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World Development Perspectives

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Case report Conceptualizing and researching health equity in Africa through a political economy of health lens – in perspective ⁎ Dennis Raphael , Morris Komakech

School of Health Policy and Management at York University, 4700 Keele Street, Toronto, Ontario M3J 1P3, Canada

ARTICLE INFO ABSTRACT

Keywords: Research on promoting health equity by reducing health inequalities in Africa presents an emerging research Health equity frontier. Concepts from the political economy of health literature such as decommodification, stratification, class Health policy mobilization, and the relative responsibility ascribed to the state, marketplace, and family in defining the quality Sub-Sahara Africa and distribution of economic and social resources, i.e., the social determinants of health, have relevance for the Rwanda African health scene. We use Rwanda as an example to show how these considerations can inform research and policy action to promote health equity in Africa. Based on evidence of Rwanda’s generally better health and narrower health inequalities than other sub-Saharan African nations, we explore some of the political, economic, and social forces promoting health equity in Rwanda. We conclude that Rwandan actions are consistent with movement towards a welfare state that acts in the service of promoting health equity.

1. Introduction processes are shaped by political and economic traditions (Bambra, 2013). While many of these concepts were developed in the Research on promoting health equity by reducing health inequal- context of Western capitalist societies, they provide a foundation for ities in Africa presents an emerging research frontier. A 2018 review of further theorization of how welfare state-related policies can promote health inequalities research output found few research publications health equity in the developing world. For Africa, applying the welfare emanating from low- and middle-income as compared to high-income concept is of particular importance due to the rapid ongoing trans- nations (Cash-Gibson, Rojas-Gualdrón, Pericàs, & Benach, 2018). There formation of national economies to the neoliberal market-oriented were only 15 outputs from Rwanda over the 49-year period of models that mirror the capitalist economies of Western societies 1966–2015. (Labonté & Ruckert, 2019; Usman & Bashir, 2018). These economic This case report illuminates how Rwanda, a nation with a complex transformations are altering the structure of African societies and relations and troubled history, is making strides towards promoting health equity between the state and citizens in a manner that generates wide-ranging and reducing health inequalities. The source of health inequalities is inequalities (De Maio, 2014; Forster, Kentikelenis, Stubbs, & King, 2019). contested such that they can be explained as emanating in genetics, In this paper we examine the health equity implications of welfare behaviours, community factors, health care systems, or societal struc- state concepts such as decommodification, stratification, class mobili- tures and processes that distribute the economic and social resources zation, and the relative role of the state, market, and family in dis- necessary for health (Bartley, 2016). A consensus is emerging that a tributing economic and social resources necessary for health. We then broad political economy analysis that considers how political and examine the Rwandan health equity scene and identify the political, economic structures and processes shape, through public policy, the economic, and social forces at play in that nation. nature of the health care system and the distribution of economic and social resources best explains the overall health of a nation and the 2. Background extent of health differences among social groups, i.e., health inequal- ities (Raphael & Bryant, 2019). These structures and processes are We acknowledge that the development of Rwanda’s nascent welfare themselves shaped by societal power dynamics and competition be- state has been influenced by Africa’s history of colonialism and the impact tween groups, sectors, and political parties (Bryant, 2010). of international donor and civil society organizations upon social policies. The concept of the welfare state explains how these structures and Especially important has been their influence upon state activity and the

⁎ Corresponding author. E-mail addresses: [email protected] (D. Raphael), [email protected] (M. Komakech). https://doi.org/10.1016/j.wdp.2020.100207 Received 23 November 2018; Received in revised form 21 April 2020; Accepted 21 April 2020 2452-2929/ © 2020 Elsevier Ltd. All rights reserved.

