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2013 UCL Lancet Lecture by Dr Agnes Binagwaho: Charity does not rhyme with development


This evening I’m just going to introduce our
wonderful speaker, my friend and colleague Agnes Binagwaho. Put simply, she is Minister
of Health for the Republic of Rwanda. But Agnes is so much more than a Minister of Health.
So let me just explain why she is so much more, for a moment. First of all she’s a paediatrician
– it’s not very common to have medical doctors as ministers of health. It’s usually said
that that’s a bad thing. But I think there’s something the UK could learn from having someone
who actually knows about the subject as a Minister of Health [applause]. I think that–
I do think Nigel Crisps in the audience, that we really could turn the world upside and
learn a lot, actually, from what’s taking place in Rwanda right now. Agnes has had a
distinguished career in her country. She led the National AIDS Control Commission, she
was Permanent Secretary in the Ministry of Health and she has academic appointments at
both Harvard and Dartmouth College. And that’s where Agnes is even more unusual as a Minister
of Health, because she takes research and evidence seriously. That is why she is here
this evening. At the moment she’s serving on two commissions that we have running. She’s
serving on a commission of women in health and one on a commission on investing in health.
We had a meeting last year on the commission on women in health and it was held at another
university in London which I wouldn’t dare mention here, and we had a day or a couple
of days of discussion and Agnes was invited, and quite honestly, we didn’t think she would
come. She’s a Minister of Health, she has responsibilities elsewhere. And she came.
We thought, well, she’ll come for half an hour to an hour and then she must go and do
other things that her embassy will instruct her to do. In fact, she spent the entire day
with us, taking part vigorously in discussions about the direction that the commission should
go. She is a serious intellectual and she seriously engages with issues that matter,
and that’s another reason why she’s here this evening. In July, she invited us all to go
to Kigali for a meeting of the Commission on Investing in Heath, and we were here guests
there. And we witnessed firsthand a remarkable health transformation that’s taking place
in Rwanda. You’re all fully aware that next year is the 20th anniversary of the genocide
that took place in Rwanda during 1994. And quite literally, the country has had to be
built from every community upwards, almost from scratch. And in one of the first slides
that she showed of what she’s doing as Minister of Health, it was entitled, “Building a Health
System.” And that is what she and her incredible team have been doing. It’s a tough challenge
and there are many challenges still to go. But if you look at the various measures of
what’s taken place in Rwanda under her leadership, PMTCT, vaccination coverage, preventing malaria,
family planning and addressing the emerging epidemic of non-communicable diseases, she
is literally leading a health transformation, one that the rest of the world needs to pay
serious attention to. And she’s not just a one minister show! She is concerned about
building capacity in her country, and she has an amazing team that she has put together,
and one of the requirements for her team is that they all have to pursue postgraduate
studies in a particular discipline relevant to their role in the Ministry of Health. There’s
another thing we could learn from Rwanda in the way we construct our Ministry of Health!
It’s a real pleasure this evening to welcome Agnes Binagwaho, and her title already is
provocative: Charity Does not Rhyme with Development, Let’s Create a New Partnership: The Golden
Age for Global Health. Please welcome Agnes Binagwaho. [Extended applause.]
>>[Agnes Binagwaho] Good evening, everybody. So thank you for your kind words. It’s my
pleasure to be here. And why I’m in your commission is because I believe that history has to be
written. And article in the Lancet, or report in the Lancet, and many other journals, influences
politicians. And I want you to influence politicians in this part of the world to do better their
job. It will help us to do better our job. [Laughter.] So, but I am very humble to be
here this evening, and thank you, Richard, and Anthony Costello, to have invited me.
Thank you also to your great team, because I was really welcome and helped. Today it’s
a general title. I guess that the majority of you are in the health sector, isn’t it?
But what I’m going to tell you it’s about, it’s in general, because health is just a
piece of what concerns people. So I’m going of course to speak as a recipient of that
aid, and also as somebody who is running the health sector. Yes. So this Rwanda, I think
that you can Google it and have it, so I’m not going to spend many time on this. The
only thing I want you to see is that we have increased life expectancy, more than doubled
it. More than doubled it without really being more rich. The majority of our people still
live under one dollar, but they have access to health. Meaning, money is not everything.
In the– what I have to tell you also, money is not everything, and if it’s — I don’t
present you my country, I think that I have to say that I have a lot of respect to be
with you here today because as Richard says, less than 20 years ago, our country was totally
destroyed, devastated. Doctors had been killed, nurses too, because I want to tell you that
the genocide started by killing the intellectual so that they can not be a barrier between
that. So we had a country that was totally destroyed and the fact, if somebody had said
that 20 years ago we will be here talking about what we think the world should do with
a lot of experience to talk about it, it’s really not — it was really not probable.
So this is the money that went in the health sector. But if we want to talk about Africa
in general now, more than one trillion dollars — it’s a lot of zeroes, I don’t even know
how much it is — but more than one trillion dollars has been given, in general, to Africa,
for its development over the last 50 years. In health also, this is only for health. But
what we need to know is that the revenue per capita, people are more poor in parts of Africa
than they were 50 years ago. So what happened that this massive influence of aid didn’t
bear fruits in Africa? There is something to think about. There is something wrong,
because this money, guys, is your taxes. You are sweating for that, or if not yours because
you are young, but not everybody is young here. [Laughter.] It’s the money of your parents.
