Performance based financing often highlighted in

Performance-based financing, often highlighted in Rwanda\'s story, has had mixed results when applied elsewhere, partly because of breakdowns in execution. For example, the failure of the performance-based financing initiative in neighbouring Uganda was caused by challenges in setting targets, delivering payments, and coordinating stakeholders. Likewise, cyproheptadine hcl insurance, which has greater than 90% coverage in Rwanda, has faced managerial challenges and uniformly low coverage (often below 30%) in other places, including countries wealthier than Rwanda, such as Senegal and Côte d\'Ivoire. In one review, four of five insurance schemes faced problems collecting premiums, which undermines their viability. Countries such as India, South Africa, Ukraine, and Zambia have been unable to align donors and vertical disease programmes around systems strengthening because of inadequate direction and coordination. Rwanda, by contrast, has been able to assert vision and control, systematically maximising these opportunities to build its health system. Rwanda also outperforms its peers on pragmatic aspects of day-to-day health-care delivery often hindered by weak implementation, such as ensuring reliable supplies of medications. This aptitude for consistent execution is not unique to its health sector. Rwanda is a positive deviant for almost all types of service delivery. It ranks 18th globally in institutional performance, including 21st in the reliability of policing and 2nd in the time required to start a business, even outpacing many high-income countries (). Rwanda has the highest primary school enrolment rate in Africa and is one of the continent\'s best performers on corruption. The country is also recognised as one of the ten most improved economies for doing business and one of few countries on track to achieve most Millennium Development Goals. These numbers point to general state capability as a common thread in the country\'s success, including its health achievements. Indeed, its success in introducing cutting-edge health policies and channeling external aid—the factors credited for its health gains—are themselves reflections of internal environment underlying capability. On measures specific for state capability, Rwanda outranks peer nations and has made great improvements in recent years (). How has such strong state capability been achieved? Rwanda has had the same politically secure leadership since 1994, enabling the sustained pursuit of a long-term vision based on country-defined priorities. Additionally, Rwanda\'s hierarchical political culture, which predates the genocide, supports centralised decision-making and strict compliance with top-down directives. The current leadership progressed from a rebel army that ended the genocide and has repeatedly earned resounding electoral mandates, reinforcing a sense of shared interest and chain of command. Coupled with its small size, Rwanda is able to concentrate discretion at the national level, yet assure that actors in the periphery implement according to plan. All of this does not, however, indicate that Rwanda\'s state capability is the result of fear or an outlier without wider relevance. Such conclusions diminish the professionalism, diligence, and ingenuity apparent throughout the country. Unlike many post-revolutionary governments that centralised authority and remained in power for prolonged periods, Rwanda\'s Government used technical assistance to edify its own capacity for policy making and administration while launching novel homegrown initiatives. Its government has made policy decisions based on technocratic evidence and instituted mechanisms, such as performance contracts for district governments, to inculcate accountability.
In just under 5 months\' time, the aspiration for the next 15 years of development efforts will be signed off at the UN General Assembly in New York, USA. These Sustainable Development Goals (SDGs) are already at an advanced stage of drafting—17 ambitious goals and 169 targets (), which have been criticised even by the UN General Secretary for being too voluminous. Amid this multitude of outcomes, those pertaining to health are reduced from three Millennium Development Goals to one SDG. What does this mean for global health research?