Lessons from Rwanda’s Health Infrastructure Rebuilding

The on-campus residences and surrounding landscape of the University of Global Health Equity. Taken by Grace Chen.

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By Grace Chen

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[dropcap]W[/dropcap]e arrive in Kigali during the tail end of the long rainy season, and this is evident when we are expelled from our cab at Nyabugogo Bus Terminal. We are left to our own devices to find Shalom Bus company, which we were told can take us to Butaro, three hours north in mountainous Burera District. The roof of the cab no longer there to shelter us, we begin asking for directions under pelting rainfall that almost immediately resigns me to a full day of wet socks, despite it hardly being nine in the morning. Soon we find ourselves loaded into a white van with fellow passengers who are clearly curious as to why this trio of foreigners is headed to one of the most rural regions in the country. Women, many with children wrapped as low-hanging backpacks behind their waists, pierce forearms through the bus windows as we await departure, dangling bags of white bread buns dripping with condensation and coaxing us to purchase some sustenance for the road.

The terrain grows rougher as we make our way north, and urban scenes of motorbike traffic peel away to reveal lush green foliage and snake-like strips of brown dirt that circumference the terraced hills we admire from above. Our presence in this vehicle also grows increasingly novel with each stop, as Rwandans peer in to discover, with surprise, our faces—of the like they might have never seen before. At one stop, a schoolgirl catches glance of my colleague and is immediately taken by his blonde hair and blue eyes. Wide-eyed, she offers him a couple of shy waves.

It is just past noon when we finally arrive in Butaro at a chic, modern university campus that feels out of place after traveling through hours of mountainous farmland. But the location is strategic, and we soon learn how this University of Global Health Equity, along with several other initiatives, has contributed to Rwanda’s incredible growth in health education and infrastructure, rebuilding by empowering local communities from the ground up.​

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From 1989 to 1997, Rwanda had the lowest life expectancy in the world, exacerbated by the 1994 genocide that took the lives of up to a million people and displaced millions more.  The violence left the country in political and societal despair with the world’s highest child mortality, a life expectancy of just 30, more than 75% of children not fully vaccinated, and a shattered health infrastructure as health workers had been killed or fled and health facilities destroyed.

Yet, from this devastation, Rwanda has seen incredible recovery. Since 1995, life expectancy has doubled. Deaths from HIV, tuberculosis, and malaria—the “big three” diseases in global health—declined by roughly 80% in the decade following the turn of the century. Maternal mortality decreased by 60% and the number of child deaths by 63% in the same period. Rwanda achieved most of its health targets set by the UN in the Millennium Development Goals, suggesting subsequent attainability of the Sustainable Development Goals. Today, nearly all Rwandans have health insurance, and the country enjoys some of the highest child vaccination rates in the world.  

Rwanda has become a model and inspiration for other resource-poor and post-conflict countries seeking to rebuild their own health infrastructures. Dr. Abebe Bekele, Dean of the University of Global Health Equity, describes Rwanda as “a shining star among African countries.” Efforts today aim to build upon these early successes and keep the country on this remarkable trajectory of recovery and growth.

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The Butaro we arrive in still remembers its reality just over a decade ago. As late as 2008, Burera District in Rwanda’s Northern Province was one of the last two districts in the country that still lacked a functioning hospital, leaving its population of more than 336,000 without access to a single doctor.,  The World Health Organization recommends a density of 2.3 physicians, nurses, and midwives per 1,000 people.

The district’s poor health indicators led Partners in Health (PIH), a Boston-based, non-profit healthcare organization that operates internationally, to begin work on a district hospital in Butaro sector. PIH had been working in the country since 2005 and has since provided services to more than 860,000 people in three of Rwanda’s poorest districts, including Burera. Butaro District Hospital brought to the region, for the first time, a broad range of services—from maternal health and pediatrics to cancer care and surgery—and provides both emergency treatment and outpatient checkups. The success of Butaro District Hospital, however, transcends its mere presence.

