A Paradigm Shift in Global Health Partnerships


The impact of the Human Resources for Health (HRH) program on Rwanda isn’t simply improving health in the African country. It’s changing everything.

“This program is a way that we can reverse the injustice of poverty,” said Dr. Agnes Binagwaho, minister of Health in Rwanda, of HRH’s long-term impact.

The seven-year HRH program is a partnership between the Rwandan government and universities and hospitals in the U.S. that strives to achieve one goal: to help Rwanda develop a high-quality and sustainable health care system. The program enables Rwanda to train and educate its health care workforce, care for the country’s patients and, as an indirect result, bring new businesses to the country that will stimulate economic growth.

During her visit to BWH last week, Binagwaho presented with BWH President Betsy Nabel, MD, about Rwanda’s health care needs and HRH’s first year of progress to a packed Bornstein Amphitheater. Binagwaho likened her country’s challenge in developing its own health care workforce to a classic “chicken and egg” conundrum.

“How can we produce these professions we need when we don’t have the people to train them?” she asked. “So we thought about creating partnerships with universities and hospitals like the Brigham. Let’s borrow ‘chickens’ from the United States to produce ‘eggs’ for Rwanda. This is a way to bring more justice by improving access to care.”

HRH launched last fall, with 97 faculty members—nine of whom are BWH physicians—participating from 23 universities in the U.S., including Harvard Medical School. The faculty members are focused on educating and training the next generation of doctors, nurses, midwives and other health care professionals.

When the program concludes in 2019, Rwanda’s workforce should be sustainable without foreign aid. In its first year, HRH is focusing on educating professionals in five specialties: gynecology, internal medicine, surgery, pediatrics and anesthesiology. After two years, the program will begin to focus on building subspecialties, such as pediatric surgery.

The needs in Rwanda are staggering. The country currently has six physicians per 100,000 people. By comparison, Boston alone boasts 1,053 physicians per 100,000 people. There isn’t a single cardiac surgeon, pathologist or cancer specialist in the country. HRH works to strengthen these and other specialty fields with critical shortages.

Led by co-investigators Robert Riviello, MD, and Corrado Cancedda, MD, HRH also builds upon the existing partnerships that many BWHers have already formed in Rwanda, including those through the Division of Global Health Equity, Partners In Health, the Center for Surgery and Public Health and the BWH-led Team Heart (see related story). While the HRH model builds on these programs and efforts, it also raises existing collaborations to an academic level to ensure Rwanda can educate the next generation of health care professionals and build a sustainable health care system.

“This is a wonderful partnership,” Nabel said. “I believe that reciprocity is the prize at the end of the day. We benefit from learning from one another and growing through this experience.”

The Coming Transformation in Global Health

The 20th century witnessed a monumental transformation in hospitals: once primarily places for poor people to die, hospitals became institutions that cured illness and promoted health. A range of facilities and professionals dedicated to treating the sick grew in tandem with the proliferation of hospitals, creating the health care systems we have today.  

Health care systems are now pervasive enough that even developing countries have structures for delivering care. Advances in treating HIV, heart disease, and other chronic conditions mean that a significant part of the population now lives for years in less-than-perfect health.  As we grow increasingly reliant on this care, the question before us is how to strengthen health systems in order to deliver quality care to all who need it.

This was the pivotal theme at the talk “The coming transformation in global health,” held at Harvard Medical School on Feb. 28.  Moderated by Paul Farmer, MD, PhD, chief of the Division of Global Health Equity, the discussion was framed by Lord Nigel Crisp KCB, former head of the National Health Service in the United Kingdom, and Dean Julio Frenk, MD, MPH, PhD, former minister of health of Mexico and current dean of the Harvard School of Public Health.

Frenk discussed the challenges and opportunities he encountered while reworking the health care system in Mexico. We can create a platform for enlightened social change by carefully and conscientiously restructuring our health care systems, but Frenk felt it was vital that these reforms be evidence-based and involve explicit ethical deliberation.  When these systems change for the better, they can have a tremendous impact: 30 percent of children with leukemia in Mexico had to stop treatment because their families ran out of money, but this number dropped to two percent after the implementation of health care reforms.

Having worked extensively in both the UK and developing nations, Crisp was particularly struck by the lack of health workers in many resource-poor settings. One way around the exodus of trained medical professionals from their countries of origin is to break down the demarcations between health professions. Crisp cites settings in Africa where nurses have been trained to do Cesarean sections—patient outcomes are comparable to doctors performing the operation, with the added bonus that nurses are less likely to move abroad.

Another potential solution for limited availability of medical professionals is to engage patients in their own care, as well as with helping and supporting fellow patients. Even in settings with abundant staff and resources, such as a self-dialysis clinic in Sweden, this approach can energize and engage patients, lower infection rates, and increase patient satisfaction. Crisp emphasized that health is a co-production function: it is not something doctors give patients, but something that patients create with intermittent assistance from clinicians.

Throughout the program, the speakers underscored that health is not separable from other human endeavors. Just as the duty of hospitals shifted from comforting the dying to curing, the challenge going forward is to reform health care systems to deliver care not just to the privileged, but to all in need.

Houses Designed to Attract Physicians to Butaro Hospital


Butaro Hospital, located in the rural Burera district of Rwanda, has grappled with the challenge of how to attract and retain top medical professionals. In response to that challenge, Brigham and Women's Hospital and Partners In Health opened permanent doctors' housing five minutes away from the hospital. The project was the brainchild of BWH donor Daniel Ponton. Read the story in the Architectural Record.