Leadership at All Levels: The Backbone of Rwanda's Health System Successes

Leadership at All Levels: The Backbone of Rwanda's Health System Successes

Dr. Jonathan Quick, President and CEO of MSH, tours with Dr. Christian Nzitimira, director of Kibagabaga Hospital in Rwanda. {Photo credit: Jon Jay/MSH.}Photo credit: Jon Jay/MSH.

In a postoperative ward of Kibagabaga Hospital, the district hospital serving Rwanda’s capital city of Kigali, Eric Bizimana sits up in bed. Bizimana, 25, had sought care after severe pain in his right leg forced him to stop work as a barber. He was diagnosed with a bone infection called osteomyelitis. Antibiotics alone couldn’t clear the infection. Without an operation to remove the diseased bone, Eric faced the possibility of losing his leg.

Eric was one of the 40 patients who enter Kibagabaga for surgery every day. In Rwanda’s tiered healthcare delivery system, patients are referred from local health centers up to the district hospital when their conditions require more complex care. Most babies are delivered at health centers, for example, but a woman suffering complications or who was expected to need a C-section would be referred to the district level.

The Power of a Vision

The system is working: over the last decade, Rwanda has cut maternal deaths by 60% and child deaths by 63%. HIV, tuberculosis (TB), and malaria deaths are down 80%. In less than 20 years since the 1994 genocide, Rwanda has dramatically reduced poverty and is the only country in sub-Saharan Africa poised to meet most of the Millennium Development Goals. The health system has emerged from devastation as a model for others.

Rwanda’s extraordinary transformation has been widely attributed to strong central governance. Recent coverage in The Atlantic magazine and British Medical Journal has recognized the importance of Vision 2020 [PDF], a development strategy that has set the tone and direction for Rwanda’s recovery. The government has used the strategy to align its efforts and those of the donor community.

In the health sector, this vision is being pursued under the leadership of Dr. Agnes Binagwaho, Rwanda’s Minister of Health. Dr. Binagwaho has brought an evidence-based approach and continually demanded better data and better systems for collecting it. For nearly a decade, with support from USAID and the Rockefeller Foundation, MSH has had the privilege of working with the Ministry of Health to design and implement health system innovations for great health impact. These have included performance-based financing [PDF] to create incentives for facilities to provide high-quality care and make community-based health insurance (CBHI) successful. CBHI has been a key component of Rwanda’s pursuit of universal health coverage, which now extends to 90% of Rwandans [PDF].

Leadership at All Levels

Effective central policymaking is only half the story. I recently observed this firsthand when I visited Kibagabaga Hospital. Dr. Christian Ntizimira, the hospital’s director, manages a team of eight physicians, serving a catchment area of over 400,000 residents in and around the nation’s capital.

I asked Dr. Ntizimira what he was most proud of, after three years at the helm. He didn’t say the number of lives saved or babies delivered. He said it was the strength of leadership and ownership found in each department of the hospital. He said Dr. Binagwaho preaches that you can’t wait for the Ministry of Health to come and solve your problems — you have to take responsibility and solve them yourself.

One might expect Dr. Ntizimira, a young palliative care specialist with the bearing of a rising star, to micromanage the staff below him. One might expect Dr. Binagwaho and her deputies, who exercise tight control over central planning and donor contributions, to exert the same force on a hospital in their home district. But instead, both have instilled a sense that each health worker is a leader in his or her own right. They lead, but they also develop leaders.

Making the Leader Shift in Post-Conflict Settings

The development of Rwanda’s health system over the last decades exemplifies MSH’s philosophy for rebuilding health systems in so-called “fragile states” – countries affected by conflict or crisis, or by collapsed or repressive governments. Improving health systems in these settings requires a two-pronged approach: strengthening the government’s role in stewardship, policymaking and coordination from the central level down, while creating the right environment to retain and motivate the health workers who provide services. Top-down doesn’t work on its own, and neither does bottom-up.

Developing leaders at all levels is critical to the success of this strategy. This requires making the “leader shift” in people’s mindsets:  from believing leaders are born to seeing that leaders can be developed; from individual heroics to teamwork; from command-and-control to empowering others; from despair and cynicism to hope and possibility; and from blaming others for problems to taking responsibility for overcoming challenges.

We’ve brought this philosophy to our work in almost a dozen other fragile states, including Afghanistan, Democratic Republic of the Congo, Haiti, Liberia, Libya and South Sudan. In Afghanistan, for example, core capacity at the ministry level was essential: the vision for universal health coverage and a high-impact Basic Services Package needed to come from the top. But it’s health workers at all levels who make those services successful. They needed to be invested, too.

So at the same time that MSH, with support from USAID, was partnering closely with the Ministry of Public Health, we were providing training and resources for community health workers and community health supervisors. Their improved ability to provide family planning, for example, raised contraceptive prevalence from 10% to 40% during that project. Meanwhile, the Ministry’s strategies were paying off. Between 2002 and 2010, maternal mortality dropped by two thirds, and the reductions in infant and under-five mortality were equal to saving 150,000 kids’ lives every year.

Eric Bizimana, 25, received surgery at Kibagabaga for a bone infection in his leg. (Photo credit: J. Jay/MSH) Eric Bizimana, 25, recovers from successful surgery at Kibagabaga Hospital. (Photo credit: J. Jay/MSH)

The Path to Health

Rebuilding a health system after armed conflict is a daunting endeavor. But these successes prove that it is possible. As we have seen in our work across several continents – and as our Rwanda colleagues have vividly illustrated – it’s about making the leader shift and instilling leadership at all levels.

Back at Kibagabaga Hospital, patients aren’t thinking about the health system. They’re thinking about getting healthy. For Eric Bizimana, life had taken a tough turn, but things were now turning for the better. His operation had been a success. When I toured Kibagabaga, Eric was feeling good—walking with a limp as he recovered from the surgery, but without the need for crutches. He smiled and talked about getting back to work. Like so many Rwandans, he can now look forward to good health.

Jonathan D. Quick, MD, MPH, is president and chief executive officer of Management Sciences for Health. Dr. Quick has worked in international health since 1978. He is a family physician and public health management specialist.