MASS Design Group, a non-profit architectural firm founded in 2008, partnered with PIH and the Rwandan Ministry of Health to take on the district hospital as its very first project. MASS, which stands for Model of Architecture Serving Society, had a radical vision: an approach to architecture that upholds social justice, community impact, and sustainability, above all else.

Jean Paul Uzabakiriho was still a first-year architecture student at the University of Rwanda when he first visited Butaro. Becoming involved in MASS’s projects first as an intern and later a Global Health Corps fellow, he now continues his work at MASS as a Design Director. We discuss the Butaro project from the balcony of MASS’s Kigali office, from which we can see the brazen intermingling of city and vegetation sprawled below. 

MASS’s approach in constructing Butaro Hospital was to mobilize local people by hiring labor from the community, Jean Paul tells me. In Rwanda, people are organized into four socio-economic categories, the Ubudehe categories, based on income. Rwandans in the first category are the most vulnerable, depending heavily on government assistance, while those in the fourth are the wealthiest. When MASS began work in Butaro, they focused their efforts on the first two categories.

“The sectors in each district have lists of people,” Jean Paul explains. “We wanted to make sure we were targeting categories one and two because these are the people who are really suffering to get jobs and make their livelihoods. They show us this list, and we invite people who are interested in construction. Then they can come to the site and express, maybe, ‘I want to do stonework,’ and you start them on training.”

The job continues even after construction ends. “Most of the time, the client also wants maintenance of their project. So, during the construction process, they investigate and see how people improve and who really cares. At the end of the project, they might say, ‘We want you to stay here.’”

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Butaro District Hospital, which opened in 2011. Photo courtesy Wikimedia Commons.

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This approach to construction and continued employment has seen both fiscal and social success. MASS’s intentional use of local labor, materials, and sustainable design accomplished a budget two-thirds that of comparable projects in Rwanda, and the project has fostered intense pride and ownership in the local community.

One man who was trained in volcanic stonework during the Butaro Hospital project now leads a local cooperative that specializes in it. Rwanda’s northern and western regions are flush with volcanic stone, a material with a unique texture that is impossible to find elsewhere in the country. MASS always attempts to express this texture as features in its work in Butaro.

“Every time we have a new project, we bring a new challenge to our volcanic team,” Jean Paul says. “Now they know how to do this stone wall, but what if you introduce an angle? What if you introduce a bevel?”

Called Amakoro, simply translated as “volcanic stone,” the group is now being contracted.

“It’s really working—training people,” Jean Paul says. “These people are using their skills to make the rest of their life.”

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MASS’s dedication to involving local people in the construction process has even enhanced the firm’s ability to accomplish healing through architectural design. A local gardener, Jean Baptiste Maniragaba, helped fulfill the vision of creating a landscape that would contribute to the healing process. His love for horticulture began in his youth, and he was introduced to Sierra Bainbridge, Senior Director at MASS, as the team was ending the construction phase of Butaro Hospital.

“Everyone had experience and skills to share,” Jean Paul tells me. “[Jean Baptiste] knew a lot of native plant species and how to plant them. Sierra knew, from the other side, where to put them and what would be better for different spaces.”

Through sketches, images, and gestures, the pair was able to overcome a language barrier and design a landscape that was both beautiful and functional. Shrubbery now stabilizes the steep hillside, shaded outdoor seating offers a comfortable area for patients to sit where transmission of airborne disease is minimized, and well-planned vegetation contributes to the draining of rainfall away from the building. Such artful landscaping has also been shown to reduce stress and pain perception in patients, as well as improve retention of nurses.

“Most architects think of the building as a standalone product,” Jean Paul says. “We think the external space—the surrounding environment, garden, landscape—should be part of the building. We believe nature has power to bring hope to the patient. We wanted them to have the chance to look outside into the landscape every time they were sleeping. So, we lowered all the windowsills.”