If it’s not producing revenue, better give that money to you so go to the pub Friday,
isn’t it? [Laughter.] So there is something we should think about: how come that this
money didn’t bear fruits? Too early. I want also to say something else: the majority of
the countries in Africa have a growth between five and eight percent. A ha! On the one hand,
a lot money and no result, and the other hand, those countries are growing. How come they
are growing with a little investment in economic development, because there is less money invested
in economic development than in health? But those countries are taking off whatever. There
is little investment, there is a good return. And in the other hand, people are becoming
poorer and poorer. Majority of African countries will not meet the MDGs, and the MDGs, what
we say in Rwanda, was not the ceiling; it was the floor. And they are not going to make
it. So, let’s talk about why this money didn’t work? And let’s talk about, if you invest
in Africa correctly, you have eight percent return systematically every year. Does your
bank give that return? [Laughter.] No?So it’s quite good. The majority of the money has
gone like this. This is a slide showing what happened in Tanzania. But for Rwanda, Kenya,
Uganda, Malawi, we have somebody from Malawi here, where are you? Is it correct? You recognise
your country? So this is the international-Africa way to do business in the health sector when
you talk about aid money, impossible to find your way. It became so fragmented that it
has no impact. Money is decided in London, Paris, Geneva, Washington, New York. Now it’s
starting in Beijing. But not in your capital, my capital, and the other capitals of Africa,
where the people are living. So there is no match with the real needs of the countries
and the amount of money that is coming. And if you have, let’s say, one million dollars
and you gave it to one person, one institution that is very good, to implement, they will
have a coordinator, this coordinator will have a house, a car, et cetera, but if you
gave that to this multitude of people, there is a multitude of coordinator, a multitude
of cars, a multitude of houses, and you end with 60% of the money your parents or yourself
are sweating for that make Toyota more rich, just to say a brand for a car, and what goes
in the ground for people like my friend Tom for people to come and implement in how to
save babies. What is remaining? If we are lucky, 40%. So there is a new way to do business
we have to think about. This also gives another problem because you have so many people that
are working for the same program and they all ask you to do the reports with all of
them having specific indicators that have been decided, again in New York, Geneva, et
cetera, and that has nothing to do with your real life. So in place of spending a lot of
hours to run programs or to give cash, we have to give a lot of reports, and we have
asked them, please, you are very intelligent people, you all go to great universities like
this one. Could you come together and have one framework we can discuss with? 2007, I
remember, December in Devon, all the people were dealing with monitoring and evaluation
in Pepfar, Global Fund, WHO and many other institutions I don’t even know, invited us
and we went in Devon, I remember. And they decided to go and talk together to come–because
PMCTC it’s a mother whose HIV-positive with a baby in her body and the virus should not
go to the baby. And for this we have a treatment that is very simple, it’s the same everywhere,
and the way to give it and the way to monitor how to give it should be simple. You agree
with me? Ah, no. [Laughter.] You and me are wrong. In London, it’s not the same than in
Washington. They are going to find an indicator that is not totally different because it’s
the same woman, but that is different because in this part of the world, they will say okay,
it’s the number of women HIV-positive that go to treatment clinic: another three, another
four, another going there is a mark of this. And you continue and you continue and you
have to fill those reports. And the poor nurse in the health centre with a queue of people
to treat have to fill this out, because if we don’t fill it, they will say “lack of accountability;
we don’t know what to do with our money”. Even if the baby is safe and we go and show
the baby, this baby is safe, it’s HIV-negative, “yes, but the mother; what was her mark?”
etc., etc. So with those types of fragmentation it’s impossible for country. We should make
a Masters in NGO Management. Are you ready to do that? It will help us a lot. Because
also, something, many of those who receive money got the money from the government, or
from foundation like Bill Gates Foundation, Rockefeller Foundation, Skoll Foundation here
in UK, SIF Foundation and those have also their own indicators. So there is the money
but we in Africa and up till the example of Rwanda, we also don’t know the amount of money
they receive. We know the targets we have to reach but we don’t know with how much.
And it’s not our business, but it’s still your money people have sweated for, because
even in Skoll Foundation there is somebody called “Skoll” one day who made a lot of money,
put it aside and said this will serve for the good health of the people but I guess
this one is dead, but the other one should inform us totally what is for Rwanda. It’s
another accountability area. We should know for how much you sweat for me. And so this
is a problem. The other issue, this is Google Map, is just to show you that poverty, HIV,
Malaria, infant death and we can continue all this, are linked. So if you really want
to tackle HIV, you should go for comprehensive development. That’s why I say what we think
here, what we are talking about, is really the overall development process, fighting
disease and fighting poverty have to go together. If we just come and give pills, we will never
end disease. We need education and that’s why we are ready to partner with you. We need
factories. We need to know how to do those pills. And this is the only sustainable way
to go. So talking about tackling all those disease, those infectious diseases and the
majority of causes of death, is to take a journey for education. So that’s why development,
aid doesn’t rhyme with charity because charity doesn’t rhyme with sustainability. If you
give me a coin because I’m starving today and I’m going to die maybe before tonight,
you don’t give me the capacity to eat tomorrow. And for an entire continent, we need the capacity
of dealing with this tomorrow. Who remembers that? Hmm? This is the Marshall Plan. A massive
aid given by the US to a portion of Europe to boost their development. And it works.
So that means we cannot say that we don’t know what to do. There were no conditionalities
of UK ladies number for the health clinic – not it’s not UK, sorry, German, hmm? There
were no measurements and et cetera, the measurement was economic growth. The money was given and
massively. The money was well used, and massively. And out of the taxes, with the industry were
put back together, the countries bought education, health, social protection, built roads to
go and get health, railway, bridge, diplomacy, universities, et cetera, et cetera. That’s
what we call now budgetary approach, in the language modern, because you know we have
to change language. This is something we have Peter Piot in this room. He was the head of
UNAIDS. He will tell you if every five years we don’t change names we feel old. [Laughter.]
So, but this mean that I give you money to boost your economy and I’m just asking you
to prove that your economy is working. And not what we– you know, when I started HIV/AIDS,
do you know how many indicators I was supposed to sign off? 800. 800. On everything. People
didn’t lose their time on that. So this was working, with this Marshall Plan, we should
see the quantity of health — it’s a good study — Germany has brought to their people
just through taxpayers generated domestic revenue. So I like this slide and it’s a good
point made last year. It’s done by a certain Sidney Harris. I emailed him and I said how
much I liked this slide. So in Rwanda, we managed to pull out of abject poverty one
million people in the last ten years. We have managed to create a community health insurance
that covers – we have universal coverage – and people are no longer dying with what we call
[unintelligible]. We have also universal access to HIV drugs, universal coverage of malaria
prevention with two bed nets per family. It’s not that every family has two bed nets but
on average there is two bed nights per family. We have decreased death due to HIV, due to
TB, due to malaria, all for more than 80%. Our cohort of people living with HIV/AIDS
have 90% survival with more than 60% virulent[?] depressed. Better than UK. Better than New
York. Better than Paris. How we
do that is because of the health sector we have. And why I put this, I like this, is
because first of all, seven years ago when I was going in conferences like this, people
were telling me propaganda. Propaganda, it’s politics, I’m a minister but I don’t do politics.
My president today, it was my first day in cabinet, I was there with six other new ministers,
he told us, ‘Don’t come and play politics. Go for results. You are there for the welfare
of our people. Just go and work and make the lives of people better.’ And when I was saying
that, I come back and people were saying propaganda. Now that the measurements have been done by
external bodies, not by us, people say, Oh it was true! My goodness! What is that miracle?
