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Studies examining the impact of different kinds of organisational and institutional reform on service delivery in the health sector in developing countries highlight and explain advances, strengths, weaknesses, shortcomings and failures in delivery. They rarely explore directly the role of the prevailing political arrangements in individual countries, specifically how politics is organised and practised, in influencing approaches to, and the nature and quality of, service delivery. This paper seeks to contribute towards filling the gap. It explores the extent to which the operation of Rwanda’s political system in the light of the prevailing political settlement shapes service delivery and outcomes in the health sector. A political settlement begets specific rules of the game and incentives, constraints, opportunities and risks in its own context. All things being equal, in Rwanda’s dominant party/dominant leader political settlement, the short- to medium-term prospects of the current government losing power to opposition rivals are slim. Consequently, there is no pressure on the government to deliver on popular expectations or suffer electoral defeat. In the face of marked achievements in recent times, therefore, the paper explores the possible influences on service delivery in post-genocide Rwanda. It argues that the nature of political organisation and how politics works are decisive.

Delivering Maternal Health Services in Rwanda: The Role of Politics