Tuesday, October 7, 2014

Rwanda: Ahead of the Curve

In recent weeks I have received numerous communications from scheduled visitors asking whether they should cancel their trip to Rwanda in light of the Ebola epidemic. http://en.wikipedia.org/wiki/Ebola_virus_disease    
It is for me to explain that they are much closer to the Ebola epidemic in the U.S. than they will be in Rwanda. Perhaps Americans should flee to Rwanda for safety. Click on: http://tomallen3.blogspot.com/search?q=the+size+of+Africa

For those who have an interest in healthcare delivery, I "re-post" an insightful (slightly edited) piece by Erin Hohlfelder, Global Health Policy Director, of ONE Campaign, entitled...

"AHEAD of the CURVE – 4 reasons why Rwanda is prepared to handle the Ebola crisis better than West African countries"
… [Although] I have been stunned at the severity of this Ebola crisis, I can’t say that I was surprised to see that Ebola was taking hold and spreading in a place like Liberia devastating its healthcare facilities.

Contrast that with my experiences… in Rwanda, [where I was] primarily interested in learning more about how its health care system continues to evolve and improve.

It was my third trip to [Rwanda], having visited previously in 2007 and 2011, giving me the chance to compare its progress against itself and against its peers. As I was packing for the trip, I was asked repeatedly by well-intentioned friends and family, “Aren’t you worried about getting Ebola?”

Given what I knew about how the disease spread, and with only one case to date approaching Rwanda’s borders in neighboring Democratic Republic of Congo, I was able to answer them with a fairly confident “no.”

But after two weeks in the country, I realized I had so many more reasons to say “no.” Of course, I’m still not bold enough today to predict that Ebola will never arrive in Rwanda, given the urgency of the crisis and models of exponential spread that merit real concern. But I had a greater understanding of why Rwanda was not Liberia, and why the health system there was better able to weather new (and old) threats.

Here are four key reasons why:

1. Health care workers

One of the clearest lessons of the West African Ebola epidemic so far has been how dangerous it is to have weak health systems and insufficient human resources for health.

In Rwanda, they not only have recruited, trained, and retained a vast army of volunteer health care workers (HCWs) — three for every single village across the country — but they have also built up a referral process around them.

These HCWs are the lynchpins of the system, ensuring that Rwandans with common and more easily treatable illnesses (such as fever, diarrhea, and malaria) can receive care at the local level without overburdening higher levels of the health system.

That, in turn, frees up nurses and doctors to work in health centers, clinics, and hospitals and to have the time and space to treat more severe or specialized cases. We visited each level of the system in our time on the ground, and it was clear at each stop that health staff knew their roles, knew when to refer patients, and had the tools available to deliver effective care.

2. Political prioritization

We heard frequently in our site visits that health care for Rwandans was a top political priority, from President Kagame on down through the government’s chain of command. This was not news to me, as I had heard Rwanda’s dynamic Minister of Health, Dr. Agnes Binagwaho, speak at many international meetings over the years and even engage citizens in a Q&A via #MinisterMondays on Twitter.

She was always the first to unabashedly point out how Rwandans knew what was best for Rwandans’ health and how focused she was on achieving outcomes for her people.

Critically, this was not just political grandstanding — it had translated into real dollars (or Rwandan francs, to be specific) and real outcomes for health in the country. Rwanda is one of just six African countries to have met its 2001 Abuja commitment to spend at least 15% of its budget on health; in fact, Rwanda regularly exceeds this target, averaging 22% each year since 2006. And unlike many of its peers, Rwanda is on track to achieve many of the Millennium Development Goals, including MDGs 4 and 6, focused on child health and HIV/AIDS, respectively.

3. Money

In addition to a growing pot of domestic resources for health, Rwanda has been the definition of a health “donor darling” over the last decade, receiving what some might argue disproportionately high levels of foreign assistance from key donors and programs relative to its size and disease burden. At nearly every health facility across the country, you see staff supported by and commodities purchased by donors including the Global Fund, PEPFAR, PMI, GAVI and various other bilateral initiatives.

By some estimates, external resources make up anywhere from one-third to nearly half of Rwanda’s health budget. But these resources appear to have had an additive effect on overall health spending and programming. By allowing donor resources to support key programs to fight diseases like AIDS and malaria, the Rwandan government has been able to spend its own health resources on broader systems strengthening, preventative health campaigns, and innovations that put it ahead of the curve.

Anecdotally, one Rwandan hospital we visited had one of the more sophisticated neonatal units I had ever seen in the region; fingerprint scanning technology for staff to enter specific buildings; and a full range of vaccines, including more expensive options such as HPV, for all its children.

4. Trust

Despite concerns about the Rwandan government’s political proclivities (I’ll leave that discussion to others for the time being), but when it comes to health, it is hard to argue that the government is not delivering results for its people.

In turn, the overwhelming majority of citizens with whom we met expressed that they trusted their government to provide health care and felt like they were seeing improvements in their day-to-day lives.

Contrast that with the situation across West Africa at the moment, where trust between the governments’ officials and their people has faltered.

We’ve seen citizens turned away from overly full health facilities, myths about Ebola continue to flourish despite formal information channels, a mistrust of health care workers, and even violence towards those who aim to provide care.

At the end of the day, if citizens don’t trust that showing up to a health facility will lead to care and improved health, they are more likely to stay home and perpetuate the spread, rather than containment, of diseases.

Of course, none of this is to say that Rwanda’s system is perfect or that the Liberian health care experience should or even could look like Rwanda’s.

And indeed, ten years of Liberian civil war a decade ago took a dramatically different physical, economic, psychological, and political toll on the country than did the (equally horrific, but very different) Rwandan genocide 20 years ago, which also has implications for how the country rebuilt and how citizens respond.

But surely, if we hope to rebuild Liberia and other affected West African countries when the Ebola crisis is eventually contained — an effort that will likely take years, not months — we can benefit from borrowing some of the lessons highlighted in the Rwandan experience.