And unfortunately, and that’s why we need to partner, we are so few and people are working
so hard, we don’t have time to write. If we say from a country where malaria was the biggest
killer and now we are in the process of getting rid of it, how have we done it? Is it what
we did with our government? Is it the spray? Is it the prevention? Is it the mosquito net?
Is it, is it, is it? We didn’t measure, we just saved lives. We were in the emergency
period, now it’s more calm. We better study. This is the life expectancy at birth how we’d
claim, it claims with the revenue per capita, it’s another proof that what we do in health
totally depends on the socio-economic situation of the country. But it’s not enough because
we are not very far. Far from our target. Many people still have less than $400 per
year. So those gains don’t reflect money. And it’s another good thing to study. What
are the impacts of policies, what are the impacts of the financial plans? When many
countries want to know, and even ourselves, we would like to know. This is the Institute
of Health Metrics who have done it, London School and Washington University in Seattle.
And you can see in blue the nutritional deficiency over time. In the year ’90s beginning you
see that up to 2000, we were not good. It was still the consequences of the genocide,
infrastructure destroyed and people killed. And after that going down drastically. What
I want to tell you with this, it is that we can see by studying those figures where the
next problem is and we can start to work on it. As I told you, we have controlled HIV,
TB, malaria, digestive diseases etc. We have the kids – I don’t want here to say glory,
but as a paediatrician I like that feeling – we have the kids the best vaccinated on
earth. They have 11 vaccines. 90% have all those doses, of 11 vaccines. The six recommended
by WHO: diphtheria, tetanus, polio, etc. Meningitis, rotavirus, hepatitis, pneumococcal and HPV.
So we have already a decline in under five mortality, with the rotavirus and pneumococcal
[gestures that it is gone], malaria control is going to be better. You can see what emerged.
We’ll see emerging non-communicable disease. I don’t think I have that slide here. Yes,
we can see emerging is the same principle but for non-communicable disease, injuries
and neonatal condition. You see in the bottom, the neonatal deaths are going to have a bigger
proportion because their cause of death aren’t under control. It’s not that children will
die more, it’s just the proportion of death due to that will be more important. So we
are working on training our people, all along the chain of the care delivery, for this.
But if I’m going to a big meeting and I show them this, and I say if we want to be efficient
we continue to do what we do in TB, malaria, HIV, HPV, blah blah blah, but we should invest
a bit in neonatology. They look at this and we see how difficult it is working together.
They look at you like my goodness but okay it’s a paediatrician, it’s normal. But in
fact it’s the next programme. And you can see also those studies are talking a lot.
Can you see the proportion of mental health increasing? This is Rwanda. Where this was
a lot, in proportion, where people were dying more of infectious diseases. The epidemic
of suicide etc is something across the world, and when you don’t die of infectious diseases
– in any case we will die, the later is the best – but you see the proportion is increasing.
And this is what is done due to war. You can see that. So just to tell you that we need
to partner to study our setting. This is the Demographic and Health Survey. I can talk
about it because it’s not us who’s doing it. It’s Macro Atlanta, and it’s a partnership
with [unintelligible] and also it’s the slides that I like a lot. You know why? Because it
just tells me that I’m doing my job. [Laughter.] You know why? This is the rate of decrease
in child mortality. And you can see that the poorest have the biggest increase – these
are the highest. That means that opportunities are well spread among the rich and the poor.
And this is one of the reasons we are successful, because my target is not my grandchild. I
have a grandchild I love, I have to talk about her. [Laughter.] My target is the child of
the poorest woman in Rwanda. Because when she will be safe and the child will be safe,
that means all the other will be safe also. And this shows us that it works. This is a
national policy in Rwanda. Whatever you do, you have to tackle the most vulnerable. Tom,
you are visiting Rwanda every two weeks, tell them if I’m wrong. But by doing so, it’s so
easy because when you tackle the most vulnerable, the others are following. I’m going to tell
you, and also we had to twist the aid we had to reach that, because 2004, 2005, 2006, 2007,
we were using drastically the money for HIV because the money that was available was HIV,
TB and malaria, tried to say at that time that we want to save women. Nobody was listening.
The woman at that time was only the prostitute, at risk of HIV. Other women don’t exist. So
we have with HIV money, we have built a natal clinic, paediatric, capacity to do vaccination
and later on, money came and it was very efficient. And this is the result of that, because there
is no global fund for under 5s. There is none. And they are dying, a lot. There is no global
movement for neonataology, where the majority of deaths occur. I’m going to tell you another
story about aid. Mutuelle de sante, it’s our community health insurance. Mutuelle de sante,
how we take off in Rwanda: we take off with the support of The Global Fund. There were
very revolutionary people at Global Fund and we explained that it would strain the system,
they let us try, we won the grant. The grant was done His Excellency, the First Lady and
the Minister of Health. Me, I was internationally with a control commission. And we won the
grant. And we won the capacity to give health insurance to the one million poorest Rwandans.
So we did. And when the last poor saw that the poorest have better access than them to
care, they all rushed and pay their two dollars. Yeah! Without a lot of movement, because people
used to say, in Rwanda, people are on the line and do because it’s a dictatorship. [Tsking
noise.] Try to explain to people, you know, we are bad but we love you. We are very bad,
we are dictators, but we will keep you alive. We are bad and dictators, but we put you at
school. 96% of children are in school. Before the genocide, you know how many? The country
was producing only 3000 high-level educated people a year. For ten million people. Can
you imagine that? How many students you have in this university, Provost? How many students?
[Provost]>>27,000.>>[Agnes] Ah, can you imagine! Now the country produces still not
enough, but more than 100,000. And we have teachers, we try, we borrow teachers from
the US. We have 100 US teachers on ground for a year. They come on the condition they
do until the academic year. And you believe that people are going to hate such a government?
They say yes, but there is no dialogue. No, I think that the way we use the aid and make
it more efficient for the most vulnerable, this is the key, that I have transformed the
way we have success with the money. So when everybody was rushing to pay two dollars per
household, the rest were supported by a domestic fund. We just called a consultation and say
okay, we have this money from Global Fund for the poorest, this money from Domestic
Fund for what is missing, now if we want to give you more care, we need the two dollar
no longer per household, but per capita. Our partners say, are you crazy? They are too
poor! You know, those two dollars are the cost of one beer, isn’t it? I have a colleague
from around there. It’s the cost of one beer per capita. So we told them, it’s one beer
for capita. They will drink a beer. And of course, the women drink less than the men
so no problems, it’s good for everybody. We did so, but we had a position in this country
too. Many partners said no. People did it. They were very happy. And now let me tell
you, one thing you become addicted to is access to care. The more you access care, the more
care you want. Isn’t it? Did you see what happened in some of the countries called wealthy
where the consumption of care is almost you want to say ‘stop!’ because it’s too much.