Please cite this article as: Dennis Raphael and Morris Komakech, World Development Perspectives, https://doi.org/10.1016/j.wdp.2020.100207 D. Raphael and M. Komakech World Development Perspectives xxx (xxxx) xxxx economic marketplace’s distribution of economic and social resources value of their work or property; second, by narrowing the extent of (Devereaux et al., 2002; Künzler & Nollert, 2017; Luiz, 2013). In this paper insecurity by enabling individuals and families to meet certain social we focus on the contemporary Rwandan situation and examine how po- contingencies (for example, sickness, old age, and unemployment) that litical economy concepts help make explicit the current forces shaping its lead otherwise to individual and family crises; and third, by ensuring health outcomes. that all citizens without distinction of status or class are offered the best standards available in relation to a certain agreed range of social ser- 2.1. Health equity vices” (Briggs, 1961, p. 14). The welfare state literature explains how the power and influence of Health equity is a normative concept that posits that most inequalities classes and groups act through political and economic systems to dis- in health among those occupying differing social locations of class, gender tribute these resources (Bryant & Raphael, 2018). Various typologies of and racial and ethnic groups, among others, are preventable, avoidable, welfare states have been devised with relevance to both developed and and unnecessary, therefore making their presence immoral, unfair and developing nations. These are summarized in Box 1. unjust (Braveman & Gruskin, 2003; Kawachi, Subramanian, & Almeida- Filho, 2002). Health inequalities are a result of social inequalities – dif- Box 1 ferences in wealth and income, influence and power, and access to care– Welfare state typologies among social groups (Grabb, 2006). The concept of health equity also implies a moral imperative to act upon the sources of these inequalities Esping-Andersen (1990) (Whitehead, 1985). Social Democratic Characterized by universalism, comparatively generous social 2.2. Political economy transfers, commitment to full employment and income protec- tion; and a strongly interventionist state. A political economy approach examines how both health and health Conservative Status differentiating welfare programmes in which benefits inequalities result from a jurisdiction’s political and economic struc- are often earnings related, administered through the employer; tures and processes (Raphael & Bryant, 2019). It directs attention to the and geared towards maintaining existing social patterns. power and influence of various societal sectors and how power differ- Liberal entials can shape public policies that distribute economic, political, and State provision of welfare is minimal, social transfers are social resources (Bryant, 2015). The state can act as a mediator of these modest and often attract strict entitlement criteria; and recipients differing interests or can cede control to one or more of these sectors. are usually means-tested and stigmatized. Wood and Gough (2006) 2.3. Power and influence Actual or Potential Welfare State Regimes (HDI) scores are high as is public spending; international flows low. Power and influence, as well as the role the state takes in mediating Less Effective Informal Security Regimes these dynamics, shape political and economic systems (Scott, 2002). Low HDI and low public spending with medium international Class, gender, race and ethnic and racial groups are afforded power and flows. influence through control of the economic, political and social leversof Externally Dependent Insecurity Regimes society that skew the distribution of resources. Power differentials can Very low HDI and low public spending with high international result in differing life chances, including health. flows. Sources: 2.4. Public policy Esping-Andersen, G. (1990). The Three Worlds of Welfare Capitalism. Princeton: Princeton University Press. Public policy is a course of action or inaction by public authorities to Wood, G., & Gough, I. (2006). A comparative welfare regime approach to global social policy. World Development, 34(10), address a problem or interrelated set of problems (Pal, 2013). Public policy 1696–1712. in numerous domains shape the quality and distribution of various social determinants of health and health inequalities (Bryant, 2016). All imply that the extent of stratification and decommodification of 2.5. Social determinants of health and the social determinants of health necessary resources and state management shape the distributions of inequalities economic and social determinants of health. Welfare states can be shaped and sustained through class and group mobilization. Social determinants of health are the economic and social conditions that Stratification refers to institutionalized differences amongst society influence the health of individuals, groups, and nations (Raphael, 2016). members and is usually defined in terms of wealth, income, education These include education, employment and working conditions, food se- and power and influence (Scott, 2014). Stratification is both a cause curity, health services, housing, income and income distribution, and the and result of the ability of specific classes and other groups to shape social safety net. public policy to meet their needs. Social determinants of health inequalities are the societal structures Stratification can lead to social inequalities whereby some groups and processes that form the quality and distribution of these determi- enjoy opportunities and rewards which in turn, create health inequal- nants (Mantoura & Morrison, 2016). The economic system distributes ities. Provision of universal benefits and services that decommodify the financial resources, the political system makes laws and regulations that necessities for health mitigates the health effects of stratification also do so, and ideological beliefs justify these distributions. These (Bambra, 2005). structures and processes are shaped by the balance of power of sectors Decommodification is the ability to have a decent quality of life in- in society and the mediating role of the state (Bryant & Raphael, 2020). dependent of paid employment (Esping-Andersen, 1990, 1999). In ad- dition to replacement income associated with retirement, sickness and 2.6. Welfare states disability, and unemployment, important features of daily life that can be decommodified – i.e., provided without payment – are elementary, A welfare state is a nation in which organized power modifies the secondary and postsecondary education, health care and social services, play of market forces in at least three directions: “first, by guaranteeing and pensions, among others (Menahem, 2010). individuals and families a minimum income irrespective of the market Roles of the state, family and market differ among welfare states

