The movement toward universal health care is growing—no matter the setting.
Two new studies highlight incredible improvements in child and maternal health in Rwanda and Madagascar in recent years, showing repeated success, in very different environments, for Partners In Health’s ground-up model of building health systems and supporting universal care.
Deaths of children younger than 5 dropped by nearly 20 percent in just two years in a poor, rural district in Madagascar—despite the island nation having the world’s lowest public health spending, per capita. Under-5 mortality in Ifanadiana District dropped from 104 deaths per 1,000 live births in 2014, to 84 per 1,000 in 2016.
A similar transformation happened in Rwanda, which has seen a nationwide reduction in child mortality. This reduction was very notable in a region of about 400,000 people in Eastern Province, where Rwanda's government worked in collaboration with PIH. Deaths of children younger than 5 dropped 60 percent between 2005 and 2010 in the region, which includes Kirehe District and southern Kayonza District. Specifically, under-5 mortality fell from nearly 230 deaths per 1,000 live births in 2005, to about 83 per 1,000 in 2010.
Both studies also showed corresponding increases in births that occurred in public health facilities, rather than mothers’ homes; in prenatal care visits; and in postnatal care visits. All three of those gains represent lifesaving improvements for new and expectant mothers.
While Rwanda has been boosted by strong government support and a vast infusion of international resources since its 1994 genocide, Madagascar has been politically unstable and largely forgotten by the international donor community.
Global health nonprofits PIVOT, in Madagascar, and Inshuti Mu Buzima, as PIH is known in Rwanda, led the efforts, in partnership with each country’s Ministry of Health.
“The positive health outcomes in both Rwanda and Madagascar document our collective progress in reinforcing universal coverage, as both a moral imperative and an achievable reality,” said Dr. Paul Farmer, PIH co-founder and chief strategist, and a co-author on the Rwanda study. “PIH and PIVOT, in partnership with the Harvard Medical School Research Core and its affiliated faculty, are charting stronger, more equitable, mechanisms for improved care delivery.”
A leader of that affiliated faculty is Dr. Megan Murray, who also is director of research for PIH and an example of how the teams behind the studies are interconnected.
PIVOT is a mission partner of PIH, and was founded in 2013 by Drs. Michael Rich and Matthew Bonds. Both doctors were leading PIH’s work in Rwanda between 2005 and 2010, and later applied lessons from those years when starting work in Madagascar.
Before they began that work in 2014, through PIVOT, questions arose in global health circles about whether a community-based, long-term model for building a health system could succeed in a southern Africa nation like Madagascar, which didn’t have strong government resources like Rwanda.
PIH and its partners have heard those kinds of doubts before. Similar questions arose years ago, when PIH began working toward expanding its model from Haiti and Peru to African nations including Rwanda.
Dr. Joia Mukherjee, PIH’s chief medical officer, said questions about whether Haiti and Rwanda were exceptions to the usual barriers facing public health improvements are not helpful, ultimately, for conversations about creating a real, viable model for universal care.
“What is helpful is to say: What can we learn?” Mukherjee said. “Why has Rwanda been so successful, and what pieces of the model are portable and can be adapted to other settings?”
PIH began working in Rwanda in 2005, at the invitation of the Ministry of Health. PIH’s initial efforts were focused in southern Kayonza and Kirehe districts, which had some of the worst health outcomes in the country, including high child mortality rates.
Actions included renovations of health facilities; recruitment and training of local health staff; development of a medical record system; increasing child vaccinations and prenatal care for pregnant women; financial support for patients; and implementation of a community health worker system to help patients with HIV, tuberculosis and other chronic conditions, through daily home visits.
Professor Agnes Binagwaho is a senior author on the new Rwanda study, and was Rwanda’s Minister of Health from 2011 through 2016. She also is on the faculties of both Harvard and Dartmouth Medical Schools, and is the vice chancellor of the University of Global Health Equity, a Rwanda-based university and PIH initiative that trains global health professionals from across the globe. “Through Rwanda's commitment to a universal right to health, we have continued to witness transformation that has rendered our country's health system an example for not only Africa, but for the world,” she said. “We embrace the shared vision and work of our partners in Madagascar. Together, we can pave the way to inclusive health systems that advance equity and health for all people.”
