Challenges

Limited health workforce

The 1994 genocide devastated Rwanda’s health system and workforce: some three-quarters of all health workers in the country either fled or were killed.¹ In the years since, Rwanda has worked to rebuild its health workforce. However, it still has significant shortages of doctors, nurses, and other health care providers. In 2018, researchers found that Rwanda had 11 doctors, nurses, midwives, and other health workers per 10,000 people, less than one-quarter of the 44.5 health workers per 10,000 people recommended by the World Health Organization in 2016.²

Financial sustainability

According to a 2019 report produced by Rwanda’s Ministry of Health, the funding challenges the health system faces include low public financing per capita, decreasing funding from development partners and other external sources, persistently high out-of-pocket payments, limited investment from the private sector, and insufficient revenue from the community-based health insurance program (CBHI).³

In 2013, more than two-thirds of households in the middle Ubudehe category reported struggling to pay their premiums,⁴ and 21% of households in this category had to pay their premiums in installments.

Finally, Rwanda’s health funding model still relies disproportionately on development assistance for health. According to the Institute for Health Metrics and Evaluation, in 2022, Rwanda received US$294 million in such funds, compared to US$378 million from the government.⁵

Disease burden

Despite the great strides Rwanda made over the course of the Exemplars study period, the country still has a high burden of communicable diseases, including malaria, tuberculosis, and HIV/AIDS, as well as noncommunicable diseases. In fact, according to the World Health Organization, noncommunicable diseases caused more than half of all deaths in Rwanda in 2019.⁶ Researchers argue that this increasing burden, combined with the country’s reliance on development assistance that focuses disproportionately on communicable diseases, means that people may not be able to access or afford the care they need for heart disease, cancer, and other serious illnesses.⁷

Data and health information systems

Rwanda has made significant investments in the collection and digitization of health data. However, systems for gathering and sharing patient health data are still not interoperable between health facilities, making it difficult for providers to coordinate with one another and make full use of electronic health records.⁸ Likewise, limitations on the availability of health data can impede data-driven decision making at the policy level.

The impact of COVID-19

While Rwanda felt the impact of the COVID-19 pandemic like every other country in the world, in some ways it also offered evidence of the efficacy of the country’s health system, which outperformed those of its peer countries and even some wealthy western countries. At the end of 2020, while neighboring countries had between 10,000 and 90,000 COVID-19 cases, Rwanda had about 6,000. Awareness campaigns, and an aggressive program of testing, as well as making it socially acceptable to admit to being infected all contributed to its strong performance. The public’s trust in the health system is credited for Rwanda’s high vaccination rates and cooperation with stringent quarantine protocols.⁹ Rwanda also used innovative methods to maintain the sustainability of no-charge testing at scale, including testing multiple samples at once, and testing individual samples only as needed to identify positive results. College students, police officers, and community health workers were deployed as contact tracers.¹⁰

Conclusion

Rwanda has outperformed its peers in improving PHC service coverage while enhancing both efficiency and equity, offering valuable lessons. The country achieved sustainable health system reform through multifaceted interventions, taking a whole-system approach rather than relying on singular actions. Rwanda’s experience shows that it is possible to enhance health system efficiency while reducing inequities, demonstrating that countries do not have to choose between the two. Additionally, Rwanda’s success underscores the importance of long-term investment in health system reform, as interventions often have complex causal pathways that require extended periods to show impact. While the reforms identified in this study are not unique to low- and middle-income countries, Rwanda’s health system was particularly effective in implementing them in ways that aligned with the system’s goals. Notably, while many countries have adopted social health insurance schemes, Rwanda’s community-based health insurance is largely tax-funded and focuses on the poor, offering premium exemptions to ensure inclusivity.