NEJM Special Report - Rwanda

Geisel helps lead pioneering program

US Partners with Rwanda to Dramatically Expand Health Workforce
Dartmouth Among Leading Medical Institutions Bridging Human Resource Gaps

KIGALI, Rwanda—On November 21, 2013, the New England Journal of Medicine releases a Special Report detailing the largest-scale global health partnership ever initiated between American universities and a low-income country. On the heels of a World Health Organization warning in Brazil last week that the world faces a shortage of 7.2 million health workers, the article’s publication marks a pivot away from short-term missions and contracts toward long-term partnerships to bridge workforce gaps.

Announced by Rwandan President Paul Kagame and former US President Bill Clinton in 2012, Rwanda’s Human Resources for Health Program is a seven-year, $150 million collaboration between the US and Rwandan government and 25 leading US academic institutions, including the Geisel School of Medicine at Dartmouth, one of the founding partners.

Former US Global AIDS Coordinator and US Ambassador for Global Health Diplomacy, Dr. Eric Goosby—senior author on the article—launched the program in Kigali in 2012. Each year, more than 100 American professors of medicine, nursing and midwifery, dentistry and health management work in Rwanda alongside Rwandan faculty to build residency programs, strengthen instruction quality, and substantially increase the output of new health workers.

“Rwanda’s example, and the Human Resources for Health Program in particular, have the potential to transform global health by serving as a model for any country that wants to increase the efficiency of foreign aid and improve the health of its people. The launch of this program has been the highlight of a decade of partnership, and I'm excited by its possibilities,” said President Clinton.

Since 2000, Rwanda has reduced mortality due to HIV, tuberculosis, and malaria by nearly 80%, and the country’s life expectancy has more than doubled since the mid-1990s. As deaths from major infectious diseases have plummeted and as HIV patients live longer, chronic non-communicable diseases account for a growing proportion of Rwanda’s disease burden—especially among the HIV-positive patient cohort. Rwanda’s Human Resources for Health Program will increase the number of Rwandan faculty available to train future health professionals. By dramatically increasing the number, quality, and skill level of Rwandan clinicians and health sciences educators, the program aims to build the health education infrastructure and workforce needed to create a sustainable and advanced health care system.

“By simply reallocating existing funds, this partnership is allowing Rwanda to move from a brain drain to a brain gain of unprecedented magnitude in the health sector,” said Dr. Agnes Binagwaho, Rwanda’s Minister of Health, lead author of the new article, and clinical professor of pediatrics at the Geisel School of Medicine at Dartmouth. “Together, we are training a highly skilled health workforce built to last, and equipping them with the tools they need to save lives. In essence, we are investing in Rwanda’s greatest resource: its people.”

The program’s $150 million budget is comprised of reallocated funding from the US President’s Emergency Plan for AIDS Relief (PEPFAR) that is channeled directly to the Rwandan Ministry of Health, along with support from The Global Fund to Fight AIDS, Tuberculosis and Malaria. In an unprecedented move to improve efficiency of existing foreign aid, the US government redirected funds from projects completed by non-governmental organizations to the Ministry of Health, lowering administrative costs and freeing funds for the new program. Because every American university partner agreed to no overhead and less than 7% administrative costs, Rwanda’s Human Resources for Health Program represents a unique model for foreign aid focused on greater efficiency, country ownership, and sustainable development. The Clinton Health Access Initiative has helped to convene the American consortium of schools and academic medical centers.

“Working with the Rwandan Human Resources for Health Program has been a highlight of my 20-plus years in global health,” says Dr. Lisa Adams, associate dean for global health at the Dartmouth Geisel School of Medicine.  Adams helped help launch the Human Resources for Health Program in Rwanda in 2012. “This program has the potential to revolutionize the health education system in Rwanda - and by doing so, set an example in the region of what is possible.   The Rwandan health leadership is solid but few in numbers - with more trained health care workers, a high quality and sustainable health education system is possible.”

“I am so proud that Geisel took the bold step to become a partner in this program - it speaks to the current leadership that Geisel Dean Chip Souba is providing in which we live up to our ideals. While we contribute to health system strengthening in Rwanda, the Dartmouth Geisel faculty who return are bringing back their knowledge and experiences to share with our medical students and trainees - the impact will be felt both here and there.”

In the HRH program, Adams works closely with her Rwandan physician counterpart Dr. Jean-Luc Nkurikiyimfura, director of the HIV Clinic at Kigali University Teaching Hospital.  Nkurikiyimfura calls their collaboration an “excellent working environment based on mutual respect.  Dr. Lisa has shared with me the recent knowledge in infectious diseases in general and specifically HIV-AIDS, which is my main subject of interest. This collaboration has allowed me to create a research study that is addressing the quality improvement of clinical care in our HIV Clinic,” says Nkurikiyimfura.

“At its very best, academic medicine integrates service delivery, teaching, and research in a virtuous cycle. For Harvard and our many American partners in this consortium, contributing to this program has been an opportunity to not only serve and improve care delivery in Rwanda, but also to learn much that we can apply back in the United States,” says Dr. Paul Farmer, co-founder of the nonprofit Partners In Health and University Professor at Harvard University.

By the program’s conclusion in 2018, Rwanda’s specialist physician capacity will have more than tripled, and the proportion of the country’s nurses with advanced training will have increased by more than 500%. An additional 550 physicians, 2800 nurses and midwives, 300 oral health professionals, and 150 health managers will have been newly trained in Rwanda—all of whom will have signed contracts to work in the country for a certain number of years based on the degree they obtain. Thereafter, the Rwandan government plans to fully finance the health workforce and medical education system on its own.

To learn more about Rwanda’s Human Resources for Health Program, please visit:

http://hrhconsortium.moh.gov.rw/

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Dr. Lisa Adams works with the Human Resources for Health Program, an ambitious project to build a high quality and sustainable health system in Rwanda. Dr. Lisa Adams works with the Human Resources for Health Program, an ambitious project to build a high quality and sustainable health system in Rwanda.

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