The rising challenge for the Rwandan health system is to reinforce the Primary Health Care (PHC) structure to be able to detect, treat and manage the changing epidemiological transitions where the exposure to environmental, social and lifestyle related risk factors lead to increased incidence of non-communicable diseases such as diabetes, hypertension, strokes, cancer, etc.

The backbone of a strengthened PHC is a well-trained, qualified, and sufficient health workforce. However, Rwanda still falls behind the WHO recommended healthcare worker density of 4.45 healthcare workers per 1,000 people. The population density of healthcare workers in Rwanda is 1 healthcare worker per 1,000 people.

Without any changes, it will take Rwanda close to 180 years to achieve the recommended healthcare worker to population ratio which threatens to stall and even revert the progress made. In this regard, the Ministry of Health (MOH) has designed a reform to train and ensure availability of a minimum of 4 healthcare workers for every 1,000 people by the next four years called the “4x4” reform.

Africa remains the region most affected by the shortage of HCWs yet has no projected improvement. On a continental scale, only 3 countries have achieved the SDG recommended target for healthcare worker density: Libya, South Africa and Botswana. Rwanda lags behind with only 1 HCW/1000 people.

Density of health care workers in Africa

Source: Adapted from WHO Global Health Workforce Statistics Database

The 4x4 reform was approved as a national priority by the Cabinet of the Government of Rwanda on 13th July 2023. The reform sets a goal of quadrupling the number of healthcare workers including residents and fellow, GPs, dental surgeons, pharmacists, nurses, midwives, and allied health sciences in the next four years to bring Rwanda closer to the WHO recommended target of healthcare worker density. The 4x4 reform is not a standalone initiative – it builds off the work conducted in the National Strategy for Health Professions Development (NSHPD) 2020-2030 that details the plans necessary to strengthen the primary healthcare workforce in the next 10 years. Additionally, it will be implemented alongside other strategic projects in MOH that include strengthening the primary health care system and public health security, championing evidence-based medicine and systems, enhancing leadership management decisions and coordination, and capitalizing on digital integration.

1. Increase the quantity and quality of trained health professional students in priority programs
2. Recapture local faculty and hire visiting faculty to fill immediate teaching needs
3. Improve training capacity and teaching facility sites
4. Coordination of the 4x4 reform implementation

• 44 medical residents to Ethiopia: Expanding specialist education through international partnerships
  Through the KFHRF, Rwanda has sent a cohort of 44 doctors to pursue specialized training in various    residency programs hosted at two esteemed institutions in Addis Ababa, Ethiopia: Tikur Anbessa  Specialized Hospital and St. Paul’s Millennium Medical College. - January 2024
• In partnership with the University of Rwanda, the MoH launched 5 new training programs, including new fellowships and residencies as part of the Ministry's 4x4 Health Workforce Development Strategy. – December 2023
• A synergy MoU signed between the Ministry of Health the Ministry of Education and all health professional training institutions and councils to fast track the implementation of the 4x4 reform. – November 2023
• Rwanda looks to quadruple healthcare workforce. – August 2023