Now that the people were used – you know in the beginning they haven’t got it and they
live with it – after that they had malaria, we treat malaria, they feel better. Now sometime
you have a pain without any reason, you take a paracetamol. And I say to them, listen,
now the more you are used to care the more you use care, the more you are addicted to
care and that is very good. But that means also you need to increase the contribution
and the premium. So in 2011 there was another big – that one took two years of consultation.
And we said, we are going to make people pay according to their revenue. And now people,
like me, pay $12 per capita of people in their house. People who are like my secretary, middle-class,
are paying $5 per capita. And people who are poor, 25% of the population, don’t pay at
all. Why do we pay their health insurance? You have 90% of the care supported. You pay
10%. For the people who don’t pay the premium, we decided to pay at point of care, even if
it’s a high transactional cost, because we want everybody to understand that care has
a cost. And we don’t want to go for free. We want people to understand that somebody
somewhere pays. So we receive the bill at point of care. But we have 92% of our people
that are covered. So this is the story of one aid that was efficient because it entered
totally in our view, and Global Fund is good for that. This is the child mortality decline,
you see that here it was again around the distribution of the health centre, but after
that you see the decline faster than ever, because even if we follow the natural curve,
we should be here. You see? So there is something that I don’t like. It’s when people say, oh
yes, you are good but it’s because everything was destroyed. You can invent a new Rwanda.
Don’t say that. It’s because, as Richard said, there is a lot of dedicated people that are
spending sleepless nights to try to find step by step what is the best move for reaching
even more. Because as my president have said, MDGs is not the ceiling; it is the floor.
But we want to show you that because there is another slide I didn’t bring because I
didn’t think I’d want to bore my friend Richard because we showed him that slide when he was
in Rwanda. If we look, the number of lives saved by investment per capita of aid in addition
to domestic funds, Rwanda is among the lowest. It’s the maximum results. Same for women lives
saved. Same for children. So there is something else that needs to be studied. This is my
health sector. And this slide shows you – it is exactly the same as this but it’s flat.
This is the central level, this is with referral hospital and the ministry and agency that
are working. This is the district hospital. We have 42 around the country. These are the
health centres. We have almost 500 around the country. And these are the villages. In
each village we have community health workers. In each health centre, we have nurses. Here
start the doctors. Here start the specialists. In reference and in the ministry, Richard
has said that all the staff have a Master’s. They have got it at work. They enter with
the degree and me, I challenge them and I say, I want you to have a Master’s, we will
find the money, we will pay it. Another way of good investment. And don’t believe that
the time they spend out of work is losing for me. They enter with the skills, they start
to work and they get this one, now they go for a PhD, wow. We are going to have the Ministry
of Health the most strong on health. Any tests change our way to do things because they know
what evidence-based means. They know what research means. They know why you don’t do
a policy because you feel like that today. [Laughter.] No no no no. It’s very important,
you know. If I talk with somebody who is totally for elderly people, I’ll do a policy for elderly
people. So we go with the real needs and studies. Evidence-based. That is what has brought that
for me. And at central level, up to here, district hospital, they are all doing a Master’s
or they have their Master’s. And here I have already more than 20 people running for a
PhD. And that’s still at work. I don’t let them come here. They can come to me, one month
etc., not more. You help them where they are. By doing so we have all along the system a
lot of quality data you cannot imagine. Rwanda is a very organised country. People are keeping
the data very well. From here to here. You talked to community health workers. Those
are people who don’t have, they just know how to read and write. You cannot imagine
how they run their business. And while I put that for aid, you see here, all the community
health workers, there are 45,000 – three per village. Two women, one man. One man and a
woman for common diseases. One man and a woman for following the maternal and child health.
They all have a phone. And when they have an alert, here, immediately an SMS. We capture
the SMS in the Ministry of Health, also the mobile emergency system, the ambulances get
it, and the people are served almost immediately. Before having that, and we did so with the
support of Global Fund, but it was a struggle because they don’t see how this brings health.
It has decreased by almost five, the death of women, because they were dying because
we were there too late. Now we know the messages come from here, here, there, and we follow
the ambulances and the ambulances come from somewhere here. Same for children. Here everybody
in the health centre has a computer and reports in the health information system all the epidemiology.
Same for this level and of course ourself. Now in the ministry, all ministries are reporting
to the prime minister. We no longer send paperwork. We can have paper, but we don’t – I always
say that we are one for cupboard saving. Isn’t it? It’s very good. And having this, we don’t
have more personnel. We still have only 600 doctors for eleven million people, ten million
point five. The number of specialists are very few, but it allows us to task shift and
to do remote supervision to ensure that the care is well done. When we start to do all
those things, HIV, TB, malaria, every time people were saying, “Not sustainable; don’t
go for that.” Three years ago we started HPV vaccine. The HPV vaccine was so high but Merck
was great to give us the vaccine for three years. Shall I say no? To save at least two
cohorts of future women, to save them from cervical cancer? They say yes but this population
doesn’t know that they have a cervix, how are they going to– ok, that’s true! So we
went and campaigned and we said to women, ‘this is a uterus, this is a cervix, and the
cancer blah blah.’ And they say, ‘Yes, but it’s not sustainable. What are they doing
to do after?’ We say we don’t care. We’ll find a solution after. We don’t lose that
opportunity. They say, they will never do it, it’s impossible; they will spoil your
name. They say to Merck. And Merck, at a certain point hesitated. I had to call very influential
former friends and say, ‘Before you were in administration, you were part of the civil
movement for IV aid to Africa.’ You remember that? You are too young guys, but it was a
fight. Peter, you remember? Saying that every African has the right to IVs. They say, not
sustainable. They don’t know how to read time. They will never follow the old prescription.
They are singers, dancers, not serious. They will spoil the global epidemic credit resistance
and we are going to be lost. Who remembers that period? Thanks to crazy people like Peter.
