In Rwanda, citizens view development as a patriotic imperative. Rwandan men and women take pride in their country and view progress as a shared obligation to which all contribute. The country’s development vision is one shared not out of top-down imposition, but from a commitment to revere and transcend communal loss. Nowhere is this more evident than in Rwanda’s healthcare system, which takes a decidedly “pro-poor” and “human-focused” approach, where citizens are assets, rather than passive objects of state-led initiatives. At a speech delivered at Yale University this past month, Rwandan President Kagame summarized the approach thus: “Nothing done against the wishes of citizens is sustainable.”
Rwanda’s healthcare system is driven by and created for Rwandan citizens. Arms of Rwanda’s new health system, the Community Health Worker (CHW) program, sliding scale health insurance, and increasing facility quality, build upon the hard work of Rwandan professionals and community members alike, and upon a culture of resilience through social support. It is truly a system in line with the wishes of its citizens.
In 1995, the newly post-conflict Ministry of Health (MoH) adopted a model of universal healthcare to minimize the medical burden borne by Rwandans, especially from HIV, tuberculosis and malaria. In the post-war context, physicians and policymakers laid out a roadmap for better care that pursued twin objectives: addressing a human capital deficit and equipping citizens to navigate financial and location-based barriers to care. The strategy facilitates universal access, but enables and encourages user self-sufficiency. The Minister says, “To empower Rwandan citizens economically, we promote a spirit of independence to make the best choices for themselves. This is the basis of democracy; when you are dependent and begging, you cannot direct your life.”
Under this system, thousands of Community Health Workers (CHWs) offer home-based care, providing services in remote communities. According to the MoH, “45,000 clinical services providers [CHWs] contributed to dramatic improvements in health outcomes over the past five years, including a 50% decline in child mortality, a 70% decline in malaria incidence, a 52% increase in the proportion of mothers delivering at health facilities, and a four-fold increase in the uptake of modern family planning methods. They serve as the first line of defense.”
Veneranda Mukamunana is a Community Health Worker (CHW) in Rubungo, a small farming community just outside Rwanda’s capital, Kigali. Speaking of her job, she says, “I love the Rwandan community and I love people. As I connected with people, I was encouraged to continue my work.”
CHWs, who are trained medical volunteers, drive Rwanda’s healthcare decentralization. In every Rwandan village (or umudugudu) of 100 or more residents, one man and two women conduct door-to-door visits, investing in healthier futures for their neighbors. They receive no salary. Most of them earn income through small-scale farming. They labor for love of and pride in their country: “We have played a great role in reducing the death rate of mothers during childbirth. We have also played a great role in treating children under age 5 [reducing infant mortality]. Even the government recognizes us as people of integrity in the community,” says Veneranda Mukamunana, Community Health Worker, Rubungo, Gasabo, Rwanda)
Dr. Angeline Mumararungu, family physician, Health Manager at Gardens for Health International where I worked, says of the volunteers’ responsibilities: “Each CHW works full time serving their village. They take child health measurements, screen for malaria and common childhood illness. They encourage women to adhere to family planning programs. They are the first responders.”
The larger system is also designed to be inclusive. Every Rwandan lives within one hour’s walk of the nearest government health center. Rwandans categorized as economically vulnerable receive free health coverage: access to consultation and medical care with a 10% co-pay per clinic visit, the equivalent of less than 0.5 USD. The national health insurance scheme, Mutuelle de Sante, like its CHW program, operates under community ownership and administration. The Ubudehe poverty mapping exercise establishes parameters for Mutuelle coverage and promotes an inclusive analysis of family socioeconomic conditions. Ubudehe refers to the agricultural practice of preparing fields in preparation for rainy season and draws on a cultural legacy of communal problem-solving. Between 2006 and 2010, enrollment in Mutuelle rose from 44% to 91%, according to government data.
To be sure, the Mutuelle and Ubudehe systems are not perfect. Occasional Ubudehe miscategorization and unforeseen economic shocks at the household level, such as loss of a home due to flooding, can create gaps in the insurance scheme, leaving some Rwandans without access to care. Demand for certain classes of drugs continues to exceed supply at public clinics, and in these cases families must weigh the costs of private pharmacies against the cost of foregoing treatment. But Mutuelle’s “growing pains” do not undermine its success as a key component in Rwandan-style development.
“People once went to private clinics, to buy medicine at pharmacies without a diagnosis, or to consult traditional healers because their services were cheaper than government services. Now, with Mutuelle, people have access to care at government health centers,” says Dr. Angeline.
The sliding-scale Mutuelle system builds on the power of community to ensure that no Rwandan is financially excluded from care. 45,000 CHWs, elected representatives, ensure that no Rwandan is geographically excluded from care. The accessibility and affordability of medicine, coupled with rising standards in the quality of care, earn the country distinction among its regional neighbors.
Rwanda faces criticism for exclusive focus on development outcomes, irrespective of a process, a “development by any means necessary” framework. Upward trending health indicators, such as the much-lauded declines in child mortality, certainly signal positive “development outcomes” for Rwanda. However, condemnation of the “Rwandan method” ignores the role that individual Rwandan citizens, like Rwanda’s CHWs and the local officials who conduct Ubudehe poverty mapping, play in the development process. Rigorous critique of human rights in development must not be abandoned, but when we allege coercion, to what extent do allegations neglect the agency of Rwandan men and women as full participants in their country’s future?
 Performance-based financing mechanisms incentivize CHWs with in-kind rewards such as land, but volunteers do not earn a steady income and cannot earn a living on CHW labor alone
 The Rwandan government uses a socioeconomic classification system called Ubudehe. Citizens are sorted into category 1, 2, or 3 depending on family financial resources. Citizens in categories 1 and 2 receive government-subsidized health insurance. Citizens in category 3 are entitled to government insurance under a cost-sharing mechanism, whereby beneficiaries are responsible for a 6 USD one-time annual co-pay.