Rwanda’s Health Care Success Story

KIGALI, Rwanda – In the less than two decades since the 1994 genocide that killed nearly a million Rwandans and displaced another two million, the country has become a spectacular public health success story and could provide a model for the rest of Africa, according to a new analysis by American health experts.

In an article published last month by the British journal BMJ, Dr. Paul E. Farmer, a founder of Partners in Health, which delivers medical services in Rwanda and Haiti, totaled up the successes the tiny country has managed. In 1994, 78 percent of the population lived below the poverty line; now 45 percent do. The gross domestic product has more than trebled. Almost 99 percent of primary-school-age children go to school.

With help from Western donors, the number of people getting treatment for AIDS rose to 108,000 from near zero a decade earlier.

Many doctors fled Rwanda before the genocide, and many were killed. Even now, the country has only about 625 doctors in public hospitals for a population of almost 11 million. But it also has more than 8,000 nurses, and a new corps of 45,000 health care workers, elected by their own villages, to do primary care for malaria, pneumonia, diarrhea, family planning, prenatal care and childhood shots.

Largely because of these workers, the country has high rates of success in curing tuberculosis and keeping people with AIDS on antiretroviral drugs.

Nearly 98 percent of all Rwandans have health insurance. Annual premiums are small and subsidized by donors, and subscribers pay 10 percent co-pays. But many aspects of preventive care, like mosquito nets and immunizations, are free. The country has a national system of computerized medical records and uses cellphone text messaging to get reports from village health workers.

Since 2000, the maternal mortality ratio has fallen by 60 percent; the likelihood that a child would die by age 5 has dropped by 70 percent.

“If these gains can be sustained,” Dr. Farmer wrote, “Rwanda will be the only country in the region on track to meet each of the health-related Millennium Development Goals by 2015.”

Outside experts disagree about why Rwanda has succeeded, with some putting it all down to foreign aid. Dr. Farmer gave credit to the national government, saying it had correctly focused on the leading causes of death and disease and systematically gone after them.