The World Health Organization’s 2006 annual report estimated a global shortage of 2.4 million health service providers and of 1.9 million health management and support workers affecting primarily low-income countries.1 Such a shortage is associated with poor health outcomes and is, in great part, due to the inability of low-income countries to increase the size, to diversify the skills, and to improve the competency of the local health workforce through formal education and in-service training.1,2 Notably, Sub-Saharan Africa suffers from 25% of the global burden of disease, yet is served by only 4% of the global health workforce.1 Health professionals with adequate clinical and programmatic competencies are therefore essential to address the region’s evolving health challenges.3,4
Rwanda: Health, Health Workforce Shortage, and Vision 2020
Rwanda, which is about the size of the state of Maryland and has a population of approximately 11 million, is Sub-Saharan Africa’s most densely populated country and is in need of a large and well-trained health workforce. The ratio of health professionals to the general population in Rwanda in 2011 was only 0.72/1,000,5 well below the World Health Organization–recommended target of 2.3/1,000.1 Additionally, the majority of Rwandan physicians and nurses do not have formal postgraduate education, and although opportunities to specialize are expanding, they remain limited. Further, insufficient and outdated infrastructure and equipment, along with a shortage of lecturers and clinical mentors, have led to gaps in training and quality.
To begin to improve health outcomes and strengthen health service delivery in Rwanda, the government has prioritized economic and human development and has incorporated a strong equity agenda into the national development plan (published in 2000), known as “Vision 2020.” This plan has paved the way for Rwanda’s subsequent development achievements including robust economic growth and some of the steepest declines in premature mortality in recent history.6 A core component of this vision is the establishment of a large, skilled, and diverse health workforce to sustain and expand these achievements.
Rwanda’s formal educational programs confer advanced degrees including medical doctorates, postgraduate specializations for physicians, and diplomas for nurses and midwives. In-service training programs allow practicing health professionals to maintain or acquire new knowledge and skills. The Rwanda Ministry of Health (MOH) and Ministry of Education (MOE) work closely to develop these programs and align them to the needs of the health workforce through their respective national strategic plans. The MOH and MOE recently consolidated all health professional schools into a single College of Medicine and Health Sciences in Rwanda, which will allow resources and expertise to be more efficiently used, and avoid gaps and overlaps. Additionally, MOH senior administrators and clinicians practicing in the teaching hospitals dedicate 20% of their time to teaching and mentoring trainees from the health professional schools in health service delivery and clinical care. Finally, the MOH has also established the Human Resources for Health Working Group to best integrate contributions of donor countries, nongovernmental organizations (NGOs), and academic institutions to formal educational and in-service training programs.
Role of International NGOs and Academic Institutions in the Capacity Building of Health Professionals in Rwanda and Other Low-Income Countries
Academic partnerships between medical schools and academic medical centers (teaching hospitals) in resource-rich countries and in low-income countries are increasing in number and expanding in scope. Regrettably, this welcome development has often led to less-than-optimal outcomes, in which academic institutions from host countries face most of the administrative and logistical challenges, while faculty and trainees from donor academic institutions benefit disproportionately from training and research collaborations.7–12 To achieve true reciprocity, such collaborations must be driven primarily by the priorities of host institutions; build local capacity for training, research, and clinical care; and ultimately create value for the local population by improving the depth, breadth, and quality of health service delivery.13–17
In this article, we describe the formal educational and in-service training programs supported by a partnership launched in 2005 by the Rwandan MOH along with the U.S. NGO Partners In Health (PIH), Harvard Medical School (HMS), and Brigham and Women’s Hospital (BWH). The partnership has since expanded to include the Faculty of Medicine and the School of Public Health in Rwanda, and other HMS-affiliated academic medical centers. The partnership has prioritized local ownership and—with the ultimate goals of strengthening health service delivery and achieving health equity for poor and underserved populations—it has helped the Rwanda MOH and academic institutions establish new or strengthen existing formal educational programs (conferring advanced degrees) and in-service training programs (fostering continuing professional development) that target the local health workforce. HMS and BWH have also benefited from the partnership and expanded the opportunities for training and research in global health available to their faculty and trainees.
To our knowledge, there is a relative lack of experience-driven reflections on long-term North–South academic partnerships that seek both to strengthen health service delivery by building health workforce capacity in host countries and to simultaneously expand faculty and student engagement in global health within donor institutions. By analyzing the strategic priorities and the achievements of the Rwandan MOH-HMS-BWH-PIH partnership, we seek to share best practices that might be applicable in other countries or for other academic institutions hoping to establish similar partnerships.
