In late February, Dr. Krishna Reddy, Country Director of ACCESS Health India, and I traveled to Rwanda to learn more about health systems strengthening from an organization that has proven itself to be a formidable leader in the field: Partners in health and the affiliated University Global Health Equity.
Partners In Health was officially established in 1987 by co founders Ophelia Dahl, Paul Farmer, Thomas J. White, Todd McCormack, and Dr. Jim Yong Kim (former President of the World Bank). It was partly chance that brought them together: Dahl and Farmer met years earlier while volunteering in rural Haiti, where they ran a community clinic that thrived despite a lack of institutional support. Their grassroots gumption, combined with their steadfast commitment to health as a social good and human right, has landed Partners In Health opportunities everywhere from Malawi and Sierra Leone to Mexico and Peru.
As might be expected, partnership—“accompaniment”, Farmer calls it—is the organization’s preferred mode of engagement, whether with national governments or community workers at the frontlines of health systems. Training and supporting local health providers that can deliver nonclinical services to people in their villages and homes is a top priority, so much so that nearly all of the Partners In Health employees stationed around the world are actually from the places where they work.
Former Minister of Health Dr. Agnes Binagwaho first invited Partners In Health to Rwanda in 2005, having taken note of their success protecting poor communities in Haiti and Peru from tuberculosis and HIV/AIDS. In the fifteen years since, their partnership with the Rwandan government has resulted in the renovation or inauguration of three district hospitals and dozens of community health centers, as well as the employment of thousands of community health workers.
Partners In Health in Rwanda (Inshuti Mu Buzima)
When Partners In Health first came to Rwanda, it was to pilot an HIV treatment program that had been successful in Haiti and Peru. Partners In Health accompagnateurs equipped members of participating communities with the skills, tools, and knowledge they needed to dismantle the barriers that keep HIV patients from seeking and receiving treatment. Many of those trained to provide counseling, transport, food, and other forms of support were HIV patients themselves.
Other early and ongoing projects include the Program on Social and Economic Rights (POSER), dedicated to mitigating social and economic barriers to healthcare; the provision of nutritional support, in the form of thousands of food packages, to patients with HIV and tuberculosis; and the renovation and refurbishment of community health centers and district hospitals.
In Rwanda, Partners In Health is known as Inshuti Mu Buzima. Dr. Joel Mubiligi, executive director of Inshuti Mu Buzima, showed me and Dr. Reddy during our stay how the organization’s projects interface multiple dimensions of health service delivery: Community health workers, community health centers, district hospitals, and district leadership. Butaro District Hospital, a collaboration between Partners In Health, the Clinton Foundation, and the Ministry of Health located on a hilltop adjacent to the University of Global Health Equity works in all four dimensions.
After Partners In Health had success implementing an innovative rural healthcare model in two of Rwanda’s poorest districts, the Rwandan government invited them to lead the creation of a hospital in the Burera district in northern Rwanda. Plans for Butaro Hospital were first hatched in late 2007.
To build Butaro Hospital, Partners In Health made the decision not to enlist major contractors or suppliers, but local labor and, when possible, local materials. Construction began in December 2008 and was finished expediently, in just two years. When the hospital opened its doors to the general public in early 2011, visitors found themselves amid the vegetal handiwork of Jean Baptiste, a Rwandan “master gardener” who collaborated with MASS Design Group to design facilities that felt open ended and restorative—even capable of healing.
Far from frivolous—though some locals, exploring the property at first sight, did ask Farmer if it was a resort—the landscape of gardens, terraces, and courtyards functions as a low tech, cost efficient strategy for infection control. Poor ventilation is a major cause of airborne tuberculosis transmission and the “biggest problem for hospitals in Africa,” according to Farmer. At Butaro Hospital, air cycles in and out of the wards a dozen times an hour at the least—an arrangement as practical for the health of patients as it is a source of pleasure.
Butaro Hospital is also home to cutting edge health facilities, technology, and services, furnished by $1.4 million dollars of medical equipment courtesy of the Ministry of Health. Among its specialized treatment centers and surgical programs is a neonatal intensive care unit created to address health problems prevalent throughout the region, such as prematurity, malnutrition, and low birth weight. There is also an outpatient mental health specialty clinic run by government employed psychiatric nurses and a psychologist—one example of a nationwide effort, another partnership between Partners In Health and the Ministry of Health, to decentralize and integrate mental health care into primary care.