He says no, we go for that. And now in our continent adherence is better than here for
other reasons that are more linked to social cohesion. There is a nice study done that
showed that for HPV the fight was starting again. I advised you to read some – I think
it was published in the Lancet – saying that I was a criminal because I sell or sold – I
don’t know how you do that verb – I have given my young people to a pharmaceutical firm.
Can you imagine that? Do their people think about that when there are vaccinated people
here? You know, we vaccinate the entire cohort of girls age 11 because the demographic and
health survey shows us that first intercourse doesn’t start before 12. All the schools,
because we decided to do school-based, it was more easy for us, they say: it’s crazy,
we never do that at national level, how are they going to do? We just partnered with Minister
for Education, Minister of Local Government, the Minister of Internal Security. You know
why? Not because people are going to steal the vaccines. But just because these ministries
have a lot of power in everywhere in Rwanda, for the police. So we borrow their car. And
in three days our vaccine leaves Kigali, go in a truck, go in every school with the help
of the nurses here in health centres, they go in every school, they vaccinate the kids.
With the help of community health workers here, community health workers during those
three days watched the children that are not at school and proposed a vaccine at health
centres. 93% compliance for three doses across a year. And over the three years, more than
98% completion for the vaccine. This is another aid effectiveness, because it was not government
to government. It was a PPP: public-private partnership. And we didn’t tackle enough in
PPP. Now it has given me ideas and I’m going to dialogue with motorbike producer to create
ambulances at community level. You know why? Because for this telephone we are now in agreement
with Samsung to upgrade them so that the community health workers can follow and understand what
we do, what they do, their job, and compare with others. And it is so important to give
to the people the capacity to own their work. The capacity to understand what they do, so
that they are the actor of their own development and not only followers and people that only
execute. It changes everything. So there are the more also, there is something that creates
another addiction: results. Those people are incredible. They didn’t get salary in the
beginning. Now we are paying them on their performance with another type of aid that
is effective. It’s a grant we get from World Bank and we create all along the country little
businesses, so Ministry of Health has created little businesses, can you imagine that, little
businesses – four hundred and something, about that, for the community health workers. And
the result, the outcome, the profit of those businesses will allow us to pay them on a
regular basis. Investing in health by creating little businesses. You understand? Those community
health workers are so proud, isn’t it, Richard? They are so proud of their life. They have
created their own domain. They are serving the people, and what made them proud, they
are elected by the people in the village. And our job, the Ministry of Health, is just
to train those elected. Only terms of reference: to be elected, know how to write and read.
You know that we had a cholera epidemic in Rwanda? In a refugee camp? A true cholera
epidemic. I am very proud to say no deaths. No delay. Confinement, immediately. Why? Thanks
to the phone. And distribution of stuff to clean the etc, etc. Thanks to the community
health workers and the people all along the chain, thanks to ICT, the manager of health
sector, we have good communication immediately. From here we can send an SMS to 45,000 people.
One person here can alert us and we alert 45,000 people. So this is, let’s say, good
health investment. I don’t know how much time I still have. So when people are telling us
‘not sustainable,’ now we are laughing because if we say 1966, the word ‘sustainable’ was
pronounced, let’s say, less than 10,000 times a day. At the present day it’s a lot. In 2036
it will be in each pages. In that day, each sentence, and some time it will be only that.
Don’t laugh, you know. When we have a good idea and we sell it, it comes so often. So
what we say, the word ‘sustainable’ is according to some people, unsustainable. But when you
have a good idea, always go for it. Money is not the true barrier because if you can
prove after that the delivery of health is less expensive with your new idea, you should
go for that. It’s investing in health. Another thing, it’s not to please you, it’s because
it’s a big debate. We have, and that’s why we can partner, many people that are really
implementers, experts. And nobody listens to them. By travelling around the world, Richard
has done a very good piece of paper around it. Meaning, this part of the world should
listen more to what our part of the world has as needs. And also, how we see and we
envision to implement that. Don’t come with solutions that are already drafted. Also if
we have managed to have success, still there is a lot to do. Still there is too many dying
for preventable things. Still, we still need to educate far more people for the health
sector. But if we have managed that it’s because the coordination was strong. We have learned
with HIV. HIV has taught us three ones: one coordinating body, one action plan, one monitoring
and evaluation plan. One way to educate. So that everybody has the same protocols and
if somebody is sick in north, east, west, can be treated and go back home without discrepancy
in treatment. Many of our country, I don’t know how it is in my sister country Malawi,
but for many people that’s the issue. We try to have an understanding in east Africa for
HIV treatment. And procure together. We don’t have the same protocols. All the majority
of protocols bring the same effect. We just have to decide what is the best for all of
us. We know it but Geneva should listen more to all of us. And this was about – this is
another story about aid effectiveness. One day we received from Canada a call. We have
a dialysis machine, it was 2006, but Rwanda has to pay the shipment and we say oh dialysis
machine, portable, that’s genius because we have those people but we don’t have the money
to buy. So we pay the shipment. 18 machines. When we opened the container, you know what
was written? [Something on the slide.] That’s not a joke. They are still packed somewhere
in Kigali because to destroy them is too expensive. Yes, effectiveness of aid. So did that person
really know, because they contact our embassy in Canada, we agree to pay on tax of domestic
funds, and the thing out there is if you want to destroy them it’s too expensive so we,
Ministry of Health, don’t have the money, it’s too expensive. I try to sell them to
the veterans, because it’s for cows, dogs, but they laugh at me and they are still there.
It’s also an example that aid should really mean that you are supporting and going a step
forward. The rest is really criminal. It’s not a joke. We had to find a place because
they were packed in the vaccination institution compound and when we start to increase the
number of vaccines from six to seven, eight, nine, now eleven, there were no more places
so we scream in Kigali to say where to put them? So they are still there. I think we
should bring them in a museum of nonsense. This is to show what we can do together. There
are very good studies to do. So in red is the cost of IVs. In blue is the productivity
gain. In green is the cost averted to have orphans. And in purple it’s saving by delaying
end of life. So you can see with such a graph, I can go everywhere, I show you that invest
in IV brings economic growth and supports the development. Those are the types of studies
that are interesting. There is no time so I don’t know where I stand. It’s okay, not,
I’m going quickly. This is another thing. We can do good, even ourselves. We need to
document, I told you. This is another area. It has been documented that we do the work
but publications are elsewhere. The people about our job are publishing one thousand
more than us, about our jobs. About how we are sweating for inventing it. That’s what
I call intellectual prostitution. So this is something also we can work on together.
