No Child Without Vaccination, No Family Without Health Insurance: The Political Economy of Public Health in Rwanda

In just 100 days, almost one million Tutsis, moderate Hutu and Twa were massacred in one of the most brutal episodes of violence n modern history. Today’s podcast episode is about the process of rebuilding from the ravages of the genocide. Paul Kagame and the Rwandan Patriotic Front that took power after 1994 have overseen an economic miracle, and real improvements in the standards of living of the Rwandan people. I will be focusing on the ideological roots of Rwanda’s economic miracle, the process of reducing corruption and improving state capacity, and resulting ability of Rwanda to dramatically improve ordinary citizens access to healthcare.
The Rwandan genocide left immense social scars in addition to physical damage. The majority of Rwanda’s population after the genocide was till overwhelmingly Hutu, the majority of whom willingly or through coercion, participated in the genocide. Both the Belgian colonial government, and the post-independence Hutu led government emphasized the difference between and inequality between a Tutsi elite and the Hutu masses. The RPF was committed, through customary Gacaca courts, to convict those guilty of crimes during the genocide while at the same time propagating an ideology that emphasized the shared language and culture of Hutu and Tutsi. At the same time, the stark reality remained that the majority of the population, whether willingly or unwillingly, participated in the genocide. The current RPF government, dominated by former exiles from Uganda, is unsurprisingly terrified of losing political power. The RPF has concentrated all political power in its hands, and has strived to gain political legitimacy by developing the country.
Part of gaining legitimacy to govern is stamping out petty corruption in the bureaucracy. To government regularly takes action such as firing hundreds of police officers, or entire departments of the ministry of health suspected of corruption and as a result Transparency International’s Corruption Index ranks Rwanda the least corrupt Least Developed Country in the world. Moreover, the government has worked assiduously with donors to adapt best practices on institutional design to local circumstances. An example of this is the Imihigo system of to a management. Imihigo refers to a precolonial system where warriors would publicly pledge what they would accomplish in battle, and face humiliation if they failed to achieve those goals. In its modern adaptation, mayors and other higher level officials would pledge to accomplish development goals, and assisted by a large core of elected local leaders in achieving those goals. While the goals were set by the central government, elected leaders have high levels of authority in how goals are to implemented allowing for best practices to spread from district to district.
One of the greatest successes of the efficient and flexible state is improving public health outcomes in Rwanda. Rwanda today has a life expectancy of 67 and an infant mortality rate of 29, levels of health outcomes similar to much wealthier nations such as India or Bolivia. Part of this success stems from the over 45,000 elected community health workers at the village level. They are generally respected members of the community and tasked with ensuring universal vaccination, and to serve as the first line of healthcare. In order to improve health in a systematic manner, the government has implemented a health insurance system that covers over 90% of the population. The bottom quarter of the population does not have to pay into the system, and even the top .5% of Rwandans only have to pay $9 a month. However, given most Rwandans hover above basic subsistence, it has taken the coercive might of the Rwandan state to make this system financially feasible.
Suggested Reading The politics of state effectiveness in Burundi and Rwanda: ruling elite legitimacy and the imperative of state performance , Benjamin Chemouni
PERFOMANCE CONTRACTS AND SOCIAL SERVICE DELIVERY- LESSONS FROM RWANDA  , African Development Bank
Near universal childhood vaccination rates in Rwanda: how was this achieved and can it be duplicated? , James Bao