Aimable Twahirwa (Lead Writer)
Daphrose Mukanyangezi, a farmer from Nyamasheke, a district in south-western Rwanda, used to live in constant fear of falling ill. She was particularly worried about the crippling cost of hospital care for her elephantiasis, a condition she has been battling for years, and which threatened her already limited financial resources.
However, with Rwanda's commitment to universal health coverage, through its expansion of the Community-Based Health Insurance (CBHI), Mukanyangezi can now access quality healthcare without thinking about the cost.
The CBHI, also known as 'Mutuelle de santé', is a partnership between local communities, healthcare providers, and the government, funded by member premiums, taxes, and donor support. It is rooted in the country's traditional values of community solidarity and mutual help, and it pools resources at different levels to cover various healthcare needs, from primary care at the local level to secondary care at the district level and tertiary care nationally.
Prior to its enhancement to cover high-cost treatments, patients like Mukanyangezi were required to pay a fee of RWF 200 ($0.14) for consultations and generic drugs at public health facilities. Additional charges also applied for specialised services. In Mukanyangezi's case, she was charged an extra RWF 5,000 ($3.73) for antiparasitic drugs, which was not included in her insurance package, adding to her overall medical expenses.
To guarantee universal access to quality healthcare, Dr. Alexis Rulisa, Director of CBHI at the Rwanda Social Security Board (RSSB), introduced new plans to expand coverage by 2025, ensuring that treatments for certain diseases, like Mukanyangezi's elephantiasis which require specialised treatment, are included.
"The move aims to assist people with diseases such as kidney transplant surgeries, cancer treatment, and patient seeking assistive devices such as prostheses for people with disabilities who face significantly higher healthcare costs," Dr Rulisa said in a recent media briefing in Kigali.
The CBHI is regulated by Law No62/2007 and other guidelines, and each district manages its own CBHI scheme in a decentralised manner, with designated staff handling tasks like enrollment and premium collection. The law also requires individuals without alternative health insurance to join a CBHI as the community-driven approach promotes collective risk-sharing and access to healthcare services for Rwandans.
How the CBHI upgrade is catering to everyone
Prior to 2004, the CBHI scheme was voluntary. However, the government has made it mandatory and increased funding to reduce the financial burden on patients. By upgrading the CBHI, the government aims to minimise hospital costs and shift away from the traditional fee-for-service payment model, where patients bear the full cost of healthcare services.
Rwanda has had a diverse range of health financing schemes, including Military Medical Insurance, the University of Rwanda Medical Insurance Scheme, and various private health insurance plans. However, these schemes have limited coverage, catering to specific populations or groups, and only provide health insurance to a small segment of the population, leaving a significant portion of Rwandans without insurance.
But the CBHI membership has a flexible premium payment tairlored to individuals' economic circumstances.
It utilises a three-tiered premium scaling system called Ubudehe, which categorises households into six levels based on income and assets. The government subsidises premiums for the two lowest categories, while households in the middle categories pay an annual premium of RWF 3,000 ($2.68), and those in the top categories pay RWF 7,000 ($6.24).
About 83% of Rwanda's population falls into Category B and C of the Ubudehe, comprising self-sufficient households that are responsible for paying their own health insurance premiums. In contrast, the government assumes the cost of premiums for individuals classified under Category D and E, who are living in extreme poverty or are unable to work due to factors such as old age, severe disability, or chronic illness, thereby ensuring that the most vulnerable segments of the population have access to essential healthcare services.
The CBHI has experienced remarkable growth since its inception as a pilot project in 1999, expanding from a mere 7% population coverage to a staggering 91% the improvement if the CBHI has also led to a surge from 75% in 2016 to 91% in just eight years. This represents a significant milestone in the country's efforts to ensure universal access to healthcare.
Additional investments for expanded coverage
By next year the Rwandan Government is considering expanding the CBHI's coverage by adding more packages for specialised treatment such as cancer and kidney transplants.
Dr Sabin Nsanzimana, Rwanda's Health Minister, takes delight in noting that the country is one that is performing well on the goal of achieving universal health coverage through the CBHI scheme, however, many officials believe that mobilising additional investments is also critical to cover those who are not yet part of the scheme. But this move is a huge financial burden for the country's healthcare sector.
"We are considering to include all the possible healthcare services under the CBHI but there are still limited capacity of the funds," Dr Nsanzimana, points out recently while addressing the Rwandan parliament.
Attaining universal health coverage not only involves ensuring financial access to healthcare services, but also necessitates investing in healthcare infrastructure to make quality medical care physically accessible to all.
To alleviate the burden on public healthcare facilities, some local investors have established private clinics, but these facilities primarily cater to individuals with alternative insurance plans or those who can afford out-of-pocket expenses, limiting access for many. Healthcare experts argue that achieving comprehensive coverage in both private and public health facilities will require government incentives, as the current situation leaves a significant gap.
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Floribert Nyirimigabo, Manager of Kibilizi Health Facility in Gisagara district, southern Rwanda, explained that though people in rural areas are still currently getting insured through government's incentives, high costs of care still persist leaving many unable to afford basic services.
Many people living in rural Rwanda are disproportionately vulnerable, with limited financial resources and income levels that often fall short of affording comprehensive healthcare services, unlike their urban counterparts. This disparity leaves families living in rural communities with reduced access to essential health services, putting them at risk of health challenges.
According to Dr. Nsanzimana, Rwanda's Health Minister, while CBHI schemes have made significant strides in reducing financial barriers to healthcare access, they are not yet perfect, and some challenges persist. Still, the CBHI has mitigated many financial barriers, even for patients referred to higher-level facilities, thanks to public subsidies.
With a commitment to continuously progress, Rwanda aims to achieve 100% universal health coverage by 2030, ensuring that all citizens have access to essential health services without facing financial hardship.