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(Saint-Arnaud & Bernard, 2003). Effective welfare states have a strong that improve the quality and equitable distribution of numerous social state role in distributing resources while others cede control to market determinants of health (Abbott, Sapsford, & Binagwaho, 2017). forces and/or dominant social groups. Class/power mobilization refers to the ability of classes or groups of 4.1. Health outcomes and health inequalities citizens to attain the power to move a state towards approaches that benefit them (Esping-Andersen, 1990). Health outcomes and extent of health inequalities are indicators of welfare state development and movement towards health equity. 3. Health-related variables in the welfare state literature Health outcomes. Rwanda compares very well to other sub-Saharan na- tions on two important health indicators, ranking 2nd in life expectancy at It appears that for both developed and developing nations, health birth and 1st in infant mortality (, 2020a, 2020b). Rwanda’s life outcomes are better when stratification is lower, decommodification is expectancy in 2000 was only 47 years, making its 2017 level of 69 years a higher, public transfers in the form of supports and services are greater, remarkable achievement. Similarly, its infant mortality rate in 2000 was taxation is more progressive, and support for progressive political 108/1000 as compared to the 2018 rate of 27/1000 (Figs. 1 and 2). parties is stronger (Bambra, Reibling, & McNamara, 2019; Bryant & Health inequalities. Health inequalities are sensitive measures of a Raphael, 2018). Wood and Gough (2006) reinforce the importance to nation meeting citizen needs. The Health Equity Assessment Toolkit of the the developing world of labour and financial markets, state legitimacy World Health Organization documents the extent of several health in- and competency, extent of societal integration, culture and values, and equalities among Rwandans (Global Health Observatory, 2018). a nation’s position in the global system. Figs. 3–6 provide indicators of access to healthcare as a function of income. 4. Application to Rwanda Rwanda does very well in extent of coverage and extent of income- related inequalities for antenatal care, births attended by skilled per- Rwanda has been identified as instituting public policies that en- sonnel and full immunization amongst one-year olds. Composite cov- hance health (World Health Organization, 2015). It met its Millennium erage is an index of reproductive, maternal, newborn and child health Goals for Health through its elaborate health sector and public policies interventions. Rwanda’s profile is encouraging.

Life Expectancy at Birth -- Sub-Saharan Nations, 2017

0.00 10.00 20.00 30.00 40.00 50.00 60.00 70.00

Botswana 69 Rwanda 68 Senegal 67 Eritrea 66 Ethiopia 66 Gabon 66 66 Madagascar 66 Sudan 65 Congo, Rep. 64 Mauritania 64 64 64 Ghana 63 Liberia 63 Malawi 63 Namibia 63 63 Zambia 63 Niger 62 Benin 61 Burkina Faso 61 61 The Gambia 61 Guinea 61

Nations Zimbabwe 61 Togo 60 Angola 60 Congo, Dem. Rep. 60 Cameroon 59 Mozambique 59 Equatorial Guinea 58 Eswatini 58 Guinea-Bissau 58 Mali 58 Cote d'Ivoire 57 Somalia 57 South Sudan 57 Chad 54 Nigeria 54 Sierra Leone 54 Sierra Leone 54 Lesotho 53 Central African Republic 52

Life Expectancy at Birth

Source: World Bank. (2020). Life expectancy at birth, total (years) - Sub-Saharan Africa. Retrieved April 14, 2020, from https://data.worldbank.org/indicator/SP.DYN.LE00.IN?locations=ZG

Fig. 1. Life expectancy Sub-Saharan Africa.

