Why Access to Healthcare Does Not Always Protect Families From Poverty

Rwanda has made significant strides towards universal health coverage (UHC), primarily through its Community-Based Health Insurance (CBHI) scheme, Mutuelle de Santé, which covers over 83% of the population. Despite this high access, families continue to face financial hardship and poverty due to healthcare costs. This article explores the legal and policy frameworks underpinning Rwanda's UHC efforts, analyzing the persistent challenges such as out-of-pocket expenses, co-payments, and non-covered services that lead to catastrophic health expenditures. It highlights the gaps in financial protection, particularly for vulnerable households, and discusses the implications for legal practitioners and future policy reforms aimed at achieving true financial risk protection alongside healthcare access.

Rwanda has been lauded globally for its remarkable progress in expanding access to healthcare services, a cornerstone of its commitment to universal health coverage (UHC). The nation's flagship Community-Based Health Insurance (CBHI) scheme, known as Mutuelle de Santé, has achieved impressive enrollment rates, covering a vast majority of the population. This widespread access is often cited as a model for other developing nations striving to meet the Sustainable Development Goals related to health.

However, a critical examination reveals a nuanced reality: access to healthcare services does not always translate into protection from poverty for Rwandan families. Despite high insurance coverage, many households continue to incur significant out-of-pocket expenses, co-payments, and costs for services not fully covered by their insurance, pushing them into financial distress or deeper into poverty. This article delves into the legal and policy landscape of Rwanda's healthcare system, analyzing the persistent challenges that undermine the financial protective aspect of its UHC initiatives and offering insights for legal professionals navigating these complexities.

The right to health is enshrined in Article 21 of the Constitution of the Republic of Rwanda of 2003, as revised in 2015, which states that all Rwandans have the right to good health. This constitutional mandate forms the bedrock of Rwanda's ambitious health sector policies, including its pursuit of universal health coverage. The government's commitment is further articulated in its Health Sector Policy of January 2015 and subsequent strategic plans, such as the Fourth Health Sector Strategic Plan (HSSP4) (2018-2024) and the recently launched Fifth Health Sector Strategic Plan (HSSP V) (2024/25–2028/29), which aim to strengthen the healthcare system and accelerate progress toward UHC by 2030.

A key instrument in achieving UHC has been the Mutuelle de Santé, a community-based health insurance scheme initially piloted in 1999 and rolled out nationwide in 2004. This scheme is regulated by laws such as Law N° 62/2007 of December 30th 2007, which made affiliation to CBHI mandatory for those not covered by other schemes, and subsequent legal frameworks. The Mutuelle de Santé operates on a tiered premium system (Ubudehe categories) based on socio-economic status, with the poorest households receiving full subsidies from the government. Other schemes, such as Rwandaise d'Assurance Maladie (RAMA) for civil servants and Military Medical Insurance (MMI), cover formal sector employees. The management of CBHI was transferred from the Ministry of Health to the Rwanda Social Security Board (RSSB) in July 2015 to improve financial accountability and ensure quality care. These mechanisms collectively aim to ensure universal accessibility, both geographically and financially, to equitable and affordable quality health services for all Rwandans.

Despite the impressive coverage rates of Mutuelle de Santé, which reached over 90% by 2020 and 83.5% by early 2025, the challenge of financial protection against health-related poverty persists. Studies indicate that while CBHI significantly reduces out-of-pocket (OOP) spending, it does not eliminate it entirely, and the impact can be heterogeneous across different income groups. For instance, a 2019 IMF working paper found that while CBHI reduced annual per capita OOP spending by about 83% compared to 2000, the benefits disproportionately favored richer households. This suggests a gap in the protective mechanism for the most vulnerable.

One significant factor contributing to financial hardship is the continued existence of co-payments and costs for services not fully covered by insurance. Even for the poorest category (Category 1) whose premiums are fully subsidized, the insurance may only cover 90% of treatment costs, leaving a 10% co-payment at hospitals that can be unaffordable for many. Furthermore, indirect costs such as transportation to health facilities, food during hospital stays, and lost wages due to illness or caregiving responsibilities are often not covered, yet they represent substantial financial burdens, particularly for rural households. Research indicates that a significant number of patients, even those with insurance, remain at risk of catastrophic health expenditure (CHE), defined as out-of-pocket spending exceeding a certain percentage (e.g., 10% or 40%) of household income or capacity to pay. One study on surgical patients with peritonitis in Rwanda found that 28% were at risk of catastrophic health expenditure when non-medical expenses were considered.

The scope of services covered by Mutuelle de Santé also presents limitations. While it provides access to a comprehensive package of health care from community to tertiary levels within contracted public and faith-based facilities, certain essential services and technologies, such as community-based eye care, eyeglasses, prostheses, orthoses, MRI, CT scans, and dialysis, are not fully covered. This forces patients requiring specialized or advanced care to incur substantial out-of-pocket costs, potentially leading to medical debt and impoverishment. The financial sustainability of the CBHI scheme itself has also faced challenges, with chronic deficits recorded in previous years, requiring government intervention.

From a legal perspective, while the constitutional right to health guarantees access, the practical implementation of financial protection mechanisms, as outlined in various health policies and laws, reveals areas for improvement. The Law N° 026/2025 (Rwanda 2025 Healthcare Law), enacted in September 2025, aims to modernize and consolidate the nation's healthcare legal framework, including provisions for professional liability insurance, which could indirectly offer some patient protection. However, direct legal provisions specifically addressing and mitigating the non-medical and indirect costs that drive families into poverty despite insurance coverage remain less explicit. The ongoing Health Sector Strategic Plan V (2024/25–2028/29) acknowledges the need for financial risk protection and increased domestic resource mobilization, indicating a continued policy focus on these issues.

Rwanda's commitment to universal health coverage through the Mutuelle de Santé is a commendable achievement, significantly improving healthcare access for millions. However, the persistent reality of families being pushed into poverty by healthcare costs underscores that access alone is insufficient without robust financial risk protection. The legal framework, while establishing the right to health and mandating insurance, has not fully insulated households from the economic shocks associated with illness, particularly due to out-of-pocket expenses, co-payments, and uncovered services.

For legal practitioners, this situation highlights the importance of understanding the intricate details and limitations of health insurance schemes like Mutuelle de Santé. Attorneys may encounter clients facing medical debt, asset depletion, or other forms of financial distress directly linked to healthcare costs, even when insured. Advocating for such clients requires a deep appreciation of the gaps in current coverage and the indirect costs that contribute to impoverishment. Furthermore, legal professionals have a crucial role to play in policy advocacy, pushing for reforms that strengthen financial protection, expand the scope of covered services, and address the indirect costs of healthcare. Watching for the implementation details of the Health Sector Strategic Plan V and any new regulations under the Rwanda 2025 Healthcare Law will be vital, as these may introduce mechanisms to better align healthcare access with genuine financial security for all Rwandan families.