This April, Rwanda will commemorate the 20th anniversary of one of the last century’s greatest human tragedies, the 1994 genocide that took the lives of one million Tutsis and moderate Hutus in just one hundred days. As the global community turns its attention to Rwanda on this occasion, they will find a country radically different from the Rwanda of the past. The new Rwanda is a stable and increasingly prosperous country, one where life expectancy has doubled since the difficult aftermath of the genocide. The government’s commitment to equity has catalyzed rapid and widespread development, largely by creating opportunity for its poorest citizens. Meanwhile, the health sector’s pioneering efforts in health care delivery have drawn global attention. With strong leadership, smart partnerships and innovative programs, Rwanda is forging a new pathway for development.


Partners In Health (PIH), a Harvard-affiliated global health and social justice organization, has worked side by side with Rwanda’s public sector for nearly a decade, embedding ourselves within the rural communities that we serve. As such, we have had a unique vantage on the country’s evolution. Rwanda has demonstrated that what PIH co-founder, Paul Farmer, has called “vicious cycles of disease and poverty” can be transformed into generative cycles of health and prosperity. Rwanda has been called a “health care miracle.” But the word “miracle” implies mystery, and there is no mystery here: the key is to link effective health care delivery systems to an equity agenda.




Rwanda in the Aftermath of Genocide


Drobac Graph

While division and conflict had been cultivated in Rwanda since the colonial period, the hundred-day span of premeditated mass violence in 1994 was shocking in its scale and swiftness. When the genocide ended on July 4, 1994, Rwanda was virtually left in ruins, its infrastructure destroyed and its society in disarray. In addition to the million lives lost, hundreds of thousands of women were raped—often as a means of weaponizing HIV—and over two million people displaced, both throughout the country and in disease- and conflict-ridden refugee camps in neighboring countries.


In a single year, the country’s GDP was halved, and according to the Rwanda Ministry of Finance and Economic Planning, eighty percent of the population was thrown into poverty. The economic system collapsed, almost no taxes were collected, and government infrastructure—both physical and human—was destroyed.


Malaria, cholera, HIV/AIDS, and waterborne infections—ever thriving along social fault lines—ravaged the remaining population in Rwanda, as well as those in the refugee camps across the border. While the health system was weak and under-resourced before the genocide, it utterly collapsed in 1994. Many clinicians either fled or were killed, and health systems laid in ruins. According to the World Health Organization (WHO), less than 5% of the population had access to clean water, and food insecurity spiked as land and livestock were destroyed throughout the country.


The genocide and its aftermath left Rwanda one of the poorest and most fragile countries in the world. Perversely, the resulting human emergency in Rwanda led many in the international community to write the country off as a lost cause. As a result, the WHO noted, per capita foreign assistance to Rwanda in the mid-1990s was the lowest in sub-Saharan Africa.




Twenty Years Later


Widely forsaken as a failed state two decades ago, Rwanda has undergone a remarkable transformation. Since 1994, GDP has quadrupled, growing at a rate of 8.1 percent annually from 2000, and per capita income has almost tripled. Between 2005 and 2011, over one million Rwandans—almost a tenth of the population—have pulled themselves out of poverty.


Moreover, as we and our colleagues have described in the British Medical Journal, between 2000 and 2011, Rwanda experienced perhaps the steepest declines in premature mortality ever recorded. The numbers are striking: life expectancy, a shocking 28 years in 1994, has since more than doubled to 58 in 2012 due to improvement in many spheres of health. HIV treatment has become universally accessible for those in need, and AIDS-related mortality fell by over 82% since 2000.


Likewise, mortality from the other major infectious killers, tuberculosis and malaria, plummeted by over three-quarters. The ratio of women dying in childbirth fell by 59.5%, and the probability of a child dying by the age of five years decreased by 70.4%—the world’s steepest rate of reduction during this period. Even mortality related to non-communicable diseases, such as heart disease and cancer—which collectively now cause a greater burden of disease and disability than infectious diseases—declined by 49% in the last decade.


It is worth noting that these health outcomes have been delivered with extraordinary value for money. According the WHO and the United Nations (UN), Rwanda’s annual per capita health expenditure of US $55 is lower than many other sub-Saharan African countries. Moreover, the country has exceeded its Abuja commitment to invest at least 15% of its domestic budget on health and education. And today, domestic investment in health exceeds external assistance.


Rwanda is now the only country in the region on track to achieve all of the health-related Millennium Development Goals (MDGs) by 2015. Given that the MDGs are measured against a 1990 baseline, the extraordinary setbacks that Rwanda experienced in 1994 make this achievement all the more remarkable.