Description of the Partnership
Strategic priorities and framework
In 2005, the Rwandan MOH invited PIH to support the scale-up of comprehensive HIV care in the underserved rural health districts of southern Kayonza, Kirehe, and Burera (Figure 1). Shortly after the partnership’s launch, leaders of both parties agreed on the following strategic priorities:
1. Use the scale-up of the HIV prevention and treatment program as the foundation for the development of a comprehensive health system in rural Rwanda;
2. Use the accompaniment model (PIH’s term for financial, technical, and implementation support provided to a host country by PIH);
3. Support quality improvement of existing clinical programs and promote innovation in specialty areas currently neglected in the global health practice;
4. Prioritize formal education and in-service training of Rwandan health professionals to establish long-term sustainability;
5. Support the establishment of a research, monitoring, and evaluation infrastructure to generate new knowledge in health service delivery;
6. Leverage the affiliations of PIH to deploy faculty, investigators, and clinicians from HMS and BWH to work in rural Rwanda.
These six strategic priorities were initially informed by Rwanda’s Vision 2020 and by the work of PIH, BWH, and HMS in Haiti, and they were further refined in two of the MOH’s main policy documents (the 2008 District Health System Strengthening Framework and the 2009 Health Sector Strategic Plan), both of which emphasized the need to address the short age of health professionals in Rwanda. The guiding framework of the partnership is to leverage all the training and research collaborations launched among the partners since 2005 to strengthen health service delivery and, in turn, to promote health equity. Therefore, formal educational and in-service training programs have favored the acquisition of competencies (rather than knowledge) relevant to specific challenges that local health professionals encounter at the point of care. Further, U.S. and Rwandan investigators have conducted research in implementation and health system strengthening rather than more traditional biomedical fields (Figure 2).
Formal educational and in-service training programs
Over the past nine years, the MOH has established partnership-supported district hospitals as national centers of excellence for in-service training in a wide range of specialty areas (Table 1). Specifically, in the northern district of Burera, the MOH, with support from PIH and the Clinton Health Access Initiative, inaugurated the Butaro District Hospital in January 2011. This modern facility has brought high-quality clinical care to a district of 400,000 people who previously did not have a functional hospital. The Butaro District Hospital now serves as a flagship center for health workforce capacity building and health service delivery innovation for Rwanda.18
Faculty from HMS and HMS-affiliated academic medical centers have supported local trainers in the development and implementation of standardized clinical guidelines tailored to address Rwanda’s epidemiology and to achieve the health system’s goal of closing the equity gap in health service delivery between urban and rural populations, men and women, and people who earn higher and lower incomes. New curricula have been developed specifically for different cadres of health professionals, including not only physicians and nurses but also community health workers and allied health professionals; these curricula are based on newly defined best clinical practices in a wide range of specialty areas. Additionally, ongoing monitoring and evaluation have helped to determine and improve the quality of the formal educational and in-service training programs being implemented (Table 1). To illustrate, in January 2012, physicians and nurses from the Dana Farber Cancer Institute and BWH became involved in a variety of in-service training programs related to noncommunicable disease and cancer prevention and treatment. As a result, at least one physician and nurse from over 20 health facilities in Rwanda received basic cancer training at Butaro Hospital in 2012. Additionally, approximately two nurses and laboratory technicians per district hospital were trained in the administration of chemo therapy, basic histopathology, and/or management of noncommunicable diseases.
The partnership has emphasized point-of-care mentoring, and this practice-based supervision has offered an alternative to the dominant paradigm of short, expensive, and financially incentivized workshops with unclear impact on therapeutic practice.19 For example, in southern Kayonza and Kirehe, the partnership implemented a mentoring and supervision program involving at least two primary care nurses in each of 21 rural health centers; the program is currently under consideration by the Rwanda MOH for nationwide implementation.
Academic ties with Rwandan health professional schools have allowed partnership-supported districts to strengthen formal educational programs offered by these institutions (Table 1). Health facilities in the health districts of southern Kayonza, Kirehe, and Burera regularly host Rwandan medical and nursing students, and over the past four years these local institutions have provided mentoring and supervision to 8 students earning master’s or doctoral degrees in public health and to 15 physicians specializing in family and community medicine.
In February 2012, the MOH, PIH, and HMS launched the first annual Global Health Delivery course for health professionals in Rwanda and around the region.20 The weeklong course addresses the effects of politics, health system governance, economic constraints, and other social factors on health in low-income countries. Previously taught only on Harvard’s campus, the course now brings HMS faculty to Rwanda, offering health sector leaders and innovators the opportunity to share and build on best practices for implementation and health system strengthening through a case-based teaching methodology.
