Four years ago, there was not a single doctor to serve the 400,000 people of a northern district of Rwanda.
Yet, on January 24, the rural Burera district will see the opening of not only its first hospital, but also one that has been described as “possibly the best hospital in central Africa.”
Built in just two years – in collaboration between Partners In Health, Rwanda's Ministry of Health, and the Clinton Foundation – the world-class, 150-bed Butaro Hospital represents a major milestone for quality health care not just for Rwanda but for the entire region.
Designed to naturally counter infection while promoting patient rights and dignity, the flagship facility will offer services rarely seen in rural settings: from a neonatal intensive care unit and three operating theatres to digital x-ray technology and an international-quality lab.
However, somewhat ironically, the campus-style facility will now form the hub of a new health system in the district designed specifically to reduce the once overwhelming need for hospital care for Burerans.
In a global model for rural health delivery, the partners have already created a system here that seeks to minimize severe illness through prevention, testing and treatment at village level, as well as nutrition, social interventions and a dramatically strengthened primary health care network. Fifteen village health centers have been dramatically upscaled by the partnership--including the physical reconstruction of two buildings--and are now being served by an army of 1,500 newly trained community health workers.
Earlier, PIH cofounder Dr. Paul Farmer said, “This sends a very clear message that high quality medical care can and must be delivered (in rural areas), with good institutions that fit into a broader network of institutions. For example, this big hospital is related to a series of health centers, and people working in the villages--community health workers who can refer to this institution.”
With at least two community health workers based in every village in the district, residents are visited regularly, and sometimes daily, to be assessed for signs of disease or malnutrition; treated and monitored for drug compliance; or accompanied to a clinic.
Dr. Peter Drobac, PIH country director in Rwanda, said the number of nurses per health center had been increased from three or four, to 12 or more, following a training and recruitment campaign, while many now had pharmacists and lab technicians as well.
“We aim to strengthen primary healthcare system at all levels of the system, starting with community health care,” he said. “We have trained and now support over 1,500 community health workers; a minimum of two in every village in the entire district, who are each day visiting their neighbors, to provide clinical care, make sure they take their medicines, screen children for malnutrition, and bring them in to the health centers or the hospital. So they are the eyes and ears who make sure people get the care they need.”
However, for those patients who do need emergency or intensive care, or medical referrals from the health centers, the new hospital will offer the kind of services normally seen only at a major teaching hospital--including teaching, itself. Orthopedic surgery, outpatient ophthalmology, gynecologic services, and an ear, nose and throat clinic will also be on site.
The Butaro Hospital was born out of chronic need in 2008, in a rural area that was the last of Rwanda’s 30 districts that was not served by a hospital. Just one of the tragic consequences people routinely faced in this community was that some women, or their newborn infants, died in childbirth, as they crossed Lake Burera on boats in efforts to reach the nearest hospital.
Partners in Health had already helped to pioneer a new rural healthcare model in two other districts, so the Rwandan government asked PIH to come to Burera, where we identified the hospital gap as a prime opportunity to demonstrate that world-class, high-level care could be delivered in the most rural setting.
PIH established a temporary 65-bed hospital at the site of an existing health center during the hospital's construction, where eight doctors and an ever-expanding team of newly trained nurses provided services never seen in the district. Hundreds of curious and joyful local villagers gathered outside this facility last year when quadruplets were successfully delivered, following an ultrasound examination that has astonished their mother.
Drobac said at least 12 full time Rwandan doctors would staff the new hospital, working alongside a rotation of western physicians, and that a recruitment drive for other staff next year would supplement a recent training campaign at the temporary facility. Having been hand-built by Rwandans, hospital construction is now finished, and Drobac said the hospital would likely be patient-ready by the New Year.
The completion of the hospital represents the culmination of a partnership to strengthen service delivery at all levels of the district health system. The collaboration between PIH and the Ministry of Health includes support for the rollout of the MOH’s national community health program, salary incentives to increase health care worker motivation, renovation of three district health centers and a temporary district hospital, and extensive training for health care workers at all levels of the health system.
Drobac said $1.4 million-worth of medical equipment--fully funded by the Ministry of Health--would be moved into place within weeks, including ultrasound units, ventilators, and incubators to handle the chronic problem of low birth weight infants.
“There has been a remarkable commitment shown by the MOH to provide funding for new, international-quality equipment,” he said. “The beauty of this is that, for instance, telemedicine becomes possible, which is key for such a remote facility.”
Drobac described the importance of the neonatal ICU as just one example of the value of the new services the hospital will offer: “Prematurity and low birth weight is incredibly common here because of malnutrition, malaria and other factors associated with poverty--even babies that come out full term look like preemies, and many of them die. Although we have incubators and other equipment, very simple things can be done to prevent this. We had the director of the neonatal ICU at Children's Hospital in Boston - a really internationally acclaimed expert--spending two months here in Rwanda developing protocols and training doctors and nurses.”
Patients and visitors will be struck by an unusual feature, beyond the multi-level campus design: a hospital entirely without hallways.
Conscious of the deadly threat posed by airborne infections like MDR-TB in hospital settings, the architectural team, Boston-based MASS Design Group, has sought to reduce enclosed spaces, like hallways, while creating a natural ventilation system that moves air up and away from patients.
Meanwhile, in an innovation drawn directly from the PIH “patient-first” philosophy, Butaro's beds will back onto central dividers in the wards, and not against the walls--giving each patient the simple dignity and pleasure of a view.
“Aside from being better from a patient flow standpoint, it's simply a more pleasant experience for a sick person in bed to stare at a beautiful courtyard or valley than staring at another person who is also sick,” said Drobac. “It’s part of what we call a 'dignification' approach.”
Farmer added, “I can't show you a double-blind study which proves that patients are better if they can see beautiful things--but I believe it.”