMJ 2013; 346: f65. Karema C, Aregawi MW, Rukundo A, et al. Trends in malaria cases, hospital admissions and deaths following scale-up of anti-malarial interventions, 2000–2010, Rwanda. Malar 2012; 11: 236. Malaria and Other Parasitic Diseases Division (MAL & OPD Division-RBC, Rwanda) and ICF International. Rwanda Malaria Indicator Survey 2013. Rockville, MD: MAL & OPD Division-RBC and ICF International, 2014. http://www.dhsprogram.com/publications/publication-MIS16-MIS-FinalReports.cfm (accessed Dec 14, 2014). Ochomo E, Bayoh NM, Kamau L, et al. Pyrethroid susceptibility of malaria vectors in four Districts of western Kenya. Parasit Vectors 2014; 7: 310. Toé KH, Jones CM, N’Fale S, Ismail HM, Dabiré RK, Ranson H. Increased pyrethroid resistance in malaria vectors and decreased bed net effectiveness, Burkina Faso. Emerg Infect Dis 2014; 20: 1691–96. WHO. Report of the sixteenth WHOPES Working Group meeting. Geneva: World Health Organization, 2013. http://apps.who.int/iris/ bitstream/10665/90976/1/9789241506304_eng.pdf. Ministry of Health, Rwanda. MOH Reports. http://moh.gov.rw/index. php?id=99 (accessed Dec 21, 2014). Hawkes N. “Irrelevant” WHO outpaced by younger rivals. BMJ 2011; 343: d5012.
www.thelancet.com/lancetgh Vol 3 April 2015
