Reduced premature mortality in Rwanda: lessons from success.

0.39 MB·English

by  Farmer, Paul E

BMJ2013;346:f65doi:10.1136/bmj.f65(Published18January2013) Page1of7
Analysis
ANALYSIS
Reduced premature mortality in Rwanda: lessons from
success
OPENACCESS
Rwanda’s approach to delivering healthcare in a setting of post-conflict poverty offers lessons for
other poor countries, say Paul Farmer and colleagues
Paul E Farmer professor123, Cameron T Nutt research fellow4, Claire M Wagner research fellow5,
ClaudeSekabaragaseniorhealthfinancingspecialist6,TejNuthulagantihumanresourcesforhealth
programdirector7,JonathanLWeigeldoctoralcandidate8,DidiBertrandFarmerdirectorofcommunity
health and social development9, Antoinette Habinshuti deputy director of Rwanda progammes9,
Soline Dusabeyesu Mugeni technical adviser9, Jean-Claude Karasi researcher10, Peter C Drobac
director of Rwanda progammes29
1DepartmentofGlobalHealthandSocialMedicine,HarvardMedicalSchool,Boston,MA,USA;2DivisionofGlobalHealthEquity,Brighamand
Women’sHospital,Boston,MA,USA;3PartnersInHealth,Boston,MA,USA;4DartmouthCenterforHealthCareDeliveryScience,Hanover,NH,
USA;5GlobalHealthDeliveryPartnership,Boston,MA,USA;6WorldBank,Nairobi,Kenya;7ClintonHealthAccessInitiative,Kigali,Rwanda;
8DepartmentofGovernment,HarvardUniversity,Boston,MA,USA;9PartnersInHealth/InshutiMuBuzima,Rwinkwavu,Rwanda;10CRP-Santé,
Luxembourg,Luxembourg
Intheimmediateaftermathofthe1994genocide,whichclaimed increasinglywellknownfactthatRwandatodayhasthehighest
uptoamillionlivesandlefttwomillionhomeless,Rwanda proportionoffemalecivilservantsintheworld.5
wasamongthepoorestcountriesintheworld.1Healthand SomehavecharacterisedRwanda’srebirthasgoodfortuneor
educationsystems,alreadyweakandlimitedinreachbefore asa“blackbox”casewithfewlessonsforothers.However,as
theconflict,layinruins;lessthan5%ofthepopulationhad doctorsandresearcherswhohaveworkedforadecadewith
accesstocleanwater;thebankingsystemhadcollapsed;almost Rwanda’sMinistryofHealthanditsdevelopmentpartners,we
notaxeswerecollected.Epidemicsofinfectious contendthatthecountry’sapproachtostrengtheningitshealth
disease—includingAIDS,malaria,tuberculosis,andwaterborne systemoffersinsightsforothercountriesfacedwithpersistent
infections—furtherthinnedthepopulation.2 povertyandlagginghealthindicators.
TodayRwandahasbeentransformed.Massviolencehasnot Reining in AIDS: a blueprint for
recurredwithinthecountry’sborders,anditsgrossdomestic
strengthening health systems
product(GDP)hasmorethantripledoverthepastdecade(box
1).Growthhasbeenlessuneventhaninothercountriesinthe
TheRwandangovernmentlaidambitiousplanstoscaleup
region,partlybecausebothlocalandnationalgovernmentshave
accesstohealthservicesintheyearsimmediatelyafterthe
madeequityandhumandevelopmentguidingprinciplesof
genocide.ItsVision2020strategyforequitablesocialand
recovery.3Recentstudiessuggestthatmorethanonemillion
economicdevelopment,producedin2000,emphasisedhealth
Rwandanswereliftedoutofpovertybetween2005and2010,
asapillarofthenationalcross-sectorapproachtoreducing
astheproportionofthepopulationlivingbelowthepovertyline
poverty.Fundsforimplementationwerescarce,however,and
droppedfrom77.8%in1994to58.9%in2000and44.9%in
AIDSandtuberculosisepidemics,compoundedbyaheavy
2010.3Lifeexpectancyclimbedfrom28yearsin1994to56
burdenofmalariaandfoodinsecurity,causedsubstantial
yearsin2012.4Itistheonlycountryinsub-SaharanAfricaon prematuredeathanddisability.2
tracktomeetmostofthemillenniumdevelopmentgoalsby
