Long-term financial sustainability of Rwanda’s universal health coverage model: Challenges and solutions (2011 - 2021) and Vision 2050

Abstract

Since 2000, Rwanda has prioritized universal health coverage (UHC) and universal health insurance, achieving significant health gains. Its UHC model - centered on Community-Based Health Insurance (CBHI) and supported by public and faith-based providers - now faces financial sustainability challenges. Under Vision 2050, Rwanda aims to meet upper-middle-income country health-care standards by 2035 and high-income country (HIC) standards by 2050. This study assesses the financial sustainability of Rwanda’s UHC model from 2011 to 2021, with projections through 2041 under four scenarios: Scenario I (status quo, fee-for-service): Projects growing deficits reaching Rwandan Franc (RWF) 89.71 billion and a cumulative RWF 913.03 billion by 2040/2041. Scenario II (Fully Active Strategic Purchasing): Project net income of RWF 81.61 billion and cumulative reserves of RWF 516.94 billion by 2040/2041. This approach supports near-free health care, aligns with SDG 3.8 and WHO’s UHC Cube, and promotes reforms such as tariff adjustments, medical tourism, dual practice, and a comfortable package integrated with Ejo Heza Pension benefits. Strategic purchasing could eliminate 56.89% of undue costs, enabling 70% prepayment for facility plans: 45% for health service delivery, 10% for prior co-payments, and 15% for staff incentives. The remaining 30% (post-verification) would fund additional essential medicines, inpatient nutrition, financial sustainability, and resilience initiatives. Scenario III (1% UHC-HRV 2050 tax): Forecasts RWF 849.41 billion in net income and RWF 6,985.66 billion in reserves. Scenario IV (equity and modernization): Aims to expand clinical capacity 12-fold by 2041. Leveraging a strengthened CBHI system and a modest 1% levy for UHC and HRV 2050, Rwanda could promote clinical capacity strengthening up to 12-fold by 2041, retention and repatriation of specialized professionals, health infrastructure modernization, and meet HIC health-care standards by 2036 - 2040, ahead of 2050 initial milestone, saving up to USD 922.86 per capita in health expenditure. Rwanda’s robust UHC commitment provides a replicable model for sustainable health reform across Africa.

Keywords

Rwanda / Community-Based Health Insurance / Financial Sustainability / Universal Health Coverage / Vision 2050

Funding

The Wellcome Trust provided financial support (grant number: 087540) for primary data collection through The Health Researchers in Vocational Excellence in East Africa (THRiVE).

Conflict of interest

The authors declare they have no competing interests.

References

[1] Asian Development Bank. (2002). ADB Annual Report. Available from: https://www.adb.org/documents/adb-annual-report-2002

[2] Carrin, G., Doetinchem, O., Kirigia, J., Mathauer, I., & Musango, L. (2008). Social Health Insurance: How Feasible is Its Expansion in the African Region? Netherlands: Institute of Social Studies.

[3] Department of Economic and Social Affairs. (n.d.). Transforming Our World: The 2030 Agenda for Sustainable Development. Available from: https://sdgs.un.org/2030agenda [Last accessed on 2024 Nov 06].

[4] Evans, D.B., & Etienne, C. (2010). Health systems financing and the path to universal coverage. Bulletin of the World Health Organization, 88(6):402. https://doi.org/10.2471/BLT.10.078741

[5] Government of Rwanda Ministry of Health. (2012). Third Health Sector Strategic Plan. Rwanda: Government of Rwanda Ministry of Health.

[6] Government of Rwanda. (2002). Poverty Reduction Strategy Paper National Poverty Reduction Programme. Rwanda: Ministry of Finance and Economic Planning.

[7] Government of Rwanda. (2012). Rwanda Vision 2020. Rwanda: Government of Rwanda.

[8] Government of Rwanda. (2015). Vision 2050. Rwanda: Government of Rwanda.

[9] Government of Rwanda. (2017). 7 Years Government Programme: National Strategy for Transformation (NST1).

[10] Hayes, A.F. (2013). Introduction to Mediation, Moderation, and Conditional Process Analysis:A Regression-Based Approach. New York City: The Guilford Press.

