Community-Based Health Insurance contributes to near-universal health coverage in Rwanda

Community-Based Health Insurance (CBHI) was introduced in Rwanda in 2004 to support universal access to healthcare and is key to the country achieving the highest health insurance coverage rate in Africa. Alongside significant public investment in health infrastructure and health system strengthening, the government of Rwanda’s ongoing development of CBHI has contributed to equitable access to health services.

The government of Rwanda has made equitable access to healthcare a core ideology in government strategies since the country stabilized following the 1994 genocide.¹ Prior to the genocide, Rwanda’s healthcare system was very weak and the limited health services available were often too expensive for most people to access.²In its aftermath, the country faced a deepening health crisis: exposure to malaria, cholera and other waterborne illnesses increased during the conflict, as did HIV/AIDS infections, and the country’s infrastructure was severely damaged.³ Initially the government introduced user-fees to help finance under-resourced health centers, but a 2001 survey found that primary healthcare use was declining and health outcomes were deteriorating.⁴

In 2004, the government introduced a Community-Based Health Insurance Scheme (CBHI) called Mutuelles de santé, following an initial pilot in three districts between 1999 and 2004. The scheme built on existing principles of mutual aid and community solidarity surrounding health in the country.⁵ Rwanda’s CBHI is a compulsory, subsidized health insurance scheme which achieved 91 percent coverage at its peak (2011-12), and covered 83 percent of the population in 2017-18 (latest date available).

Implementation

CBHI schemes in Rwanda are centrally organized partnerships between communities and healthcare providers and are funded by member premiums, general taxes, and donor funding.⁶ CBHIs involve collective pooling of risk at local levels for primary health care, larger district-level pooling of risk for secondary care, and national-level pooling of risk for tertiary care.⁷ CBHIs are regulated by Law No. 62/2007 and other provisions that determine how they are created, managed and implemented.⁸ “In line with the government’s fiscal, administrative and decentralization strategies, the schemes are managed at the district level in a decentralized manner. Each district has its own designated staff in charge of enrollment drives, collecting insurance premiums… and so on.”⁹

Member contributions are determined by a three tiered premium scaling system called Ubudehe which assigns households to one of six categories based on their income and assets. Local governments assign people to Ubudehe categories based on information from the National Income Categorization Database.¹⁰ People living in the two lowest categories receive full government subsidies for their health insurance, households in the two middle categories pay an annual premium of RWF 3,000 (USD 2.68)¹¹ and households in the top two categories pay the maximum premium of RWF 7,000 (USD 6.24). While membership is voluntary in principle, Law No. 62/2007 states that every person not insured by another health insurance scheme must join a CBHI.¹² Local officials were tasked with setting up and recruiting members for CBHIs at the encouragement of top leadership in the country.¹³

Cost

Around two thirds (66 percent) of Mutuelles de santé funding comes from annual member premiums, 14 percent from government funding, 10 percent from donor funding, 6 percent from co-funding, and 4 percent from other sources.¹⁴ In 2019, Rwanda spent USD 51.40 per capita on current health expenditure, below the average for sub-Saharan Africa USD 78.87 per capita.¹⁵

There are concerns about the financial sustainability of the CBHI schemes as they have consistently run deficits which the Government of Rwanda has had to intervene in. ¹⁶

Assessment

Community-based health insurance schemes have been adopted in a range of lower-income settings as an alternative to standard health insurance products, but with mixed results.¹⁷ In the case of Rwanda, CBHI has been found to contribute to a significant decrease in out-of-pocket spending on health and a reduced incidence of catastrophic healthcare spending, though these impacts have been found to favor wealthier households over poorer households as they are more likely to enroll in the scheme.¹⁸ Poorer households that don’t qualify for fully subsidized premiums continue to face challenges in maintaining payments. Access to insurance has been found to contribute to increased health service utilization, with insured households estimated to be twice as likely to use health services than those without coverage.¹⁹

There is some indication that the scheme has contributed to more equitable access to healthcare. One study found that the poorest 20 percent of the population made up only 10 percent of outpatient visits in 2000, and their share increased to 14 percent in 2010.²⁰ There are, however, ongoing challenges faced by people living in poverty. The Ubudehe classification system has lacked transparency, with local authorities in a position to assign households to categories eligible for subsidized payment at their discretion.²¹ The central government has recognised this challenge and is implementing measures to address it. Local officials are monitored on their success in recruiting CBHI members, and pressure to achieve full coverage has led to harsh tactics by some to push people to register. ²² And while the poorest people have their premiums subsidized, there is pressure on those that do not qualify for subsidies to register, even in cases where the premiums are prohibitive.

Tags

• Health
• Low-Income Country
• Low-Income Groups
• Rwanda
• Social Protection
• Sub-Saharan Africa
• Universal