Prior to the construction and opening of Butaro Hospital, Burera district, home to more than 320,00 residents, had not a single hospital or even a doctor. Reaching the nearest hospital took several hours by foot and two hours by vehicle. Health indicators were at rock bottom—the country’s worst.
Within a year of opening, Butaro Hospital had served almost 25,000 patients total. The hundreds of successful surgeries, deliveries, and HIV screenings completed from 2011 to 2012 have since multiplied into thousands. One area of care in particular stands out as a landmark addition to health service delivery systems not just in Rwanda, but East Africa: the cancer center.
Butaro Cancer Center of Excellence
Infectious diseases currently cause more deaths in Africa than noncommunicable diseases like cancer, but this won’t always be the case. Noncommunicable diseases are expected to become the most common cause of death as early as 2030, beating out maternal, perinatal, and nutritional diseases. Because of this, Rwanda has committed to building more national public oncology infrastructure—and who but Inshuti Mu Buzima could be enlisted to help.
The Butaro Cancer Center of Excellence is Rwanda’s first public cancer center. It consists of an inpatient oncology ward, which opened at Butaro Hospital in 2012, and Butaro Ambulatory Cancer Center, an outpatient clinic that opened in 2013. Staffed by both Rwandan and American physicians, the cancer center provides high quality, full spectrum cancer treatment and care—from chemotherapies to surgeries to palliative care—at little to no cost to patients, thanks to generous government subsidies.
The Butaro Ambulatory Cancer Center was created to ease some of the pressure on Butaro Hospital’s 24 bed oncology ward, which overflowed regularly. Housing and psychosocial support are offered to patients who remain for extended stays—which is usually the case, especially since many patients come from surrounding countries like Burundi and the Democratic Republic of the Congo.
Before the Butaro Cancer Center, oncology care was too far and too expensive for most Rwandans. Those that could afford to be transferred to hospitals abroad had to travel as far as India for radiotherapy. For the less fortunate, a cancer diagnosis was all but a death sentence. Since opening in 2012, the Butaro Cancer Center has treated thousands of patients and trained nearly 70 nurses in providing specialized cancer care.
A recent report from Dr. Cyprien Shyirambere, Inshuti Mu Buzima’s oncology program director and leader of the Cancer Center of Excellence, brought light to the development of a continuing education program for oncology clinicians in partnership with the Dana Farber Cancer Institute at Harvard Medical School. Dr. Shyirambere also spoke to some of the challenges and limitations that the Butaro Cancer Center is working to overcome, among them the costliness of critical drugs and modern imaging technology.
In 2015, Partners In Health embarked on an endeavor in as yet without precedent: a pioneering medical and public health school called the University of Global Health Equity. The University invites aspiring health professionals from across the country and around the world to learn about health systems from a wide array of overlapping perspectives: the medical, the social, the managerial. Through their research and fieldwork, students can combine this education with prior personal and professional experiences to cultivate a global perspective of their own—a vision, the seed of global health leadership.
Students at the University of Global Health Equity are shaped as much by the unique curriculum and world class faculty as their campus in Butaro. John Urschel, my host in Rwanda and director of partnership development at the University, was kind enough to give me and Dr. Reddy a tour, which is all but fifteen minutes away from Butaro Hospital.
As the co founder and former director of CARE Hospitals, a hospital network in India that spans six states, serves five million people, and makes a priority of caring for the disadvantaged, Dr. Reddy knows a thing or two about what it takes to reform health systems for the better. Now at ACCESS Health International, he is working with our India team to create the Institute for Health Systems Strengthening, a Hyderabad based think tank that revolves around five specific frontiers: Health Systems Governance, Health Finance, Healthcare Provision, Digital Health, and Community Health.
Partners In Health and ACCESS Health have a lot in common, particularly when it comes to our mission, core values, and desired impact. We are looking forward to future opportunities to coordinate and collaborate on projects that help us deliver care to people no matter where they live, and no matter what their age.