What did Rwanda do?

Before and during the Exemplars study period from 2000 to 2018, Rwanda implemented policies as part of efforts to recover from the genocide and to ensure systems could deliver PHC services. Some of these reforms aimed to increase autonomy at the district and facility levels of the health system, making services more tailored to local need, and boosting citizen confidence in the system. Rwanda also increased access to PHC nationwide by decreasing the amount of money citizens paid out of pocket for health care and increasing the number of health workers and health facilities, especially in rural areas. Rwanda’s efforts to improve health system performance and efficiency fall into three main pathways:

Primary health care is a comprehensive, multisectoral approach to care that has many components and addresses a large and diverse set of health needs. In Rwanda, as in every Exemplar country, officials used a combination of interactive, complementary policy levers across the health system’s building blocks—governance, financing, facilities, workforce, supplies, service delivery, and data and information systems—to enable whole-system change.

In Rwanda, Exemplars research identified three ways, or pathways, through which reforms have improved PHC outcomes. Reforms are often complex, with multiple components, and thus they can often operate using multiple pathways. Indeed, efforts to reform PHC in all Exemplar countries have been interactive and complementary and have evolved and built on each other over time.

• The first pathway enabled health system efficiency by distributing authority and responsibility for decision making across national and subnational levels and improving overall planning and coordination of PHC resources.
• The second pathway enabled health system efficiency by implementing data systems for monitoring and accountability of health programs as well as strategic purchasing schemes to incentivize improved PHC delivery.
• The third pathway increased equitable access to quality PHC services by focusing on making PHC services more affordable and prioritizing community-driven and community-based care.

Health system improvement does not happen overnight. Before and during the Exemplar study period, Rwanda invested in its PHC system in two phases:

In the first, transitional phase (1994–2005), Rwanda focused on rebuilding its health system after the genocide. In this phase, Rwanda made substantial investments in rebuilding its health infrastructure as well as increasing the number of health workers and improving their capacity to deliver health services through trainings. Toward the end of this phase, officials also began to facilitate decentralization by restructuring for local health systems administration. Localities also started experimenting with community-based health insurance to ensure financial protection for vulnerable populations and improve access to PHC services.

In the second, developmental phase (2005–present), Rwanda continued to expand and improve health system infrastructure; enhance strategic planning processes with improvements in sectoral coordination; institutionalize and improve the community-based insurance system; and introduce further reforms related to decentralization, accountability (such as performance-based financing), and evidence-based decision making.