InDecember2002,only870ofthetensofthousandsof
2015.Althoughmetricsforequityaredisputed,itisan
RwandanswithadvancedHIVdiseasewerereceiving
antiretroviraltherapy—mostinprivateclinicsinKigali,and
Correspondence to: P E Farmer Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston, MA
02115, USA [email protected]
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BMJ2013;346:f65doi:10.1136/bmj.f65(Published18January2013) Page2of7
ANALYSIS
Box1:Rwanda’ssocialandeconomiccontext
• Population(2011):10942950
• Populationlivinginruralareas(2011):81.2%
• Populationbelowage15(2011):42.8%
• Parliamentaryseatsheldbywomen(2011):56.3%
• Netenrolmentinprimaryeducation(2010):98.7%
• Grossdomesticproduct(GDP)percapita(2011):$582.79(£361;€435)
• AverageannualGDPgrowthoverpastdecade(2002-11):7.6%
• AgricultureaspercentageofGDP(2010):32.2%
• Externalassistanceforhealth(2010):$277m
• Externalassistanceasproportionoftotalhealthspending(2010):47%
• Publicspendingonhealthasproportionofpublicspending(2010):20.1%
• Totalhealthspendingpercapita(2010):$55.51
• Physicians/nurses/midwivesper1000population(2011):0.84
manyerratically.6Intheearly2000s,newfundingmechanisms, 000communityhealthworkershasperformedmanytasksover
mostnotablyfromtheGlobalFundtoFightAIDS,Tuberculosis thepastdecade.Afterbeingelectedbytheircommunities,health
andMalaria(GlobalFund)andtheUSPresident’sEmergency workersaretrainedtodiagnoseandprovideempiricaltreatment
PlanforAIDSRelief(PEPFAR),substantiallyincreased formalaria,pneumonia,anddiarrhoealdisease.Theyalsoplay
developmentassistanceforhealth,butthesefundswereoften akeyroleinhealthpromotioneffortsforfamilyplanning,
restrictedtospecificprogrammes,especiallyforHIV. antenatalcare,andchildhoodimmunisationsandcanrefer
Itsoonbecameapparentthatadvocacyandfundingalonedo patientstohealthcentresandhospitals.12Thisapproachhas
notguaranteethatqualityhealthserviceswillreachthosewho extendedthereachofthehealthsystem,helpedpreventthemost
needthemmost. vulnerablefromfallingthroughthecracks,andimprovedthe
coordinationofcare.Rwandaachieveda91%successratefor
RwandasoughttocontrolAIDS,tuberculosis,andmalaria,
communitybasedtuberculosistreatmentin201011andeven
buildingastrongerhealthsystemasitdidso.Integrationof
higherratesoflongtermadherenceforcommunitybasedHIV
disease-controlprogrammeswasrecognisedasaworthygoal.
care.13
Fromthestart,Rwanda’sAIDSprogrammewascharacterised
notonlybyeffortstointegratepreventionandcontrolbutalso AnotherpillarofRwanda’shealthstrategyisuniversalhealth
byattentiontoconcomitantproblemssuchastuberculosisand coverage.Anationalcommunitybasedhealthinsurancescheme
malnutrition,andtostrengtheningthehealthcaresystem.As knownasmutuellesdesantéwaspilotedin1999andextended
Rwanda’sministerofhealth,DrAgnesBinagwaho,says:“If nationwidebythemid-2000s,facilitatedbythecountry’s
yougiveRwandamoneytosavethelifeoftheoldestpersonin improvedfinancialsituation.AsofJune2012,90.6%ofthe
Rwandatoday,wewillmakesurethattheinfantborntonight populationwasenrolled,whileanother7%arecoveredbycivil
benefitstoo.”Diseasespecificor“vertical”fundingfromthe service,military,orprivateinsuranceplans.Inadditiontoannual
GlobalFundandPEPFARwasusedtorebuildthecountry’s premiums,subscriberspay10%copaymentsatthepointofcare
healthinfrastructureanddeveloprobustplatformsforprimary forservicesnotfullycovered.(Manypreventiveinterventions,
care.7SimilarapproacheshadbeensuccessfulinruralHaiti.8 suchasbednetsandvaccinations,arefullycovered,alongwith
treatmentforHIVdisease,tuberculosis,andsomecancers.)