Lastly, the establishment of long-term ties with Rwanda has facilitated the engagement of HMS and BWH with the MOH for broader training and research collaborations informed by strategic priorities similar to those of the partnership. For example, HMS and BWH (together with other HMS-affiliated academic medical centers and the Harvard School of Dental Medicine) have joined a consortium of 23 U.S. academic institutions participating in Rwanda’s Human Resources for Health Program. Led by the Rwanda MOH and funded by the U.S. government, this seven-year initiative seeks to strengthen the whole of Rwanda’s formal health professional education infrastructure by establishing new programs in global health and further developing existing schools of allied health through the contribution of faculty from top U.S. academic institutions.21
Over the past nine years, HMS and BWH have also benefited from the partnership: The partnership has expanded opportunities for international deployment for Harvard and BWH faculty and students, generated new knowledge in global health through research and scholarship, and consolidated such knowledge in curricula and other educational materials.22,23 For example, since 2007, several HMS students, BWH medicine and surgery residents, and students from Harvard-affiliated institutions have pursued their clinical or research internship in Rwanda.
The long-term engagement of PIH, HMS, and BWH in Rwanda, paired with orientation training prior to departure, and the ongoing presence of U.S. faculty in country, has allowed newly deployed and rotating HMS and BWH faculty and students to adapt to and reflect on the realities and challenges of working in a resource-poor setting. Simultaneously, two Rwandan health professionals per year have attended the Global Health Effectiveness course at the Harvard School of Public Health, and many others have traveled to the United States to attend conferences, workshops, and in-service training programs within their area of expertise.
Rwanda has achieved major improvements across a number of health indicators (HIV, tuberculosis, and malaria mortality; maternal mortality; and under-five mortality).6 The country’s ability to maximize the impact of partnerships such as the one described in this article has played a key role in these improvements. In districts supported by the partnership (which were the most remote and underserved), initial health indicators were significantly worse compared with the rest of the country but have since been closing in on the national average.24,25 Additionally, preliminary evidence has demonstrated that access to and the quality of health services delivered in partnership-supported health centers and communities improved between 2009 and 2013 with enhanced health professional mentoring and supervision,26,27 better infrastructure and equipment, novel electronic medical record systems, and other health-system-strengthening inter ventions.27 Lastly, the HIV prevention and treatment program supported by the partnership showed higher retention rates and a greater increase in CD4 counts after initiation of antiretroviral therapy when compared with control programs in other health districts.28,29
The budget for the partnership has been approximately $15,000,000 per year. The funding is from a combination of foundation and research grants, private donations, and direct funding from PIH, HMS, and BWH. While the annual budget for the partnership has remained more or less constant over the years, there has been a shift in the focus of spending among the partners. The MOH has taken ownership of the majority of health facility operational costs while PIH has shifted spending mostly towards health service delivery innovation (and the associated training and research activities). For example, the Rwanda MOH now covers 75% of operational costs at Butaro District Hospital (an increase from an initial 25% when the hospital was first inaugurated in 2011), and PIH covers the remaining 25%.
Over the past nine years, the partnership described in this article implemented several “best practices” that other low-income countries seeking to strengthen formal educational and in-service training programs for local health professionals might find relevant (List 1).
List 1 Generalizable Best Practices Used in the Partnership Among the Rwandan Ministry of Health, Partners In Health, Harvard Medical School, Brigham and Women’s Hospital, and Leading Rwanda Academic Institutions, 2005–2013 Cited Here...
Close relationship and clear division of roles among different partners
* Ministry of Health: leadership, identification of priorities for health service delivery and health workforce capacity building, implementation, health service delivery
* Nongovernmental organization: implementation, health service delivery, provision of financial and technical assistance through “accompaniment”a
* Academic institutions: provision of training, research, and clinical expertise
Health service delivery framework and health equity agenda at the core of all the partnership training and research collaborations
Emphasis on mentoring and supervision at point of care rather than on didactic classroom teaching
Establishment of enduring, sustainable formal educational and in-service training infrastructure in host country
Benefits distributed equally among partners
* Host country: capacity building of health professionals, improved quality of care in partnership-supported districts
* Donor country: development availability of global health academic programs opportunities for faculty and trainees, generation of new knowledge in health care service delivery of global relevance
aAccompaniment is Partner In Health’s term for financial, technical, and implementation support.
Close relationship and clear division of roles among partners
First, the cornerstone of the partnership has been the close relationship and the clear division of roles and responsibilities among the parties involved. The MOH has provided leadership and governance and has identified priorities for both health service delivery and (in partnership with local academic institutions) health workforce capacity building. PIH has provided financial, technical, and implementation support through accompaniment and has helped engage HMS and BWH effectively.
