Rwanda is primarily comprised of two ethnic groups, the Hutu and Tutsi. Colonialism in Rwanda from the late 1800s to the early 1960s resulted in considerable economic disparities and animosity between the minority Tutsi, who were favored by colonizers, and the majority Hutu, who composed about 85% of the population. Following independence from colonial rule, a decades long power struggle ensued between the groups resulting in years of civil war and culminating in a massive genocide orchestrated against the Tutsi.

Over the course of 100 days in 1994, close to 1,000,000 of the total 7,700,000 Rwandans— including 70% of the country’s Tutsi population — were murdered. Additionally, 500,000 women had been raped. The economic, societal, and health repercussions of the genocide were severe. Over 40% of the population had fled the country, buildings and infrastructure were decimated, and much of the country’s material wealth had disappeared, which in turn resulted in marked poverty and a precipitous rise in preventable death from infectious disease and unsafe births. Between 1989 and 1997 Rwanda had the lowest life expectancy in the world at 28 years of age. Similarly, it was the among the poorest countries in the world with nearly 70% of the population living below the poverty line.

In the first decade of 2000, Rwanda made tremendous strides in rebuilding its health systems resulting in some of the steepest declines in premature mortality ever, thanks in part to systematic investments by the Ministry of Health. As the country rebuilt its infrastructure, many who fled the conflict returned. Today, nearly all Rwandans have health insurance, and the poorest among them pay no fees. Life expectancy has risen to a record 68 years. Much of the rapid success in the health sector came from shifting medical decision making from doctors —which there was a severe shortage of — to nurses and community health workers. As the country continued to address its healthcare infrastructure, the demand to reconstitute specialty care and improve the efficiency of its care grew; however, Rwanda continued to have a healthcare provider density which was well below the recommended level.