Ensuring Equitable Access to Health Services: Introducing a Sliding-Scale Payment System for Rwanda’s Community-Based Health Insurance System

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Rwanda’s Journey toward Universal Health Coverage

In 1998, the Rwandan government launched an ambitious plan to become a middle- income country by 2020. Central to their strategy was universal access to health care—not a simple objective for most developed countries, let alone one emerging from conflict.The Ministry of Health’s strategy to realize universal health care is three- pronged and includes performance-based financing to incentivize improved service delivery, quality improvement initiatives, and national health insurance to defray the cost of care.To address the latter aspect of their strategy, in 2004 the ministry launched a community-based health insurance (CBHI) scheme to provide access to health care for the roughly 94 percent of Rwandans who were not enrolled in private or other government-sponsored health insurance programs.

Under the original CBHI system, the yearly total enrollment fee per person was 2,000 Rwandan Francs (RWF) ($3); individuals paid half of this fee and the government paid the remaining 1,000 RWF. The government paid the full membership fee for indigents. The insurance covered the cost of all services at health centers, less a small copayment of 200 RWF ($0.30), and 90 percent of the cost of hospital care.The system reduced the incidences of catastrophic health spending in Rwanda (see graph), however, the system lacked equity, as the rich and the poor were paying the same flat fee. Furthermore, the system was not bringing in enough revenue.

Increasing Equity through a Sliding-Scale Payment System

To improve equity within the CBHI system, while at the same time increasing the population’s financial contribution to the system, in 2009 the Integrated Health Systems Strengthening Project (IHSSP) worked side-by-side with the ministry to redesign the insurance system’s payment structure. In the revised scheme, Rwandans pay into the system on a sliding scale, based on their household assets.The highest and middle groups pay an annual fee—7,000 RWF ($10.50) and 3,000 RWF ($4.50) per person, respectively—plus a small copayment at health centers and are responsible for 10 percent of the cost of care at referral facilities.The government of Rwanda covers the enrollment fees for the 25 percent of Rwandans with the fewest assets, who are not charged for their insurance or for health services at any public facility.The government believed that this system would better distribute the financial burden so that all Rwandans could access health services, and at the same time raise sufficient funds to finance quality service delivery throughout Rwandan facilities.