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Infant Mortality per 1000 Live Births -- Sub-Saharan Nations, 2018

0 10 20 30 40 50 60 70 80 90

Rwanda 27 Namibia 29 South Africa 29 Botswana 30 Eritrea 31 Kenya 31 Senegal 32 Gabon 33 Uganda 34 Zimbabwe 34 Ghana 35 Malawi 35 Madagascar 38 Republic of Congo 38 Tanzania 38 Ethiopia 39 The Gambia 39 Zambia 40 Burundi 41 Sudan 42 Eswatini 43 Togo 47 Niger 48 Burkina Faso 49 Cameroon 51 Nations Angola 52 Mauritania 52 Guinea-Bissau 54 Liberia 54 Mozambique 54 Cote d'Ivoire 59 Benin 61 Mali 62 Equatorial Guinea 63 South Sudan 64 Guinea 65 Lesotho 66 DRC 68 Chad 71 Nigeria 76 Somalia 77 Sierra Leone 79 Central African Republic 85

Infant Mortality per 1000 Live Births

Source: World Bank. (2020). Mortality rate, infant (per 1,000 live births) - Sub-Saharan Africa. Retrieved April 14, 2020, from https://data.worldbank.org/indicator/SP.DYN.IMRT.IN?locations=ZG

Fig. 2. Infant mortality Sub-Saharan Africa.

Figs. 7 and 8 show inequalities in infant and under five years this figure had increased to 27.1%. Similarly, in 2005/06, 43.7%of mortality rates. Rates in Rwanda are lower than most other sub-Saharan households were shielded with a metal sheet roof; by 2016/17 it had nations, yet inequalities persist. Fig. 9 shows significant inequalities for improved to 67.3%. Other indicators include improved drinking water, children sleeping under insecticide-treated nets. improved sanitation, households with a radio set, and households owning a . Of note, the percentage of households owning 4.2. Non-Health indicators of welfare state development a mobile phone was only 6.2% in 2005/6 but increased to 66.9% by 2016/17. Key indicators of welfare state development that inform health out- Income inequality. Rwanda’s income inequality is considered to be comes are GDP, income inequality and rates. These in turn are mid-range in Africa (Odusola, Cornia, Bhorat, & Conceição, 2017 driven by public policies that manage stratification, decommodify necessary ). It is amongst the highest in East Africa but unlike other East African resources, and provide programs that provide economic and social security. nations, it is declining (Oxfam Uganda, 2017). In the 2005/6 Overall, total expenditures by the Rwandan central government have been period, the Gini index was 0.522. By 2017 it had declined to 0.429 increasing and this includes wages and salaries and purchases of goods and (National Institute of Statistics of Rwanda (NISR), 2019). services (National Institute of Statistics of Rwanda (NISR), 2019). Education and literacy rates. Rates are improving. In 2005/6 the Since 2013/14, the national budget has increased by percentage of individuals that had ever attended school was 78.7%. By more than 25 per cent in nominal terms. Of this budget, social protection 2016/17 it had increased to 86.2%. The net attendance rate in primary expenditures in 2017/18 accounted for 4.5% of public spending school similarly increased from 86.6% to 87.6% over this period and ( Children’s Fund, 2017). General public services take up net attendance rate in secondary school improved from 10.4% to 33.9% of public spending. 23.2%. The literacy rate among people aged 15 to 24 was 76.9% in Overall GDP. Rwanda has been making steady progress in increasing 2005/6; it is now 86.5% for the 2016/17 period. its GDP. As of 2018, its total GDP was 8.61 billion USD, continuing a Poverty rates. Poverty rates in Rwanda are declining. There are two rapid increase from 1.667 billion USD in 2002; approximately a 7% a indicators of poverty provided. The extreme poverty rate was 35.8% in year average increase. On a per capita basis GDP has increased in 2005/06. It has declined to 16.0% in 2016/17. The poverty rate was constant dollars from $709 USD in 2012 to $787 USD in 2018. 56.7% in 2005/06 and declined to 38.2% during 2016/17. Access to necessities. The 2019 Statistical Yearbook provides in- Health care coverage. Rwanda is unique in Africa with a very high formation on Rwandans’ access to necessities (National Institute of health insurance rate of 86%. As shown earlier, near-universality is Statistics of Rwanda (NISR), 2019). For virtually all these indicators, being met in key areas. According to the Ministry of Health, the number the situation is improving. For example, in 2005/6 only 4.3% of of health facilities increased from 1342 in 2017 to 1534 in 2018 households had electricity as the main source of lighting. By 2016/17 (National Institute of Statistics of Rwanda (NISR), 2019).