To most observers of Rwanda in the 1990s, such a transformation would have seemed improbable at the least. By historical standards, the odds of further instability and political violence in the wake of the genocide were significant. So how did Rwanda defy the odds? Extraordinary government leadership, strategic partnerships including efforts to attract private investment, the development of a reconciliation-oriented legal process for over 100,000 perpetrators of violence, social protection programs for survivors, and reintegration of returnees were all critical factors. The government also resolved that investments in health and broader poverty reduction initiatives, when linked to a participatory process and an equity plan, would create a shared prosperity. This shared prosperity would, in turn, serve as both an antidote to violence and a foundation on which to build an ambitious future.




Building Effective Health Care Delivery Systems


By investing in poverty reduction initiatives and through concerted efforts to address inequity in the health care system, Rwanda is becoming a world leader in bridging the “know-do” gap – harnessing an evidence-based approach to what works (the “know”) and effectively delivering these interventions to the people who need them the most (the “do”). With pioneering partnerships, innovative programs responsive to local context, and a focus on results, Rwanda has been developing a robust and high-value health system. We highlight four key delivery principles, all of them replicable.


First, Rwanda has leveraged disease-specific global health funding to build robust, comprehensive health care delivery platforms. By utilizing funding for “vertical,” or disease-focused, interventions to strengthen the broader health system, Rwanda was able to increase widespread access to primary health care, build health workforce capacity, and finance infrastructure development. A decade ago, just as substantial HIV funding was becoming available, Rwanda’s rural health system had seen only halting improvement since the devastation of the genocide. Much of the health facility infrastructure was destitute, many districts lacked a single physician, supply chains were unreliable, and the rural poor faced substantial geographic and economic barriers. While improvements were necessary in each of these areas to properly deliver HIV care, Rwanda integrated its HIV programs within the primary health system, thereby leveraging limited resources. Maternal and child health services, vaccination coverage, and tuberculosis care all improved as a result.


Thus, by the time that the national HIV program became one of the first in Africa to exceed the 80 percent target for universal access to HIV care, dramatic gains in broader health indicators were also in evidence.


Second, Rwanda’s community health system has reinforced facility-based care, extending the health system into communities to increase uptake of high-value primary health services. A network of 45,000 community health workers (CHWs)—three in every village in the country—are elected by their peers and trained by the Ministry of Health to perform health education, screen for childhood malnutrition and tuberculosis, and diagnose and treat common ailments such as malaria and diarrheal disease. Increasingly, CHWs also provide adherence support for patients living with chronic diseases, from HIV to cancer.





Third, Rwanda has closed the delivery gap through early adoption and rapid implementation of new treatments and technologies. Rwanda was the first low-income country to introduce lifesaving vaccines against pneumococcus and rotavirus into the childhood immunization schedule, and achieved near-universal coverage for nine vaccines. Vaccination against human papillomavirus (HPV), which protects against the viral strains that cause 80 percent of cervical cancers, is more challenging, as it is typically administered in three doses to school-aged girls. By leveraging school-based health campaigns and the extensive CHW network, the Rwanda Ministry of Health delivered the full vaccine series to an unprecedented 93 percent of twelve-year-old Rwandan girls in the program’s first year—more than triple the coverage rate in the United States. Rwanda also provides a supportive environment for testing of new and innovative devices. When a new non-surgical male circumcision device proved simple and effective, Rwanda facilitated rapid national roll-out, adding an important and proven prevention tool to further reduce the rate of new HIV infections.


Rwanda has also leveraged its existing delivery platforms to tackle previously neglected diseases. For example, a non-communicable disease program has adapted the principles of HIV care delivery—task shifting from doctors to nurses and community health workers, robust information systems, social and economic support—to complex chronic diseases including diabetes, heart disease, and epilepsy. In 2012, the Butaro Hospital Cancer Center of Excellence (pictured) introduced widespread access to cancer care, attracting patients from across the east African region.


"[CBHI] provides a critical safety net that has dramatically increased uptake of high-value health services and reduced catastrophic household spending due to illness"

Fourth, results-oriented governance and targeted performance incentives have driven rapid progress in the scale and quality of services delivered. The Performance-Based Financing (PBF) system, which rewards health facilities and individual practitioners for meeting clinical performance targets, has led to improved uptake and quality of maternal and child health services. Rwanda’s PBF approach is now being widely adapted in other countries. At the governance level, local government leaders develop and sign annual performance contracts, or Imihigo, which set measurable development objectives aligned with country strategic plans. These goals might include a commitment to build a new clinic in an underserved region, enroll 10,000 additional people in the health insurance scheme, or drill new wells to improve safe water access. Mayors of all 30 districts in Rwanda sign Imihigo contracts with the President, and independent evaluations with rankings are made publicly available. This system ensures accountability for achieving results—accountability to both the central government and, importantly, to the Mayor’s voting constituency.




