Page 256 - GHES-3-3

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

increased to 74.40% (calculated as 57.16×100/76.83) According to Nyandekwe et al. (2020), despite the third-
in 2020/2021 after the GOR’s financial top-up, party payment mechanism at the hospital level through
which was valued at Rwandan Franc (RWF) 22.63 CBHI, the 10% co-payment is unaffordable for the majority
billion. Had the complement granted by GOR not of Rwandans. The Integrated Household Living Conditions
been provided, the CRR would have worsened to Survey 5 reports that 44.1% of Rwandans faced at least one
44.94% (calculated as 34.53×100/76.83). health shock in 2018, relying on savings or borrowing to
The literature review of key developments since 2000 access health-care services (National Institute of Statistics
also highlighted significant advancements in health of Rwanda, 2018)
impacts, as illustrated in the following paragraphs. As an ultimate positive impact of the well-coordinated
Rwanda has made significant progress in improving key CBHI and public/agree (P/A) health-care system (also
health indicators since 2000. Under-five stunting decreased known as the faith-based health-care system) illustrating
from 47.4% in 2000 to 33.0% in the most recent Rwanda health status, life expectancy at birth has increased from
Demographic and Health Survey in 2019/20. Similarly, 47.22 years in 2000 to 62.33 years in 2010, 69.06 years in
infant mortality rates dropped dramatically, from 107 2020, 69.38 years in 2021, 69.69 years in 2022, 70.00 years
deaths/1,000 live births in 2000 to 33/1,000 in 2019/2020. in 2023, 70.27 years in 2024, and is anticipated to reach
Under-five mortality also saw a marked decline, falling 70.54 years in 2025. (Macrotrends, n.d.).
from 196 deaths/1,000 live births in 2000 to 45/1,000 in The efficient management of resources, coordinated aid
2019/2020. Maternal mortality has improved significantly efforts, mutual accountability, and transparency among
as well, decreasing from 1,071 deaths/100,000 live births in stakeholders have all contributed to the performance of
2000 to 203/100,000 in 2019/2020. These statistics reflect Rwanda’s remarkable health-care system.
the country’s continued efforts and progress in improving However, both the CBHI and health-care systems
public health over the past two decades.
face persistent financial uncertainty. According to the
Regarding the United Nation’s Sustainable Development CBHI Annual Reports from 2011/2012 to 2018/2019, as
Goal (SDG) Target 3.8.2 (UHC index), which measures well as the revised budgets for 2019/2020 and 2020/2021,
the proportion of the population spending more than 10% Rwanda’s CBHI – the foundation of the country’s UHC
of household consumption or income on out-of-pocket and universal health insurance programs – has consistently
payments as a proportion of total income or expenditure, faced financial deficits. In 2020/2021, the GOR allocated
the indicator has remained low and fluctuating between RWF 22.63 billion to CBHI, with annual increments,
24.46% in 2000 and 26% in 2015 for the total population through the prime minister’s Order No.034/01 of January
(Muremyi et al., 2020); 10.8% in 2011/2012 within CBHI 13, 2020, to supplement CBHI’s finances. Despite this
members (Nyandekwe et al., 2014); 4.9% in 2018 and 4.5% financial support, the deficit has worsened nominally
in 2020 – 2021 according to the Fourth Health Sector compared to the previous year, with no significant changes
Strategic Plan (HSSP IV) 2018 – 2024 and its midterm in CBHI or health-care utilization (Tables S1-S4).
review, respectively; compared to 10.1% down from On the supply side, i.e., P/A health-care system,
11.67% in 2019 according to Index Mundi Country Facts,
reflecting improved financial protection mechanisms literature reviews reveal health-sector budget and funding
in the health sector. Rwanda’s projected OOP health constraints. The health sector saw a budget reduction in the
expenditure in 2024/2025 would be approximately 9.7% of last 2 fiscal years (FYs) after an increase in 2021/2022 due
current health expenditure, assuming a continued annual to COVID-19. Indeed, according to the United Nations
decline of 1.01%. Children’s Fund (2023), Rwanda’s health sector budget
allocations showed notable fluctuations over recent years,
Regarding the same indicator, after an individual with RWF 245.41 billion allocated in 2019/2020, increasing
premium contribution averaging RWF 3,000 (equivalent to RWF 282.3 billion in 2020/2021 and peaking at RWF
to USD 2.56, based on the exchange rate of USD 1 = RWF 432.2 billion in 2021/2022, before declining to RWF 367.1
1,170.6 as of July 21, 2023), prepaid annually, a symbolic flat billion in 2022/2023 and RWF 363.7 billion in 2023/2024.
fee of RWF 200 (USD 0.17) is co-paid at the health centers The health sector represented 8.1%, 8.1%, 9.9%, 7.8%, and
and/or primary health-care level by non-poor patients as a 7.2% of the national budget in these years, respectively. As a
deductible. At the hospital level, 90% of billable health-care
services are paid collectively through the CBHI central percentage of gross domestic product (GDP), the allocations
risk pooling, with 10% co-paid by non-poor patients. This were 2.5%, 2.9%, 4.2%, 2.1%, and 2.4%, respectively.
demonstrates strong protection for CBHI beneficiaries Despite global fluctuations, Rwanda has sustained and
against financial hardship at the point of use. improved its health-care system, surpassing countries

Volume 3 Issue 3 (2025) 248 https://doi.org/10.36922/ghes.5842