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Reduced premature mortality in Rwanda: lessons from success

BMJ 2013; 346 doi: (Published 18 January 2013) Cite this as: BMJ 2013;346:f65

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  1. Paul E Farmer, professor123,
  2. Cameron T Nutt, research fellow4,
  3. Claire M Wagner, research fellow5,
  4. Claude Sekabaraga, senior health financing specialist6,
  5. Tej Nuthulaganti, human resources for health program director7,
  6. Jonathan L Weigel, doctoral candidate8,
  7. Didi Bertrand Farmer, director of community health and social development9,
  8. Antoinette Habinshuti, deputy director of Rwanda progammes9,
  9. Soline Dusabeyesu Mugeni, technical adviser9,
  10. Jean-Claude Karasi, researcher10,
  11. Peter C Drobac, director of Rwanda progammes29
  1. 1Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
  2. 2Division of Global Health Equity, Brigham and Women’s Hospital, Boston, MA, USA
  3. 3Partners In Health, Boston, MA, USA
  4. 4Dartmouth Center for Health Care Delivery Science, Hanover, NH, USA
  5. 5Global Health Delivery Partnership, Boston, MA, USA
  6. 6World Bank, Nairobi, Kenya
  7. 7Clinton Health Access Initiative, Kigali, Rwanda
  8. 8Department of Government, Harvard University, Boston, MA, USA
  9. 9Partners In Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda
  10. 10CRP-Santé, Luxembourg, Luxembourg
  1. Correspondence to: P E Farmer Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115, USA paul_farmer{at}
  • Accepted 26 November 2012

Rwanda’s approach to delivering healthcare in a setting of post-conflict poverty offers lessons for other poor countries, say Paul Farmer and colleagues

In the immediate aftermath of the 1994 genocide, which claimed up to a million lives and left two million homeless, Rwanda was among the poorest countries in the world.1 Health and education systems, already weak and limited in reach before the conflict, lay in ruins; less than 5% of the population had access to clean water; the banking system had collapsed; almost no taxes were collected. Epidemics of infectious disease—including AIDS, malaria, tuberculosis, and waterborne infections—further thinned the population.2

Today Rwanda has been transformed. Mass violence has not recurred within the country’s borders, and its gross domestic product (GDP) has more than tripled over the past decade (box 1). Growth has been less uneven than in other countries in the region, partly because both local and national governments have made equity and human development guiding principles of recovery.3 Recent studies suggest that more than one million Rwandans were lifted out of poverty between 2005 and 2010, as the proportion of the population living below the poverty line dropped from 77.8% in 1994 to 58.9% in 2000 and 44.9% in 2010.3 Life expectancy climbed from 28 years in 1994 to 56 years in 2012.4 It is the only country in sub-Saharan Africa on track to meet most of the millennium development goals by 2015. Although metrics for equity are disputed, it is an increasingly well known fact that Rwanda today has the highest proportion of female civil servants in the world.5

Box 1: Rwanda’s social and economic context

  • Population (2011): 10 942 950

  • Population living in rural areas (2011): 81.2%

  • Population below age 15 (2011): 42.8%

  • Parliamentary seats held by women (2011): 56.3%

  • Net enrolment in primary education (2010): 98.7%

  • Gross domestic …

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