District hospitals in Rwanda play a crucial role in healthcare delivery, but their efficiency is often suboptimal. A systematic review of existing literature on methods used for evaluating and improving the operational efficiency of health facilities in Rwanda. District hospitals show varying degrees of inefficiency, with some achieving improvements when adopting evidence-based management practices. Current methodological approaches to assessing hospital efficiency are varied but generally lack robust statistical validation. More rigorous randomized field trials and standardised protocols for evaluating hospital efficiency should be implemented. district hospitals, Rwanda, healthcare efficiency, systematic review, randomized field trial Treatment effect was estimated with $\text{logit}(p_i)=\beta_0+\beta^\top X_i$, and uncertainty reported using confidence-interval based inference.