Of course, to do such a approach by listening, trust and do with us, we need a legal framework
as well as doing research in Rwanda then the way we manage. Because we cannot put the blame
on the developing world only, for not following what we agreed at an international level,
the way to proceed. We need a strong legal framework. A strong law of finance, also procurement,
also a manual of aid policy, so that everybody knows what to do and follow. And also a zero
tolerance for corruption. So also aid should really promote reverse elevation. There is
a lot we can invent and if I go to the community health workers and say this is the problem
we want to solve, how should you do that, they have a lot of ideas. That’s how we can
invent the way to implement or the way to do things or the way to do something else.
Don’t believe that global health doesn’t concern you and you just come and help us. You come
to me, I come to you, for us to have a good journey together for better health for the
world. Because if people, if diseases like that are spreading, you are not safe. We better
work on it when it starts to spread, because all the world is concerned. Also I told you,
health is fundamentally social, so it needs to be tackled as a – we need to tackle also
the social determinant of health. And if health is a human right, tackling the social determinant
is also in that category. I’m going to pass quickly on the example of MDR-TB. This is
the example of investing the money right to produce more health per dollar invested. And
I would like you to think about dealing with humanitarian as a business. Where do you put
your energy to produce the more health? Just to show you that more result and decline per
investment. Also it’s important to know that we manage that because we govern by cluster.
The social clusters are all those ministries. And when I decided to do something in the
health sector, I consult all my colleagues to see how we can work together. This is the
comprehensive governance. So we have this, the solution is ownership. It is equity. You
go for the more vulnerable. It is also science. You give evidence on what you are doing before
taking decisions. Participation: never do something without the other people concerned
as beneficiary or as implementers. And if we can have those principles applied to the
global – to the money that is outside for health, we will succeed. Those are the places
where the decisions have been made to respect countries. There was Rome, there was Paris
and after that we change continent. We went to Accra! Still, status quo. The burden of
this is still on the countries that have to report differently but HP+ plus never take
off. Accountability of donor country is very, very low. I want to show you that hospital,
it’s a hospital that was not sustainable because it was built in the middle of nowhere. [Laughter.]
And it’s a beautiful hospital. I just want to tell you, it doesn’t cost more to do beautiful
things than to do bullshit. [Beautiful.] It’s the same cost. But the difference is this:
and also, this now we are working to make it a medical campus. We are going to have
a new Faculty of Medicine, new faculty in the middle of nowhere. We create cities etc.,
of course there will be a market, and of course there will be a cinema, because students need
to relax, and also the teachers, etc. So build a school, etc. I am ending because I see that
my friend is nervous. I talk too much. [Laughter.] I’m very talkative. But I want to end on this,
because this is the philosophy. It’s from Martin Luther King Jr, and there is a word
that they told me how to pronounce but I’m sure I’m going to pronounce it badly. “True
compassion means more than – fledging? flading? – a coin to a beggar; it comes to see that
an edifice which produces beggars needs restructuring.” You can change now, by the international aid
and you have the solution. Thank you Martin Luther King. [Applause.]
>>[Richard] Now it wasn’t that I wanted to cut you off, it’s just that I know our audience
might want to ask you some questions because it’s not every day that you will be coming
here to UCL. So now the timetable was that we were going to finish at 7:00pm so that
you could go across and have a drink but I’m going to steal a little bit of that time unless
somebody waves violently at me from the back to give you a chance to make some points.
So let’s take three or four points from people from the audience.
>>[Agnes] Can I have a pen?>>[Richard] Oh yes.>>[Agnes] Thank you.>>[Richard] So,
who’d like to start? Yes please, and if you could say who you are. The microphone will
come and find you.>>[Audience member] Hello, I’m Jian Lee, studying
currently at the London School of Hygiene and Tropical Medicine, but I used to be part
of the charity community because I worked with World Vision for five years, and I deeply
sympathise and agree with crazy indicators, the fact that economic development is a sustainable
solution, but because there is always going to be some charity people who take sustainability
seriously, would you actually give suggestions or some good cases you’ve seen of NGOs, external
players, collaborating with community and government in making this development sustainable.
I think it would be wonderful to hear from you.
>>[Richard] That’s great. Let’s take a few comments. Yes please.
>>[Audience member] Hello, I’m Andrew Tompkins, and I work in this Institute. I think we’ve
been absolutely astounded to have such a clear vision of inspiration leadership and you’ve
shown what very, very strong and clear and excellent leadership gives and a health service
delivery like no other country. Could you say something about the other side of the
coin, which is the community. What movements were there within the community that possibly
contributed to the remarkable reduction in mortality? The reason I ask is that certainly
in Africa many other countries are looking not just at service delivery but they’re looking
at ways in which social development and community participation can make a big difference, and
it would be really helpful to have your comments on that. Thank you.
>>[Richard] Okay there are two comments down here. Man in the blue jumper and then the
gentleman behind in a scarf. And I’m looking for gender equity here.
>>[Audience member] Thank you very much. Michael Heinrich, School of Pharmacy. I’m the head
of Pharmocognosy. But a very different question: governance. i think the big challenge for
me after your talk is how can we develop a governance structure which facilitates all
this and finds the place between community and NGOs and governments where things went
grossly wrong in many cases.>>[Richard] Very good, thanks. Just behind
you.>>[Audience member] Hi, I’m Chekwe, I’m a
public health physician and I blog on Nigeria Health Watch. Quick question simply on leadership:
Every African here today we are exceptionally proud of your presentation, but a question:
what seems to be holding back your colleagues, ministers of other African countries in having
the same type of vision, inspiration and drive that you have demonstrated this evening. Simple
question on leadership.>>[Richard] That’s a great question, thank
you. Agnes, we’ll go to you on some of those.>>[Agnes] So this one is… so the first question
on NGOs. Madame or Mademoiselle. I think we need to be clear. In Rwanda the government
coordinates. The government should never implement. We implement when there is nobody to implement
correctly, because we need to go forwards. Our objective is to have nationally the capacity.
