In tiny Rwanda, staggering health gains set new standard in Africa

When Agnes Binagwaho began her career as a doctor in the slums of Kigali, Rwanda, in 1996, she worked in one of the most precarious health environments in the world.  

The rickety public hospitals that had not been destroyed in the genocide two years before were filled with AIDS patients. But drugs – and doctors – were scarce or nonexistent. Meanwhile, Rwandans were dying in massive numbers from malnutrition, malaria, and tuberculosis.

“We could do nothing for them,” she remembers. “We didn’t have drugs even for ordinary diseases.”

19 years later, however, Rwanda is on pace to become the only country in sub-Saharan Africa to meet all of its health-related Millennium Development Goals, and the tiny pocket of Central Africa has posted some of the world’s most staggering health gains in the past decade, outpacing nations that spend far more per capita on healthcare.

And Dr. Binagwaho, who once stuffed her suitcases full of basic medicinal supplies to take home to Kigali whenever she traveled abroad, is now leading that charge as minister of health.

In an article published earlier this year in the British Medical Journal (BMI), a team of doctors and researchers working in Rwanda laid out the country’s swift rise.  

Between 1994 and 2012, they wrote, the country’s life expectancy climbed from 28 years to 56 and the percentage of the population living in poverty dropped from 77.8 percent to 44.9 percent.

In the past decade, deaths from HIV have fallen 78 percent – the single largest decline in the world during that time frame – while tuberculosis mortality has dropped 77 percent, the most significant decrease in Africa.  

Of course, the starting point in Rwanda’s climb was a harrowing one: In 1994, between 500,000 and 1 million people — up to 20 percent of its total population — were killed in an ethnic genocide, and some 2 million more fled. Many doctors were among the dead and exiled, and the country, including its healthcare system, was left in tatters.  

That year, less than a quarter of Rwandan children received immunizations and more than 1 in 4 children were dead by their fifth birthday.

But in the years that followed, Rwanda became the darling of the international development community, a case study for how a country could use a transformative post-conflict period to effectively rebuild its core institutions.  

As aid poured in, Rwanda’s new government channeled it into a wide variety of social programs, including healthcare. It rolled out a system of universal health insurance, doled out vaccinations and mosquito nets, and put nearly every AIDS patient on antiretrovirals.

And it did all of this in a place that still faces what the BMI article called “one of the greatest shortages of human resources for health in the world.”

Indeed, the country of 11 million has only 625 doctors in its public hospitals nationwide. But there are also now more than 45,000 “community health workers,” trained to treat basic health issues and help ensure adherence to drug regimens in rural areas far from hospitals and clinics.

As a result of these efforts, the probability that a child will die before the age of five has fallen by 70 percent and is now half the regional average. Some 108,000 people now receive antiretroviral treatment for AIDS – a figure approaching universal access.

But as the healthcare system has lurched forward, it has also come under attack for its heavy reliance on foreign aid: Nearly half of the government’s health budget comes from external funders.

Unlike many other countries, however, Rwanda has used these cash infusions to build institutions, not merely fund programs, says Peter Drobac, the Rwanda director for Partners in Health, a public health nonprofit, and one of the authors of the BMI paper. 

Indeed, Rwanda spends no more on health than many of its neighbors, ranking 22nd among 49 sub-Saharan African countries in per capita health spending. That comes to about $55.50 per person each year, which Drobac says is a “tremendous value for money.”

But Rwanda’s government has ambitiously called for the country to be aid-free by 2020, an undertaking that would require a massive pivot away from its current healthcare funding model. In reality, that goal may be decades off, but in the meantime, officials have built the scaffolding for a sturdy healthcare system, Drobac says.

“The lesson we have learned is that you cannot solve every [health] problem at once,” Binagwaho says. “So you do the best with what you have, and you don’t leave anyone out.”