ASSESSING THE EFFECTS OF HEALTH INSURANCE ON THE ACCESSIBILITY OF

QUALITY HEALTH SERVICES IN RWANDA.

By

Uwase Belyse, Umwali kelvine, Ishimwe Sandrine, Kanyesigye Andrew

In partial fulfillment of the requirements for the Degree

of Bachelors in Applied Statistics
School of Economics
College of Business and Economics

University of Rwanda

2024-06-26

© Uwase Belyse, Umwali kelvine, Ishimwe Sandrine, Kanyesigye Andrew

 DEDICATION

we firstly and foremost dedicate this dissertation to Almighty God for His blessings and for being
our shield in this way of life. Our respectful supervisor, beloved family, parents, friends, and
colleagues are also dedicated to this work for their effort in taking into account all our needs and
support which have motivated us to work so hard to make this possible and applicable.

May the Almighty God bless you all abundantly

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 DECLARATION

We hereby declare that this dissertation entitled by “ASSESSING THE EFFECTS OF HEALTH
INSURANCE ON THE ACCESSIBILITY OF QUALITY HEALTH SERVICES IN RWANDA.”
unless specified it is entirely our own work and it has not been submitted to any other university for
the same purpose.

Signature. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Name of students

Uwase Belyse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Umwali Kelvine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Ishimwe Sandrine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Kanyesigye Andrew. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Place. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Date:. . . . . . ./. . . . . . . . . / 2023

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 ACKNOWLEDGMENTS

we would like to show our gratitude and heartfelt to each individual contributes to our dissertation,
your guidance, and any other kind of support you provided are very precious to accomplish this
piece of work, without your precious support it would be very difficult.

We would also like to kindly appreciate MR. HATEGEKIMANA NATHANAEL for very consciousness
support and guidance for the accomplishment. we would like to extremely thankful and show our
gratitude to the University of Rwanda, College of Business and Economics, School of Economics
and Department of Applied Statistics for their special guidance to the undergraduate students’ thesis.
Special thanks goes to our parents, sponsors, family and friends for both directly and indirectly
support and guidance to accomplish this duty, you are very important and we appreciate your
participation and contribution to our dissertation.

In conclusion, we thank our colleagues, friends, and everyone who directly or indirectly contributed
in any way, it may be time, prayers, or anything else. we acknowledge/concede your support.

May God bless you all!!!

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 TABLE OF CONTENTS

Dedication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ii

Declaration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii

Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv

List of Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii

List of Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix

List of Acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . x

abstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i

Chapter 1: Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1.1 INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1.2 Problem statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

1.3 Study objective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

1.3.1 Main objective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

1.3.2 Specific objective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

1.3.3 Organisation of the dissertation . . . . . . . . . . . . . . . . . . . . . . . . 4

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 1.3.4 RESEARCH QUESTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Chapter 2: LITERATURE REVIEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

2.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

2.2 DEFINITION OF THE KEY CONCEPTS . . . . . . . . . . . . . . . . . . . . 6

2.2.1 Health insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

2.2.2 Universal Health Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . 6

2.2.3 Insurance for national or social health (NHI/SHI) . . . . . . . . . . . . . . 7

2.2.4 Community based health insurance . . . . . . . . . . . . . . . . . . . . . . 7

2.2.5 Total health expenditure . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

2.2.6 Out of pocket cost . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

2.3 Conceptualizing Health Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 8

2.4 Theoretical Literature Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

2.4.1 Premium Rating Regulations and Community Rating . . . . . . . . . . . . 11

2.4.2 Consumer theory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

2.4.3 Expected utility theory (EU) . . . . . . . . . . . . . . . . . . . . . . . . . 12

2.4.4 Poverty literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

2.4.5 State dependent utility theory . . . . . . . . . . . . . . . . . . . . . . . . . 13

2.5 REVIEW OF PREVIOUS STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . 13

2.6 SUMMARY REVIEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Chapter 3: RESEARCH METHODOLOGY . . . . . . . . . . . . . . . . . . . . . . . . 16

3.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

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 3.2 Research Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

3.3 Study Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

3.4 Study Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

3.5 Data source . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

3.6 Validity and Reliability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

3.7 Hypothesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

3.8 Method of Data analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

3.9 Limitation of the study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Chapter 4: DATA ANALYSIS AND FINDINGS . . . . . . . . . . . . . . . . . . . . . . 19

4.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

4.1.1 INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

4.2 DESCRIPTIVE STATISTICS . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

4.3 Empirical results and discussion . . . . . . . . . . . . . . . . . . . . . . . . . . 21

4.4 Logistic regression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Chapter 5: SUMMARY, CONCLUSION, AND RECOMMENDATION . . . . . . . . . 24

5.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

5.2 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

5.3 conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

5.3.1 Recommendation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

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 LIST OF TABLES

4.1 Descriptive statistics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

4.2 Tabulation of coved by health insurance by gender . . . . . . . . . . . . . . . . . . 21

4.3 Tabulation of insured respondents and type of insurance . . . . . . . . . . . . . . . 21

4.4 Dependent variable: Quality of healthcare services . . . . . . . . . . . . . . . . . . 22

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 LIST OF FIGURES

2.1 the health insurance process (source: Health systems Resources Centre) . . . . . . 9

