By Steve Nsamaza
At 61 years old, Faustine Habimana wakes up at five every day to milk his cows, feed his chickens, and care for his family. His primary focus is farming his four-hectare land in Cyeru Cell, Ruhuha Sector in Bugesera District, Eastern Rwanda.
With Theresa, his wife, Habimana is one of the most successful poultry farmers in this remote rural village. He transitioned from subsistence farming with a mere Rwf.500,000 (about $372) from family savings.
Habimana’s journey from a struggling farmer plagued by peptic ulcers to a healthy, thriving farmer began when he started making savings from personal and his family’s medical bills.
In 2014, he enrolled his family of six in Community-Based Health Insurance (CBHI), Rwanda’s universal health coverage.
The family now delights in being insured, which allows them to cut medical bills and break the cycle of poverty.
CBHI, locally known as Mutuelle de Santé, is Rwanda’s solidarity-based national health insurance system. Under it, families pay contributions to protect themselves and receive medical care.
The government and stakeholders established the Mutuelle de Santé to help low-income individuals access healthcare without financial strain.
The adoption of this universal health insurance in 1999 saw subscription rates soar from a mere 2% to an impressive 93.1% of the population, according to the latest 2022 Rwanda Population and Housing Census (PHC)
This policy has improved access to healthcare and significantly enhanced the overall well-being of Rwandans, demonstrating the government’s commitment to social welfare.
“At first, many in my village doubted the scheme, believing it was too costly. Today, almost everyone, especially farmers, understands the value of the mutuelle system,” Habimana recalls.
He says: “I used to live in constant fear of falling ill or having a sick family member. The high cost of hospital care threatened my limited financial resources, so I committed to paying the annual premium of Rwf.3,000 (about $2.23) per family member.”
Through this initiative, Habimana realized that the money he previously spent on healthcare could be better invested in other economic needs. “Before enrolling in CBHI, medical consultations and medication would cost me about Rwf.35,000 (about $26), with additional charges for specialized services, on each hospital visit. Annually, medical bills would climb to over Rwf.400,000. It was too much—I had to sell part of my land to cover the costs,” Habimana explains.
Today, Habimana can access affordable medical treatment by paying only Rwf.200 (about $0.15) or 10% of the total bill at a health centre, district, or referral hospital.
As a CBHI member, he and his family no longer worry about medical costs whenever they get sick, knowing they can access public medical facilities quickly and affordably.
According to Mutoni, a neonatal nurse at Muhima Hospital located in the suburb of Kigali city, many mothers with preterm babies faced difficulties because they would spend between 30 to 60 days in the hospital, and their bills would climb to more than Rwf.200,000.
Many who failed to cover their medical treatment bill would be detained at the hospital, which forced others to avoid seeking maternity care services.
Today, according to senior hospital health officials, almost all pregnant women are insured at least for the affordable CBHI, and no one can fail to pay the medical bill.
Donatah Mukunzi had a preterm birth, and she spent 15 days at Muhima Hospital, but when the bill came, she was surprised at how little she had to pay because the insurance had covered 90% of the total.
“Mutuelle is very important for us. I am no longer afraid of seeking medical care for my family because we are covered. If it weren’t for Mutuelle, I wouldn’t have been able to pay medical bills, especially during my maternity leave. I would not often visit health centres as I do nowadays,” Mukunzi notes.
Introduced in 1999, the CBHI program was piloted in three districts as a partnership between local communities, healthcare providers, and the government, funded by member premiums, taxes, and donor support.
Health insurance in Rwanda, which was initially voluntary, has undergone many changes and has been made mandatory for all residents. According to the law governing health insurance schemes, any person on the Rwandan territory is required to have health insurance.
CBHI and the law on insurance have led to a spike in the percentage of the insured population. At least 97.3 percent of the population is insured, including CBHI (93%), Rwanda Social Security Board (RSSB) for workers (4.1%), Military Medical Insurance (MMI), and other private insurance plans with limited coverage catering to specific groups.