Scale-upofAIDSservicesbeganincitiesandtownsandthen
Since2006,bothpremiumsandcopaymentshavebeen
expandedintotheruralregionsinwhichmostRwandanslive.
subsidisedforthepoorestquarterofthepopulationbytheGlobal
InJune2012,108113peoplewithadvancedHIVdiseasein
Fundandotherpartners.14Afterresearchshowedthatlower
Rwandawerereceivingantiretroviraltherapy,makingRwanda
incomeenroleesoftenfacedahighriskofcatastrophicmedical
(alongwithmuchricherBotswana)oneofonlytwocountries
expenditures,15theMinistryofHealthintroducedathreetiered
insub-SaharanAfricatoachievetheUnitedNationsgoalof
feestructure,sothatpoorerpeoplepaysmallerpremiums.16
universalaccesstoantiretroviraltherapy.9Rwanda’sHIV
epidemichasremainedataprevalenceofabout3%forthepast Aperformancebasedfinancingsystem,launchedin2005,
sevenyears.10 rewardscommunityhealthworkercooperatives,healthcentres,
anddistricthospitalsforbetterpatientfollow-upandimproved
primarycareindicators,suchastheproportionofwomen
Rebuilding the health system
deliveringathealthfacilitiesandchildrenreceivingafullcourse
Tacklingconditionsrangingfromobstructedlabourtochronic ofbasicimmunisations.17Suchincentiveshavehelpedboost
infectiousdiseasesrequiresmodernhealthinfrastructureand theuseofmaternalandchildhealthservices(fig1⇓).18-21
well-trainedstaff.Rwanda’shealthfacilities—fivereferral Rwandahasalsobeenanearlyadopteroftechnological,clinical,
hospitals,42districthospitals,469healthcentres,andmany andprogrammaticinnovations.Thecountry’sonlinehealth
privateclinics—arecurrentlystaffedby625physicians,8273 managementinformationsystem22andnationalAIDS
nurses,and240nursemidwives,heavilyconcentratedinurban informaticssystem,TRACnet,23aggregatedataandimprove
areas.11Decadesofinstabilitycontributedtoanexodusofmany informationflowbetweenprocurementanddistributiondivisions
healthworkersintheyearsleadinguptothe1994genocide, oftheministry,inadditiontofacilitatingmanagementofthe
whenmanymorewerekilled.Rwandafacesoneofthegreatest performancebasedfinancingsystem.Amobilephonebased
shortagesofhumanresourcesforhealthintheworld. alertandauditserviceformaternalandchildhealth,RapidSMS,
Addressingthisshortagebytrainingphysiciansandnurseswill linkscommunityhealthworkerstonearbyhealthfacilities.12
takemanyyears;thiseffortisnowunderway.Acadreof45 Anopensource,customisableelectronicmedicalrecordsystem,
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ANALYSIS
OpenMRS,hasbeenpilotedat24healthfacilitiesandis reasonsforthesuccess.37SomehaveclaimedthatRwanda’s
currentlybeingrolledoutacrossthecountry.24 progresslargelyreflectshighspendingonhealthcare,muchof
Rwandawasamongthefirstcountriestointegratetherotavirus, itfinancedbyforeignaid.Certainlytheproportionofpublic
pneumococcal,andhumanpapillomavirus(HPV)vaccinesinto spendingonhealthishighat20%,butRwanda’stotalhealth
itsnationalimmunisationsystem,achievinggreaterthan93% expenditureperpersonperyear($55.51;£34.60;€42.50)is
coverageforeachofninevaccines(rotavirusdataarenotyet similartothatofotherlowincomecountries.38Of49countries
available).25Thisincludes93.2%coverageforallthreedoses insub-SaharanAfrica,Rwandawasranked22ndintermsof
oftheHPVvaccineamongeligiblegirlsin201126;bycontrast, healthspendingpercapitain2010,whiletherelativescaleof
lessthanaquarterofeligiblegirlsintheUnitedStateshave itsrecentreductionsinprematuremortalityexceedthoseof
receivedacompleteseries.27Rwanda’sschoolbasedHPV othercountriesintheregion(table⇓).Moreover,thepaceof
vaccinationprogrammeservesasanexampleofcross-sectorial thesereductionshasacceleratedasRwandaapproachesits
collaboration,duringwhichhealthauthoritiespartnerwiththe millenniumdevelopmentgoaltargets.