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Fig. 3. Antenatal care.

5. Public policies responsible for these indicators national stewardship of health policy and coordination with interna- tional partners (Iyer et al., 2018). Drawing from experiences of other African states, the government The quality and equitable distribution of health care and additional instituted a series of actions with the goals of achieving near health care social determinants of health are enhanced through investments in universal coverage (Iyer et al., 2018; Sayinzoga & Bijlmakers, 2016). health care, education, poverty reduction, and water and sanitation. Locally operated health clinics strive to enroll residents and involve Rwanda implemented five means of improving the health and well- them in planning and implementation; low income residents are sub- being of people (Binagwaho & Scott, 2015). sidized; and there are sliding scales for health care premiums based on wealth. Overall planning is under the control of the central government. (1) Advancing concrete and meaningful equity agendas that drive the These actions are driven by the perceived need for health care reform post-2015 Millennium Development Goals; and clear ideas about goals and means to achieve them (Chemouni, (2) ensuring that goals to meet Universal Health Coverage incorporate 2018). These ideas included numerous programs to develop human a focus on improving quality; and not only quantity of care; resources, decentralization of health service delivery, development of (3) bolstering education and the internal research capacity within health information systems, various forms of health care financing, and countries to improve local evidence-based policymaking;

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Fig. 4. Births attended.

(4) promoting intersectoral collaboration to achieve goals, and This program has three components; 1) public works; 2) Ubudehe (5) improving collaborations between multilateral agencies – that are credit scheme (local collective actions); and 3) unconditioned cash helping to monitor and evaluate progress towards the goals that are transfers that are part of an active collective participatory poverty re- set – and the countries that are working to achieve improvements in duction strategy (Giovannetti & Sanfilippo, 2011). It is noted that the health within their nation and across the world. central government developed and then communicated these policies to Ministry of Health officials at the central and district levels through a These authors see Rwanda as having implemented a “pro-poor and series of health sector strategic plans. External actors (NGOs and Do- pro-vulnerable agenda that extends beyond the traditional ‘health nors) were then invited for their technical and financial support. In sector’ to tackle the determinants of health” (p. 203). The Vision 2020 Rwanda, the role of non-state actors in health service delivery is re- and the Economic Development and Poverty Reduction Strategy ex- stricted. emplify this approach. Poverty reduction occurs through collective participatory activities More specifically, specific aspects of the elaborate Rwandan public whereby transfers are government-directed but managed at the village policy environment have been described as participatory, sustainable level such that villagers identify those most in need and work together and cost effective (Iyer et al., 2018). Through its Vision 2020, Rwanda for the common good (Joseph, 2005). The Rwandan social policy ap- developed the Umurenge Program, a central government-led initiative proach has reduced poverty among beneficiaries from 40.6% to 9% with full support across the political spectrum. from its inception (Giovannetti & Sanfilippo, 2011). It is seen as effi- cient and accountable with little resource waste.

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Fig. 5. Immunization.

