Laos & Rwanda: Access

A community-based health insurance (CBHI and called Mutuelles in French) program was established in Rwanda in 1999 to improve utilization of services following reinstatement of user fees in 1996.1  Although it was managed by the Rwandan Ministry of Health, the program was decentralized with branches at various health centers. The Mutuelles demonstrated tremendous growth following implementation; in 1999, it was piloted in only three districts, and as of 2013 it covered 74% of people without another source of insurance. Enrollment in the Mutuelles was associated with increased utilization of care and decreased catastrophic health spending. However, consistent with literature on equity effects of CBHI,2 compared to enrollees with higher income, the poorest quintile experienced less utilization and greater catastrophic health spending based on data from 2000 to 2006.3 The copayments for the Mutuelles still presented a significant financial barrier for these individuals. A successive pilot program removing user fees for the poorest population enrolled in the Mutuelles found increased utilization among this population by nearly 100%,4 and in 2010, the Government of Rwanda introduced a sliding scale premium payment to increase enrollment among poor populations.1 Although the sliding scale has improved equity considerably, payments remained slightly regressive. This case highlights the value of pairing multiple financial access strategies, including removal of user fees, discussed in greater detail below. It is important to note that much of the success of this Mutuelles can be attributed to subsidization and centralized risk pooling by the government, which required significant infrastructure and coordination but provided greater protection.5

In Laos, CBHI programs intended to expand financial access to the poorest and most vulnerable have also come under the purview of the government in order to increase risk pooling and improve financial sustainability. There are four health insurance plans in Laos. Two of these plans cover civil servants and salary workers, and the other two plans are CBHI programs. A voluntary CBHI plan managed by the Ministry of Health is offered to informal workers and self-employed individuals. Additionally, this plan is also purchased by the government and offered to some of the lowest income individuals in the country.6 This strategy was intended to not only improve access for this segment of the population but also to increase the size of the risk-pool. An evaluation of the CBHI plans in Laos found that those enrolled in CBHI were more likely to use both inpatient and outpatient services. Additionally, they were more likely to access lower-level facilities and utilize referral systems, contributing to stronger continuity and coordination of care. Finally, those enrolled in CBHI were more likely to use public facilities. In Laos, private facilities have few resources, which often results in the provision of drugs without significant consultation time, advice, or a diagnosis.7 Again, it is important to note that although CBHI in Laos is organized at the local level, the government has contributed to its success by purchasing insurance and increasing the risk pool.


  1. Management Sciences for Health. The Impact of Community-Based Health Insurance on Access to Care and Equity in Rwanda. 2016;(March):1–25. Available from:
  2. Umeh CA, Feeley G. Inequitable Access to Health Care by the Poor in Community-Based Health Insurance Programs : A Review of Studies From Low- and Middle-Income Countries. Vol. 5, Global Health Science and Practice. 2017.
  3. Lu C, Chin B, Lewandowski JL, Basinga P, Hirschhorn LR, Hill K, et al. Towards universal health coverage: An evaluation of Rwanda Mutuelles in its first eight years. PLoS One. 2012;7(6).
  4. Dhillon RS, Bonds MH, Fraden M, Ndahiro D, Ruxin J. The impact of reducing financial barriers on utilisation of a primary health care facility in Rwanda. Glob Public Health [Internet]. 2012;7(1):71–86. Available from:
  5. Mathauer I, Mathivet B, Kutzin J. Community Based Health Insurance: How can it contribute to progress towards UHC? 2017;(3):1–14.
  6. Bodhisane S, Pongpanich S. The Impact of Community Based Health Insurance in Enhancing Better Accessibility and Lowering the Chance of Having Financial Catastrophe Due to Health Service Utilization: A Case Study of Savannakhet Province, Laos. Int J Heal Serv. 2017;47(3):504–18.
  7. The World Bank. Community-Based Health Insurance in Lao P . D . R . Understanding Enrollment and Impacts. 2010;(November).