Health system design
Lessons from Haiti and Rwanda
Paul Farmer, MD, PhD
Harvard Medical School
Brigham and Women’s Hospital
Partners In Health
Health Science & Technology S14
MIT, Building 32
May 4, 2012
1
Partners in Health, 2012
Russia
Boston
Mexico*
Haiti
Guatemala*
Burundi*
Rwanda
Malawi
Lesotho
Research, Training, Service
Image by MIT OpenCourseWare.
2
What is health system strengthening?
Community-based
Hospital-linked
3
Health-center enriched
10 000
Countering failures of imagination
10 billion
8.9 billion
9000
8000
8.3 billion
7000
US$ million
6000
5000
4000
3000
PEPFAR
2000
1000
Resources for AIDS
212
0
257
59
UNGASS
World Bank MAP
Global Fund
BMGF
1623
FOKAL/OSI
UNAIDS
292
Harvard Consensus Statement
HEI
UNAIDS & WHO unpublished estimates, 2007.
4
1987
1990
1993
1996 1997 1998
2000 2001 2002 2003 2004 2005 2006 2007
Accompaniment
A cornerstone of care
June 1999
1 year later
With accompagnateur
5
10 years later
Public-private partnerships
Boucan Carré, 2003
6
Public-private partnerships
Lascahobas, 2008
7
Public-private partnerships
Map of Haiti showing Zanmi Lasante locations removed due to copyright restrictions.
8
Informatics and care for those who need it most
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see http://ocw.mit.edu/fairuse.
10
© Health Affairs. All rights reserved. This content is excluded from our Creative
Commons license. For more information, see http://ocw.mit.edu/fairuse.
From Haiti to Rwanda
2005: GoR, with CF support, invites PIH to implement rural
health model
11
Service
12
Strengthening and studying rural health systems
•
Research and professional
development of trained health
workers
•
Evaluate large-scale model delivered
in public sector
•
Build local clinical and research
capacity
Graph showing increasing number of people treated per month for
tuberculosis and HIV has been removed due to copyright restrictions.
13
Training
14
(Re)building infrastructure
Rwinkwavu, 2005
15
(Re)building infrastructure
Butaro, 2011
GoR covered 25% construction costs and 48% operating costs
16
Horizontal, vertical, diagonal
People on ART nationwide
People on ART at PIH/IMB sites
100000
6000
90000
5000
80000
70000
4000
60000
50000
3000
40000
2000
30000
20000
1000
10000
0
0
2000
Year 2002 2003 2004 2005 2006 2007 2008 2009 2010
2002
2004
2006
More than 90,000 Rwandans on ART (>80% of PLWA)
Source: National AIDS Control Commission. “Annual Report for the Fight Against AIDS.” Annual Report 2008.
17
2008
2010
2012
Horizontal, vertical, diagonal
Maternal mortality
Child mortality
3,500
3,000
2,500
2,000
1,500
1,000
500
0
250
200
150
<5 deaths
per 1,000
live births
100
50
0
1995 2003 2008 2010
18
Source: UNICEF Rwanda Health Statistics 2011. Available: http://www.unicef.org/infobycountry/rwanda_statistics.html;
WHO World Health Statistics 2005. Available: http://www.who.int/whosis/whostat/whostat2005en.pdf
Deaths per
100,000
live births
Scaling up in rural Africa
1
29
30
Democratic Republic
of the Congo
UGANDA
TANZANIA
MTS.
Butaro
a
ng
u
Vir
1
Ruhengeri
Byumba
Gisenyi
KIGALI
Kibuye
2
Mulindi 2
Rwanda
Ruklra
Gitarama
LAC
Kivu
Rwinkwavu
Nyarubuye
Kirehe
Burundi
Rusuma
Cyangugu
Butare*
TANZANIA
BURUNDI
3
29
0
30 0
20
40 km
20
Malawi
3
Lesotho
40 ml
Image by MIT OpenCourseWare.
Various logos removed due to copyright restrictions, including Partners in Health, Khotso Pula Nala,
Republic of Rwanda Ministry of Health, Malawi Ministry of Health, Clinton Foundation, and others.
19
Global Health Delivery Online
Professional/
Medical
Trade
Publisher,
Association
Media
3%
7%
Academia
25%
NonGovernmental
Organization
30%
For-Profit
Organization
6%
Medical
Institution
9%
Government
13%
International
Agency
6%
20
More than 6,800 members
representing more than 2,149
organizations across 158 countries
“Natural disasters” & the limitations of health
system design: 2010 nursing school collapse
21
Cholera in Haiti and the limitations of
health system design

Cholera confirmed Oct 22 by
Haitian Ministry of Health and CDC
within 48 hrs of outbreak of acute
watery diarrhea in the lower
Artibonite

Confirmed in PaP by Nov 8

As of Apr 8:

> 532,925 cumulative cases

> 7,095 deaths
Source: MSPP Cholera update, March 1, 2011. Available: http://reliefweb.int/node/419780
22
Diagram removed due to copyright restrictions. Please see diagram here: (PDF)
23
(Re)building water and sanitation systems?
Photos of faucet with clean water and group of villagers waiting with
buckets to collect water have been removed due to copyright restrictions.
24
What is health system strengthening?
Community-based
Hospital-linked
25
Health-center enriched
Mirebalais Hospital, 2012
26
Nicholas Clark Architects
Thank you
MIT OpenCourseWare
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HST.S14 Health Information Systems to Improve Quality of Care in Resource-Poor Settings
Spring 2012
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