Health care systems in low-resource settings abroad: Lessons from Rwanda

When it comes time to build or reinforce health care infrastructure in resource-poor areas of the world, what role should aiding physicians play—and what can they learn in the process?

“Global is all the world, not only Africa or … foreign countries,” said Agnes Binagwaho, MD, PhD, the minister of health in Rwanda, in a podcast interview featured in the July issue of the AMA Journal of Ethics®.

An article featured in this month’s issue, “Why U.S. health care should think globally,” suggests that learning from practitioners in resource-poor settings can help allopathic physicians connect with local and global populations and motivate reciprocity.

“Successful health care systems in low-resource settings are designed to target and serve the poor in ways that are contextually appropriate, addressing social, cultural and economic barriers to care,” the authors said. “These systems have already learned how to make efficient use of limited resources.”

Methods developed for or in low-resource settings abroad also can be used in the U.S. to address inequalities in health status and health care, access and quality.

Two tools developed abroad, a low-cost ventilator and a mobile-based flow cytometer used to diagnose some infections and cancers, are already being used in the U.S.

In her podcast interview, Dr. Binagwaho detailed how further development of the health care system in Rwanda improved access and quality.

“Before 1994, we were producing around 20 doctors a year,” she said. “Now we produce hundreds.” The most important lesson learned in the development of the Rwandan health care system, according to Dr. Binagwaho, was to understand the needs of the people of her country and develop a system that met those needs.

“First of all, [we needed] to understand our city,” she said, “What are our needs? So that means propose decisions that are evidence-based, that you can explain to others and also proceed by creating your own plan. And after that, agree altogether how we’d implement it so that we create the trust in the system and the people can use the system … because they know that the system is there and responding to their needs.”

“You put everybody around the table from communities, from civil societies, from government, and leaving nobody out,” she said. “A plan done by the people who will live with that plan is always better than any plan done elsewhere.”

Mortality rates on several fronts have improved since the implementation of new strategies in Rwanda. “The mortality rate for HIV/AIDS has decreased by 78.4 percent,” Dr. Binagwaho said. For tuberculosis, the mortality rate decreased by 77 percent and for malaria by 85 percent.

When physicians travel to other countries offering their expertise to local populations, it is important to remember a few things:

• Help countries know their cities and understand the needs of the people in those cities, Dr. Binagwaho said. When traveling to another country, “understand the right to health and ethics … [and] go with humility and say ‘I have always something else to learn; I have always something to share.’ … And then go and listen.”

• “Don’t act like a teacher; act like a student,” she said. “Learn the culture—how to do, how to say, how to express. Because the most important [aspect of] the conversation is not to say what you want; it’s to make sure that the person you talk to has understood.”

• “You have to be like a chameleon: ready to change [to] the local color and bring the shining color from your country in addition,” Dr. Binagwaho said. “You always have to say what you believe—say it loudly—but with a lot of humility.”

Carolyn Sargent, PhD, professor of anthropology at Washington University in St. Louis and co-author of “Blending western biomedicine with local healing practices,” an article featured in this month’s issue, shared a story of her experience abroad.

While conducting fieldwork in a rural West African village as a scholar of reproductive health, she found that after deliveries, birth attendants would place dung on the newborn’s umbilical cord stump to dry it out. Knowing this practice is considered dangerous in Western medicine, she felt conflicted. As an allopathic practitioner she had to decide whether or not to say something to the midwives regarding what she knew without sounding disrespectful.

When she described her dilemma to an elder woman and respected community leader, the elder said, “Your duty is to convey what you know. And the family’s duty is to decide what they think is best.”

“The elder’s statement encapsulates the heart of the challenge posed by the concept of autonomy,” Sargent said in the article. “Sometimes we must respect—at least in the short term—decisions that we might not fully support.” But, as Dr. Binagwaho said, it is important for medical professionals to share what they know because that is one important reason why they are there.

The July issue of the AMA Journal of Ethics is available now and features articles on several other issues in global health, including “Medicine, empires and ethics in colonial Africa,” and, “Changing donor funding and the challenges of integrated HIV treatment.”

The journal’s editorial focus is on commentaries and articles that offer practical advice and insights for medical students and physicians. Submit your work for publication.