The political path to universal health coverage: Elite commitment to community-based health insurance in Rwanda

Rwanda is the country with the highest enrolment in health insurance in Sub-Saharan Africa. Pivotal in setting Rwanda on the path to universal health coverage is the community-based health insurance (CBHI), which covers three-quarters of the population. Despite the importance of the Rwandan case, analyses of the history and politics behind the scheme are largely absent. This article fills this gap by identifying the political drivers behind its development. It engages in process-tracing of the critical policy choices regarding the CBHI: the design of the first pilot, the decision to make enrolment mandatory, the policies to ensure its adequate funding, and the strategy of day-to-day implementation. It argues that the commitment to expanding health coverage is part of the broader efforts of the ruling coalition to foster its legitimacy based on rapid socio-economic development in a context of a dominant political settlement. The paper also argues that CBHI was chosen as a solution to expand access to healthcare over other approaches because it was the policy option that was the most compatible with the ruling coalition core paradigmatic ideas of popular participation, individual and national self-reliance.