So NGOs international groups have a lot to do. But first of all, not to come into business
forever. Come and train Rwandan to do business forever. And also what we do, I think, if
we are here, we can learn to be here, with the NGOs. And when you are here, you learn
to be here, and so on. We’re always partners, and that’s how we have implemented the human
resourcefulness. It’s not that it was against NGOs, we want our society to come at the stage
we were. We want universities. So we implement the aid program ourself. We save some money
— we contract American universities because it’s American money, to come and teach our
people. You see? So we always need these civil societies but it’s different according to
the society. But I also want to remind that the systems are not created by NGOs. This
is a big mistake. People come to create a country – no. You are there to help people
to create their own country. Then it works. For the second question: it was about, I don’t
know, it was about what was the role of communities. Fantastic. There is something that makes us
all shivering, you know, because you believe that we are very popular. Uh uh. My merger
is given by my community. Every year they rate us, satisfaction, and this study is done
by local government and reported directly to parliament. If I can do the best, if the
people are not happy, they will put me in red. So that means whatever we do, we need
to explain. And we make them part of the things and don’t do that without them. I’m going
to give you an example. An African here will understand me. Normally, an African man thinks
about talking to a child when the child is reasonable. Isn’t it? That was the tradition.
It’s the tradition, before it was the matter of the woman. What came with PMCTC? When we
need the men to go and test for a baby he has even not seen? There is a lot of cultural
revolution in the health sector. It is the first time men in Africa are concerned with
the baby that is even not born. Going and giving his blood for something that have no
existence in our, we don’t consider traditionally, not now, now a pregnancy is considered as
a child. Just to say that community, don’t think that what I ask you to do is me. I can
do that with the community. For the other question, the governance, it’s very simple.
When people are corrupt, why do you give them money? Corruption has two hands: you give
me, I steal me, you have given me and you know, you are as guilt as me. So the traditional
way the north and the west give money to corrupt governments is what has killed us. And I say
to my colleagues, when you steal money, you damage my program because you remove trust
from the world and Africa. That is the other thing we have to say. Africa, for the majority
of people, is a black box, very damageable, full of microorganisms, dirty, etc. And that’s
true. You know. [Laughter.] You know, that’s true that you think so and that’s not true.
There is a lot of hope in Africa. I can give you an example. In the morning there is a
street full of black shit, some with blood etc. If it was in Africa none of you will
cross that corridor. Because it’s in London, you will just cross. The image of things have
a different signification according to the place of the world where we are. In Africa,
somebody serve you a glass like that, you don’t drink it because there is a lot of microbe,
was it clean, etc. Here, we just drink and we don’t ask question. Mindshift, guys. We
need to shift minds. So that’s what I want to say for the leadership. How to stop it,
stop fund it. Or ask accountability. Why you don’t ask accountability? And why my colleagues
are not like me? Many are like me, it’s just that I’m very talkative. [Laughter.] [Applause.]
>>[Richard] Okay, let me go back and ask for a few more. Yes please. The microphone will
find you.>>[Audience member] Yvonne Madesi from Malawi,
by the way of the University of Southampton, and thank you so much for a very interesting
presentation, and I really admired everything you said and I admire you very much, and I
echo what my Nigerian colleague said about how we wish we had more of you. But I was
interested in what you said about giving telephones to the community health workers and getting
them to actually learn what’s happening in other places. And I wondered about the power
of information for the communities and what role that plays. Does it help, for example,
in terms of accountability, but does it also help change mindsets in the ways they actually
deliver care and so on?>>[Richard] We’ll take another one. Joy…
>>[Audience member] Thank you so much Agnes. As a fellow African woman, I was born in the
bush of northern Uganda, I just collected the wrong skin. I think it’s fantastic not
just to see an African woman on the platform but to talk about the hope and the power and
the reality of Africa today, not what people often see, which is the Africa of previous
decades, and you’ve shown us that change can happen. But I particularly want to point back
to your slide about the burden of disease in Rwanda. And you highlighted the increasing
proportion of neonatal deaths. And what you said is what we hear from ministers all over
the world, that this is now our burden, and yet when they’re saying to donors, that isn’t
what the donors are funding. Donors are saying no we don’t do that. So I would like to hear
how you’ve answered that and how you think your fellow African ministers. And I’d just
like to point out that Rwanda has shamed Britain because you had about four times as many female
MPs as you do so maybe that’s your secret. [Applause.]
>>[Richard] There was a question down here as well, I think. Just here down the front.
Second row.>>[Audience member] B. Roshodende, paediatrician,
Nigerian. Thank you for your lecture. You’ve addressed the collaboration that takes place,
or that is meant to take place, between what is often referred to as the north and the
south. What I’d like to ask you is what are your thoughts in terms of how best to go about
collaboration between south and south. That’s one. The second question — oh
>>[Richard] No, go on, go on. Very quickly, go on.
>>[Audience member] Okay. The second question I wanted to ask is in terms of the if you
like, the details
of interaction between the various parties, how do you engage the local community in determining
what needs doing? I’m not just talking about the research processes that, for example,
in response to someone who says you should build a bridge rather than give treatment?
>>[Richard] Okay, very good. Just there.>>[Audience member] Thank you. Cam Stocks,
I’m the national director of medicine which is the UK’s global health network. You very
astutely identified at the beginning of your talk that this is a room full of young faces,
and so I just wondered first of all what was the contribution to this incredible change
that happened in Rwanda and how are you including people in the developments you’re making in
the future, and secondly, to this room full of future global health leaders, what is your
one key message?>>[Richard] That’s great, okay.
>>[Agnes] Okay, so, it started with the telephone. How the telephone has changed mindsets. It’s
incredible how the telephone changes mindsets. The power of communication. That means, the
world became a little village. But Rwanda became a little portion of a village. Meaning,
by knowing they can communicate with us, they are, they take more risks. They know how to
ask advice, they feel empowered to do their job. By people also knowing they have that
power, they go more to them, to seek services. But it’s not the only way that it works. It
gives also more accountability to people like me because we have, I was supposed to but
it’s too long, we have what we call a national dialogue day. It’s two days, where we are
like you, sitting in the parliament, chaired by His Excellency, co-chaired by the Prime
Minister. In the room we have all the heads of the army, the police, all governors, all
the mayors, all people who have a decision. We are more than 800. And people, there is
a screen, communicate with SMS, there is Facebook, there is Twitter, and there is a phone. And
let me tell you, it’s soon. And it’s my two hard days. You know why? Because everything
can be asked. And that’s good because if I mistreat, it is there. Because on Twitter,
it doesn’t disappear. And there is a Twitter for that and His Excellency and other people
are reading those tweets. So if I am a bad lady, it will transpire. If somebody’s bad
some way, it will transpire. And you have people who just as I told you, we have three
phones per village, that’s for health suddenly. We have also a phone for anti-corruption,
we have also a phone for other sectors. So those are there, communication is there, it’s
good. You know why? One day people say, I was entitled to receive a cow with this program.