About 1,600 miles south and across the Mozambique Channel, the island nation of Madagascar has a population of about 25 million, with low rates of HIV but significant health priorities including malnutrition, maternal health and tuberculosis.
Results in the new Madagascar study cover PIVOT’s work from 2014-16, in the rural district of Ifanadiana, and represent the organization’s first batch of data-driven outcomes.
Dr. Alishya Mayfield, senior clinical advisor on strategy for PIH, worked with PIVOT as a consultant for two years, and frequently traveled to Ifanadiana between 2015-17.
“The challenges that PIVOT faced when they started working in Ifanadiana District in rural Madagascar were similar to the challenges that PIH has faced in most of the countries we’ve worked in,” Mayfield said. “They had some of the worst child and maternal health outcomes in the country.”
Mayfield said PIVOT took steps similar to steps PIH has taken in several countries, such as developing human resources by training and retaining staff, improving public health facilities and infrastructure, building reliable stocks of essential medicine, and reducing financial barriers to care. PIVOT and Ministry of Health teams worked primarily with four health centers and the district’s one hospital.
In addition to fewer deaths of young children, they also saw a reduction in wealth-related inequalities, while overall use of the health system tripled.
PIVOT and the ministry also developed the first public ambulance network in Madagascar.
"A lot of these health centers in Ifanadiana are very remote. It's quite hilly, it can be dense jungle, there are large rivers, they have flooding and big storms, so it's difficult to get to a health care facility, for a lot of people,” Mayfield said. “So, early on they set up an ambulance system, and they worked with health centers they weren’t supporting to have a mechanism where those facilities could contact PIVOT and say, ‘We have a woman who's going into labor and she's having some complications,’ or, ‘We have an acutely ill child we needs a higher level of care.’”
The network includes designated meeting points on local roads. Patients whom an ambulance can’t reach directly can go to a meeting point and be picked up in emergencies.
“That's part of how they had a larger, district-wide impact, even while focusing on a small number of health facilities,” Mayfield said.
She added that the majority of health staff put in place through PIVOT are Malagasy.
“I think that has profound ripple effects over time, when you build capacity of the local staff,” Mayfield said. “And once the word gets out that you’re providing better care, and that services are being offered at no charge to people who can’t afford them, then more and more people come to the facilities for care.”
The success of that model is spreading beyond PIH and PIVOT sites.
Mukherjee said shared lessons from empowering community health workers and strengthening care are also reflected in Mali, where health nonprofit Muso used a community-based model to drop child mortality from 154 deaths per 1,000 children to seven between 2008 and 2015. Those findings also were published by BMJ Global Health, in March.
“We have many groups around the world that we support,” Mukherjee said. “This is not an isolated phenomenon.”
Rich said the collective results are realizing a fundamental PIH vision, of working to achieve universal care.
“I think, all along, the overall goal of PIH has been to create a movement in global health equity,” Rich said.
PIVOT Co-CEO Tara Loyd agreed.
“PIVOT and Partners In Health ascribe to the same, unshakable philosophy – that no one should die of preventable illness,” said Loyd, who worked for PIH in Lesotho and Malawi before helping launch PIVOT in 2013. “Partnering with communities and governments, we have seen that it is possible to transform health care in some of the most challenging environments in the world.”
Rich added that while, globally, child mortality has fallen by half over about 25 years, Rwanda’s corresponding drop took just five years, in the catchment areas identified by the new study.
“We actually can make a difference in the world and solve these problems,” he said.
Mukherjee described PIH as, “uniquely positioned to support countries in the delivery of care, to progressively achieve universal health coverage,” which is one of the United Nation’s Sustainable Development Goals.
“A lot of people are talking about financing of universal health coverage. Many fewer people are talking about the delivery of care,” Mukherjee added. “We feel like we have something really important to add about delivery of care.”
Bonds said the studies reflect the broad scale and impact of PIH’s global work to improve health care for all. That work is poised for future collaboration between PIH, PIVOT and other partners.
"This is equally about the culture of the global health movement and the practical tactics for impact,” Bonds said. "We will continue to build systems of care that work for everyone and prove that it’s possible and effective to provide care at the last mile. These papers have shone a light on the cumulative scale of what we have already accomplished, and the promising work we have yet to do.”