Removing Financial Hardship to Increase Access and Promote Preventive Health Care

Speeches Shim

A client presents her CBHI card to the Remera-Rukoma Hospital receptionist.
A client presents her CBHI card to the Remera-Rukoma Hospital receptionist.
Alanna Savage, MSH

Raissa Iradukunda has two children and lives near Remera-Rukoma hospital in Rwanda about one hour from Kigali. She and her family are covered under Rwanda’s community-based health insurance program (CBHI), known locally as Mutuelle de Santé: “We are farmers,” she explains, “but we can afford to pay the required 3000 Rwf per year because we know that Mutuelle de Sante has enabled us to access health care even in situations where we did not have enough money for some services.”

Community-based health insurance improves people’s access to services by removing the financial hardship of medical costs. It also promotes a culture of prevention by encouraging people to acc/global-health/health-systems-innovation/health-systems/primary-health-careess preventive health care at no cost. For example, attending antenatal visits early and often helps health workers identify potential issues with pregnancy and counsel women to delivery in facilities with the appropriate level of care, if needed, which reduces the likelihood of costly emergency services and mitigates the risk of adverse outcomes for the mother and baby. CBHI is coordinated at the district level, where each of Rwanda’s 30 districts has a pooled-risk fund. Membership fees are received at the community level, the community then reimburses health centers for services rendered.

Additionally, membership premiums are income-based, meaning that enrollees pay according to their income. At the Government of Rwanda’s request, USAID designed a database breaking down over nine million Rwandan households into six categories, based on income and assets, to stratify CBHI payments according to need and thereby increase equity in accessing services particularly among the poorest part of the Rwandan population. In category 2, Raissa pays 3000 Rwf a year, or the equivalent of $3.45 USD.

As 71 percent of the Rwandan population has access to a CBHI scheme, the country’s gap in health service coverage between the rich and poor for all of the pregnancy, birth, and newborn-related services is low, and Rwanda is performing better than its neighbors in the Central and East African regions.

For the past 10 years, USAID has provided substantial financial and technical support to the Government to maintain the community based health insurance systems. Now having built this capacity, only targeted technical assistance on complex or novel issues is provided as the Rwanda Social Security Board (RSSB) effectively oversees ongoing management such as raising awareness among other government institutions on the financing gap so that the gap can be filled if necessary, RSSB manages the CBHI fund, ensures registration of beneficiaries and disbursement to beneficiaries.

When the management of CBHI transitioned from Ministry of Health to the RSSB, members, like Raissa, feared their families would not receive the same health benefits. If enrollment rates decreased because of this fear, the CBHI would no longer have been sustainable. In fact, there was a 7 percent increase in enrollment, from 76.3 percent in fiscal year 2014/15 to 81.6 percent in 2015/16, which shows the RSSB is effectively managing the insurance scheme and meeting expectations of the population.

CBHI helps improve equity in the health system, by enabling people with diverse incomes to access care and not fear financial hardship. By encouraging access to primary and preventive care, CBHI is helping Rwandans stay healthy and preventing significant future health expenses by the population as well as the government. This is a major step toward financial protection along the journey to self-reliance.


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