The hospital was completed in 2011, and Jean Baptiste continues to work as master gardener today.

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Color-coded signage at Butaro District Hospital. Taken by Grace Chen.

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The Butaro campus of the University of Global Health Equity (UGHE) is woven together by a single brick pathway, its hexagonal tiles leading from the administration building to the classrooms, cafeteria, and dormitories. The vision for the university began in 2013 in a conversation among leaders of the Cummings Foundation, the Bill & Melinda Gates Foundation, and Partners in Health (PIH).

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The Butaro campus of the University of Global Health Equity, which opened in January of 2019. Taken by Grace Chen.

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The Cummings Foundation had a vision for a new university that would serve not only Rwanda, but all of Africa. The Gates Foundation had a long history of supporting initiatives to advance global health. PIH similarly desired to grow its impact in education, as it had been a leader in health care delivery and social work in underserved communities for many years.

The gap they identified in previous approaches to advancing health education in low-resource communities was the lack of an institution that emphasized equity in its teaching model while physically existing in an environment where health inequities are most acutely felt. While PIH, as well as other organizations, had been funneling resources for years in efforts to train much-needed health care workers, they realized that an essential second step was to train these workers on how to actually deliver their care in neglected, under-resourced communities. To truly be able to implement their skills and services in the field, they needed education in the field.

With Butaro District Hospital and other PIH-supported facilities nearby, Butaro seemed a natural location for PIH to construct the new university. While a private institution, UGHE also saw significant support from the Rwandan government, which donated the land for the campus, paved roads to better link Butaro to more densely populated regions of the country, and improved access to water, electricity, and internet. MASS’s visionary approach was called upon again for the construction of UGHE, and the campus opened its doors in January of 2019. 

UGHE’s pioneering educational model is being realized through its flagship degree, the Master of Science in Global Health Delivery (MGHD). The MGHD program is modeled after one at Harvard Medical School where Paul Farmer, co-founder and chief strategist at PIH, also currently holds professorship. Alongside a curriculum taught by guest faculty from around the world, the MGHD program also emphasizes field experiences through the Practicum, the understanding of social and political systems over mere symptoms, and mentorship to develop soft skills in leadership and management. 

This past June, UGHE also welcomed its first cohort of students for its second degree-granting program, a dual Bachelor in Medicine, Bachelor in Surgery/Master of Science in Global Health Delivery (MBBS/MGHD). In both the MGHD and MBBS/MGHD programs, students participate in case studies, research projects, and volunteer programs at Butaro Hospital and other health centers and clinics in the area. The medical students are required to spend two to four weeks per year directly working in the community for the duration of their six and a half-year program.

Like Butaro Hospital, UGHE demonstrates its deep dependence on and entwinement with the local Butaro community. Much of the university’s needs are fulfilled by the local community: after construction, local workers continue the landscaping, gardening, and maintenance of the campus; foodstuffs like potatoes and onions and materials like wood are sourced from local cooperatives; and the kitchen and security companies the university has contracted are required to hire certain percentages of their workers from the Butaro area.

Further, each time the university needs to approach the Butaro community, they do so through a local committee of Butaro elders, leadership, and other residents.

“We treat the community with utmost respect, and we want to show them they own the campus,” says Dr. Abebe Bekele, Dean of UGHE. “So, whenever we have messages to transmit, it goes through that committee.”

The collaboration has inspired UGHE leadership to continue finding ways to serve Butaro.

“There is a desire for education in the community,” Dr. Bekele tells me. “We are now trying to set up a system where high school students can use our library and computer lab for free over the weekends. How can we support [Butaro] high schools and elementary schools?”

