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

Two decades ago, the genocide against the Tutsis in Rwanda led to the deaths of 1 million people, and the displacement of millions more. Injury and trauma were followed by the effects of a devastated health system and economy. In the years that followed, a new course set by a new government set into motion equity-oriented national policies focusing on social cohesion and people-centred development. Premature mortality rates have fallen precipitously in recent years, and life expectancy has doubled since the mid-1990s. Here we reflect on the lessons learned in rebuilding Rwanda’s health sector during the past two decades, as the country now prepares itself to take on new challenges in health-care delivery.

Ensuring financial access to health services is a critical challenge for poor countries if they are to reach the health Millennium Development Goals (MDGs). This article examines the case of Rwanda, a country which has championed innovative health care financing policies. Between 2000 and 2007, Rwanda has improved financial access for the poor, increased utilization of health services and reduced out-of-pocket payments for health care. Poor groups' utilization has increased for all health services, sometimes dramatically. Use of assisted deliveries, for example, increased from 12.1% to 42.7% among the poorest quintile; payments at the point of delivery have also been reduced; and catastrophic expenditures have declined. Part of these achievements is likely linked to innovative health financing policies, particularly the expansion of micro-insurance ('mutuelles') and performance-based financing. The paper concludes that the Rwanda experience provides a useful example of effective implementation of policies that reduce the financial barrier to health services, hereby contributing to the health MDGs. Today's main challenge is to build the sustainability of this system. Finally, the paper proposes a simple set of rigorous metrics to assess the impact of health financing policies and calls for implementing rigorous impact evaluation of health care financing policies in low-income countries.

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