[11] Higashi, H., Khuong, T.A., Ngo, A.D., & Hill, P.S. (2011). Population-level approaches to universal health coverage in resource-poor settings: Lessons from tobacco control policy in Vietnam. MEDICC Review, 13(3):39-42. https://doi.org/10.37757/MR2011V13.N3.9

[12] Hsiao, W.C., Paul Shaw, R., & Fraker, A. (2007). Phusit Hanvoravongchai, and Grace Chee. Social Health Insurance for Developing Nations. Washington, DC: World Bank.

[13] Investopedia. (n.d.). Gross Profit vs. Net Income: What’s the Difference? Available from: https://www.investopedia.com/ask/answers/101314/what-are-differences-between-gross-profit-and-net-income.asp [Last accessed on 2024 Nov 06].

[14] Jarl, C. (2012). Health in Rwanda is improving! Mid Term Review (MTR) of the Rwanda Second Health Sector Strategic Plan.

[15] Kabagwira, A., Mukanyonga, A., Barrère, M., Mariko, S., Production, M.A., Khan, H., et al. (2000). Rwanda Demographic and Health Survey 2000 Key Findings. Available from: https://www.macroint.com/dhs

[16] Lagomarsino, G., Garabrant, A., Adyas, A., Muga, R., & Otoo, N. (2012). Moving towards universal health coverage: Health insurance reforms in nine developing countries in Africa and Asia. Lancet, 380(9845):933-943. https://doi.org/10.1016/S0140-6736(12)61147-7

[17] Macrotrends. (2025). Rwanda GDP Per Capita 1960-2025. Macrotrends LLC. Available from: https://www.macrotrends.net/global-metrics/countries/rwa/rwanda/gdp-per-capita

[18] Macrotrends. (n.d.). Rwanda Life Expectancy 1960-2025. Available from: https://www.macrotrends.net/global-metrics/countries/rwa/rwanda/life-expectancy

[19] Muremyi, R., Haughton, D., Kabano, I., & Niragire, F. (2020). Prediction of out-of-pocket health expenditures in Rwanda using machine learning techniques. The Pan African Medical Journal, 37(1):357. https://doi.org/10.11604/pamj.2020.37.1.21489

[20] National Institute of Statistics of Rwanda, & Rwanda Ministry of Health. (2016). Rwanda Demographic and Health Survey, 2014-15: Final Report. National Institute of Statistics of Rwanda, Ministry of Finance and Economic Planning; Ministry of Health, The DHS Program, ICF International.

[21] National Institute of Statistics of Rwanda, & Rwanda Ministry of Health. (2019). Rwanda Demographic and Health Survey. Rwanda: National Institute of Statistics of Rwanda.

[22] National Institute of Statistics of Rwanda. (2018). Integrated Household Living Conditions Survey 5 (EICV-5). Available from: https://www.statistics.gov.rw/datasource/integrated-household-living-conditions-survey-5-eicv-5

[23] National Institute of Statistics of Rwanda. (2022). 5th Population and Housing Census. Rwanda: National Institute of Statistics of Rwanda, Ministry of Finance and Economic Planning, Ministry of Health, The DHS Program, ICF International.

[24] Nyandekwe, M., Nzayirambaho, M., & Kakoma, J.B. (2014). Universal health coverage in Rwanda: Dream or reality. The Pan African Medical Journal, 17:232. https://doi.org/10.11604/pamj.2014.17.232.3471

[25] Nyandekwe, M., Nzayirambaho, M., & Kakoma, J.B. (2018). The health-related Millennium Development Goals (MDGs) 2015: Rwanda performance and contributing factors. The Pan African Medical Journal, 31:56. https://doi.org/10.11604/PAMJ.2018.31.56.11018

[26] Nyandekwe, M., Nzayirambaho, M., & Kakoma, J.B. (2020). Universal health insurance in Rwanda: Major challenges and solutions for financial sustainability-Case study of Rwanda community-based health insurance part I. The Pan African Medical Journal, 37(55):1-12. https://doi.org/10.11604/PAMJ.2020.37.55.20376

[27] OECD. (2009). Health at a Glance 2009: OECD Indicators. Pairs: OECD.