6. Explaining the political and economic forces driving these in local capacity. improvements These successes have come about as a result of three key aspects of the Rwandan situation: 1) the dominance of the Rwandan Patriotic As suggested earlier, promoting health equity is more likely when Front and its commitment to Rwandan development as stated in its governance ensures universality, reduces stratification and promotes Rwanda Vision 2020 statement (Box 2); 2) control of the public policy decommodification, and power and influence is not ceded to anyone environment by the state rather than the private sector; and 3) com- sector. On each of these counts, the Rwandan government scores high mitment and implementation of an anti-corruption agenda. These have grades. Iyer et al. (2018) attribute the success of the Rwandan health served to limit stratification and its health effects and decommodified care system to factors that can also be applied to other health-related key social determinants of health such as health care, education, and in policy areas: strong public sector leadership, investments in informa- some cases, housing (Jaganyi et al., 2018). tion systems, equity-driven policies, and the use of foreign aid to invest

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Fig. 6. Composite coverage.

Box 2 Key elements of Rwanda Vision 2020 6.1. Rwandan Patriotic Front

Reconstruction of the nation and its social capital anchored on The ruling Rwandan Patriotic Front (RPF) was formed as a military • good governance, underpinned by a capable state; group and came to power by ousting the genocidal ruling party in 1994. Transformation of agriculture into a productive, high value, became leader of the RPF in 1998 and was elected pre- • market-oriented sector, with forward linkages to other sectors; Development of an efficient private sector spearheaded by sident in 2003. The RPF is the dominant party and rules through a • competitiveness and entrepreneurship; multi-party coalition. Rwanda provides a high level of government Comprehensive human resources development, encompassing services and the RPF is clearly promoting the improvement of living • education, health, and ICT skills aimed at public sector, standards as well as emphasizing gender equality (Chemouni, 2017). private sector and civil society. To be integrated with de- Its commitment and actions towards these goals has given it a re- mographic, health and gender issues; putation of competency and legitimacy (Matfess, 2015). It has been • Infrastructural development, entailing improved transport suggested that: “The Public Sector Reforms (PSR) has been successful links, energy and water supplies and ICT networks; and and so strongly embraced because rulers considered an effective public Promotion of regional economic integration and cooperation. • sector as a crucial tool for their legitimation strategy, which was based At all times, these will be affected by a number of cross-cut- on achieving rapid socio-economic progress and projecting an image of ting issues including, gender equality and sustainable environ- impartiality” (Chemouni, 2017, p. 2). Against this backdrop of success, mental and natural resource management. Rwanda has also been criticized for its human rights record such that a Source: Rwanda Ministry of Finance and Economic Planning. clear dichotomy exists in the academic literature with many lauding its (2000). Rwanda Vision. : Author. developmental achievements (Abbott et al., 2017; Iyer et al., 2018) and

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Fig. 7. IMR. others critiquing its human rights record (Matfess, 2015; Sobel & government… These arrangements allowed Rwanda’s government McIntyre, 2018). to maintain control over how projects were implemented and to steer policy (p. 204). 6.2. State control of the public policy environment Another key feature of the Rwandan public policy scene is the use of the RPF-owned private holding company, Tri-Star Investments/CVL, to In a comparison of health outcomes between Rwanda and Burundi, invest in metals trading, road construction, housing estates, building Iyer et al. (2018) highlight the key role of the Rwandan central gov- materials, fruit processing, mobile telephony, and printing, furniture ernment in providing primary health care with relevance for under- imports and security services (Matfess, 2015). The investment standing other public policy domains associated with health. by Tri-Star/CVL to ventures that are expected to have high social In Rwanda, decisions were made by the national government. benefits is an important component of the political economy of Rwanda Health policy was communicated to Ministry of Health officials at (Booth & Golooba-Mutebi, 2012). the central and district levels through a series of health sector strategic plans, emphasizing the key areas of focus. Non-govern- 6.3. Implementation of an Anti-Corruption Agenda mental organizations (NGOs) and multilateral donors were then consulted for technical and financial support. Rwanda discouraged The central government has implemented, in numerous legislative the independent implementation of health programs by NGOs, acts, a rigorous anti-corruption agenda that is monitored through the mandating that the work be done in collaboration with the Office of the Ombudsman (Khan & Pillay, 2019). These include the

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Fig. 8. Under 5 mortality.

