In the fall of 1994, nearly a million people died in the Rwandan genocide when Hutu extremists massacred minority Tutsis. Those on both sides who survived the killings faced a second threat: a scourge of infectious diseases, including AIDS, tuberculosis, malaria and waterborne illness — less than 5 percent of the population had access to clean water.
Almost 20 years later, striking achievements in health care and health outcomes in Rwanda have set the country apart and made it a model for other poor African countries. Since the genocide, life expectancy in Rwanda has nearly doubled, from 28 years to 56. The country's gross domestic product has tripled in the last decade and more than a million Rwandans escaped poverty between 2005 and 2010 alone.
Paul Farmer, a medical anthropologist, physician and thought leader in the global health sphere, says Rwanda is the only country in sub-Saharan Africa that could meet a majority of the Millennial Development Goals in 2015 -- eight measurable objectives related to poverty, health and education crafted by the United Nations in 2000.
Rwanda's health achievements, specifically the country's drastic declines in maternal and childhood mortality, are the result of focused, intentional and "almost ruthless attention" to improving the delivery of live-saving interventions, says Dr. Gavin Yamey with the Global Heath Group at the University of California, San Francisco.
Accountability is the buzzword . Yamey says Rwanda's minister of health, Dr. Agnes Binagwaho, has demanded that a doctor or nurse phone and inform her any time a mother dies in Rwanda -- day or night.
"Some years ago she was getting eight or nine phone calls a day, and now she's getting one a day," Yamey says.
Rwanda received about $277 million in global aid in 2010 alone. But it was prudent spending that allowed the country to emerge as a health leader, Farmer said in a report published in the British Medical Journal.
Rwanda established universal health coverage through a program known as "Mutuelles de Santé," which required subscribers to pay 10 percent co-payments and yearly premiums. More than 90 percent of Rwandans enrolled in public health care and another 7 percent received coverage through the civil service, military or private insurers. Many preventive interventions like bednets and vaccinations -- as well as treatments for HIV, tuberculosis and certain cancers -- are fully covered.
In addition, Rwanda expanded its AIDS outreach to include rural regions where most Rwandans live, said Farmer. In doing so, Rwanda has maintained an HIV prevalence of only 3 percent for the last seven years. The outcome of these efforts signals hope for other poor countries.
But presidents and finance ministers need something more tangible than hope. The Global Health 2035 report, published by the Lancet Commission, a group of global health experts and economists, offers evidence.
Yamey is a member of the commission and lead author of the report, which is being officially unveiled Tuesday in San Francisco.
"We argue that there is good evidence that the health needs of the most vulnerable people can be most directly and most expediently addressed by investing within the health sector," Yamey says.
Sir Richard Feachem, director of the Global Health Group at the University of California, San Francisco, says the report gives reason to believe in better health outcomes throughout the developing world.
"With respect to the diseases of poverty, the people of the low-income and middle-income countries can have a health status similar to the people in the high-income countries in the next 20 years," Feachem says.
This concept of raising poorer countries' health outcomes to meet those of industrialized nations is known to the commission as the "grand convergence." The idea that focusing on health could benefit both the lives and the economic prosperity of poorer countries was borne out in an earlier report, now 20 years old.