Overview

Under-five mortality reduction in Rwanda

U5M Topic Icon

From 2000 to 2015, Rwanda reduced its under-five mortality (U5M) rate by 67 percent.

From 2000 to 2015, Rwanda's under-five mortality (U5M) rate decreased by 67 percent. See how it prioritized primary health care and coordinated partners in line with this vision, to significantly reduce its U5M.
Authors
Lisa Hirschhorn Felix Sayinzoga Caroline Beyer Kateri Donahoe Agnes Binagwaho

Contents

A mother brings her infant son for vaccinations at a public health center in Kabuga, Rwanda.
A mother brings in her infant son for vaccinations at a public health center in Kabuga, Rwanda.
©GATES VENTURES

KEY INSIGHTS

Rwanda consistently promoted and supported policies and expenditures to strengthen the overall primary care system—instead of the disease-specific interventions often favored by donors and foreign partners.

The government invested heavily in building institutional capacities to generate and interpret data and other forms of empirical evidence. To maximize accountability, the national government devolved implementation to the district and local levels, allowing straightforward evaluations of high-performance and low-performance jurisdictions, facilities, and interventions.

Key Insight

Commitment to “horizontal” health system improvements

A crucial element of Rwanda’s progress against U5M was its consistent preference for policies and expenditures that would strengthen the overall primary care system—instead of vertical, disease-specific interventions often favored by donors and foreign partners.

The government held fast to a system-wide, “horizontal” vision of primary-care improvement, placing a priority on such fundamentals as clinic construction; personnel training and retention; high-quality data systems; and vaccination delivery infrastructure.

An emphasis on primary care generally—and U5M specifically—was evident in the government’s Vision 2020 document, which was released in 2000. In time, the government’s focus on primary care would yield immense dividends, including the reduction of U5M. For example, Rwanda’s implementation of the pneumococcal conjugate vaccine was also designed to strengthen future vaccination campaigns.

Lower respiratory infections mortality versus intervention coverage
Data Source: Institute for Health Metrics and Evaluation (IHME) GBD 2017; WHO-UNICEF Estimates of National Immunization Coverage (WUENIC) 
Key Insight

Government-led donor/NGO coordination

Rwanda insisted that donors and non-governmental organizations (NGOs) align their actions and expenditures with the country’s vision of a strong, unified and national health system.

A UNICEF poster promoting childhood vaccination is displayed in a clinic in Kigali, Rwanda.
©GATES ARCHIVE

While maintaining control over its own health policies, Rwanda skillfully drew upon its donor and partner relationships to ensure that those policies incorporated expertise from respected outside sources. Even as the national government held its donors close, it took unambiguous steps to make sure everyone understood who wielded ultimate authority. When well-meaning donors earmarked money for disease-specific “vertical” interventions, Rwanda sought wherever possible to steer those funds toward uses that were consistent with broader systemic improvements.

Even during the fragile first decade following the genocide, when much donor funding for health care was earmarked for disease-specific projects, the nascent government strove to ensure that resources were used to build and strengthen primary health care systems.

Key Insight

Strong community-based health services

By investing in its community health worker (CHW) program—and in the construction and renovation of health facilities in remote rural areas—the national government developed the human and infrastructural resources needed to serve its population and gather necessary data.

Rwanda inaugurated a community health worker (CHW) program in 1995 to compensate for a severe shortage of health care workers; the nation now has 45,000 CHWs working across 15,000 villages. CHWs are responsible for general health interventions for the entire community, including for children under five. CHWs are trained in a cascading, train-the-trainer model on their assigned community-health activities, which have varied over time. By 2007, CHWs nationwide had undergone training at their local health centers on home-based management of fever.

A community health worker prepares to make her daily rounds in Rumyongza, Rwanda.
©GATES ARCHIVE
Key Insight

Emphasis on data and evidence

The government invested heavily in building institutional capacities to generate and interpret data and other forms of empirical evidence.

A nursing assistant completes child vaccination records at Kabuga Health Care Centre in Kabuga, Rwanda.
©GATES ARCHIVE

This strong data culture is sustained through performance-based financing and performance contracts, with negative consequences for low-quality or limited collections of data. Rwanda used its strong accountability and data culture to create financial incentives for high performance, a policy that generated meaningful health gains when used judiciously. The culture of data was also reflected in the adaptation of evidence-based interventions before and during implementation, and a willingness to incorporate new evidence from the global community.

Key Insight

Decentralization of authority and responsibility

To maximize accountability, the national government devolved implementation capacity and responsibility to the district and local levels.

This commitment to decentralization allowed straightforward evaluations of high-performance and low-performance jurisdictions, facilities, and interventions. The emphasis on local accountability has been accompanied by a commensurate expansion of local implementation authority. The national Ministry of Health (MOH) sets national policy, gathers and evaluates data, and provides overall supervision. The districts and localities carry out Kigali’s directives more or less as they see fit.

Data Source: Demographic and Health Survey (DHS)