correspondence
The Human Resources for Health Program in Rwanda To the Editor: Binagwaho et al. (Nov. 21 issue)1 emphasize physician-oriented, even “subspecialty,” expertise in their well-meaning human resource approach for Rwanda. However, this approach may import the expensive, Western, compartmentalized, highly curative model and jeopardize more effective basic health interventions. The commendable advances in Rwanda came predominantly from simple, widely delivered interventions: immunization, bed nets to prevent malaria, improved nutrition and contraception,2,3 and community-based treatment for malaria, pneumonia, and diarrhea.4 Yet, huge basic health challenges remain. Only 4.5% of houses have running water.3 One of five infants older than 6 months of age has diarrhea in any 2-week period, and only 29% receive oral rehydration salts. The duration of exclusive breast-feeding is insufficient, and 44% of children have stunted growth.3 The need for contraception remains high.3 The program to introduce new vaccines in Rwanda is highly ambitious. Moreover, newborn mortality, now 50% of infant mortality,3 calls for better maternal nutrition, strengthened antenatal care, simple resuscitation, chlorhexidine for cleansing the umbilical cord, and community-based sepsis treatment. Human resource support should prioritize public health specialists, managers, supervisors, clinical officers, sanitation specialists, specialists in behavior change, logisticians, and community outreach personnel. We commend the broader health system support provided by the U.S. President’s Emergency Plan for AIDS Relief, as mandated by U.S. congressional legislation.5 However, basic, widely applied public health measures should remain foremost. James D. Shelton, M.D., M.P.H. U.S. Agency for International Development Washington, DC [email protected]
Stephen Hodgins, M.D. Save the Children Washington, DC The views expressed in this letter are those of the authors and do not necessarily represent those of the U.S. Agency for International Development.
Dr. Shelton reports working for USAID, which provided partial support for the research described in the article. No other potential conflict of interest relevant to this letter was reported. 1. Binagwaho A, Kyamanywa P, Farmer PE, et al. The human
resources for health program in Rwanda — a new partnership. N Engl J Med 2013;369:2054-9. 2. National Institute of Statistics of Rwanda. Rwanda: standard demographic and health survey 2005. Rockville, MD: ICF International (http://measuredhs.com/what-we-do/survey/ survey-display-252.cfm). 3. Idem. Rwanda: standard demographic and health survey 2010. Rockville, MD: ICF International (http://measuredhs.com/ what-we-do/survey/survey-display-364.cfm). 4. Farmer PE, Nutt CT, Wagner CM, et al. Reduced premature mortality in Rwanda: lessons from success. BMJ 2013;346:f65. [Erratum, BMJ 2013;346:f534.] 5. Barbiero VK. Fulfilling the PEPFAR mandate: a more equitable use of PEPFAR resources across global health. Global Health Sci Pract 2013;1:289-93. DOI: 10.1056/NEJMc1315971
The Authors Reply: Does the right to health encompass only interventions that might be termed “low-hanging fruit,” such as oral rehydration salts and (some) vaccines? What if the same mother receiving such services presents with obstructed labor or the same child receives a diagnosis of Burkitt’s lymphoma? These are central questions for global health. In our article, we presented a new partnership for health workforce development in Rwanda, while noting that the approximately 45,000 community health workers in the country remain the backbone of the health system as primary care is strengthened further. Community-based primary care indicators in Rwanda before the launch of the Human Resources for Health Program show the concrete achievements resulting from investments in decentralized primary care provision at the village level in Rwanda (Table 1).1-4 We agree with Shelton and Hodgins that community-based care offers the highest standard of care for many conditions across countries,5 but we argue that these services must be supported by health centers and linked to hospitals to bridge gaps in health systems. Until 2013, Rwanda had not a single on cologist (but plenty of cancer) and just 12 general surgeons (but strikingly high mortality from conditions that require surgery). Most health workers trained by the new program in
n engl j med 370;10 nejm.org march 6, 2014
The New England Journal of Medicine Downloaded from nejm.org at NEW YORK MEDICAL COLLEGE on August 11, 2015. For personal use only. No other uses without permission. Copyright © 2014 Massachusetts Medical Society. All rights reserved.
981
correspondence
Table 1. Community-Based Primary Care Indicators in Rwanda before the Launch of the Human Resources for Health Program.* Indicator
Value
Reference
Combined health-service-provider density of physicians, nurses, and midwives per 1000 population (no.)
0.84
Farmer et al.1
WHO minimum recommended providers per 1000 population (no.)