In 2016, Habimana and Theresa received training in modern agricultural techniques through the THRIVE (Transforming Household Resilience in Vulnerable Environments) program. This marked a turning point, equipping them with the skills to launch poultry farming.
Starting with 50 chicks, their farm has grown to over 250 chickens, producing more than 90 eggs per day. The income from eggs and livestock farming has allowed them to educate all four children, two of whom have already completed university, and two are in secondary school.
Over the years, Habimana and Teresa have reinvested their profits in more cows to grow their herd to four while diversifying their income streams. They supply vegetables to nearby schools and sell milk at the local trading centre.
“We made economic progress because of improved healthcare, which allows us to work hard while saving on the money we used to pay medical bills; our lives have changed for the better,” observes Habimana.
How does Community-Based Health Insurance work
Universal health insurance covers everyone—from the poor to the rich, the young to the old, and urban and rural populations. It is the only policy in sub-Saharan Africa covering over 90% of the population and significantly reducing the cost of healthcare services for members.
The RSSB has managed CBHI since July 2015, when it was moved from the Ministry of Health for accountability and quality services.
Funded by annual membership premiums, taxes, and donations, CBHI is tailored to Ubudehe and is classified based on household economic status. Four Ubudehe levels are divided into three payment regimes; the first category pays Rwf.3,000 (about $2.23), but the government and other donors support households in this category. Category II & III of Ubudehe pays Rwf.3,000 per person, whereas individuals in Category IV pay Rwf.7,000 (about $5.2) per person.
The payment system has been digitalized and can be done on different platforms by dialling *909# for individual mobile payments. After payment, a list of subscribers and ID numbers for the head of the household is admitted to RSSB.
Members of CBHI can get medical treatment at any local health post or health . In emergencies or complicated cases, a patient is given a transfer note to a superior facility, such as a district or referral hospital.
However, this insurance scheme is limited to public medical facilities; only services and medication are offered there. Some diseases and certain medications are not included under the cover, affecting some patients.
To improve access to healthcare, plans are to increase coverage for treating diseases that have not been previously included. According to Dr. Alexis Rulisa, Director of CBHI at the RSSB, the new plans to expand coverage are expected in 2025 and will cover diseases such as cancer or kidney transplants.
Dr. Rulisa notes that the initiative aims to support vulnerable individuals facing high healthcare costs, such as persons with disabilities who may require prostheses.
Jean Marie Bizimana, a 56-year-old resident of Kindama in Ruhuha Sector, Bugesera District, acknowledges the benefits of the Mutuelle de Santé system, which has made affordable healthcare accessible to many locals. Even so, he has reservations about certain aspects of the system. “Sometimes when I fall sick, I’m not given the proper medication, or there is a drug stockout, and I’m referred to a pharmacy where the medicines are too expensive for me to buy.”
Bizimana notes that sometimes prescribed drugs are not available at the health centre, and he has to buy them from private pharmacies, which are expensive.
“Given you have the means, one would not seek medical care from Mutuelle because of the process and long waiting time someone has to endure at the health centre that you feel affects your health.
A leading professional Society for Health Economics and Outcomes Research (ISPOR) study found that 18% of current CBHI members are dissatisfied with the services. 76.4% indicated that CBHI does not always cover prescribed drugs, while 37.8% indicated that CBHI-related medications are not always available at the facility.
The survey found three significant challenges for CBHI members: long waiting times, drug stockout, and travel to the nearest health facilities. Some members also feel that the current premiums are unaffordable.
Despite these challenges, the CBHI program has mitigated many financial barriers, even for patients referred to higher-level facilities, thanks to public subsidies. Rwanda remains committed to achieving 100% universal health coverage by 2030, ensuring all citizens can access essential health services without financial hardship.
Affordability and equity in healthcare are central to Rwanda’s reconstruction policy. Since the 1994 genocide against the Tutsi, mutual health insurance has not only enabled timely medical treatment but has also become a vital strategy in the fight against poverty.
This article was first published in Rwanda Dispatch
