The Dartmouth Center for Health Care Delivery Science

Lessons from Rwanda

The key to sharing the best practices of an innovative, successful national health care system? Making sure that research is available to everyone, everywhere.

After 1994, following the brutal genocide that killed nearly a million people and devastated Rwanda’s healthcare workforce and facilities, most international observers assumed that the tiny central African country would get stuck in a hopeless cycle of poverty and disease. A year after the genocide, nearly 80 percent of the population lived below the poverty line. The life expectancy of the average Rwandan was just 30 years.

What happened since then has defied all expectation — the country’s health care and service delivery have steadily improved. Following major health system reforms since the genocide, deaths from HIV/AIDS, tuberculosis, and malaria have dropped by 80 percent; maternal mortality has dropped by 60 percent, and life expectancy has doubled — all at an average annual health care cost of $55 per person. The country’s poverty rate has fallen below 45 percent and continues to drop. Under the leadership of its Minister of Health, Dr. Agnes Binagwaho, Rwanda has created a potential model for the rest of Africa — with important lessons for the developed world, as well.  “The Fierce Urgency of Now”

Pinch Point: Need for research support to policymakers given time-intensive management and reporting duties among senior policymakers.

Opening: Creation and funding of special TDC Fellowships to assist researchers in Rwanda’s Ministry of Health. Former Dartmouth student Cameron Nutt ’11 has worked for Minister Binagwaho on studies addressing pediatric HIV, multidrug-resistant tuberculosis, cervical cancer, and health workforce capacity.

Pinch Point: Limited reader access to leading medical journals, restricted by cost of subscriptions and reprint fees.

Opening: Actively advocate for “open-access” publication, which shifts revenues from subscription and user fees toward “author fees” paid by the submitting research teams. The majority of studies TDC undertakes with Rwandan partners are published in journals with strong open-access policies.

Opening: Actively advocate for the waiver of author fees from research teams in under-resourced countries.

Pinch Point: Information in medical journals confined to scientific and medical communities or confined to readers in the U.S. and western Europe.

Opening: Rwanda’s Ministry of Health and TDC have cultivated relationships with open access journals respected by global health policymakers, and with editors who realize the importance of true partnership in international research collaborations.

Opening: Place advocates in positions of influence. Dr. Agnes Binagwaho sits on the international advisory board for the Lancet Global Health journal, on the editorial board of the Journal of Health and Human Rights, and on the editorial board for the Public Library of Science. TDC Director Al Mulley sits on the editorial board of Health Expectations.

For Rwanda’s best practices to spread beyond its own borders, though, a sequence of circumstances has to play out. The service delivery needs to be linked with rigorous, well-designed research. That research needs to be published in respected, peer-reviewed journals. The journal articles need to be read by scientists, health care professionals, and policy-makers in other countries. Each step in the process is fraught with barriers that have led to major global inequalities in scientific publishing.

“When faced with a treatable disease, where you live shouldn’t determine if you live.”

The world’s premier peer-reviewed medical literature — its authorship, publication, and access — has long been controlled by western cultures. A recent study showed that just six percent of the articles published in leading medical journals in a calendar year included a single author or co-author from a developing country. At the same time, the business model sustaining those journals has depended on expensive subscription fees paid by libraries and reprint fees paid by individual users — severely limiting access for readers in Africa and other low-resource settings.

The Dartmouth Center for Health Care Delivery Science has been a partner in helping Rwanda’s health experts address each of those historical challenges (see chart), and the ramifications are profound: Fully opening access to peer-reviewed literature will not only help spread the successful practices coming out of Rwanda, it will introduce people everywhere to sound research and evidence-based delivery outcomes wherever they occur. And — importantly — developing-world research in leading journals will reach beyond the medical community into policy-making and mainstream media.  A November 2012 article detailing Rwanda’s success, for instance, co-authored by TDC-sponsored research fellow Cameron Nutt and Dartmouth alumna Claire Wagner, appearing in the medical journal BMJ (formerly British Medical Journal), led to thought-provoking features in the United States in The New York Times and The Atlantic. Those publications, with large, educated audiences, helped put Rwanda’s health care success story on the map.

“In the end,” says Cameron Nutt, “the task of open access is to produce original research, and be part of the conversation in the scientific community, and engage the public. That general media piece is important. The long-term goal is to create a social movement for people who believe that, when faced with a treatable disease, where you live shouldn’t determine if you live.”

Farmer PE, Nutt CT, Wagner CM, et al. (2013). “Reduced Premature Mortality in Rwanda: Lessons from Success” BMJ346(f65): 20-22.