Rwanda, 20 years on: an inspiration for health systems strengthening

07 April 2014 - Geneva - Two decades on and the stories are coming out to mark the 20th anniversary of the 1994 Rwandan genocide; a conflict that claimed nearly a million lives and displaced another two million. It was an almost unimaginable tragedy in which the ethnic conflict between the Hutus and Tutsis exploded across the Great Lakes Region of Africa, also affecting DR Congo, Burundi and Uganda as well.

At the time, Rwanda was one of the poorest countries in the world. Its health services were rudimentary and infectious diseases, including a growing AIDS epidemic, tuberculosis and a serious malaria problem, were having a devastating impact on the country. More than one in four children were dying before their fifth birthday. Rape and population displacements due to the genocide worsened both the AIDS epidemic and the malaria incidence.

"Whether survivor, perpetrator, or member of the diaspora, no Rwandan emerged unaffected," writes Dr Binagwaho Rwanda’s minister of health. "Much of the rest of the world stood idly by."

"Tuberculosis control programmes, weak before the genocide, were in complete disarray; for years afterwards, many patients received only intermittent therapy. Moreover, most health workers had either been killed or fled the country; many who remained had been complicit in the genocide, and trust in physicians and nurses were frayed."

Since then, Rwanda under President Paul Kagame has made dramatic progress on many fronts - health, economics and infrastructure. Much of the country’s turnaround is largely the result of the country’s leaders prioritizing equity, human development and health care for the poorest and most vulnerable. Strong government planning by using a foundation of community health workers to bring health care into every community, supported by low-cost, high impact solutions that can be scaled up to improve health outcomes across the country are the very reasons for Rwanda’s turnaround.

In a study published this week by The Lancet medical journal, a group led by Dr Binagwaho and US Harvard professor in global health Dr Paul E. Farmer, reports on how life expectancy in the country has doubled, from the world’s highest child mortality and lowest life expectancy at birth to today 62.9 years, higher than 31 of the 46 countries in Sub-Saharan Africa.

Rates of under-5 mortality, maternal mortality and deaths due to tuberculosis and malaria have fallen alongside the burden of HIV. Rwanda is now on course to be the first in sub-Saharan Africa to meet every one of the health-related Millennium Development Goals (MDGs).

Speaking to the UK newspaper The Guardian, Dr Farmer, co-founder of Partners in Health, said there are important lessons to be learned. "In the last decade death rates from AIDS and tuberculosis have dropped more steeply in Rwanda than just about anywhere, ever.

"In the 30 years that I’ve been involved in the provision of health-care services to the poor and marginalised, I can think of no more dramatic example of a turnaround than that achieved in Rwanda."

In 2000, the Rwandan government created a plan called Vision 2020, with the primary objective of rapidly transforming Rwanda into a middle-income country. Health was identified as a key pillar in the government’s vision for economic development and poverty reduction. With aid from governments and multilateral funders like the Global Fund to Fight AIDS, TB and Malaria, the country has been able to subsidise premiums and co-payments for around 2 million of the poorest Rwandans, thus making it an incredible public health success story which now could provide a model for the rest of Africa.

To Western funders, it is encouraging to see that Rwanda has used its donors’ money wisely, utilizing it to build a complete health system - and to make that system available so freely to all its citizens. For many countries, Rwanda’s rebuilding should offer hope that they too can remake their countries and recover from crises in the coming decades.