Page 276 - GHES-3-3

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

contracting unless they can reduce their costs (Hsiao et al., 4.6. Rationale for abolishing the co-payment scheme
2007; Nyandekwe et al., 2020). Although most providers The prepayment system reflects CBHI members’ ownership
oppose capitation, the study argues that bundled payments can and aligns with Rwanda’s constitution, which mandates the
effectively control costs and should be implemented, as they state to promote health and involve the population in health
can reduce deficits and mismanagement. Data from Rwanda’s activities. Despite high membership coverage, Nyandekwe
CBHI (2011/2012 – 2020/2021) supports the assertion that et al. (2014) reported that only 2.17% of the 94% CBHI
cost escalation occurred under the FFS PPM practice. target population can afford the 10% co-payment for
specialized treatments, such as kidney transplants, costing
4.5.1. Ghana
RWF 2 – 2.5 million. Without abolishing the co-payment
Ghana, a low-middle-income country in West Africa, scheme, 91.83% of CBHI members would be excluded,
had a GDP per capita of USD 2,409 in 2020 (up from raising concerns over government accountability.
USD 1,779.89 in 2017) and per capita health spending of To address this, we propose abolishing co-payments at
USD 84.98. In 2005, Ghana launched the National Health public/agreed health-care facilities, with CBHI reimbursing
Insurance Scheme (NHIS) to promote UHC. While NHIS costs via a third-party mechanism. This would ensure
expanded health-care access, financial sustainability has equal access to specialized care for all members. The CBHI
been a concern, with the deficit rising from 4.8% in 2009 annual premium of RWF 3,000 (USD 2.56) accounts for
to 23.7% in 2010 before dropping to 1.87% in 2012 after 3.2% reducing to 3% of the projected per capita health
adopting the DRG payment policies. The NHIS attributed expenditure of USD 81.17 for 2024/2025. Abolishing
rising deficits to “moral hazards” and mismanagement, co-payments would raise subsidized CBHI coverage
prompting cost-containment measures, including the to 97%, enabling Rwanda’s health-care system – from
capitation paid claims scheme. Health-care professionals community health workers home-based care to tertiary
have criticized the fairness of this payment method. During hospital levels – to deliver nearly free care across all levels,
the pilot phase of the “Mutuelles de santé” in Rwanda, many ensuring universal access and protecting members from
health-care providers opposed the capitation PPM, which financial hardship.
was ultimately rejected due to failing to cover the actual Abolishing co-payments would increase CBHI
costs of health services (Schneider and Diop, 2000). member’s coverage to 96.8% (100% minus 3.2%) rounding

4.5.2. Indonesia to 97% and enable Rwanda’s health-care system – from
community health workers to tertiary hospitals – to
Indonesia, a middle-income country in Southeast Asia, provide nearly free primary, hospital, specialty, and super
had a GDP per capita of USD 4,333 in 2020, with health specialty care, ensuring universal access and shielding
expenditures at USD 132.96 per capita. In 2014, Indonesia members from financial hardship.
launched the Jaminan Kesehatan Nasional (JKN) program,
covering 145 million people, with 86.4 million eligible for Abolishing co-payments at primary health-care levels
financial assistance. Despite promoting equity, actuarial would reduce health-care costs for CBHI members,
studies show that JKN’s per capita subsidy is insufficient encourage timely visits, and prevent complications that
could result in costly hospital treatments. At hospitals, it
to cover its costs. While the government adopted a would improve access to expensive care for the 91.83%
provider contracting system to address this, the financial of members who cannot afford the 10% fee. In addition,
gap remains, requiring higher contribution rates and cost- maintaining a fixed CBHI premium rate until 2040/2041
containment strategies. would protect members from catastrophic health expenses

4.5.3. Thailand and increase resilience against health-care shocks.
Thailand, a UMIC, had a GDP per capita of USD 7,067 in 4.7. Limitations of the study
2020, with a per capita health expenditure of USD 305.09. While the study did not survey Rwandan health
Thailand achieved UHC through its Social Health Insurance stakeholders on the proposed FASP PPM, it is known that
program (1988 – 1997), funded by taxes, with no premiums many health-care providers, including those in Rwanda,
for beneficiaries. The government also provides benefits to oppose the capitation PPM. Initially used in “Mutuelles
civil servants through the Civil Servants Medical Benefit de Santé,” the capitation PPM was later rejected due to its
Scheme. Despite cost-control efforts such as capitation and failure to cover the actual costs of health services (Schneider
DRG systems, disparities remain between civil servants and and Diop, 2000). While DRGs, widely used to reduce costs,
other program participants, similar to issues seen in Rwanda’s remain controversial (particularly in countries such as
other private social health insurance institutions and CBHI. Ghana), past resistance from health-care providers should

Volume 3 Issue 3 (2025) 268 https://doi.org/10.36922/ghes.5842