[28] Philippe Gatarayiha, J., Mukanyonga, A., Kayirangwa, E., Kabeja, A., Rukundo, A., Kabagwira, A., et al. (2006). Republic of Rwanda Rwanda Demographic and Health Survey 2005. Available from: https://www.measuredhs.com

[29] Reese, S.D. (2011). Managing uncertainty:Journalism practice in the 21st century. In: Lowrey, W., & Gade, P.J. (eds.). Changing the News: The Forces Shaping Journalism in Uncertain Times. England, UK: Routledge, p.17-36.

[30] République, du Rwanda. (2007). Loi No 62/2007 du 30/12/2007 Portant Création, Organisation, Fonctionnement et Gestion des Mutuelles de Santé. Rwanda: République du Rwanda.

[31] Roberts, M.J., Hsiao, W.C., Berman, P., & Reich, M.R. (2004). Getting Health Reform Right:A Guide to Improving Performance and Equity. Oxford: Oxford University Press.

[32] Rwanda Ministry of Finance and Economic Planning (MINECOFIN), & Republic of Rwanda. (2008). Economic Development and Poverty Reduction Strategy 2008-2012. Rwanda: Republic of Rwanda.

[33] Rwanda Ministry of Finance and Economic Planning (MINECOFIN). (2013). Economic Development and Poverty Reduction Strategy II 2013-2018. Available from: https://www.glcmc.com

[34] Rwanda Ministry of Health. (2009). Health Sector Strategic Plan. Rwanda: Rwanda Ministry of Health.

[35] Rwanda Ministry of Health. (2010). Rwanda Community Based Health Insurance Policy. Rwanda: Rwanda Ministry of Health.

[36] Rwanda Ministry of Health. (2018). Fourth Health Sector Strategic Plan. Rwanda: Rwanda Ministry of Health.

[37] Rwanda Ministry of Health. (2019a). Health Financing Strategic Plan. Rwanda: Rwanda Ministry of Health.

[38] Rwanda Ministry of Health. (2019b). Rwanda Health Sector Performance Report. Sabiiti, D. (2024). Rwanda’s Progress in Raising Healthcare Standards. KT Press. Available from: https://www.ktpress.rw/2024/03/rwandas-progress-in-raising-standard-of-healthcare-system

[39] Schneider, P., & Diop, F.P. (2000). Development and Implementation of Prepayment Schemes in Rwanda. United States: U.S. Agency for International Development.

[40] Sekabaraga, C. (2005). Santé et Pauvreté au Rwanda: Reconstruire et Réformer Les Services de Santé dans la Perspective des Objectifs du Millénaire Pour le Développement (OMD). United States: World Bank.

[41] Statista. (2023). Rwanda:Startup Funding and Deals 2022. Available from: https://www.statista.com/statistics/1398197/rwanda-startup-market-size-by-funding-and-deal-count

[42] Stuckler, D., Feigl, A., Basu, S., & McKee, M. (2010). The Political Economy of Universal Health Coverage. In: Background paper for the Global Symposium on Health Systems Research.

[43] United Nations Children’s Fund. (2023). UNICEF Annual Report 2023. https://www.unicef.org/media/157491/file/unicef%20annual%20report%202023%20en.pdf [Last accessed on 2025 Apr 03].

[44] United, Nations. (2015). The Millennium Development Goals Report. United States: United Nations.

[45] Wisevoter. (2023). Best Healthcare in the World. Available from: https://wisevoter.com/country-rankings/best-healthcare-in-the-world

[46] World Health Organization. (2000). The World Health Report 2000: Health Systems-Improving Performance. Available from: https://www.who.int/publications-detail-redirect/924156198x

[47] World, Bank. (2020). Current Health Expenditure Per Capita (Current US$) - Rwanda. World Bank Open Data. Available from: https://data.worldbank.org/indicator/sh.xpd.chex.pc.cd?locations=rw

[48] World, Bank. (2020). World Development Indicators: Rwanda. World Bank Group. Available from: https://databank.worldbank.org/source/international-comparison-program

[49] World, Bank. (2023). Financing for Health Systems in Low- Income Countries: Progress and Gaps. Available from: https://www.worldbank.org/health-financing-2023