Editor’s note: This is a follow up (a day or so behind schedule) to an article I did last week on what many see as the humanitarian dilemma of Rwanda – a success story in aid and development in an nation with a questionable record on basic freedoms and human rights. Since it’s original posting, I’ve made changes to clarify that everyone agrees community health workers are invaluable to success. The question is one of emphasis.
Rwanda is widely celebrated for having demonstrated that major improvements in health can be achieved in a poor country, at relatively low cost per capita, by good strategy, innovation and focusing on the best bang for the buck.
“There’s really been an extraordinary level of leadership by the Rwandan government, in terms of central planning and coordination,” said Peter Drobac, Rwanda director of Partners in Health, the health aid and advocacy organization founded by physician-activist Paul Farmer and Jim Y. Kim, now director of the World Bank.
The Rwandan government has implemented an insurance program that has covered most of the population with an emphasis on basic, preventative care that the British Medical Journal recently reported has greatly increased life expectancy, significantly reduced AIDS and TB as well as maternal and child mortality — all for about $55 per person.
“I think we’ve learned some lessons here that can be applied universally,” said Drobac.
Rwanda is being held up as a model within the global health community, but planning and coordination is nothing without execution. Digging down past all the sound-bites and buzz words, what has really made the difference?
Arguably, some of the more critical players in this scheme have been relegated to a minor supporting role when it’s possible they are actually in the lead.
Community health workers. Rwanda has 45,000 of them, or about three per village.
Partners in Health has been a pioneer, and major proponent of the use of community health workers to extend the reach of the health system in poor countries. But Sachs thinks their role still remains underappreciated in media reports and policy discussions.
“There has been a dramatic change in terms of what you can do with community health workers in poor villages,” said Jeffrey Sachs, a leading aid and development economist who has recently proposed a massive expansion of community health workers as the most powerful means to achieve many key global health goals. Advances in diagnosis and treatment along with the ubiquitous cell phone means lower-skilled health workers have a greatly expanded care repertoire.
Rather than continue to focus on disease-specific interventions or trying to increase high-level health capacity, Sachs thinks the most obvious lesson learned from Rwanda’s success in health is that these low-level trained health workers are most powerful.
“This is a new idea,” Sachs said. “We’ve had community health workers for many years, but they are generally viewed as complementary components when what I’m talking about is making them central components in a new system of public health.” Continue reading