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.”
When Drobac and his colleagues, working with the Rwandan Ministry of Health, published their report on the nation’s health successes, I got into a discussion on Twitter with Cameron Nutt, a Dartmouth research fellow assigned to work with the Minister of Health Agnes Binagwaho. We debated the value of “physician density” in low-resourced countries. Nutt was a co-author on the BMJ paper who did many of the analyses, including showing the value of community health workers.
Partners in Health has built hospitals and clinics and rotates in volunteer physicians, as well as assisting in training community health workers in Rwanda. That conversation on Twitter attracted the attention of Sachs, who’s been trying to shift the focus in global health away from investing in doctors or highly skilled health workers and towards a new system founded on community health workers.
Sachs thinks Rwanda’s success is highly dependent upon its 45,000 community health workers. Even if increasing physician density would be financially feasible in Rwanda, he said it’s not a likely prescription for other poor parts of the world. Rwanda’s health system is significantly supported today by foreign aid and organizations like Partners in Health. Said Sachs:
“While physicians are needed, there’s a pretty significant recognition that they are not going to be a breakthrough for the next few years,” Sachs said. There aren’t enough of them, they cost too much and they aren’t really needed for the bulk of health needs in poor countries, he said.
Drobac agreed that the use of community health workers has been transformative. But he disagrees with Sachs’ contention that they should be placed at the center of health system reform for poor countries.
“Community health workers mean many things to many people,” Drobac said. “Too many times community health workers have been used as a replacement to physicians…. We find that community health workers are best thought of as complements to a well functioning system.”
That said, he described how his organization along with Rwandan health officials have installed well-trained, compensated health workers into every community to make sure that pregnant women get routine prenatal care, kids get their shots, people at risk for chronic disease go in for screening, children with fever get seen immediately for malaria diagnosis and take other basic steps that reduce the threat of illness as well as the high costs of late treatment.
“Before we got these programs in place, we were regularly losing kids and mothers simply because they came in too late,” Drobac said. In addition, these health workers do education in the community that helps people help themselves.
“One of the key factors here has been a recognition of the social determinants of health and disease,” he said.”Providing medical care alone without addressing poverty is insufficient… You can’t just give pills to a starving person. Taking HIV medication without food is like washing your hands in dirt.”
Similarly, he said, trying to shift a focus away from doctors and nurses to an over-emphasis on community health workers is too simplistic. “I would push back against the doctors versus community health workers argument… It’s a false dichotomy.
Sachs emphasized that he’s not trying to pit doctors against community health workers. But he is trying to get the traditional global health community (led by mostly of western-trained doctors) to recognize that one of the lessons out of Rwanda is that we shouldn’t force poor countries to make the same mistakes the West has made in health care.
“We’ve had a physician-centered approach to health care and look where it’s gotten us,” he said. American health care is the most expensive and one of the least cost-effective approaches that could ever be devised, Sachs said.
We need to come up with a different kind of system for the developing world, he said, that stands a reasonable chance of furthering the progress made in places like Rwanda – and especially if we wish to move toward the more ambitious goal of universal health coverage.
“There is a coalescing consensus that we need to push for universal health coverage, that the best way to achieve our many goals in health is for everybody to have access to primary health care,” Sachs said.
That’s not a new idea either and it’s never gotten very far in most parts of the developing, he added, noting we have yet to achieve it here in the United States either. Perhaps one explanation for this failure is we can’t get past the West’s high-cost, physician-centered approach to health, he said.
“We need a new approach and I think building a new kind of public health system based on community health workers is the way to go,” Sachs said. “I think that’s the lesson of Rwanda.”