Understanding health system reconstruction in conflict-affected states: a repeated cross-sectional study of healthcare coverage trends in Rwanda

Health systems are often a casualty of conflict, with widespread disruption caused by the loss of infrastructure, resources, and the workforce. The recovery of these systems, termed reconstruction or rehabilitation, is crucial to national recovery, but our understanding of this process remains limited. Rwanda experienced conflict in the form of genocide in 1994 which devastated the healthcare system. They have since made significant progress in health system development, providing a key case study to further our understanding of health system reconstruction. This paper aims to use a quantitative, health system-focused method to analyse the recovery of the Rwandan health system. This study uses a repeated cross-sectional design to examine trends in essential healthcare coverage in Rwanda, based on Demographic and Health Survey data between 1990 and 2019. Measures of maternal health provision were used as proxy markers for essential healthcare coverage. Trends were visualized using basis splines, and significant breaks were tested using post-estimation Wald tests. Piecewise beta linear regressions were used to clarify changes in trend. Consistent trends across proxy markers demonstrate that healthcare coverage is decreased after conflict. Following a post-conflict lag of 3-10 years, healthcare coverage undergoes a marked increase in a rehabilitation phase present for all proxy markers. After 2011, healthcare coverage plateaus at a high level, providing evidence for a sustainable development phase in Rwanda’s post-conflict recovery. Primary care markers show increased coverage earlier than secondary care markers. The example of Rwanda suggests that key strategies for successful post-conflict reconstruction may include investment into primary care, early adoption of sustainable solutions, and strong internal co-ordination of reconstruction. Analysis of health system reconstruction should use health system-based approaches, and longer time frames of analysis. Further research should aim to create evidence-based resources that aid recently conflict-affected states.