Towards universal health coverage in Rwanda?
By Dr Benjamin Chemouni
5 January 2017
In 2010, the WHO estimated that, every year, 100 million people are pushed into poverty and 150 million suffer financial catastrophe because of out-of-pocket expenditure on health services. Providing affordable healthcare to the populations of low- and middle-income countries is consequently at the top of the development agenda. Universal health coverage is one of the central targets of the Sustainable Development Goals (SDGs).
Rwanda currently has the highest health insurance coverage of any country in Africa. This was achieved mainly by rolling out the Community-Based Health Insurance (CBHI) scheme, otherwise known by its French name mutuelles de santé. The scheme works as follows: an individual pays a yearly a sum of money to the state (specifically, to the Rwanda Social Security Board) to be covered by the health insurance. This in return allows the individual to access healthcare at 10 percent of the billable cost of services.
The performance of Rwanda in terms of population coverage has been surprising in many regards. First, the sheer number of people enrolled is impressive, as the scheme now covers more than 70 percent of the population. This stands in stark contrast with many other experiences across the African continent, where CBHI coverage has been disappointing, due to managerial and fiscal issues. Second, the Rwandan scheme displays original features. It is compulsory. This historically has been done in Europe as well, for example through payroll deductions for national health insurance. In Rwanda, an additional challenge is that most of the population works in the informal sector, making compulsory enrolment difficult to implement. Another original feature is that Rwanda was able to harness donor money, notably from the Global Fund to Fight AIDS, Tuberculosis and Malaria, to finance the scheme. Finally, the formal sector has supported the scheme through compulsory financial transfers to the CBHI.
The sheer number of people enrolled is impressive, as the scheme now covers more than 70 percent of the population.
While this experience has been documented from a technical point of view, work on the origins and history of the scheme, and on the politics underpinning this exceptional experience, are absent. My paper sought to fill this gap by looking at the political drivers behind the Rwandan CBHI. It is part of a wider project with ESID, comparing elite commitment to social protection in five African countries: Ethiopia, Kenya, Rwanda, Uganda and Zambia.
The political economy behind the roll-out of the CBHI explains its success, both in terms of coverage and its form. First, the commitment of the ruling elite to reach high coverage can be attributed to its attempt to quickly deliver tangible benefits to the population to foster its legitimacy, a dynamic not different to that which can be observed in Ethiopia. This dynamic is especially strong in Rwanda, where the legitimacy of the post-genocide regime was scarce. Such a legitimation project has been facilitated by the political settlement in Rwanda. The ruling party, the Rwandan Patriotic Front (RPF), dominates the political scene, making policy decisions easy to make and implement.
Yet, if this explains why the elite has been committed to providing good financial access to healthcare, it does not explain why it chose compulsory CBHI as a solution. Other solutions, such as tax-funded national health insurance lifting of user fees could have been compatible with the Rwandan political settlement. The CBHI solution won the favour of policymakers, however, because it was the solution that best fits the underlying ideas of the RPF. Particularly, the CBHI, by asking the population to financially contribute to improve access to healthcare, fits the ideological emphasis on national and individual self-reliance that the RPF has maintained since its creation. The CBHI, in the long run, is viewed as a way to decrease individual and national dependence on donors. It is also aligned with the RPF’s visceral belief that ‘one should not get anything for free’ in post-genocide Rwanda. Furthermore, it fits the RPF paradigmatic idea that financial participation has a transformative power for the poor. People should work towards solving their own problems, which a policy of ‘free healthcare’ is thought not to allow, by making people passive recipients.
The CBHI fits the ideological emphasis on national and individual self-reliance that the RPF has maintained since its creation.
The Rwandan experience reveals that the path towards universal health coverage is not simple. While its population coverage is impressive, the quality of the healthcare provided can be limited. Also, the healthcare package covered by the CBHI is incomplete. For instance, mental illness is not covered. Finally, compulsory enrolment came at a price. It has created a strong pressure on the bureaucracy to maintain high mutuelle membership. Compulsory enrolment has led to the use of swift, if not at times harsh, methods by local officials, including confiscating livestock, banning entrance to local markets, and denying administrative documents to the non-bearers of mutuelle cards. These practices run the risk of decreasing the population’s buy-in to the scheme. On the other hand, enforcing mandatory enrolment is one – if not the main – factor behind Rwanda’s high health insurance coverage, and behind the relative financial sustainability of the scheme.
This post is based on ESID Working Paper 72, ‘The political path to universal health coverage: Elite commitment to community-based health insurance in Rwanda‘.
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