[This is an excerpt from an article in The Round Table: The Commonwealth Journal of International Affairs and Policy Studies.] 

The Rwandan government is a proponent of health reforms, using aid strategically rather than being a passive recipient.Footnote7 For instance, Mutuelle and the CHW programme are in fact, locally initiated reforms, even if they were donor-supported (Binagwaho et al., Citation2014). In the case of the latter, this was introduced in 1995, prior to the availability of large-scale donor funding in the country.Footnote8

In addition, where challenges arose such as the dispersal of benefits beyond urban centres, the government intervened to ensure more equitable access. The impact of this coordination was evident in its response to HIV/AIDS as early donor activity was highly fragmented and concentrated in the capital (Drobac et al., Citation2013). This meant that by 2003 less than 150 people living outside of Kigali received ART, despite the country hosting at least 150 non-governmental organisations that provided treatment. But with government support, the country managed to surpass the international threshold of 80% coverage for ART by 2009 (Vogel, Citation2011).

The strategic management of external resources is also evident in the resilience of Rwanda’s health system to donor transitions. For instance, when funding from the US President’s Emergency Plan for AIDS Relief (PEPFAR), the second largest donor to Rwanda’s HIV/AIDS programmes, was reduced by 20% in 2012, the country continued to maintain 90% ART coverage (Binagwaho et al., Citation2016). This was achieved through the deployment of Mutuelle to offset the shortfall. Moreover, Rwanda’s integrated health management information system enabled greater efficiency as resources were redirected to high-burden locations (Awuni & Mbinta, Citation2025).

At the moment, the full impact of President Donald Trump’s dramatic reduction of PEPFAR and dissolution of USAID on Rwanda is yet to be determined. Nevertheless, while disruptions in services are expected, as observed in countries like Nigeria, Ghana and Zambia (Awuni & Mbinta, Citation2025), Rwanda’s past performance suggests that it may prove resilient. For example, self-sustaining HIV programmes is a priority for the government, and over successive years it has intensified its efforts to mobilise more domestic resources to ensure service continuity (Binagwaho et al., Citation2016; The US President’s Emergency Plan for AIDS Relief [PEPFAR], Citation2021; UNAIDS, Citation2025). Political will has been identified as an essential factor in sustaining the HIV response beyond donor transitions (Kimmel et al., Citation2026). Hence, Rwanda is well-positioned to begin mitigating the effect of the funding shortfalls. This is in contrast to the projections made for other sub-Saharan African countries whose health systems are also highly dependent on aid (Hontelez et al., Citation2025).

What Rwanda should expect from the Commonwealth
Rwanda and the relevance of the Commonwealth in the 21st Century

Opportunities for cooperation within the Commonwealth

Based on these experiences, there are opportunities for cooperation within the Commonwealth as the health systems of several of its members are impacted by similar issues. In addition to the discussed economic vulnerabilities, small states, which form a majority of the Commonwealth (33 of 56 countries), are susceptible to large-scale disruptions such as natural disasters (The Commonwealth, Citationn.d.). This was most recently seen in Jamaica with the passage of Hurricane Melissa which not only caused economic devastation but also took a toll on the mental wellbeing of the population (Charite, Citation2025). So learning how to pursue healthcare innovation in resource-constrained settings is important as developing countries face a constant onslaught of disasters and disruptions.

Even countries that possess more resources, such as the UK, can garner valuable insight from Rwanda’s experience. It is estimated that one in six UK residents are afflicted with a neurological condition (Batty, Citation2024). With less neurologists than needed (Association of British Neurologists, Citation2026), the UK may benefit from expanding its pilot CHWs programme (Tredinnick-Rowe et al., Citation2024). Therefore, given the burden of these conditions worldwide, countries can learn from each other as neurological and mental health issues do not discriminate.

Conclusion

Rwanda’s experience highlights how health systems can be transformed when states prioritise this mission. This is now more urgent than ever given the surge in neurological and mental health conditions. Addressing this crisis will require more than disease-specific programmes. It will depend on integrating brain and mental health within national policy agendas, embedding care within communities and stewarding limited external support to strengthen local health systems. While Rwanda’s experience does not offer a strict blueprint, it does demonstrate that even under extreme circumstances, prudent policy choices can reshape the trajectories of care for complex and long-neglected conditions.

Gloria Charite, DPhil Student in Clinical Neurosciences, University of Oxford, Oxford, UK.