An electric year in northern Rwanda

Thousands of patients served during Butaro Hospital's first year. Facility shows health care can be provided at a world-class level, even in poor, remote communities.

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By Aubrey Davis, PIH/IMB External Relations Coordinator, Rwanda

There’s something electric in the air around Butaro Hospital. It sizzles through the bustling wards, around the angular, elegant buildings, down the hospital’s mountaintop perch, and flows into the spectacular backdrop of northern Rwanda’s hills and valleys. The buildings themselves buzz with the sounds of lab coats swishing down the portico halls, oxygen pumping from the walls in the wards, and lights humming in the operating rooms.

But the doctors and nurses here don’t dwell for too long on the buzz; there’s too much work to be done. Since the hospital opened one year ago on January 24, 2011, PIH and the Rwandan Government have worked closely together to provide health care at a level never seen before in any part of rural East Africa. And word of the state-of-the-art facility has spread—heavy streams of patients began arriving from far and wide since Butaro officially opened its doors. In its first month, the hospital admitted 266 inpatients, completed 64 deliveries, and tested 308 people for HIV.

	Inside a ward at Butaro Hospital. ©Matthieu Zellweger

One year later, the numbers have continued to grow. Butaro hospital staff has seen 16,638 outpatients and 7,206 inpatients suffering from conditions ranging from malaria, TB, and pneumonia to broken bones, burns, and a variety of cancers. Impressively, 941 women have given birth at Butaro Hospital, 416 of those being Caesarian deliveries, and with only a single maternal death. That’s no small feat when one considers that most of the deliveries that take place at the hospital are high-risk or involve complications—women who have routine deliveries almost always give birth at one of the district’s 15 health centers.

 

The Road to Butaro

In 2008, the Burera District in the Northern Province of Rwanda was the only district in the country without a functioning district hospital, and it suffered from the worst health indicators in the country. In fact, there was one doctor in the district for a population of more than 320,000 people.

PIH’s Rwandan sister organization Inshuti Mu Buzima (which means “Partners In Health” in the local language of Kinyarwanda), had been producing impressive results in the rural Eastern Province since 2005 by fostering a strong partnership with the Rwandan Ministry of Health to improve the entire district health system. Based on this relationship, the Ministry asked Inshuti Mu Buzima (IMB) to spread its operations to the Northern Province, and IMB agreed to build a world class public hospital on a hilltop in the village of Butaro in Burera District.

Construction began in 2009 after careful planning from a partnership including PIH/IMB, the Rwandan Ministry of Health, and MASS Design Group, the social justice architecture firm. Most materials were chosen from local sources, such as the volcanic stones that beautify the exterior of the buildings. Drawing on 25 years of experience in hospital construction, PIH/IMB saved millions of dollars by engaging the local community to build the hospital in what was a massive act of umuganda, or community service. In total, 3,500 jobs were created for local workers, and invaluable skills were transferred that are still in high demand today. Reflecting on the construction and design process, PIH co-founder Dr. Paul Farmer says, “The architecture here responds to real problems, and does so in creative and efficient ways.” 

	Rwandan President Paul Kagame cuts the ribbon to officially open Butaro Hospital. ©Adam Amoroso

The hospital construction was complete in December 2010, and on January 24, 2011 it was inaugurated; Rwandan President Paul Kagame cut the ribbon himself.

"Overseeing the construction of Butaro Hospital was a great innovative experience,” reflects Emmanuel Kamanzi, the District Project Manager for the PIH/IMB. He adds that construction was only one part of the overall goal. “Keeping it functioning to achieve its vision of serving as a model in providing high quality medical care and a center of excellence in medical education is greater one. We will make efforts to make the function follow its form."

 

Redefining the expectations for health care in poor, rural communities

Today, Butaro Hospital provides more than basic medical needs. Thirteen doctors, 96 nurses, and 37 paramedical and administrative staff offer services that eclipse the standards of healthcare for this region, proving that world-class facilities can and do work, even in the most remote corners of the world. Every day, IMB redefines the limits of what a rural African hospital can do, while striving to help the Rwandan Ministry of Health meet their ambitious goals for their country.

For patients at Butaro, miracles seem to happen every day. While these “miracles” would be routine acts of care at a Western hospital, such routine care simply did not exist in this area. Three examples include the hospital’s surgical, neonatal care, and mental health programs.

	Dr. Josh Lamb with Rwandan colleagues Dr. Thotho Kolombo, Dr. Eric Rutaganda, and nurse Kamanzi Elia, repairing a femur fracture in an operating room at Butaro Hospital.
	The Neonatal Special Care Unit at Butaro Hospital.

