Rwanda in part attributes its progress toward Universal Health Coverage (UHC) to the implementation of Community Based Health Insurance (CBHI). Some evidence shows that in Rwanda, CBHI has led to increases in health service utilization and better financial protection since 2005. As of 2019, for example, 83% of Rwandan women and men ages 15 to 49 had health insurance; of those, 93% were members of the CBHI scheme. Despite the realised successes, there is a constant concern of the financial sustainability of the CBHI, and equity concerns. In this paper, the authors assessed the strengths and shortcomings of health purchasing arrangements for three health financing schemes in Rwanda including the CBHI. The study found that Rwanda has made progress in many areas of strategic purchasing and has a strong foundation for building further. However, some overlaps and duplication of functions weaken the power of purchasers to improve resource allocation, incentives for providers, and accountability. In addition, some of the policies within the purchasing functions could be more strategic. In particular, open-ended fee-for-service payment in the CBHI scheme not only threatens the scheme’s financial sustainability but also imposes a high administrative burden, and poses equity concerns.
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