Page 255 - GHES-3-3

Global Health Economics and
Sustainability
Sustainability of Rwanda’s UHC: 2011–2021 and vision 2050

1. Introduction By 2011/2012, over a decade after CBHI’s introduction,
reports showed Rwanda was close to achieving UHC
1.1. Background (Carrin et al., 2008; Evans & Etienne, 2010; Higashi et al.,
The background in the current study extends that of our 2011; Lagomarsino et al., 2012; OECD, 2009). According
previous study (Nyandekwe et al., 2020). Rwanda, a small, to Nyandekwe et al. (2014), the target of effective UHC in
landlocked country in east-central Africa, suffered the Rwanda became a reality by 2012.
1994 genocide against the Tutsi ethnic group in 1994, Twenty-four years after the CBHI scheme began
during which 1 million people were killed, and the health- in 1999/2000, Rwanda’s UHC performance remains
care system was destroyed. At that time, all socioeconomic impressive, aligning with six of Stuckler et al. (2010) interim
and development indicators were among the lowest in sub- metrics as detailed in previous studies (Nyandekwe et al.,
Saharan Africa and low-income countries (Sekabaraga, 2020). A seventh metric, CBHI self-financing capacity
2005). and/or cost-recovery ratio (CRR), was added, indicating

Since 2000, Rwanda has made universal health coverage its financial viability (Nyandekwe et al., 2014).
(UHC) and universal health insurance a national priority, According to Nyandekwe et al. (2014; 2018; 2020), the
leading to significant progress in the health-care system, evidence-based updated UHC performance is impressive,
epidemiological profile, economy, and social health sector. except for the CRR, as detailed below:
These improvements are demonstrated by evidence- (i) CBHI coverage: Coverage reached 90.7% in
based policies, laws, decrees, health gains, and outcomes 2022/2023, up from 83.2% in 2017/2018, with total
(Government of Rwanda, 2017; Kabagwira et al., 2000; coverage (including other insurers) at 97.1% in
National Institute of Statistics of Rwanda and Rwanda 2022/2023.
Ministry of Health, 2016; 2019; Nyandekwe et al., 2008; (ii) Other health insurance: These providers covered
Rwanda Ministry of Health, 2009; 2018). 6.4% of the population, maintaining a total coverage

In 2000, Rwanda developed Vision 2020, a long-term of 97.1% since 2010/2011.
strategy aiming to provide universal access to quality Health facility network and geographical access: The
health care by 2020 (Government of Rwanda, 2012). The CBHI system.
essence of Rwanda’s UHC lies within this strategy. In (iii) Supported by community health workers, ensures
1999/2000, Rwanda launched “Mutuelles de santé” (now the access at all administrative levels from cells, sectors,
Community-Based Health Insurance [CBHI]) with support districts, provinces, and national/central levels
from the Partnerships for Health Reform project under (iv) Comprehensive UHC: Rwanda offers UHC across all
the United States Agency for International Development health levels, from village care to tertiary hospitals
(Schneider & Diop, 2000). This initiative aimed to improve (v) Utilization rate: Health visits increased from
access to health services and reduce inequalities in the 0.31 visits per person in 2003 to 1.46 visits in
health-care system. The 2003 Constitution of Rwanda, 2020 – 2021 in the general population, whereas
revised in 2015, outlines in Article 45 (p.16) the state’s CBHI beneficiaries averaged 2.1 visits annually
duty to promote public health: “The State has the duty to in 2020/2021, as triangulated and adjusted by the
mobilize the population for activities aimed at good health, current study
and every Rwandan must take part in them.” (vi) Skilled birth attendants as proxy health services
utilization (%) metric: The percentage of deliveries
The prepayment scheme transitioned from voluntary
mutual health to the current mandatory CBHI, which with skilled attendants rose from 39% in 2000 to
94.8% in 2019/2020
covers the informal sector, especially the rural uninsured (vii) Patient roaming system: CBHI members can
population, as per Law Nº 62/2007 (République du access services at public and faith-based facilities
Rwanda, 2007). The CBHI evolved through policies, laws, nationwide
and a strong legal framework aimed at achieving UHC and (viii) Governance and integration: Good governance and
ensuring the financial viability of the scheme.
the integration of public and faith-based health
In 2009/2010, the government of Rwanda (GOR) facilities have contributed to these successes
introduced the 2010 CBHI Policy, which was implemented (ix) Out-of-pocket spending: Spending was 4.5% in
on July 01, 2011. The policy addressed key challenges, 2020/2021, well below the 10% threshold
including (i) institutional capacity-building, (ii) financial (x) CRR: The metric declined from 138.46% (calculated
sustainability, (iii) equitable access to health care, and (iv) as 27.97×100/20.20) in 2011 – 2012 to 67.92%
protection against financial risks. (calculated as 22.95×100/39.68) in 2015/2016. It then

Volume 3 Issue 3 (2025) 247 https://doi.org/10.36922/ghes.5842