The Equity Imperative


“There is no correlation between money and what you can offer your people,” said Rwandan Minister of Health Agnes Binagwaho. “Money is not the obstacle; your vision is the obstacle.”

Paul Farmer, MD, PhD, Chief of the Division of Global Health Equity at BWH, introduced Binagwaho to the audience gathered on July 23 at Harvard School of Public Health. Binagwaho was a guest speaker at Harvard’s Global Health Effectiveness Program, which is co-directed by Joseph Rhatigan, MD and Rebecca Weintraub, MD, both Associate Physicians in BWH’s Division of Global Health Equity.

Over the next two hours, Binagwaho shared how reforms in Rwanda’s health care sector had produced stunning results: Despite a GDP of less than $1000 per capita, life expectancy in Rwanda has doubled since 2004.

The groundwork for this accomplishment was the creation of a network of community health workers (CHWs). Each village elected three CHWs, who did not need any background in health care. These 45,000 CHWs were then provided with six weeks of training by the Ministry of Health. Returning to their villages, CHWs performed basic functions like conducting HIV tests and administering vaccines.

Today, 80% of the burden of disease in Rwanda is addressed by CHWs at the village level, helping the country achieve dramatic changes many key areas. In the last decade, deaths from tuberculosis have decreased by 77 percent, deaths from HIV/AIDS have decreased by 78 percent, and maternal mortality has decreased by 60 percent.

While tremendous progress has been made in providing basic services, Rwanda continues to face a shortage of specialist care.  In 1996, Rwanda had 10 million people and only one psychiatrist.

To address this challenge, Rwanda brought together a consortium of government, NGO and academic partners to create a program called Human Resources for Health (HRH). HRH brings doctors and nurses from partnering academic medical centers in the United States (including BWH) to Rwanda for a year. American clinicians train their Rwandan counterparts in both medical and teaching skills, and, after seven years, Rwandan clinicians will have sufficient expertise to train future generations of health care workers independently.

HRH completes its first year at the end of the month, and is expanding next year to include a residency program for psychiatrists as well as other specialists.

“Health is a right,” said Binagwaho. “You shouldn’t be deprived of this right because you were born in a poor part of the world. It is our world.”