Interview: PIH founder says building systems is vital in ensuring quality healthcare

Dr Paul Farmer, a medical anthropologist and an infectious disease expert, has said Rwanda is on track to addressing disparities in healthcare. The Chair of the Department of Global Health and Social Medicine at Harvard Medical School and Chief of the Division of Global Health Equity at Brigham and Women’s Hospital in Boston praised the country’s system, saying “one of the things we find most exciting about Rwanda is that the leadership wants to address these disparities in health care.” Dr Farmer, also a co-founder of Partners In Health (PIH), an international non-profit organisation, is in the country for an official visit, to, among others, assess the activities of PIH. Maria Kaitesi had a chat with him on an array of issues. Below are the excerpts;-What are some of the PIH activities in Rwanda and what impact have they had on Rwanda’s public health system?Partners In Health is serious about partnership because it’s a partnership organisation. I have been coming here for a dozen years and we’ve been here for over eight years while partnering with Rwanda’s Ministry of Health. We can’t have any impact except through partnerships.In the last 10 years, life expectancy has doubled in Rwanda not only in the three districts and hospitals where we operate but in the whole country. We mainly work in Kirehe, Kayonza and Burera districts. We are proud to be part of this along with other partners we work with.The whole point of this work is to build, under the Rwandan leadership, a health system and we are working on specific projects such as mentoring nurses and doctors in rural areas, cancer care, the human resources for health project and the three public hospitals and more than 30 health centres that we support. When we came here, there were about four districts without hospitals at all and we went to three of the districts which had no hospitals, then established hospitals there in close partnership with the Government of Rwanda and the Ministry of Health.One of PIH’s overarching goals is to bring the benefits of modern medical science to those most in need of them; how have you managed to do that in Rwanda?After the 1994 Genocide, it was a difficult situation in terms of infant mortality, child mortality, maternal mortality, HIV/Aids and malaria. It was a grim situation. Some of the highest mortality rates in the world were here and Rwanda was one of the poorest countries on the face of the earth after the Genocide.However, our mission is to link academic medical centres and resources to people living in poverty and facing the burden of disease.The government wants to build a health system that can serve everyone. They have always had an equity agenda around healthcare so that rural areas, poor people and those with the highest burden of disease are cared for as well. That’s not how most health systems work, although they are supposed to work that way.Academic medical centres don’t [typically] go to where the poorest people are and they go to only the cities. Therefore, this mission pushed us here and we are working with President Bill Clinton as the beginning of our project was with the partnership of the Clinton Foundation and Rwanda’s Ministry of Health.You are one of the most passionate and influential voices for global health equity and we know that health disparities exist between Rwanda and the developed nations. How do we bridge the gap and ensure that our population access quality healthcare?Disparities exist between countries and within countries. The equity agenda is really key and one of the things we find most exciting about Rwanda is that the leadership wants to address these disparities.The first thing you do is build a system. When Rwandans talk about self-reliance, it means being a self-reliant nation. But if someone is sick, for example, if a child has leukemia, you’re not going to say you should be more self-reliant. You build a system and it has to be a compassionate and effective system.When you link effectiveness and compassion in a system, that is the right prescription for addressing disparities in healthcare. The equity agenda is also powerful.Doing an analysis of the burden of the disease is also vital. For instance, if you don’t have cancer here then why worry about it? Assessment of the burden of disease is a critical step to building a system that makes sense.You have to have the human resources to do the work as well such as doctors, nurses, medical specialists and generalists. This country is on track and they are building research capacity, too.Critics often say it doesn’t make sense to have a cancer centre in a rural area like Butaro. Some say cancer cases are mainly in urban areas...Cancers common in Africa such as leukemia and cervical cancers aren’t a lifestyle issue. It’s a common idea in the US, too, but a false one. It’s like saying poor people don’t get cancer. Two thirds of all cases of cancer in the world come from low and middle income countries.No one is taking care of cancer in rural areas and so we decided to do so. Most Rwandans also live in rural areas as Rwanda is still a rural nation. Most of the cancer patients we have seen here over the years were from rural areas and had travelled allover looking for treatment. They might end up in the city but most of them aren’t from Kigali.Our mission is to go where patients are and where the pathology is, hence addressing health disparities. The Ministry of Health equity agenda means taking care of people closer to where they live. What is your general observation about healthcare trends in Rwanda? Do you think Rwanda is making progress in healthcare provision and what are the challenges?It’s stunning! There is remarkable progress made, especially if you look at fertility rates, mortality rates or life expectancy. If you look at only six indicators such as death due to Aids, malaria, tuberculosis and during child birth and from vaccine preventable illnesses and under five, significant progress has been made.Rwanda is the only country in sub-Saharan Africa on track to meet all the health-related Millennium Development Goals. If you look at those six indicators, you see that Rwanda has the steepest decline in mortality ever documented anywhere at any time, so that means even more than Europe after the war. It’s very striking. Every Rwandan ought to be proud of that.Some of the challenges, however, include human resources and financial resources. Rwanda still doesn’t have as much money as we believe it wants to invest in health care, and that includes prevention, diagnostics, and research. Rwanda doesn’t have enough and it has real constraints. Other issues that are still a problem here include stunting from malnutrition, although it’s a problem that the government is trying to address aggressively. Rwanda is building a primary and secondary healthcare system. It’s ridiculous to say that Africa or Rwanda needs only primary healthcare; everybody needs to have these investments and the infrastructure needs to be good so there is a lot of challenges, but I think that’s moving forward as well. Rwanda is also the only country, besides Botswana which has the GDP that’s more than 10 times Rwanda’s, on the track for universal Aids care as well. What would you say about Rwanda’s two initiatives to address health issues; Community Health Workers and Community Health Insurance in Rwanda?Mutuelle [health insurance] is increasing a social safety net across this country and I think it has got problems like any other health insurance scheme but it’s another innovation. Community health workers who are tasked to roll out more health services to the community level is also another big advance.

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Interview: PIH founder says building systems is vital in ensuring quality healthcare