In our opinion, NGOs (such as PIH) are often optimally placed to mediate between the health sector and academia in low-income countries; however, they are not always necessary. Other partnerships, such as Kenya’s Academic Model Providing Access to Healthcare, have been quite successful in aligning health service delivery with training and research without using NGOs as “effector arms.”14 Further, Rwanda’s Human Resources for Health Program, which does not involve NGOs, requires participating U.S. faculty to practice in local hospital wards and health centers, thereby providing more effective mentorship and supervision to local trainees.21
A strong health service delivery framework and a clear equity agenda
Second, a health service delivery framework and a health equity agenda have been at the core of all the partnership training and research collaborations. Rwanda’s vision, articulated in Vision 2020, has laid a strong foundation for the partnership. PIH in turn has facilitated the translation of such vision into practice (in part by drawing on lessons learned from its work in Haiti). The partnership has worked to leverage Rwanda’s internal partners and other U.S. academic partners strategically and effectively to address critical gaps in health professional formal education and in-service training and to generate new knowledge in implementation and health system strengthening.
Point-of-care training through mentoring and supervision
Third, the partnership has emphasized mentoring and supervision at point of care and—rather than new knowledge—the acquisition of competencies.26,27 A critical mass of three to four full-time HMS and BWH faculty members (each deployed for at least 11 months within a year) provide mentorship and supervision (along with additional Rwandan and part-time U.S. faculty). These faculty oversee Rwandan trainees and U.S. students rotating through each of the three partnership-supported districts. The development of context-specific standardized clinical guidelines (which optimize the allocation of locally available resources and simplify treatment options without sacrificing quality of care), as well as the creation of competency-based curricula (which help enact those guidelines), has also helped address the ethical challenges faced by local health professionals (and by U.S. faculty and students in Rwanda).
Enduring, sustainable training infrastructure
Fourth, the partnership has differed from short-term training missions and instead sought to establish an enduring and sustainable formal educational and in-service training infrastructure in Rwanda. Rwanda’s strong leadership and governance have been central to the partnership’s achievements; however, the partnership has also directly contributed to building local capacity in leadership and governance and, as a result, has further enhanced local ownership and sustainability. PIH, HMS, and BWH (together with local academic institutions) have in fact devoted most resources and expertise to driving innovation in health service delivery and to training local health professionals as leaders, innovators, and clinicians. Simultaneously, the MOH has gradually taken ownership of implementation and operational costs when innovation has moved from an early phase to national scale-up.
Fifth, the partnership has prioritized reciprocity and bilateral innovation. Not only local trainers and trainees but also U.S. faculty and students have benefited from enhanced educational and in-service training opportunities. Further, both U.S and Rwandan partners have participated in mutually beneficial training and research collaborations.
Growth and Next Steps
The knowledge and curricula generated by the partnership have not remained limited to Rwanda; rather, the wisdom and materials have informed the work of PIH, HMS, and BWH, strengthening their ability to “accompany” local partners and train health professionals from Haiti and Peru to Russia and the United States.30,31 Additionally, PIH is now supporting sister NGOs in several low-income countries (Burundi, Liberia, Mali, Nepal, and Togo) to establish partnerships similar to that established in Rwanda and to engage (with varying degrees of depth and breadth) academic institutions through the lens of health service delivery. At the same time, the Rwandan MOH has used the platform generated by the Global Health Delivery course to train health sector leaders and innovators from other countries in the region. In parallel, a large body of scientific literature generated by the partnership over the past nine years (always featuring Rwandans among the lead authors) has consolidated, disseminated, and shared with the international community much of this critical knowledge.
A Blueprint for Global Health Equity
The partnership described in the article has successfully linked the traditional strengths of U.S. academic institutions in training and research to an NGO engaged with the public sector in health service delivery. The role that HMS, BWH, and other HMS-affiliated academic medical centers have played in the partnership can illustrate for other U.S. academic institutions how to channel the innovation, creativity, resources, and expertise of academia toward the pursuit of global health equity. The proliferation of similar partnerships would allow low-income countries to build local health workforce capacity and would allow partner medical schools and academic medical centers in resource-rich countries to strengthen their own formal global health educational and in-service training programs—while, at the same time, generating new knowledge in health service delivery of potential relevance to both host and donor countries. The partnership framework is not entirely unique to Rwanda, nor to PIH, HMS, or BWH. Other low-income countries, NGOs, and U.S. academic institutions have already adopted (or have developed in parallel) aspects of it.14 Additional low-income countries seeking to build health workforce capacity may have to adapt the breadth, depth, and timeline of their formal educational and in-service training programs to their unique circumstances, but Rwanda, once one of the poorest, disease-ridden countries in the world, provides a valuable example of the potential successes that lie ahead if best practices are adopted and implemented.
Acknowledgments: The authors express sincere gratitude to many who have built this partnership and contributed to research for the present article. They would especially like to thank Brienna Naughton, Cassia van der Hoof Holstein, Kara Galer, Jill Hackett, Celia Reddick, Mieke Visser, Maaike Flinkenflögel, Neo Tapela, Gedeon Ngoga, Karen Finnegan, Rebecca Weintraub, Ira Magaziner, Pascal Bijleveld, and Djordje Gikic.
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