Institutionalizing Equity


Yet these advances in health care delivery would not have generated such dramatic gains in population health if the country’s poor majority were left behind. By linking efforts to strengthen health systems with a preferential option for the poor—a cross-cutting equity agenda known as the Economic Development and Poverty Reduction Strategy—Rwanda has amplified the impact of its health system investments.


One key social protection program, community-based health insurance (CBHI), has ensured broad access to key preventive and curative health services. Initiated in 1999 and brought to scale five years later, CBHI has grown to cover over 90 percent of the population as of 2010. Together with private, military and civil service insurance schemes, which cover another 7 percent of the population, Rwanda has achieved near-universal health insurance. CBHI offers access to basic yet comprehensive primary health services in return for a small annual premium and modest user fees, administered on a sliding scale.


For the poorest 25 percent of the population, premiums are paid by the government (in part through external aid), thereby reducing the economic barrier of user fees. Key services, such as HIV and tuberculosis care and malnutrition treatment, are free. Though CBHI is far from adequate to fully finance the public health system, it provides a critical safety net that has dramatically increased uptake of high-value health services and reduced catastrophic household spending due to illness.


When Partners In Health first arrived in Rwanda in 2005, many rural families had to travel six hours or more to reach the nearest health facility. Even with health insurance, such geographic barriers led patients to delay or forgo health care, often until it was too late. For patients with chronic diseases requiring frequent health encounters, such as HIV, the economic and opportunity costs of such travel were prohibitive. In addition to extending the health system into communities through the CHW program, the government has rapidly expanded the number of health centers in the country, targeting remote communities with the goal of having a health facility within 60 minutes walk for every citizen.


Rwanda’s pro-poor development agenda extends far beyond the health sector, addressing several social and economic determinants of health. Impressive advances in gender equity were catalyzed by grassroots advocacy from female survivors of the genocide. Constitutionally-mandated reforms corrected the historical exclusion of women from property ownership and access to credit. In 2008, Rwanda became the first country in the world to boast a female-majority parliament. Health policy reforms have dramatically increased access to voluntary family planning services—now utilized by over half of eligible women—thereby decreasing fertility rates, strengthening families, and increasing economic opportunity for women.


Universal primary education now boasts over 91 percent enrollment, and was recently extended to 12-year basic education. The National Social Protection System, known as the Vision 2020 Umurenge Program, aims to eliminate poverty by 2020 through the delivery of public works employment, unconditional cash transfers for families in extreme poverty, and microloans. One Cow Per Family, or Girinka, has provided cows as economic and nutritional investments to over 150,000 families. Such services, which have collectively benefited well over a half million people, target the poorest of the poor in part through a village-led, participatory poverty assessment known as Ubudehe.


These programs are among several of Rwanda’s “homegrown innovations” that adapt deeply held cultural traditions to a modern development agenda that interrupts poverty cycles. Their participatory nature ensures that communities have both a voice in their own development and a responsibility to help their neighbors, thereby promoting critical social cohesion. Moreover, such programs have grown substantially through foreign assistance, catalyzing a shift from donor-driven to a Rwanda-led development agenda.




The Development “Hat Trick” and a Look Ahead


By one powerful measure, Rwanda’s equity agenda is succeeding. Between 2005 and 2011, when the country’s GDP increased by approximately 8 percent annually, inequality as measured by the GINI index decreased. Growth incidence curves published by the National Institute of Statistics indicate that the majority of the country’s economic growth during that period benefited not the wealthiest one percent, but rather the poorest 10 percent of the population. This striking combination of rapid economic growth, dramatic gains in population health and poverty reduction, and reduced income inequality was dubbed Rwanda’s development “hat trick” by Oxford development economist Paul Collier.


Looking ahead, many challenges remain. A temporary spike in malaria cases that followed a supply chain disruption of mosquito nets in 2010 underscores the fragility of the country’s health gains. Sustained focus and investment, even in the face of diminishing global health aid, are imperative.


Moreover, progress is not uniform. Chronic malnutrition and food insecurity remain stubbornly high, and 44 percent of children have stunted growth. Over 40 percent of the population is still living in poverty, and fewer than 20 percent of households have access to the electricity grid. A significant shortage of skilled healthcare providers poses a challenge to the continued development of the health sector as the country faces an increasing burden of complex chronic diseases.


Rwanda is endeavoring to tackle these challenges using the same recipe for success: smart partnerships, relentless innovation, results-oriented governance, and an insistence on leaving no one behind.


All told, the country’s accomplishments over the last two decades, borne against overwhelming odds, should be cause for optimism. Rwanda has demonstrated that a focus on equity is not only morally sound, but epidemiologically smart. It is also a cost-effective way of doing business, as long as the delivery platforms are effective. This requires evidence-based policies, data-driven innovation and adaptation, and a participatory process with strong accountability mechanisms. As the global community seeks solutions to accelerate progress toward the elimination of poverty in the post-MDG era, Rwanda provides a powerful example.