Experience around the world has demonstrated that attention to governance is important to the ability of health systems to fulfill essential public health functions. Health governance concerns the institutions and linkages that affect the interactions among citizens/service users, government officials and health service providers. There is general agreement that good health governance is characterized by responsiveness and accountability; an open and transparent policy process; participatory engagement of citizens; and operational capacity of government to plan, manage, and regulate policy and service delivery. However, explorations of health system strengthening through the governance lens are few. Thus health decision-makers and international assistance agencies have few examples of how to incorporate health governance into system strengthening. This report contributes to filling that gap; it provides a case study of Rwanda’s experience in addressing health governance in tandem with service delivery improvements.