Context

Key Points 

• In 2000, Rwanda faced a severe shortage of trained health care providers and facilities, resulting in limited access to treatment and services in the face of urgent public health needs.
• At the time, Rwanda trailed both its East African neighbors and its low-income peers in such vital measures as health expenditure per capita and in the number of births attended by skilled health staff.
• Of greatest concern were the five leading causes of under-five mortality: lower respiratory infections; malaria; diarrhea; malnutrition; and neonatal disorders.
• To address these, in addition to the evidence-based interventions and implementation strategies discussed in the previous sections, three main contextual factors were key to Rwanda's success: an institutional culture of accountability, a commitment to decentralization, and high levels of national health expenditure and donor financing
  
   

Background

In 2000, Rwanda was still grappling with the aftermath of the 1994 genocide that killed nearly one million people, displaced another two million, and devastated the nation’s health care system.

President Paul Kagame’s administration - which began in April 2000 - faced the daunting task of reinstating the rule of law and creating a viable path to development in a land where few civic structures remained in place.

The country faced a severe shortage of trained health care providers and facilities, resulting in limited geographic access and poor coverage in the face of urgent public health needs.¹ At the time, Rwanda trailed the averages of both its East African neighbors and its Countdown to 2030 low-income peers in health expenditure per capita and in the number of births attended by skilled health staff.²

The doctors and nurses who were available were highly centralized, with three-quarters of the physicians and half of the nurses located in Kigali.³ In an overwhelmingly rural country, this meant that large portions of the nation were chronically underserved.

In Gikongoro province, for example, only 30 percent of the population lived within five kilometers of a health center.⁴ The nation’s Ministry of Health (MOH) recognized that the low density of health facilities - many of which were understaffed - was a significant contributor to Rwanda’s high U5M rate.

Of greatest concern were the five leading causes of under-five mortality: lower respiratory disorders; malaria; diarrhea; malnutrition; and neonatal disorders. Along with measles - which was still a significant public health concern at the time - these conditions accounted for approximately three-quarters of all deaths of children under

Contextual Factors Contributing to Success

How is it possible that a nation as poor, as small, and as ravaged as Rwanda was in the mid-1990s could go on to achieve impressive gains against under-five mortality (U5M) within a mere decade and a half?

In addition to the evidence-based interventions and implementation strategies discussed in previous chapters, three main contextual factors are commonly cited by Rwandans and by outside observers as reasons for the nation’s notable successes in this area.

An institutional culture of accountability

The government invoked the pre-colonial imihigo concept of accountability, and infused it into the health care system. What made this more than an empty bromide was the government’s willingness to give personnel the training, the tools, and the data they needed to hit their goals - and a no less notable willingness to decentralize implementation in order to swiftly identify successes and address failures.

Several of the Rwandan interviewees drew attention to the importance of imihigo, an indigenous concept that is broadly synonymous with accountability; the word is a plural form of umuhigo, which means “to vow to deliver.” The national government has invoked imihigo in setting performance goals and holding districts responsible for meeting them. Every year, ministers and all district mayors sign imihigo performance contracts with the president himself. These contracts include up to 100 indicators, including several - typically over a dozen - that are health-related. Districts are then ranked according to their achievements.

A commitment to decentralization

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, while the districts and localities carry out Kigali’s directives.⁵

In 2006, to foster greater efficiency, Rwanda consolidated its 106 administrative districts into 30, and 12 provinces into five. Under the old territorial system, the nation’s health districts were organized around hospitals and often cut across administrative districts, blurring political accountability for health outcomes.⁶ In the new districting format, health districts were eventually incorporated into the administrative districts, and placed under the authority of the mayor (the elected head of a district).

The national government also reduced its staff, sending some positions out to the districts.⁷ Indeed, in 2008, Rwanda granted full autonomy to the districts for health decisions, including the right to hire and fire health workers (with some exceptions for doctors and nurses in remote rural areas to ensure adequate levels of clinical service).⁸ The new levels of district autonomy created challenges at first, but over time decentralization has come to be seen as a crucial component in Rwanda’s U5M gains, enabling local personnel to implement national initiatives more rapidly and equitably than might have otherwise been the case. At the same time, these districts are still held accountable to the national government through the aforementioned performance contracts and imihigo system.

High levels of national health expenditure and donor financing:

Over the last 15 years, Rwanda’s health sector has benefited from a strong national commitment to health care, as well as a steady increase in both external and internal funding. Between 2000 and 2015, Rwanda's total expenditure on health increased from $327 million to $1.8 billion.¹⁰  This has corresponded with an increase in per capita health spending from $41 in 2000 to $149 in 2015 (2017 PPP dollars).⁹

Regarding external funding, Rwanda has been very successful in securing foreign aid to help fund its health programs, receiving higher per capita health assistance than its immediate neighbors (although it is not the largest regional recipient of such aid, as several sub-Saharan African nations exceed Rwanda's receipts in both absolute and per capita terms).

Over time however, health-related aid as a percentage of total health spending dropped from nearly 60 percent of the nation’s total health expenditure in 2000 to about 40 percent in 2015.¹⁰ The fact that total health spending has generally remained on an upward trajectory is due in part to the national government's increasing contribution to total health expenditure, from $109 million in 2000 to $430 million in 2015.⁹ This increase in government contributions shows the emphasis placed on improving health outcomes.