Universal health insurance in Rwanda: major challenges and solutions for financial sustainability case study of Rwanda community-based health insurance part I

Nyandekwe, Médard; Nzayirambaho, Manassé; Kakoma, Jean Baptiste

doi:10.11604/pamj.2020.37.55.20376

Cited by 78Healthcare Systems and ReformsHealthcare Policy and ManagementHealthcare Systems and Practices

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Universal health insurance in Rwanda: major challenges and solutions for financial sustainability case study of Rwanda community-based health insurance part I

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Nyandekwe, Médard, Nzayirambaho, Manassé, Kakoma, Jean Baptiste·2020·Pan African Medical Journal

DOI 10.11604/pamj.2020.37.55.20376PMC PMC7648486

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Abstract

INTRODUCTION: Universal Health Coverage (UHC) has engaged attention of policy makers at both global and country levels. UHC is one of three strategic priorities of World Health Organization's (WHO) general program of work for 2019-2023, and it is then a global health priority. Rwanda Community-Based Health Insurance is considered the vehicle for UHC and Universal Health Insurance in Rwanda. CBHI was officially introduced in 1999/2000 and through 2011/2012 Rwanda was not far from effective UHC. However, since then, CBHI faced chronic financial deficit. This study aims to assess challenges facing Community-Based Health Insurance financial sustainability and to propose indicative solutions. METHODS: quantitative, qualitative, analytical, longitudinal (2011-2018) and documentary mixed methods were applied. One National Pooling Risk (100%), 15 Community-Based Health Insurance districts (50%) and 60 Community Based Health Insurance sections (13.33%) were randomly selected and included in the study. To assess major challenges, "analyzing qualitative data G3658-6 approach" and "prioritization hanlon method" were used. RESULTS: the study highlighted five major challenges: (i) disproportionate risk-equalization in the social health insurance contributory system; (ii) unit cost exceeding individual income (premium plus other revenues and subsidies); (iii) imperfection in funding mobilization and recovery; (iv) cost-escalation; (v) diseconomy of scale; and the study proposed indicative solutions including injection of additional funding and shifting from current fee-for-service payment to fully active strategic purchasing mechanisms as accompanying measures. CONCLUSION: CBHI financial sustainability is achievable, but this is contingent upon persistence of political commitment efforts to achieve UHC, correction of highlighted imperfections and injection of additional funding to allow Rwanda Community-Based Health Insurance to meet and/or exceed its cost in the long-term.

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Universal health coverage in Rwanda: dream or reality
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Authors: Nyandekwe, M., Nzayirambaho, M., & Kakoma, J. B.
Affiliations: University of Rwanda (RW)
University of Lubumbashi (CD)
Corresponding author: Nyandekwe, Médard
ORCID: Nzayirambaho, Manassé
Venue: Pan African Medical Journal
Publisher: Pan African Medical Journal
Published: 2020
Volume: 37
Pages: 55-55
ISSN: 1937-8688 (ISSN-L)
DOI: 10.11604/pamj.2020.37.55.20376
PMC: PMC7648486
OpenAlex: W3086915092
Cited by: 77
References: 13
Citations by year: 2026: 14 · 2025: 25 · 2024: 11 · 2023: 8 · 2022: 13 · 2021: 6
FWCI: 7.02
Type: journal article
Language: en
Open access: gold
doi.org
Licence: cc-by
Locations: Pan African Medical Journal (publishedVersion, cc-by)
PubMed Central (publishedVersion, cc-by)
PubMed (publishedVersion)
DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
Topics: Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Healthcare Systems and Reforms
Social Sciences › Economics, Econometrics and Finance › Economics and Econometrics › Healthcare Policy and Management
Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Healthcare Systems and Practices
Keywords: universal health coverage, community-based health insurance, financial sustainability, risk equalization, unit cost, premium affordability, cost escalation, diseconomies of scale, strategic purchasing, fee-for-service, health care financing, political commitment
MeSH terms: Community-Based Health Insurance, Humans, Longitudinal Studies, Rwanda, Fee-for-Service Plans, Universal Health Insurance, Risk Adjustment

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Universal health insurance in Rwanda: major challenges and solutions for financial sustainability case study of Rwanda community-based health insurance part I

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