Deaths of children under 5 have dropped by nearly 20 percent in just two years in a poor, rural district in Madagascar—despite the island nation having the lowest health-spending level in the world. This transformation echoes the strength of results seen across the last decade in rural Rwanda, where under-5 mortality dropped 60 percent between 2005 and 2010 in Southern Kayonza and Kirehe districts.

Both achievements were products of grassroots movements to build and strengthen health systems founded on principles of public partnership, data science and universal access to care for all.

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“The positive health outcomes in both Rwanda and Madagascar document our collective progress in reinforcing universal coverage as both a moral imperative and an achievable reality,” said Paul Farmer, the Kolokotrones University Professor of Global Health and Social Medicine at Harvard and co-founder and chief strategist of global health nonprofit Partners in Health, one of the co-authors of the Rwanda study.

The health systems transformations were led by Partners In Health (PIH) in Rwanda and the nonprofit organization PIVOT in Madagascar, and, in partnership with the ministries of health in both countries. Both teams included faculty members from the HMS Department of Global Health and Social Medicine. The results are detailed in two new papers published in BMJ Global Health.

“PIH and PIVOT, in partnership with the HMS Global Health Research Core and its affiliated faculty, are charting stronger, more equitable, mechanisms for improved care delivery,” Farmer said.

Many of the baseline conditions of the two study areas are remarkably similar: both francophone, subsistence agricultural economies, with per capita incomes among the lowest in the world, and nearly identical, staggering under-5 mortality rates of 1 in 6.

At a time when Rwanda witnessed the fastest drops in under-5 mortality ever recorded, the remote districts where PIH was working saw rates drop twice as fast. Indeed, the world has tracked Rwanda’s rise as a model for health-system transformation, seeing the country’s development as an anomaly as it became the only country in sub-Saharan Africa to achieve its health Millennium Development Goals.

But while Rwanda has been boosted by strong government support for health projects and a vast infusion of international resources in the aftermath of the 1994 genocide, Madagascar has been politically unstable and largely forgotten by the international donor community.

That is why, the study authors say, the results in both countries taken together demonstrate evidence for the global replicability of the ground-up health systems model, with success in vastly different settings.

“Through Rwanda's commitment to a universal right to health, we have continued to witness transformation that has rendered our country's health system an example for not only Africa, but for the world,” said Agnes Binagwaho, HMS senior lecturer on global health and social medicine, senior author on the Rwanda study, and Rwanda Minister of Health from 2011–16.  “We embrace the shared vision and work of our partners in Madagascar. Together, we can pave the way to inclusive health systems that advance equity and health for all people.”

Binagwaho is also adjunct professor of pediatrics at Dartmouth Geisel School of Medicine and is the vice chancellor of the University of Global Health Equity, a new Rwanda-based university that trains global health professionals from across the globe.

Other co-authors on both papers include PIVOT co-founder Michael Rich, who was executive director of PIH-Rwanda from 2005–10; Megan Murray, the Ronda Stryker and William Johnston Professor of Global Health at HMS; and Matthew Bonds, assistant professor of global health and social medicine at HMS and co-founder and co-CEO of PIVOT.

This story is adapted from a joint news release from PIVOT and PIH.