I didn’t receive it because I don’t have land, but I was receiving that cow to increase my
economic growth. Immediately in that very setting, which sector you come from, which
mayor is the sector, governor mayor, tell u what happened? So police, tell the police
to go and see if it’s true. It’s true. Bring the cow back to the guy. Now are there many
other cases like that? Immediately, we receive the Minister for Agriculture and the police
receive one month to track all the cows that get to the wrong person. You understand? This
is what we call accountability day. People like me, I had to inform– to explain, I was
PS at the time, there was another minister, this is Vera, who had to explain why we have
closed all the A2 nurses’ school. And we had to explain that it’s because we opened A1.
We upgraded. That’s what I call, let’s say, direct democracy. But it’s good so phones
are key. Also how we engage communities, there was another question. How we engage the communities,
I think, people are good. They just need to understand have to be explained. But also
sometime we need to make them feel uncomfortable, leaving your comfortable zone. What we did
for maternal death, for example, we have the maternal death thing. Before we did not know
what happened, why the women were disappearing. For the woman who dies in hospital or health
centre, there is a professional autopsy. We have to say what happened. For those who die
in the village, there is what we call a community autopsy. Meaning, there is a committee created
with villages, private sector, local leaders, etc. who go in that house and say, what happened
to that lady. She was not supposed to die, did she complain before, etc. Everybody knows
that. So men don’t want to be asked. So now when a woman say “ah!” [in pain] they say,
“let’s go to the health centre!” [Laughter.] And that’s the best way to do it. You do moral
pressure for the good. So that’s how we engage, an example to engage community. For the collaboration.
You are a very good country. We have a collaboration with you. You bring some health professionals
for two years in Rwanda. But I think that we need to collaborate for better understanding
our health sector. We have differences but we have similar populations. Also we should
start to collaborate in production. That mean that today if all the houses of the health
want a mosquito net, there is not enough production. Is that it? How can we start production in
the continent to serve the continent if we don’t have it. Don’t forget, but we don’t
have it. This country can do this. This country can do that. And together we don’t replicate
and we create economic growth also. Also, the new born, how we engage, I don’t — the
question is what we say exactly to get money, or?
>>[Richard] Why aren’t we supporting new born health despite the fact that–
>>[Agnes] Because they don’t understand. And they are in their comfortable zone, again
in New York, Geneva, and London, and they don’t know that we can save children with
little actions that doesn’t cost a lot. And they are not interested. I think we need a
new mindset. The charity should be in the heart and removed from aid. But if people
tell you that this is my problem, believe them! Believe them. And if we tell them we’ll
be accountable with this, we will save this number of children, just come and see. And
saving neonatal is the best family planning tool. Because people have children because
they don’t trust that you will keep them alive. When I came back in Rwanda in 1996, I had
only two girls. My family just say, “two girls, are you crazy? First of all you need a boy.”
[Laughter.] Then we bring boys. And after that they say, “Only two! Me, I had eight!
Only one is alive. You will die alone. You understand that?” The best family planning
tool is keeping the children alive in a peace land where people have access to care. The
key message for youth, and the role of youth. Youth are fantastic because they are not yet
spoilt. So I think that exchange is good, I love that. And also the youth before coming,
just teach them how to be humble. We have so much knowledge, life knowledge, in people
that don’t know how to write and read. You know, our people are very polite. Why I am
saying all of those things is because, probably, my siblings education was somehow wrong. In
Rwanda, like in many African country, they are not telling what they think, but they
don’t like arrogance. And this slow collaboration. You go with humility to those people and just
learn about them. I have learnt so much. They know so much; they don’t know who is [a person]
but they know how to serve their life better than you do. So these are the messages: come
with humility, and also young people of the world, know that you can do the revolution
peacefully. You are the one who will change. And they are the future.
>>[Richard] Very powerful. The Provost has given us a few minutes more. So I’m going
to go top left there, yes please.>>[Audience member] Hello, I am the industrial
partnership manager for UCL Enterprise, and I was thinking about the public/private partnership.
I was just wondering if you could give some examples that you’ve used in Rwanda and it
was very successful, that could be used in other places. Than kyou.
>>[Richard] Okay, and Tom.>>[Audience member] Tom Nissau, paediatrician
in Rwanda, and I’m pleased to say have done a lot in terms of health partnership with
you in Rwanda. I was going to ask something a bit different, and that is, here we’re at
a university and we’ve heard about the great universities we have in the UK. What would
you most like from our universities?>>[Richard] Let’s take those two questions
and then we’ll finished.>>[Agnes] So, the public/private partnership.
The telephone I show you. It’s really a public/private partnership. The host is a company. The provider
is a company. The government have found the money and also paid for those. You can do
nothing now in a country like mine if the government doesn’t give the seats something.
We don’t have a private sector that will grow, we will go nowhere, because a backbone of
a country is the private country. Even though I believe that the backbone of quality care
and well distribution should be coordinated by the government, but my dream is private
sector strong in Rwanda, they pay a lot of taxes so that we can build hospitals. So another
example of public private partnership, there is public-private community partnership. You
saw the 42 hospitals. These are called district hospitals. PPCP. 40% of them belong to churches
or to NGOs. We treat them the same. They have the same advantages and they have 50% of the
health professionals. In exchange, the have our health system and they have the same category
of prices and they accept everybody if it’s a muslim hospital, they don’t have to be muslim.
It has two advantages. We don’t have to build all those 40%, we can concentrate on something
else, and also it brings the community together. You saw the village and the health centres.
In between there is a bag called the cell. We have almost five, seven to ten cells belonging
to one health centre. We want to propose a PPCP there by having a nurse, A2, running
a health post, we don’t pay her salary, she makes her own money by reimbursement of the
care by health insurance and selling things in drug store. The community give the place.
The community elect the nurse. We recognise and we train her. I think PPCP is the future,
at least in Africa. The other thing is what I like in university – I like the rigour,
I like academics, and I like education. Under the condition that you don’t delay saving
life. Don’t go for doing study only, go for — your best motivation should be saving lives
as soon as possible. But doing it with rigour, with good documentation, allowing young people
to do research, make the brain of young people more smart, etc. That’s great. That’s what
I like.>>[Richard] Okay, now we could listen to you
all evening, but there is a reception outside. I’d like to thank you, Agnes, on behalf of
everyone in the audience. [Applause]

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