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Yale leads largest-ever collaboration to educate health workers in Rwanda

Dr. Grace Igiraneza was in her second year of residency at the University of Rwanda when things started to change. Staffing on the wards increased as doctors from Yale and other American medical schools arrived to take on clinical and teaching duties.

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Dr. Andre Sofair, a professor of medicine at Yale, observing a Rwandan resident examining a patient.

“We had dedicated physicians in Rwanda, but the clinical workload and education activities were conflicting,” Igiraneza said. “When Yale came on board it became easier for residents to learn because we had more physicians. You need a mentor who is there day to day to help train you in clinical reasoning and see how you examine patients.”

In addition to more supervision on the wards, Igiraneza said, improvements included the introduction of journal clubs and evidence-based medicine, as well as mentorship in clinical research.

The changes came about in 2012 when Yale and other academic medical centers in the United States joined with the Rwandan Ministry of Health’s Human Resources for Health Program (HRH) to strengthen the country’s medical resources and increase the quantity and quality of its workforce. The HRH —a seven-year training program focused on medicine, nursing, dentistry, and health management — is led by the government of Rwanda and funded by the U.S. President’s Emergency Plan for AIDS Relief through the Centers for Disease Control and Prevention and the Global Fund to Fight AIDS, Tuberculosis, and Malaria.

At the annual meeting of the Clinton Global Health Initiative in New York in 2012, former President Bill Clinton acknowledged Yale’s participation in the HRH with a nod to Elizabeth Bradley, then director of the Yale Global Health Leadership Institute. (Bradley has since become president of Vassar College.) The HRH consortium partners with 16 medical centers, six nursing schools, one public health school, and two dental schools in the United States.

“This is the largest single collaboration in health workforce education to be funded by the United States,” said Dr. Asghar Rastegar, director of the Office of Global Health at the Yale School of Medicine. “It demonstrates how we can bring our knowledge and capacity to bear to improve medical training and health care in the developing world.”

One of the beneficiaries of this collaboration is Igiraneza, who in January was three months into a year-long fellowship in nephrology at Yale New Haven Hospital funded by the International Society of Nephrology. It was her third stint at Yale. In 2013, during her third year of residency, she spent a month on clinical rotations here. A year later she returned for 10 weeks of clinical training.

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Dr. Grace Igiraneza

While the 34-year-old doctor’s two sons, aged 6 and 7, and her husband, a flight engineer for the Rwandan national airline, remain in Rwanda, she now spends her days at Yale New Haven Hospital. Every morning at 8 a.m. she meets with her nephrology team — another fellow and an attending physician — to review patient charts, see up to 10 patients a day, and observe medical procedures. Afternoons are devoted to teaching activities, typically rounds and conferences.

Later this year, when she returns to her post as head of dialysis at a teaching hospital in Kigali, Rwanda’s capital, she expects that her skills will lead to improved care for patients and better training for Rwandan residents. “I needed more training to lead that service,” she said. “It is my obligation to give back what I have been given.”

The HRH is part of an effort to rebuild Rwanda’s health system that began in 2000, but the story dates back earlier, to the 1994 inter-tribal genocide that left 800,000 people dead. Among the casualties was the nation’s health care system. Rwanda already had the world’s lowest life expectancy as well as other poor health indicators, but the genocide made things worse. A country already lacking doctors saw many physicians leave the country or be killed.

A key change to the health system in 2000 was empowering nurses and community health workers to take on clinical decisions, a key factor in reducing infectious disease. Over the next 10 years, life expectancy rose from 48 to 63 years of age. Most Rwandans now have health insurance, and by 2011 the country was on track to meet health targets set in the Millennium Development Goals by the United Nations. But the country still suffers from a shortage of trained health professionals — in 2011 the country had 0.84 physicians, nurses, and midwives per 1,000 population, well below the World Health Organization recommendation of 2.3 per 1,000.

Since HRH began, the U.S. medical centers have sent about 99 faculty to Rwanda each year to support 22 training programs. Those programs expect to graduate more than 4,600 students by next year. By the end of the program’s seventh year, an estimated 300 physicians will have received training in 13 medical specialties. And, since the program’s inception, the number of medical students enrolled in the country’s only medical school, which until 2010 graduated about 100 students each year, has doubled.

Before 2012, about 90% of Rwanda’s physicians trained as generalists. Yale is providing training in four areas: internal medicine, obstetrics and gynecology, pediatrics, and health management. Yale faculty have spent between 2 and 12 months in Rwanda each year to provide this training.

In the clinical areas, Yale is helping to develop residency programs at the National University of Rwanda and its teaching hospitals; has brought Rwandan faculty to New Haven for training in specialty and subspecialty areas; and has trained 10 chief residents. Yale has also helped establish a master’s program in hospital and health administration in the Rwanda University School of Public Health. That program expects to graduate 94 students next year.

“Yale has been involved in this innovative and ambitious project from the beginning,” said Rastegar, “and many graduates of these programs are now employed to work as faculty in the teaching hospitals as well as in district and provincial hospitals. It has had a significant impact on training and medicine throughout Rwanda.”

Igiraneza expects that she will add to that impact on education and clinical care when she returns. In the meantime, she offers thanks to her nephrology “family” at Yale, including her colleagues and attending physicians.

“I am grateful for the partnership between Yale and the University of Rwanda and the University Teaching Hospital of Kigali and the global health program at Yale,” she said. “Through them I have been able to come here and learn. When I go back I will be able to help Rwandans and offer a standard of care in nephrology.”

Jimirasire

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