Twenty years after the genocide, Paul Farmer reflects on how Rwanda became a model of inclusive healthcare.
The rapid recovery of healthcare in Rwanda since the 1994 genocide has been nothing short of historic. Life expectancy has doubled. Child mortality has fallen by more than two-thirds since 2000. In the past decade, death rates from AIDS and tuberculosis have declined at record speed. Vaccination rates for many diseases surpass those reported in the United States. And Rwanda is on track to become the first African country to achieve the Millennium Development Goals for health.
Partners in Health, an organization dedicated to providing good healthcare to the poor in several countries around the world, has worked with the Rwandan health ministry since 2005. Today, in partnership with sister organization Inshuti Mu Buzima, Partners in Health helps provide healthcare to 800,000 people in three rural districts.
Partners in Health co-founder Paul Farmer reflects on the lessons of Rwanda’s remarkable turnaround since the country's genocide 20 years ago.
GlobalPost: What can other governments and the development community learn from Rwanda's success story?
Paul Farmer: With this kind of reduction in mortality, one of the first lessons is that we must try to learn the lessons — most of the time we don’t even bother. This is more easily said than done, since improvement of this magnitude, like sudden and catastrophic failure, inevitably generates discrepant claims of causality. That is, “success has many mothers,” just as failure has difficulty establishing paternity. Three more lessons might be the following:
First, focusing on the burden of disease, especially among the poor and vulnerable, and the gaps in attention to it, is a great way to respond to past and current failure. If you were in Rwanda in 2004, as we were lucky enough to be, you’d see that the programs to respond to AIDS, tuberculosis, and malaria were quite weak. According to one estimate, just $14 per capita was being spent on healthcare that year (though such studies can fail to capture out-of-pocket expenditures by families seeking care for catastrophic illness). In 2004 and 2005, deaths from malaria reached their peak in Rwanda’s recent history.
The “burden and gap” approach — among the rural poor in this case — taken since then by the public sector and its partners offers some real programmatic examples of the implications of an “equity agenda.” Deaths from AIDS and tuberculosis have fallen more rapidly in Rwanda than just about anywhere, ever. Child mortality has fallen three times faster in rural areas than in cities, and disparities in child survival between the wealthiest and poorest Rwandans have shrunk.
Another lesson is the foundational importance of integrating prevention and care, as well as the risks of failing to do so. There’s a cost to failing to integrate in general, and in the middle of these epidemics, you can’t make that mistake.
Finally, there’s a great deal of synergy in public-private collaborations. Bypassing the public sector is a big mistake that non-governmental organizations have made in many other post-conflict settings. This has been one of the problems in Haiti in the past couple of decades. It makes a real difference to have NGOs and other partners work with the public sector — the guarantor of long-term investments and the possibility of universal access to health care.
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