MinistriesofEducation,Gender,andLocalGovernmentaswell Othersarguethatthe1994genocidepresentedanopportunity
asdevelopmentpartners,religiousorganisations,andcommunity forreformthatrendersRwanda’srebuildingstrategies
members. inapplicableelsewhere.Butin1995,mostdevelopmentagencies
Rebuildinghealthsystemsrequireslongtermstrategiesand werereadytogiveuponRwanda—thenoneofthepoorestand
investments.Formorethan15years,thegovernmentofRwanda mostfragilecountriesintheworld.1Rwandareceivedless
hasplacedapremiumonRwandanleadershipofforeignaid foreignassistanceforhealthpercapitathatyearthananyother
efforts,atbothnationalandlocallevels.28TheMinistryofHealth countryinsub-SaharanAfrica.38Lifeexpectancyremainedthe
demandsrobustfinancialmanagement,transparency,and lowestintheworldfrom1989to1997.5
accountabilitystandardsofallofitspartners.29Some SubstantialcreditforRwanda’sprogressisduetothecentral
non-governmentalorganisationsreluctanttoworkinaccordance government,includingtheMinistryofHealth.Forthepast
withnationalstrategieswereaskedtoleavethecountry.30 decadehealthauthoritieshaveresistedpittingpreventionagainst
Donorsaretakingnote:inearly2012,Rwandabecameoneof care,publicsectoragainstprivate,andverticalprogrammes
thefirstnationstoreceivedirectbudgetsupportfromPEPFAR.31 againstprimarycare.Theministryhassoughtinsteadtoidentify
InAugust2012,inpartnershipwiththeUSgovernmentandthe andaddresstheleadingcausesofmortalityandmorbidity,while
GlobalFund,Rwandalauncheditsambitioushumanresources expandingaccesstobasichealthservicestothepoorand
forhealthprogramme,asevenyearplantobuildcapacity strengtheningthehealthsystem.Forexample,Rwandahas
throughtrainingintenpriorityspecialties(internalmedicine, includedwrap-aroundsocialsupport(includingfundingtravel
paediatrics,obstetricsandgynaecology,surgery, costsandprovidingfoodsupplements)initsnationaltreatment
anaesthesiology,familyandcommunitymedicine,oncology, programmesforAIDSandtuberculosis.Recentresearchinrural
radiology,pathology,andemergencymedicine)throughlong regionssuggeststhatinvestingincomprehensivehealthsystems
termpartnershipswithAmericanuniversities.32 canhelpbreakthecycleofpovertyanddiseasedescribedacross
thecontinent.3940
Vital signs Rwanda’sprogresshasnotbeenuniform,however,andmany
challengeslieahead.Chronicchildhoodmalnutritionremains
Whataretheresultsoftheseinvestmentsandpolicies?Over high:44.2%ofchildrenwereclassifiedasstuntedin2010
thepastdecade,Rwandahasseenlargefallsinpremature (comparedwithabout51%in2005).21Severeanaemiaamong
mortality(table⇓).MortalityassociatedwithHIVdiseasefell childrenandwomenincreasedbetween2008and2010.2021
by78.4%(thegreatestreductionintheworldduringthat Despiteafourfoldincreaseinfamilyplanninguptakeanda
timeframe)2andmortalityfromtuberculosisby77.1%(the declineinthetotalfertilityratefrom6.1to4.6between2005
greatestdeclineinAfrica).33From2005to2011,deathsfrom and2010,contraceptionremainsunavailableto(orunderused
malariadroppedby87.3%.34Between2000and2010the by)manyRwandans.2021Whileinfantandchildmortalityhave
country’smaternalmortalityratiofellby59.5%.35The decreaseddramatically,neonatalmortalityremainsachallenge.
probabilitythatachilddiesbytheageof5yearsdecreasedby Newbornsaccountedfor39%ofalldeathsamongchildrenin
70.4%between2000and2011—fallingbelowhalfofthe 2011.36Rwandaalsofacesasubstantialburdenof
regionalaverageandapproachingtheglobalmean(fig2⇓).36 non-communicablediseases.41
Ifthesegainscanbesustained,Rwandawillbetheonlycountry Districtandreferralhospitalshavedevelopedactionplansto
intheregionontracktomeeteachofthehealthrelated tackletheseandotherunmetchallenges.42Implementingthem
millenniumdevelopmentgoalsby2015.Yet,notlongago,it willrequireresolveandacontinuedcommitmentbothto
wasthecountryleastlikelytodoso:thegoalsmeasureprogress partnershipandtosurmountingthebarriersthatimpededelivery
againsta1990baseline,sotheydonotaccountfortheevents ofhealthservicestothepoorandunderserved.
