Dr. Agnes Binagwaho

Millions of lives saved by taking the time to listen

The story of how Rwanda has doubled life expectancy.

Bending the Arc tells the story of three friends who believed that poor people shouldn’t die because they didn’t have access to basic medical treatment and medication. It’s the story of how a few young people fought back against apathy and a global health system that didn’t facilitate real medical care. Their actions sent shock waves through an establishment that was allowing people to die unnecessarily.

One of the more remarkable stories captured in the film is the transformation of Rwanda from a center of tragedy to the home of one of the world’s most successful health systems. The 1994 Rwandan genocide claimed as many as one million lives in 100 days. In addition to the human cost, the genocide devastated an already poor country’s economy and infrastructure. To make matters even worse, Rwanda received less foreign aid following the tragedy than any other country in Sub-Saharan Africa. The country was written off.

Against all odds, Rwanda has emerged as a model of public health, achieving almost universal coverage and doubling life expectancy. It is now held up as an example for other developing countries such as Haiti and Peru, and it has been suggested that even the United States should learn from Rwanda.

What was the key to this transformation? In short, it was listening and insisting that others do the same. The country developed a plan that prioritized primary healthcare, community health workers, and data. The Ministry of Health regularly communicates with the population, studies results, and adapts programs as needed. Despite the lack of foreign investment following the genocide, Rwanda didn’t seek out charity or foreign aid at all costs. On the contrary, the country insisted that non-governmental organizations either stick to the plan or stay out of Rwanda.

In Bending the Arc, Dr. Agnes Binagwaho recalls attending a meeting of HIV/AIDS experts in New York, where she first met Dr. Paul Farmer, one of Partners in Health’s co-founders. “I was quite impressed because there were all so many knowledgeable people in that room,” she remembers. “But they were quite saying nonsense you know. And I say, ‘My goodness, if it is this, and we have to follow that, we will go nowhere.’”

Dr. Binagwaho and her colleagues didn’t need a lecture about what was wrong with the broken Rwandan health care system. They needed partners who would take the time to listen, and Dr. Farmer’s team was up for this approach. To put things in perspective, here are a few of the successes that have resulted from building a partnership focused on listening and learning:

  • More than 90 percent of the Rwandan population now has access to health care
  • Life expectancy has doubled
  • Infant mortality is down 70 percent since 2000
  • Rwandans see a doctor eight times more frequently than they did in 1999
  • 93 percent of eligible girls have been vaccinated against HPV and cervical cancer
  • 91 percent of HIV patients receive continuous care (compared to 57 percent in the U.S.)

To be sure, it’s tempting to oversimplify how Rwanda achieved these results. The reality is of course, complicated, but there are some standout lessons about what worked well.

For one thing, Rwanda put the emphasis on primary care. That may seem counter-intuitive given Sub-Saharan Africa’s urgent struggles with critical communicable diseases like HIV/AIDS, but having widespread access to primary care has made it possible to greatly reduce HIV and tuberculosis infection and death rates.

Rwanda currently funds about half of its health system with foreign aid, so outsiders do play a significant role. However, the country enforces a high level of transparency among its NGO partners, and insists that they integrate their efforts with its comprehensive strategy. These organizations, as well as the aid provided by foreign governments like the United States, do not dictate how healthcare functions in the country. Rather, they are integrated into a program that is ultimately informed by the Rwandan people.

The country has also historically done a good job of adapting its plan to the needs of the patients it is meant to serve. Despite premiums as low as two dollars and co-pays as low as 35 cents, the government found that the poorest Rwandans were priced out and not able to access healthcare. So in 2010, the government adjusted its priorities and began subsidizing premiums and co-pays.

The whole program leans heavily on an army of 45,000 community health workers, who provide in-home care and psychosocial support. That aspect of the plan is comparable to the accompaniment model used by Partners In Health, which has been scaled up nationally in Rwanda based on lessons gleaned from listening to patients in Haiti, Peru, and elsewhere.

Finally, data drives health policy decision-making in Rwanda to ensure that limited resources are used as effectively as possible. As Dr. Binagwaho has said, “You will not succeed in bringing up a strategy or policy that is not backed up by evidence.”

Without trying to reduce the complexity of how Rwanda achieved these results, it’s clear that listening has played a vital role.

Rwanda is still a poor country and it has a long way to go. Still, the nation is moving more quickly in a positive direction than its peers in the region. In fact, in terms of the sheer speed of its advancements, Rwanda greatly outpaces the U.S. Over the years, Dr. Farmer has brought students and educators from Harvard Medical School to Rwanda so they can learn more about the program. “This is a country that can teach a lot to other settings in the world, including the United States,” he has said. “Everything you see here has been done through collaboration and taking on problems.”

If we truly believe that health is a human right, we have to understand that listening to each other and learning from one another is the only way we’ll be able to realize that right for all.

This story was submitted as a guest post to AMPLIFY, a publication run by Global Health Corps.