Reduced premature mortality in Rwanda: lessons from success

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