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Improving Health Outcomes in Rwanda
Neal Emery’s recent article in The Atlantic highlights Rwanda’s progress in significantly improving its health outcomes over the last decade. Emery claims that some analyses over-state the foreign aid effect—which attributes the successes to a health system completely rebuilt by the foreign aid received in the wake of the genocide’s devastation. However, Rwanda actually began this process while receiving less aid than other sub-Saharan African countries.
Even today, Rwanda achieves its superb improvement while spending only $55 per person on health care and public health per year — 22nd among the 49 countries in sub-Saharan Africa. Rwanda achieves exceptional results not from how much money they spend on health, but from how they spend it.
Dr. Paul Farmer and colleagues have published an article in the British Medical Journal highlighting key factors that have led to Rwanda’s successes- factors which they hope other countries might learn from and replicate. For example, Rwanda has used international aid (from the Global Fund, PEPFAR, etc.), not for disease-specific programs, but rather to build a “robust” primary care system. Additionally, they built local capacity by training 45,000 community health workers to bring care directly to the homes of those who might not otherwise receive it.
However, one of the most important factors in Rwanda’s success has been its commitment to transparency. Vision 2020, Rwanda’s plan to advance the country to middle-income status, identified health as a necessary component for effective and efficient development. As such, all government ministries were required to deal with certain cross-cutting health issues, allowing for a more coordinated response to some of the country’s most burdensome health problems. Furthermore, all international funding must fit within the Vision 2020 standards for transparency and accountability.
In the case of foreign aid, the government has taken leadership on aid allocation to fit within Vision 2020. If funding organizations or NGOs want to work in Rwanda, they must fit within that plan and meet transparency and accountability standards, or they will be asked to leave.
In a similar vein, Rwanda has succeeded in reaching its most vulnerable populations by strictly adhering to the data when allocating funds.
Just as the Ministry of Health responded to research on health utilization by cutting for the poorest, Rwanda bases all health policies on available health data. Dr. Binagwaho explains that, “You will not succeed in bringing up a strategy or policy that is not backed up by evidence” — policies not justified by robust data are rejected. The government relies on what Dr. Farmer calls “burden and gap analysis,” first looking at what problems cause the most ill health and then identifying the areas where an affordable, effective intervention can fill the gap. The goal of this analysis is to ensure that every dollar goes as far as possible. As Rwanda brings infectious diseases under control, non-communicable diseases make up an increasing share of burden of disease.
By defining its commitment to transparency, Rwanda has championed its own progress rather than allowing it to be dictated by foreign aid or agendas. The result has been a more coordinated and efficient health system which produces some of the best outcomes in the region. While no two countries face the same circumstances and challenges, Rwanda’s success points to the importance of intentional, transparent development.