Rwanda provides primary care lessons we can learn from

As reviewed in many other sources, the relative underinvestment of resources in primary care in the U.S. has a great deal to do with the fact that we spend far more on health services than anywhere else in the world but rank near the back of the pack in key health metrics such as life expectancy, infant mortality, and disability compared to other high-income countries. Although economic inequality, lack of insurance coverage, and shrinking public health budgets are also part of the problem, I’d argue that diverting dollars from redundant multi-million dollar proton beam facilities to provide a patient-centered medical home for every American would have positive effects on population health.

Even though I feel that the U.S. has a lot to learn from other countries about building infrastructure to support high-quality primary care, it was still hard for me to get my head around the premise of an Atlantic headline that caught my eye earlier this year: “Rwanda’s Historic Health Recovery: What the U.S. Might Learn.”

Like most Americans who have never traveled there, I suspect, my impressions of Rwanda have been strongly influenced by popular dramatizations of the 1994 genocide such as the movie “Hotel Rwanda” and Immaculee Ilibagiza’s memoir Left to Tell. I had a difficult time imagining how any semblance of a functioning health system could have emerged even two decades later, much less a system that would have something to teach the U.S.

But a recent BMJ article by Paul Farmer and colleagues documented impressive gains in Rwandan life expectancy, led by declines in morbidity and mortality from tuberculosis, HIV, and malaria that resulted not only from investments in lifesaving drugs but in preventive and primary care. 93% of Rwandan girls have received the complete HPV vaccine series to prevent cervical cancer, compared to only 33% of eligible U.S. girls in 2012.

Here’s the thing, though: the foot soldiers in the Rwandan primary care revolution aren’t doctors. In fact, there were only 625 practicing physicians in the entire country in 2011. (According to a report published in the same year, Washington, DC alone has about 3,000.) How, then, has Rwanda been able to staff its network of community health cancers and reach out to its eleven million people, many of whom are so poor that they can’t afford the national health insurance premium of $2 per person? (That’s right, 2 dollars for an entire year. According to the Kaiser Family Foundation, the average monthly individual premium for generally healthy persons in 2010 was $215, or just over $2500 per year.)

They do it primarily by relying on community health workers, trusted local residents who receive a minimum of basic medical training and are then integrated into more comprehensive primary care teams. As described further in BMC Health Services Research article by the group Partners in Health:

Each district is served by a network of community health workers (CHWs) — three per village — offering health education, basic preventive and curative services, and family planning. CHWs are supported by local health centers, which serve approximately 20,000 people and are staffed by nurses, most of whom have a secondary school education level. Health centers provide vaccinations, reproductive and child health services, acute care, and diagnosis and treatment of HIV, tuberculosis, and malaria. District hospitals, staffed in part by 10-15 generalist physicians, provide more advanced care, including basic surgical services, such as cesarean sections.

Rwanda provides primary care lessons we can learn from

The lesson to take home isn’t that the U.S. can get away with training fewer primary care physicians than it already does. Indeed, Rwanda has every intention of training more doctors with assistance from other countries, including the U.S. What’s important is the pyramidal structure of their health system, with primary care at the base and more specialized care at the apex. If you took the U.S. physician workforce, which consists of about 70% specialists and 30% generalists, and mapped it to a similar structure, it would look more like this (apologies for my poor graphical skills):

Rwanda provides primary care lessons we can learn from

At the top, you have the super sub-specialists, who are experts on a single narrow spectrum of diseases confined to one organ system (e.g., hepatologists). Lower down are the ordinary specialists, such as gastroenterologists, cardiologists, and pulmonologists, whose expertise is limited to a single organ system and age group (e.g., adults). Still lower are generalists whose scope of practice is limited by age group. Finally, at the bottom, are the family physicians, the only type of physician whose scope is not limited by age, gender, or organ system.

The problem with this upside-down pyramid is that it’s inherently unstable. In Washington, DC, it’s sometimes easier for a patient with musculoskeletal low back pain to get an appointment with a spine surgeon or for a patient with panic attacks see a cardiologist than it is to find a family physician. You can get a same-day MRI for any number of problems that probably don’t require any imaging at all. Such a health system is inefficient and wasteful at best, harmful at worst, and destined to get the extremely poor results it does.

Kenneth Lin is a family physician who blogs at Common Sense Family Doctor.

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  • Dr. Drake Ramoray

    While I can’t necessarily disagree that we could use less fancy proton beams and more primary care resources I can’t help but point out the major flaw in the premise of your article, and the irony of the proton beam example you used.

    =============================================
    As reviewed in many other sources, the relative underinvestment of resources in primary care in the U.S. has a great deal to do with the fact that we spend far more on health services than anywhere else in the world but rank near the back of the pack in key health metrics such as life expectancy, infant mortality, and disability compared to other high-income countries.

    =============================================

    The life expectancy of the American citizen is the worst because we have more guns, more cars, more weight, the least activity, and the worst diet of just about every nation on earth. All of these can end your life early, some of them rather abruptly in an otherwise healthy person. Now, I’m not saying diet and exercise isn’t tremendously important, I’m just pointing out a 20 minute appointment with me, or even an hour appointment with me, is not going to go a long way to fix that in a culture that accepts all of the above things. Diet and exercise is one of the things I struggle most with my patients. Perhaps I’m jaded a bit given the number of non-compliant diabetics I see, but more healthcare spending by a third party isn’t going to fix this, regardless of where you spend it.

    Now if you look at say outcomes of medical diagnoses which removes a lot of the cultural factors from the statistics for the measurements you chose to use then you get a completely different picture on the success of medicine in the United States.

    The US beats every other country in almost every major type of cancer for a 5 year survival rate. (See table 5)

    http://www.cancer.org/acs/groups/content/@epidemiologysurveilance/documents/document/acspc-027766.pdf

    Do I think there is a discordance of expenditures spent on some specialists, for some sure, although they train a lot longer. Do I think healthcare is too expensive in this country (because of mandates, and third party payors) yes. Do you think I’m exaggerating about the cultural effects on your chosen statistics, I hope not.

    “In the case of Britain, firearms murders are 48 times fewer than in the US.”

    http://www.juancole.com/2011/01/over-9000-murders-by-gun-in-us-39-in-uk.html

  • ninguem

    Are you saying they have a Cheesecake Factory car dealership with charismatic pilots in Rwanda?

  • May Wright

    “[We] rank near the back of the pack in key health metrics such as life expectancy, infant mortality, and disability”

    It’s hard to compare country-to-country when different countries all have different standards for measuring these “key health metrics”.

    “Infant mortality” and “disability” especially. And as for life expectancy, our Dr. Drake makes some good points.

    Another point to make about Rwanda specifically is that the majority of Rwandans live on less than US$1.25 a day: so yes, their “health insurance” (whatever that consists of – I’m pretty sure it wouldn’t be up to American standards) looks cheap compared to the $2500/year average Americans on average incomes pay for theirs. I’m not sure what the point of that comparison was – to make America look bad in comparison to Rwanda?? But anyway, if there were such a thing as an American living on less than US$1.25 a day, they’d be getting free healthcare to a standard _we_ might complain about but which I’m pretty sure most Rwandans would be envious of.

    Your point about our specialist-heavy provider system is well made and worth having a discussion about, but we could probably do that without interjecting the near-obligatory and increasingly tiresome “look how awful America is!!!” chest-beating.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    I agree – Rwanda is as relevant to U.S. health care as Washington D.C.

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