of1994,whenchildimmunisationratesplummetedbelow25%
andmorethanoneinfourchildrendiedbeforetheir5th Conclusion
birthday.2536From2000to2011theabsolutenumberofchild
deathsannuallyfellby62.8%36(evenasthepopulationincreased Duringthe2011UnitedNationshighlevelmeetingon
by35.1%),5whileRwanda’sregionalrankingforchildmortality non-communicablediseases,Rwanda’sministerofhealth,Agnes
wentfrom42ndto7th.Rwanda’saverageannualrateof Binagwaho,remindedtheassemblythatprioritisingequityin
reductionof11.1%forthisperiodwastheworld’shighest(fig thehealthsectoris“notonlyamoralimperativebutalsoan
3⇓). epidemiologicalandeconomicimperativeifwewanttogrow
asanation.”
Contributing factors Certainly,Rwandawillfacegreatchallengesifitistomeetits
goalofbecomingindependentofaidby2020:nearlyhalfofits
Rwanda’sturnaroundisincreasinglywellknowninpublichealth
healthsectorbudgetwasexternallyfinancedin2010.37Evenif
anddevelopmentcircles,butthereisdisagreementaboutthe
Rwandasustainsitsimpressivepaceofeconomicgrowthinthe
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ANALYSIS
comingdecade(andmanybelieveitiswellpositionedtodo 9 WorldHealthOrganization,JointUnitedNationsProgramonHIV/AIDS,UnitedNations
so),43redistributivefundingmechanismssuchasPEPFARand Children’sFund.Towardsuniversalaccess:scalinguppriorityHIV/AIDSinterventionsin
thehealthsector.2010.www.who.int/hiv/pub/2010progressreport/en/index.html.
theGlobalFundwillcontinuetohaveacrucialroleinthefuture 10 RwandaBiomedicalCenter.CountryprogressreportforJointUnitedNationsProgram
onHIV/AIDS2012.www.unaids.org/en/dataanalysis/knowyourresponse/
successofglobalhealthinitiatives.
countryprogressreports/2012countries/ce_RW_Narrative_Report.pdf.
Butthechallengesaheaddonotdiminishthepresentsuccesses 11 MinistryofHealthofRwanda.(2012).Rwandahealthstatisticsbooklet2011.http://moh.
gov.rw/english/wp-content/uploads/2012/05/MOH_Annual_booklet-2011.pdf.
ordilutethelessonslearnt(box2).Theimpressivereduction 12 MugeniC.Rwanda’scommunityhealthsystem:frompolicytoaction.Firstannual
inprematuremortalityspeaksforitself.Linkingsoundanalysis internationalcommunityhealthsummit.Kigali,Rwanda,25January2011.www.icchrwanda.
org/index.php?option=com_content&view=article&id=60&Itemid=3.
toacollaborativeapproachtostrengtheninghealthsystems,
13 RichML,MillerAC,NiyigenaP,FrankeMF,NiyonzimaJB,SocciA,etal.Excellentclinical
Rwandahasinstitutedpoliciesthathaveproducedremarkable outcomesandhighretentionincareamongadultsinacommunity-basedHIVtreatment
programinruralRwanda.JAcquirImmuneDeficSyndr2012;59:e35-42.
outcomes.Thishasoccurredinconcertwitheconomicgrowth.
14 KalkA,GroosN,KarasiJC,GirrbachE.Healthsystemsstrengtheningthroughinsurance
Althoughtheterm“localownership”isofteninvokedin subsidies:theGFATMexperienceinRwanda.TropMedIntHealth2010;15:94-7.
developmentcircles,itisraretoseeitimplementedsuccessfully. 15 LuC,ChinB,LeeJ,BasingaP,HirschhornLR,HillK,etal.Towardsuniversalhealth
coverage:anevaluationofRwandamutuellesinitsfirsteightyears.PLoSONE
ThelessonsfromRwanda’ssuccessshouldinformtheworkof 2012;7:e39282.
thosearoundtheworldwhoseektodeliveronthecommitment 16 MinistryofHealthofRwanda.RwandaCommunity-BasedHealthInsurancePolicy.2010.
http://moh.gov.rw/english/wp-content/uploads/2012/05/Mutual_policy_document_final1.
ofcomprehensiveandequitablehealthcareforall. pdf.