2.3
WHO2
Contraceptive use among women 15–49 yr of age (%)
52
WHO3
Infants exclusively breast-fed for first 6 mo of life (%)
85
WHO3
Prevalence of stunted growth among children younger than 5 yr of age (%)
44
WHO3
Vitamin A supplementation among children younger than 5 yr of age (%)
93
WHO3
Population using improved drinking-water sources (%)
69
WHO3 WHO4
Immunization coverage rates (%) For 1-yr-old children Bacille Calmette–Guérin
99
Diphtheria–tetanus–pertussis
99
Measles
97
Polio
98
Hepatitis B
98
Haemophilus influenzae type B
98
Pneumococcal conjugate
98
Rotavirus
99
For adolescent girls Human papillomavirus
97
Deaths Child deaths per 1000 live births (no.)
54
WHO3
Decrease in annual child mortality, 2000–2011 (%)
11
WHO3
Neonatal deaths per 1000 live births (no.)
21
WHO3
Decrease in annual neonatal mortality, 2000–2011 (%)
6
WHO3
340
WHO3
Maternal deaths per 100,000 live births (no.) Decrease in annual maternal mortality, 2000–2010 (%)
9
* WHO denotes World Health Organization.
Rwanda will indeed be nurses and managers, but investing in essential specialist capacity is also a key step on the path to universal health coverage. Agnes Binagwaho, M.D. Ministry of Health Kigali, Rwanda [email protected]
Paul E. Farmer, M.D., Ph.D. Harvard Medical School Boston, MA Since publication of their article, the authors report no further potential conflict of interest.
982
1. Farmer PE, Nutt CT, Wagner CM, et al. Reduced premature
mortality in Rwanda: lessons from success. BMJ 2013;346:f65. [Erratum, BMJ 2013;346:f534.] 2. World health report 2006: working together for health. Geneva: World Health Organization, 2006 (http://www.who.int/whr/2006/en). 3. World health statistics 2013. Geneva: World Health Organization, 2013 (http://www.who.int/gho/publications/world_health _statistics/2013/en). 4. Rwanda: WHO and UNICEF estimates of immunization coverage: 2012 revision. Geneva: World Health Organization, 2012 (http:// www.who.int/immunization/monitoring_surveillance/data/rwa.pdf). 5. Farmer PE. Shattuck Lecture: chronic infectious disease and the future of health care delivery. N Engl J Med 2013;369:2424-36. DOI: 10.1056/NEJMc1315971 Correspondence Copyright © 2014 Massachusetts Medical Society.
n engl j med 370;10 nejm.org march 6, 2014
The New England Journal of Medicine Downloaded from nejm.org at NEW YORK MEDICAL COLLEGE on August 11, 2015. For personal use only. No other uses without permission. Copyright © 2014 Massachusetts Medical Society. All rights reserved.
The Human Resources for Health Program in Rwanda To the Editor: Binagwaho et al. (Nov. 21 issue)1 emphasize physician-oriented, even “subspecialty,” expertise in their well-meaning human resource approach for Rwanda. However, this approach may import the expensive, Western, compartmentalized, highly curative model and jeopardize more effective basic health interventions. The commendable advances in Rwanda came predominantly from simple, widely delivered interventions: immunization, bed nets to prevent malaria, improved nutrition and contraception,2,3 and community-based treatment for malaria, pneumonia, and diarrhea.4 Yet, huge basic health challenges remain. Only 4.5% of houses have running water.3 One of five infants older than 6 months of age has diarrhea in any 2-week period, and only 29% receive oral rehydration salts. The duration of exclusive breast-feeding is insufficient, and 44% of children have stunted growth.3 The need for contraception remains high.3 The program to introduce new vaccines in Rwanda is highly ambitious. Moreover, newborn mortality, now 50% of infant mortality,3 calls for better maternal nutrition, strengthened antenatal care, simple resuscitation, chlorhexidine for cleansing the umbilical cord, and community-based sepsis treatment. Human resource support should prioritize public health specialists, managers, supervisors, clinical officers, sanitation specialists, specialists in behavior change, logisticians, and community outreach personnel. We commend the broader health system support provided by the U.S. President’s Emergency Plan for AIDS Relief, as mandated by U.S. congressional legislation.5 However, basic, widely applied public health measures should remain foremost. James D. Shelton, M.D., M.P.H. U.S. Agency for International Development Washington, DC [email protected]
Stephen Hodgins, M.D. Save the Children Washington, DC The views expressed in this letter are those of the authors and do not necessarily represent those of the U.S. Agency for International Development.
