Context

Geography and culture

Rwanda is a landlocked country in East Africa with a population of about 13.2 million. It is one of the smaller countries in Africa—in size (46th out of 54) as well as population (29th of 54). It is also one of the most densely populated: 503 inhabitants per square kilometer as of August 2022.¹

Rwanda’s population is young: nearly half of the population is 15 years old or younger. Some 65% of private households reside in planned rural settlements called umudugudu.²

About 69% of private households are engaged in rainfall-dependent agriculture, mostly crop farming. Major crops include beans, maize, cassava, sweet potatoes, and bananas.² Tea and coffee are the country’s major exports.³

The Rwandan population comprises three ethnic, class, and regional sub-groups: the Hutu, the Tutsi, and the Twa.⁴

Politics

Unlike most modern African countries, Rwanda was a unified kingdom for hundreds of years before its colonization.⁵ In 1884–1885, the Berlin Conference—which formally mapped and divided African territory among the major European powers—left Rwanda intact and named it a province of German East Africa.^5,6 Belgium took control of the territory during World War I, and the League of Nations granted it a mandate to govern in 1924.⁷

In 1962, Rwanda and its neighbor Burundi declared independence from Belgium.⁸ However, ethnic conflict persisted between the Hutu, the majority of the population, and the Tutsi, who had been relatively empowered under colonial rule. Tens of thousands—and eventually hundreds of thousands—of Tutsi became refugees in neighboring countries.⁹

In 1972, army chief of staff Juvénal Habyarimana took control of the Rwandan government in a bloodless coup and established a one-party state propped up by Belgium, France, the Vatican, and other former imperial powers.^5,10 The international human rights community typically recognizes that exiles and refugees have a “right to return” to their home countries, but Habyarimana took the position that Rwanda was too poor and crowded for Tutsi refugees to exercise this right. Thus, in 1988, Tutsi exiles formed the Rwandan Patriotic Front (RPF) in Uganda.

In 1990, the RPF attacked Rwanda, and the country’s Hutu dominated government began to argue that all Tutsis who remained in Rwanda were traitors. Media, especially radio, spread this rumor nationwide, and Hutu extremists began planning to exterminate Tutsi civilians and moderate Hutus. In April 1994, a genocide began. In just a few months, more than a million Rwandans were killed by their neighbors. Hundreds of thousands more were tortured and raped.

Since 1994, the RPF and the military leader Paul Kagame have ruled Rwanda.¹¹ Kagame has been the country’s president since 2000.

Many see Rwanda’s response to the 1994 genocide as a model for countries recovering from atrocity. Tribunals provided a means for confessions to be heard, sentences passed, and some measure of truth and reconciliation to be established.^12,13

Economy

As of 2022, agriculture accounts for 25% of Rwanda’s GDP and 34% of its national export earnings. Most of the country’s citizens earn their living in the agricultural economy.¹⁴

Rwanda’s Vision 2050 plan aims to make Rwanda an upper-middle-income country by 2035 and a high-income country by 2050. Officials believe that agriculture and food systems will play a substantial role in this economic transformation.¹⁵

Organization of Rwanda’s health system

Rwanda’s 1994 genocide substantially disrupted its health system. Infrastructure and equipment were destroyed, and many health workers were killed. Many more fled the country. ¹⁶ The incidence of preventable illnesses such as malaria surged.¹⁷ Soldiers and others also commonly used rape as a weapon of war and tool of genocide, and many deliberately infected their victims with HIV.^18,19

After 1994, Rwanda reconstructed its health system in two phases: the emergency or transition phase (1994–2003), in which the Ministry of Health (MoH) invested in rebuilding health infrastructure and increasing the number of health workers, and the development phase (2005–Present), in which the MoH established strategic plans to meet key health sector priorities including the increased availability of human resources, drugs, and vaccines; increased geographical and financial accessibility of health services; and capacity strengthening across institutions in the health sector.²⁰

Rwanda’s health system, like the rest of its government, is administratively decentralized. The central MoH steers the health sector and makes policy and regulations. Since 2011, the Rwanda Biomedical Center has implemented policy and strategy for the MoH.

At the district level, health offices coordinate and provide services. District health units under the auspices of the vice-mayor for social affairs are responsible for planning, monitoring, and supervising service delivery and implementation.

Service delivery takes place at three levels: the central level, including teaching, referral and national hospitals; the intermediate level, including district hospitals; and the peripheral level, including health centers, posts and community health services. This structure ensures that patients have access to comprehensive and essential health services at the first point of care.. ²¹

More than 1,100 health posts serve as extensions of health centers at the cell -- or peripheral – level. They deliver PHC to people in remote and rural areas.²²

As of 2017, the public sector owned more than 60% of health facilities in Rwanda—28% were operated by faith-based organizations, and the rest were operated for profit.²⁰

Health spending

Rwanda’s health sector is predominantly funded by external aid, followed by government transfers and out-of-pocket payments.²³ However, the government is committed to decreasing its reliance on external aid by mobilizing funds through increased domestic resource mobilization, improving efficiency such as improved financial management within health facilities, and increasing financial protection of citizens.²¹