prevention and punishment of money laundering, financing of ter- promoting health equity for other African nations. rorism, and especially important, assuring that the supply chain and procurement of governments is free of corruption. 7. Placing Rwanda into existing welfare state typologies These activities have received the praise of international authorities. Indeed, the 2019 Corruption Barometer of Transparency International ranked As noted earlier, Gough and Wood (2006) identify a) Actual or Rwanda the 4th least corrupt country in sub-Saharan Africa only after Potential Welfare State Regimes; b) Less Effective Informal Security Botswana, Seychelles, and Cape Verde (Transparency International, 2019). Regimes; and c) Externally Dependent Insecurity Regimes (Wood & Gough, State control of public policy, directed by the pro-development 2006). It appears to us that Rwanda is a Potential Welfare State clearly ideology of the ruling RPF, and facilitated by anti-corruption initiatives moving towards provision of health care and emphasizing important therefore play a large role in Rwanda’s positive health outcomes. social determinants of health such as education, housing and income. It Rwanda has provided leadership in health where centralized health and has achieved notable successes in providing health care on a universal other policy decisions promote a national agenda that limits the role of basis which has been assisted by its investments in poverty-reduction transnational actors to the periphery (Iyer et al., 2018). and various social determinants of health. As a result of these public policies, Rwanda is addressing issues of stratification and decommodification through the Ubudehe and other 8. Implications for research policies. It reduces waste due to corruption, thereby promoting its re- putation of competence and legitimacy. These main themes are con- Research into health inequalities in Africa has necessarily taken a sistent with the general welfare state literature and offer suggestions for backseat to more pressing concerns related to the provision of basic

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Fig. 9. Nets.

health needs such as water and sanitation, provision of healthcare, and which Rwanda has been a both model of failure during its disease prevention. There is much scholarship that has examined the genocide and is now a reconciliation success – is also worthy of study political economy of Rwanda and the economic, economic and social (Grayson, Hitchcott, Blackie, & Joseph, 2019; Karlsson & Talp, 2017). forces shaping public policy (Lavers, 2016; Mann & Berry, 2016). Few of these analyses have however, been explicitly applied to the health equity scene (Abbott et al., 2017; Chemouni, 2018; Iyer et al., 2018). 9. A final note: democratic governance At the last two conferences organized by the Society for the Advancement of Science in Africa, a very few presentations Democratic governance is a concern in both developed and devel- were concerned with health inequalities and their sources oping nations (Raphael, Komakech, Bryant, & Torrence, 2019; Wood & (Kapalanga & Raphael, 2020; Kapalanga, Raphael, & Mutesa, 2019). Gough, 2006). There is no denying many of the successes of the Rwandan This paper was written to spur research activities into the sources of government in improving the quality and equitable distribution of the health inequalities and means of reducing them through a political social determinants of health. For some however, the impressive gains in economy perspective that makes explicit the structures and processes of social progress in Rwanda have come at the cost of “voice and ac- society and how they shape health. Special attention should be directed countability” (McKay & Verpoorten, 2016). The issue of balancing social to processes of stratification and decommodification and the state role progress with human rights must always be viewed in the context of each in shaping the quality and distribution of the social determinants of nation’s history, contemporary context, and its balancing of priorities health. The ability of the state to manage existing groups tensions – for (Gurusamy & Janagaraj, 2018; Kritz, 2019).

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World Health Organization (2015). Success factors for women’s and children’s health: inequality and poverty, immigrant health, the quality of life of communities and in- Rwanda. Retrieved April 14, 2020 https://apps.who.int/iris/bitstream/handle/ dividuals, and the impact of government decisions on Canadians' health and well-being. 10665/178638/9789241509084_eng.pdf. Morris DC Komakech MPH/Global Health, is a PhD student at York University in the Dennis Raphael PhD, is a Professor of Health Policy and Management at York University School of Health Policy and Management. Mr. Komakech has extensive experience working in Toronto. Dr. Raphael has published over 300 scientific publications that focuse on in Toronto Public Health in chronic disease and injury prevention among adults and older health policy, the political economy of health, and social determinants of health. Dr. adults. Mr. Komakech has also conducted health research in Africa in maternal child health, Raphael is also an author and editor of several books on the health effects of income HIV/AIDS, the political economy of noncommunicable diseases, and health policy.

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