Beyond Replication - Rwanda scales up PIH model as National Rural Health System

Members of the Haiti Innovation Community are by now no doubt familiar with the organization Partners in Health and the pionerring work their team has done in Haiti bringing community based health care to  the lowest possible resource settings, and in particular, developing novel new approaches to treating both HIV/AIDS and Tuberculosis.

I left the Peace Corps in 2002.  Though Haiti is at the heart of the organization, the support of a growing number of donors has allowed it to expand its reach into a numebr of new countries.

It is worth mentioning that although PIH has become increasingly well known, and Paul Farmer an increasingly valued advocate for global health, it has for most of its existence, been beset by "experts" full of reasons why their model would not work.

First it was said that community based approaches to treating people living with HIV/AIDS in low resource settings would not work because the poor "can't keep time".  The compliance rate, higher than the United States, showed otherwise.  

Once successful, the experts said that the model could not be replicated elsewhere.  PIH is not only increasing its programming in Haiti it is replicating the model in both Lesotho and Rwanda.

Now the experts say these models are not sustainable, but this depends on what one means by sustainable.  In terms of economics, expansion is expensive.  In terms of saving lives, keeping families together, and contributing to a healthier and more productive society, the benefits outweigh the costs many times over. My money is on PIH being in it for the long haul.

Sometimes I feel like saying something is not sustainable is either an excuse for us to be passive when it comes to bringing about real change, or an excuse for our own failures.  The PIH approach is not to implement their model and create dependency - instead they intend to train up a "critical mass" of local staff, beginning in the four neediest districts, so that they can apply the model to their own community and others as well. 

We are proud to say that success in Haiti has also translated into hope for Rwanda. The article is below and can be found at the PIH website   

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Inshuti Mu Buzima (IMB), PIH’s partner organization in Rwanda, has accomplished a great deal during its first two years of work in two destitute rural health dis­tricts. It has enrolled more than 2,500 HIV patients on antiretroviral therapy, trained and hired more than 800 villagers as community health workers, and recorded nearly 100,000 patient visits in 2006.

Not content to stop there, IMB and their partners in the Rwandan Ministry of Health and the Clinton Foundation have now committed them­selves to an even more daunting and inspiring challenge—to make IMB’s approach to delivering comprehensive, community-based care the model for Rwanda’s national Rural Health system. Plans have already been drafted to extend the model first into the districts most in need of services and then to all 27 districts and 9 million residents of rural Rwanda.

PIH’s model has already been replicated around the world, says Dr. Michael Rich, PIH’s country director in Rwanda. “However, there’s a difference between replication and scaling up a model in an entire country,” he says. The difference is not only in sheer magnitude, but also in the close coordination needed with all government ministries and providers of health care. “So how do we go from replication to a countrywide scale-up?”

Instead of PIH finding and training staff and procuring equipment and facilities, the focus will be on training Rwandans to replicate the model, and then creating a “critical mass” of people who can teach the model to other areas, says Dr. Rich. The goal is for PIH to work mainly as facilitators, helping the Rwandan government meet its own national health goals, which are addressed as part of this rural health scale-up.

“What’s especially exciting about this is that the Ministry of Health is committed not just to scaling up treatment for HIV, which would be great, but to our entire comprehensive, holistic approach that considers the dignity of the patient,” said Dr. Blaise Bucyibaruta, who heads up pediatric HIV programs for IMB. “We do whatever it may take,” he added. “That includes ensuring that poor people have access to care, training community health workers well and paying them fairly, and making sure that patients and their families have enough food to eat, access to education, and a means to generate income.”

All of these dimensions of the PIH model are included in a set of 10 principles that PIH and their partners in the Ministry of Health have established for the national scale-up (see box to the right). These principles commit the partners to provide:

1) Comprehensive health care, available to all;
Relentless focus on the patient and quality of care, regardless of the challenges of the environment;

2) A community-based model, decentralized where possible from hospital to health center and from health center to patients’ homes;

3) Holistic care for the community beyond the purely clinical, including food, education, clean water, and income generation projects.

The plan will be launched in four of the neediest districts in 2008 and will then be rolled out to all 27 rural districts across the entire country. Work in each district will include four levels of involvement: at the district hospital, health centers, health posts, and with the community health workers.

Finding the resources—both human and financial—remains a huge challenge for the scale-up, says Dr. Rich. For example, there are currently only about 3,000 nurses in all of Rwanda. “That’s one limitation,” he says. “It would really take about 6,000 nurses” to staff the scale-up, backed by all the funding needed to train and pay them.

“Right now in Rwanda, very little money gets spent on health, maybe only a couple of dollars per year [for each person living in a rural area],” Dr Rich continued. “We want to increase that almost ten-fold, to about $23 to be spent on that person for health care.”

Although that would represent a steep increase in spending, it pales in comparison to current U.S. health spending of about $6,700 per person. More importantly it fits within the plans and commitments of the Rwandan government and in the first few years of the plan, it still falls below the targets endorsed by the African Union of spending 15 percent of national budgets to provide essential health services.

Dr. Agnes Binagwaho, who heads Rwanda’s National Commission to Fight AIDS, emphasizes that the scale-up is a necessary and affordable com­ponent of “a development process that includes the most vulnerable.”

“Our institutions seek to trans­form Rwanda from a poor country to a middle-income country,” she explained. “This transformation takes place by developing high-quality care that is available equitably across our country. That’s why the model called ‘Rwandan rural health care’ is seen as a necessary step towards rapid development, fair and shared by all. I also support this effort because it has already been implemented in two districts and has shown us that it is possible, a sound investment, efficient, and necessary for sustainable development."

Some of the money is already in the country, from the government’s existing $100 million national budget for health care, and from NGOs and other funding sources. Some of these resources can be directed towards the scale-up strategy, says Dr. Rich. “But we will still have a ways to go.”

As for medical workers, many locals can be trained and employed as community health workers to ease the workload for nurses, which will also contribute to the goals of providing income-generating opportunities and strengthening local economies. But this form of task-shifting will only stretch so far. In all, estimates put the cost of the providing a comprehensive model of health care at about $280 million per year nationwide.

Scaling up resources to that level and extending comprehensive, community-based care throughout rural Rwanda will not happen overnight. But hope abounds. Manzi Anatole, a Rwandan nurse working with IMB radiates his excitement over the planned scale-up, “We have many challenges,” he says, “But we want to show the people of the village, the province, the country, the world, that such things are possible.”