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maternalandchildhealthservicesinRwandaofpaymenttoprimaryhealth-careproviders
WethankCassiavanderHoofHolstein,JonNiconchuk,MichaelRich, forperformance:animpactevaluation.Lancet2011;377:1421-8.
GraceRyan,MickeySexton,andDanaThomsonfortheircontributions. 18 NationalInstituteofStatisticsofRwanda,MacroInternational.Rwandademographicand
healthsurvey2000.http://measuredhs.com/what-we-do/survey/survey-display-165.cfm.
WealsothankreviewersSuwitWibulpolprasertandFrankChimbwandira
19 NationalInstituteofStatisticsofRwanda,MacroInternational.Rwandademographicand
forfeedback.Althoughthispolicyanalysiswasnotfundedbyanyspecific healthsurvey2005.http://measuredhs.com/what-we-do/survey/survey-display-252.cfm.
20 NationalInstituteofStatisticsofRwanda,MacroInternational.Rwandainterimdemographic
grants,theauthorsaregratefulforthesupportofPartnersInHealth,
andhealthsurvey2007-2008.http://measuredhs.com/what-we-do/survey/survey-display-
theBrighamandWomen’sHospital,HarvardMedicalSchool,andthe 323.cfm.
DorisDukeCharitableFoundationAfricanHealthInitiative. 21 NationalInstituteofStatisticsofRwanda,MacroInternational.Rwandademographicand
healthsurvey2010.http://measuredhs.com/what-we-do/survey/survey-display-364.cfm.
Contributorsandsources:Theauthors,whoincludephysicians,other 22 MinistryofHealthofRwanda.Healthmanagementinformationsystem.2012.http://moh.
gov.rw/english/?page_id=2221.
serviceproviders,andpolicyexperts,haveworkedinRwandawith
23 NsanzimanaS,RutonH,LowranceDH,CishahayoS,NyemaziJP,MuhayimpunduR,
non-governmentalorganisationsandinstitutionsofhigherlearningfor etal.Cellphone-basedandinternet-basedmonitoringandevaluationofthenational
thepastdecade.Thisreviewdrawsinlargepartondatapresentedin antiretroviraltreatmentprogramduringrapidscale-upinRwanda:TRACnet,2004–2010.
JAcquirImmuneDeficSyndr2012;59:e17-23.
theRwandaDemographicandHealthSurvey,implementedbythe 24 AmorosoCL,AkimanaB,WiseB,FraserHS.UsingelectronicmedicalrecordsforHIV
NationalInstituteofStatisticsofRwandaincollaborationwiththeMinistry careinruralRwanda.StudHealthTechnolInformat2010;160:337-41.
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ofHealth.Thefundingforthesurveywasprovidedbynationaland forRwanda.2012.http://apps.who.int/immunization_monitoring/en/globalsummary/
multilateralfundingmechanisms;publiclyavailablereportsofthissurvey, timeseries/tswucoveragebycountry.cfm?country=RWA.
26 BinagwahoA,WagnerCM,GateraM,KaremaC,NuttCT,NgaboF.Achievinghigh
itsmethodologies,anditsresultshavebeenpresentedtopartnersand
coverageinRwanda’snationalhumanpapillomavirusvaccinationprogramme.BullWorld
fundersandmaybeaccessedathttp://measuredhs.com/what-we-do/ HealthOrgan2012;90:623-8.
27 HirthJM,TanA,WilkinsonGS,BerensonAB.Completionofthehumanpapillomavirus
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ledthewritingprocess,provideddirectionontheorganisationofthe 28 RwangombwaJ.Thestruggleforownershipofassistance:healthandHIV/AIDSin
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handle/10986/4566.
guarantor.CTNcollecteddata,createdthetablesandfigures,conducted 29 LogieD,RowsonM,NdagijeF.InnovationsinRwanda’shealthsystem:lookingtothe
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30 PorterME,LeeS,RhatiganJ,KimJY.PartnersinHealth:HIVcareinRwanda.Harvard
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SDM,andJCKparticipatedinanalysisanddraftedsectionsofthe
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publications/world_malaria_report_2012/en/index.html.