Butaro’s surgical program has performed a staggering 636 surgical procedures since opening its two operating rooms. Dr. Thotho Kolombo, a general practitioner who focuses on surgery, has taken on the lion’s share of surgical responsibilities. And in October, the hospital’s first full-time orthopedic surgeon, Dr. Josh Lamb, and anesthesiologist Dr. Emily Nelson, arrived at Butaro. Between the three of them, they have treated conditions including uterine ruptures in pregnant women, cancers, skin infections, burns, and broken bones. In addition, these clinicians are helping to provide surgical and anesthesiology training for a team of Rwandan doctors and nurses, which will help ensure that in the long term, surgical care will be available for Rwandans by Rwandans.

“Many of our patients cannot travel to the capital for health care, so we are trying to create a system that can effectively care for patients who present with surgical emergencies,” says Dr. Nelson. “This process will take years, not months, but we are beginning to see improvements in the surgical services we can safely provide at Butaro Hospital.”

In April 2011, the Neonatal Special Care Unit opened. Since then, a team of doctors, eight specially trained nurses, and a row of incubators have treated 230 premature and severely sick infants weighing as little as 1.2 kg and as young as 29 weeks. Without access to these advanced medical services, nearly all of these babies would likely have died.

Caring for patients with mental health disorders has become a focus over the past year. With the arrival of PIH’s first psychiatrist in Rwanda, the district physicians and mental health staff have worked diligently to care for patients with mental disorders at Butaro, consistent with the Ministry of Health’s goal to decentralize psychiatric services rather than transfer patients three hours away from their families to the neuropsychiatric hospital in Kigali.

 

Partnerships key to addressing new challenges

And while there is much to be celebrated on the one-year anniversary, there is much more left to be done. Despite improvements in the quality of care at the community and district levels, chronic malnutrition persists. Despite a nearly 60 percent drop in child mortality, newborn deaths remain unacceptably high. And as life expectancy has increased for the community, more patients are being diagnosed with non-communicable diseases (NCDs) like hypertension and cancer. Preventing, treating, and curing NCDs on a wide scale is a new challenge to the country and the continent that will require resources, both financial and human, and new protocols and policies across the board.

	A view of Butaro Hospital. ©Iwan Baan

Partnerships will be a key to addressing these challenges. An exciting new partnership with the Jeff Gordon Children’s Foundation (JGCF), the Dana Farber Cancer Institute, and the Ministry of Health, will open Rwanda’s first cancer referral center at Butaro later this year, bringing world-class oncology care to the rural poor in Rwanda. The Butaro Center of Excellence in Cancer Care will feature an on-site pathology lab, an intensive care unit, surgical services, chemotherapeutic medications, and committed clinicians.

Partnerships will also be vital in working to reduce newborn deaths and improve neonatology care. In consultation with PIH/IMB and Children’s Hospital Boston, the Ministry of Health has designed national neonatal care protocols that draw on lessons learned from PIH/IMB’s neonatal programs. As part of the Ministry of Health plans, PIH/IMB’s facilities will become national models for neonatal care, and will train neonatal care providers and continue to develop innovative care strategies that reach beyond the hospital’s walls into the health centers and community.

PIH/IMB’s close partnership with the Rwandan Ministry of Health will be crucial to increasing and improving the services offered at Butaro Hospital. Impressively, the Government of Rwanda now contributes 48 percent of the hospital’s operating costs, which this year total $3.1 million. “The Republic of Rwanda has been the best of all partners: heavily engaged in every step of the way and assuming responsibility for Butaro’s maintenance and management,” says Dr. Farmer.

Underscoring all these new efforts is PIH/IMB’s mission to uphold the dignity of each patient. “My wish for the year ahead is to reach not only the expectations of our patients, but to reach their rights,” says Dr. Joel Mubiligi, District Clinical Director. “I want this hospital to be the example not only in terms of equipment capacity, innovations, and quality of services, but also in terms of caregiver-patient relationships in order to treat not only their bodies, but all their being, and to make a real change in their lives.”

These achievements of the past year and goals for the next do more than help heal patients. They show the community, the country, the region, and the rest of the world that superior care can and should be delivered not only in the West or in cities, but wherever there are sick people without access to care. In the poorest, most remote corners of the world, world-class health facilities can and do work.

Butaro Hospital at dusk. ©Iwan Baan

Watch CNN news coverage of Butaro Hospital.

Watch a video of PIH co-founder Dr. Paul Farmer discussing Butaro Hospital.