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At the University of Rwanda’s College of Medicine and Health Sciences (CMHS), another health education initiative is training specialized physicians and administrators. By motorbike, colloquially “moto,” I travel to the Remera campus to meet with the principal of CMHS, Dr. Jeanne Kagwiza. She greets me in her office, a spacious but cozy, room filled with darkly stained wood furniture and bookshelves that climb the walls behind her executive desk.

In 2011, the ratio of health professionals to the general population was just 0.72 per 1000, less than a third of the density recommended by WHO. Further, the majority of physicians in Rwanda were trained as generalists and access to specialist care was largely limited to Kigali, the capital city. With the University of Rwanda, the only public university in the country and only medical school at the time, training just 100 new physicians per year from 2004-2010, the gap between demand and need was only growing larger.

To address this, Rwanda’s Ministry of Health (MOH) collaborated with the Clinton Health Access Initiative, the ELMA Foundation, the US Centers for Disease Control and Prevention, and the Global Fund to launch the Human Resources for Health (HRH) program in 2012. HRH convened a consortium of 16 academic medical centers, six schools of nursing, two dental schools, and one school of public health from the US to form a 7-year partnership with Rwanda’s MOH and CMHS.

Since August of 2012, the program has deployed about 100 faculty each year from the consortium of US institutions to CMHS. Following a “twinning” model, the program pairs guest faculty with counterparts at CMHS in a valuable partnership for both participants. While the Rwandan faculty receives training in specialized care delivery and management, the American faculty gains valuable experience that will be applied to the strengthening of global health curricula back in the US.

HRH has also brought about the birth of several new programs within CMHS and a wave of cultural change that increasingly emphasizes research and interactive teaching. 12 new programs, including degrees in a new School of Dentistry, a Master’s in Health and Hospital Administration, and specialties in nursing, internal medicine, surgery, and more have contributed to the growth of CMHS, which now offers 22 degree-granting programs.,  Increased collaboration between students and faculty from both Rwanda and the United States have also allowed research partnerships to flourish.

“I used to just give lectures,” Dr. Kagwiza says, reflecting on how HRH has influenced her own approach to teaching. “But now, we involve students in discussion, give them assignments, and tell them to research something. There is now a culture of publishing and research. People didn’t use to publish their students’ pieces—but it’s [the students’] work too.”

At an estimated cost of $152 million dollars over the 7-year period from 2012-2017, HRH is no small investment for a country whose entire nominal health budget was about $213 million in the 2017/18 fiscal year. But according to Dr. Kagwiza, this deep investment by the MOH is precisely why the program has been hailed for being so successful.

“MOH supports us, but the end result is also the MOH,” Dr. Kagwiza explains. About 90% of students at CMHS receive a government scholarship, and they sign a contract to work for the MOH for a number of years after graduation. “There was a time in this country where there were not many specialists. This training informs and strengthens the MOH’s work in reaching the goal of having a specialized health system.”

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Rwanda’s unprecedented recovery can be attributed largely to two themes that are reflected in these initiatives in Butaro and the University of Rwanda: first, the mobilization and empowerment of local communities and second, the political will and dedication of the federal government. MASS’s novel approach to construction and maintenance, UGHE’s continued partnership with the local community, and the emphasis of field experience, case study, and research in academic curricula has fostered a culture that prioritizes the community. From the donation of the land that the University of Global Health Equity now sits on to the efficient utilization of government and aid funds in the Human Resources for Health program, the Rwandan Ministry of Health has also clearly played a crucial role in catalyzing recovery. While these initiatives are just case studies of a style of approach to health infrastructure rebuilding, they reflect broader themes of community involvement and political will in a host of initiatives that, together, have resulted in growth.

“Health without the commitment of the leaders—there will absolutely be no progress,” Dr. Bekele says. “You can show some window dressing, you can show some quick rinse, but grounded development like Rwanda will not happen.”

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Grace Chen is a junior in Berkeley College studying Molecular, Cellular, & Developmental Biology and History of Science, Medicine, & Public Health. She can be contacted at grace.chen@yale.edu.