Dr. Shelton reports working for USAID, which provided partial support for the research described in the article. No other potential conflict of interest relevant to this letter was reported. 1. Binagwaho A, Kyamanywa P, Farmer PE, et al. The human
resources for health program in Rwanda — a new partnership. N Engl J Med 2013;369:2054-9. 2. National Institute of Statistics of Rwanda. Rwanda: standard demographic and health survey 2005. Rockville, MD: ICF International (http://measuredhs.com/what-we-do/survey/ survey-display-252.cfm). 3. Idem. Rwanda: standard demographic and health survey 2010. Rockville, MD: ICF International (http://measuredhs.com/ what-we-do/survey/survey-display-364.cfm). 4. Farmer PE, Nutt CT, Wagner CM, et al. Reduced premature mortality in Rwanda: lessons from success. BMJ 2013;346:f65. [Erratum, BMJ 2013;346:f534.] 5. Barbiero VK. Fulfilling the PEPFAR mandate: a more equitable use of PEPFAR resources across global health. Global Health Sci Pract 2013;1:289-93. DOI: 10.1056/NEJMc1315971
The Authors Reply: Does the right to health encompass only interventions that might be termed “low-hanging fruit,” such as oral rehydration salts and (some) vaccines? What if the same mother receiving such services presents with obstructed labor or the same child receives a diagnosis of Burkitt’s lymphoma? These are central questions for global health. In our article, we presented a new partnership for health workforce development in Rwanda, while noting that the approximately 45,000 community health workers in the country remain the backbone of the health system as primary care is strengthened further. Community-based primary care indicators in Rwanda before the launch of the Human Resources for Health Program show the concrete achievements resulting from investments in decentralized primary care provision at the village level in Rwanda (Table 1).1-4 We agree with Shelton and Hodgins that community-based care offers the highest standard of care for many conditions across countries,5 but we argue that these services must be supported by health centers and linked to hospitals to bridge gaps in health systems. Until 2013, Rwanda had not a single on cologist (but plenty of cancer) and just 12 general surgeons (but strikingly high mortality from conditions that require surgery). Most health workers trained by the new program in
n engl j med 370;10 nejm.org march 6, 2014
The New England Journal of Medicine Downloaded from nejm.org at NEW YORK MEDICAL COLLEGE on August 11, 2015. For personal use only. No other uses without permission. Copyright © 2014 Massachusetts Medical Society. All rights reserved.
981
correspondence
Table 1. Community-Based Primary Care Indicators in Rwanda before the Launch of the Human Resources for Health Program.* Indicator
Value
Reference
Combined health-service-provider density of physicians, nurses, and midwives per 1000 population (no.)
0.84
Farmer et al.1
WHO minimum recommended providers per 1000 population (no.)
2.3
WHO2
Contraceptive use among women 15–49 yr of age (%)
52
WHO3
Infants exclusively breast-fed for first 6 mo of life (%)
85
WHO3
Prevalence of stunted growth among children younger than 5 yr of age (%)
44
WHO3
Vitamin A supplementation among children younger than 5 yr of age (%)
93
WHO3
Population using improved drinking-water sources (%)
69
WHO3 WHO4
Immunization coverage rates (%) For 1-yr-old children Bacille Calmette–Guérin
99
Diphtheria–tetanus–pertussis
99
Measles
97
Polio
98
Hepatitis B
98
Haemophilus influenzae type B
98
Pneumococcal conjugate
98
Rotavirus
99
For adolescent girls Human papillomavirus
97
Deaths Child deaths per 1000 live births (no.)
54
WHO3
Decrease in annual child mortality, 2000–2011 (%)
11
WHO3
Neonatal deaths per 1000 live births (no.)
21
WHO3
Decrease in annual neonatal mortality, 2000–2011 (%)
6
WHO3
340
WHO3
Maternal deaths per 100,000 live births (no.) Decrease in annual maternal mortality, 2000–2010 (%)
9
* WHO denotes World Health Organization.
Rwanda will indeed be nurses and managers, but investing in essential specialist capacity is also a key step on the path to universal health coverage. Agnes Binagwaho, M.D. Ministry of Health Kigali, Rwanda [email protected]
Paul E. Farmer, M.D., Ph.D. Harvard Medical School Boston, MA Since publication of their article, the authors report no further potential conflict of interest.
982
1. Farmer PE, Nutt CT, Wagner CM, et al. Reduced premature
mortality in Rwanda: lessons from success. BMJ 2013;346:f65. [Erratum, BMJ 2013;346:f534.] 2. World health report 2006: working together for health. Geneva: World Health Organization, 2006 (http://www.who.int/whr/2006/en). 3. World health statistics 2013. Geneva: World Health Organization, 2013 (http://www.who.int/gho/publications/world_health _statistics/2013/en). 4. Rwanda: WHO and UNICEF estimates of immunization coverage: 2012 revision. Geneva: World Health Organization, 2012 (http:// www.who.int/immunization/monitoring_surveillance/data/rwa.pdf). 5. Farmer PE. Shattuck Lecture: chronic infectious disease and the future of health care delivery. N Engl J Med 2013;369:2424-36. DOI: 10.1056/NEJMc1315971 Correspondence Copyright © 2014 Massachusetts Medical Society.
n engl j med 370;10 nejm.org march 6, 2014
The New England Journal of Medicine Downloaded from nejm.org at NEW YORK MEDICAL COLLEGE on August 11, 2015. For personal use only. No other uses without permission. Copyright © 2014 Massachusetts Medical Society. All rights reserved.