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requestfromthecorrespondingauthor)anddeclare:CSandJCKhave Fund,WorldBank.(2012).TrendsinMaternalMortality:1990to2010.Geneva,
workedfortheMinistryofHealthofRwanda.Allauthorshave Switzerland:WorldHealthOrganization.www.who.int/reproductivehealth/publications/
monitoring/9789241503631/en/index.html.
collaboratedwiththeMinistryofHealthofRwandaonotherresearch 36 UnitedNationsChildren’sFund,WorldHealthOrganization,WorldBank,UnitedNations
initiatives.NocurrentemployeeoftheRwandanMinistryofHealthor PopulationDivision.Levelsandtrendsinchildmortality.2012.www.unicef.org/media/
files/UNICEF_2012_IGME_child_mortality_report.pdf.
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6 NationalAIDSControlCommissionofRwanda.CountryprogressreportJanuary english/?page_id=2200.
2008-December2009:UnitedNationsGeneralAssemblyspecialsessiononHIVand 43 CrisafulliP,RedmondA.Rwanda,Inc.:howadevastatednationbecameaneconomic
AIDS,2010.http://data.unaids.org/pub/Report/2010/rwanda_2010_country_progress_ modelforthedevelopingworld.PalgraveMacmillan,2012.
report_en.pdf. Accepted:26November2012
7 PriceJE,LeslieJA,WelshM,BinagwahoA.IntegratingHIVclinicalservicesintoprimary
healthcareinRwanda:ameasureofquantitativeeffects.AIDSCare2009;21:608-14.
8 WaltonDA,FarmerPE,LambertW,LéandreF,KoenigSP,MukherjeeJS.Integrated Citethisas:BMJ2013;346:f65
HIVpreventionandcarestrengthensprimaryhealthcare:lessonsfromruralHaiti.JPub
HealthPolicy2004;25:137-58.
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ANALYSIS
Box2:LessonsfromRwanda:strategiesforstrengtheningcomprehensivehealthsystems
Nationalleadership—Highlevelpoliticalcommitmenttoequityandtoservicedeliveryaswellasaclearplanforaction
Healthsystemsapproach—Harnessingfundingfordiseasespecificorother“vertical”programmestobuildandstrengthenplatformsfor
integratedservicedelivery
Countryownership—Healthsystemspendingmanagedbyorinpartnershipwithnationalandlocalgovernment
Communitybasedcare—Forexample,usingcommunityhealthworkerstoincreasetheeffectivenessandefficiencyofcaredelivery,
especiallyforchronicdiseases
Evidencebasedpolicymaking—Acritical“feedbackloop”linkingresearchtoserviceandtrainingtopromoteaccountabilityandimprove
thequalityofcare
Cross-sectorcollaboration—Strengtheninghealthsystemswithpartnershipsbetweenthepublicandprivatesectorsandalsoacross
sectorsandministries
Thisisanopen-accessarticledistributedunderthetermsoftheCreativeCommons isotherwiseincompliancewiththelicense.See:http://creativecommons.org/licenses/by-
AttributionNon-commercialLicense,whichpermitsuse,distribution,andreproductionin nc/2.0/andhttp://creativecommons.org/licenses/by-nc/2.0/legalcode.
anymedium,providedtheoriginalworkisproperlycited,theuseisnoncommercialand
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ANALYSIS
Table
Table|PrematuremortalityinRwanda,2000-11222333435
Annualrateofreduction
2000 2011 Totalreduction(%) (%) Regionalrank Globalrank*
Tuberculosis
Malaria
Childandmaternalmortality
HIV/AIDS
HIVincidence/100000 207 88† 57.5 9.5 5 8
AIDSdeaths/100000 190 41† 78.4 17.0 1 1
Incidence/100000 326 94 71.2 11.3 1 4
Mortality/100000 48 11 77.1 13.4 1 5
Totalcases 1669614‡ 212200 87.3 34.4 NA NA
Totaldeaths 1582‡ 380 76.0 23.8 NA NA
Deaths/1000livebirths 183 54 70.4 11.1 1 1
Totaldeaths 61343 22813 62.8 9.0 2 4
Maternalmortalityratio/100000livebirths 840 340§ 59.5 9.0 1 6
*Onlycountrieswithpopulationsgreaterthan500000included.
†2009data.
‡2005data.
§2010data.
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ANALYSIS
Figures
Fig1UptakeofmaternalandchildhealthinterventionsinRwanda,2000–1018-21
Fig2Mortalityamongchildrenuptoage5years,1990-201136
Fig3Globalhealthexpenditureandannualreductionsinchildmortalityfrom2000to2011(includesonlycountrieswith
population>500000)336
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