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 List of Acronyms

AIDS Acquired immune deficiency syndrome

CBHI: Community Based Health Insurance

CHWs:Community Health Workers

DHP: Demographic Health program

DHS: Demographic Health Survey

NISR: Rwanda National Institute of statistics of Rwanda

MHI: Mutual Health Insurance

MMI: Military Medical Insurance

NHI: National Health Insurance

NISR: National Institute of statistics of Rwanda

RAMA: : Rwandaise d’Assurance Maladie

SHI: Social Health Insurance

UHC: Universal Health Care

UHI: Universal Health Insurance

WHO: World Health Organization

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 Abstract
Studies have shown a link between rising health insurance coverage and improved access to
healthcare. Since 1999, the Rwandan government has actively encouraged citizens to participate
in community health insurance programs. However, some residents have reported concerns about
the quality of care they receive. This study aims to investigate the impact of health insurance
on access to high-quality healthcare services in Rwanda. The research employed data from the
2019-2020 Demographic Health Survey to examine the connection between health insurance and
access to quality healthcare in Rwanda. Logistic regression analysis was used to assess the strength
of this relationship. The study reveals a significant link between health insurance and access to
quality healthcare in Rwanda, as measured by factors like financial burden (money for treatment)
and accessibility (distance to health facilities). However, a concerning finding emerged: insured
respondents were 0.8229285 times more likely to face challenges accessing quality care compared
to the uninsured. This suggests that simply having insurance doesn’t guarantee high-quality care for
everyone in Rwanda. The Ministry of Health should prioritize expanding healthcare infrastructure,
particularly by increasing the number of distributed health posts. This will address the issue of
distance as a barrier to accessing quality care and Exploring strategies to negotiate better coverage
with pharmaceutical companies or identifying alternative financing mechanisms to ensure access to
essential medications.
 CHAPTER 1

BACKGROUND

1.1 INTRODUCTION

Health insurance is a system that allows individuals to pay for medical expenses through regular
contributions to a pool of funds, which are subsequently used to cover the costs of healthcare
services when needed. This system aims to reduce the financial burden on individuals and families
when seeking necessary medical treatment, ultimately increasing the accessibility of quality health
services. It can come in various forms, such as private insurance, public insurance, or employer-
sponsored insurance, each with its unique features and coverage options. For example, private
insurance is typically purchased directly by individuals or through employers, offering a range
of plans with different premiums, deductibles, and coverage limits. the concept of ”quality” in
healthcare services is multifaceted. It encompasses aspects like clinical effectiveness, patient
safety, patient satisfaction, and efficiency. While access to basic services might improve with
health insurance coverage, concerns remain regarding the quality of care delivered. Issues like
provider shortages, inadequate infrastructure, and financial incentives within insurance schemes
can potentially compromise the quality of care patients receive. Research by Lagarde et al.
(2007). highlights the issue of provider shortages and inadequate infrastructure, particularly in rural
areas, which can compromise the quality of care patients receive. Additionally, some insurance
schemes might incentivize specific services over others, potentially impacting the overall quality and
comprehensiveness of care Lagarde et al. (2007).Universal healthcare systems, prevalent in many
developed nations, aim to provide comprehensive coverage for all citizens, promoting accessibility
Wagstaff & Lindelow (2008). Conversely, countries with private or employer-sponsored insurance
plans may leave segments of the population uninsured, creating barriers to access?. Additionally,
funding mechanisms and benefit packages within each model vary considerably. These variations
can significantly impact how readily individuals can access services, particularly preventive care,
specialist consultations, and advanced treatments Magnussen et al. (2009). Understanding the
specific healthcare landscape of different countries is crucial. The region faces a unique set of
challenges, including limited healthcare infrastructure, a shortage of qualified medical professionals,
and a high burden of communicable and non-communicable diseases Organization et al. (2020).
Existing health insurance schemes in East Africa vary considerably. Some countries, like Rwanda,

1
have implemented national health insurance programs aiming for broad population coverage
Chemouni (2018). Others, like Kenya, have a mix of public and private insurance options, raising
concerns about equity in accessMbuthia (2022). These variations in design and implementation
significantly impact how individuals navigate the healthcare system, potentially creating disparities
in accessing essential services, preventive care, and advanced treatments. During the war, many
health institutions were destroyed, and the health condition of Rwandans became worse. Rwanda’s
pre-genocide government deeply divided society. Power and resources were allocated based on
ethnicity, creating a system with extreme inequality. This segregation mirrored itself in healthcare,
with a health insurance program for the privileged 150,000 civil servants (out of a total population
of 600,000) funded by payroll taxes. This unequal system ultimately contributed to the outbreak
of war and genocide. The scheme lasted for a mere 2 years and contributed to a negative impact,
and the chaotic aftermath of the genocide has led to its abandonment. This unfortunate period
has left the country to this day with a rapidly increasing number of poor people, and the damage
was a devastated economy, political upheaval, and a polarized society. There comes a concept of
CBHI. itself wasn’t brought by the government of Rwanda. It was learned by the founder of the
idea, Dr. Richard France, from the experience of having a Health Maintenance Organization in the
United States. Rwanda’s limitations – both resource scarcity and a largely rural population (over
600,000 people) – made the complex HMO system impractical. This led to the concept of a simpler,
community-based health insurance (CBHI) plan in 1986. However, the initial attempt in Kigali
that year was cut short by the outbreak of war. It wasn’t until 1999 that CBHI was successfully
introduced in Rwanda. That’s the starting point of the successful implementation of CBHI in
Rwanda Those who want insurance must pay an annual premium of 2,500 francs per family, up
to seven people, at the time of enrollment (as of July 1999, RWF 2,500 US$7.50).Bucagu et al.
(2012) . It has made a great impact for those who are in the rural area by offering them health
insurance, but there was a lack of government support, and still, there were people who could
not afford to pay the insurance. Then, during the same year, there was a start of a long process
involving a variety of stakeholders, and the aim was to find a means to provide the country with
a form of prepaid healthcare financing which can risk protecting, affordable for all, and could
decrease the high rate of cost-sharing on the patients. In the early stages of its development, the
health insurance plan was being initiated by the workers of the main agriculture sector in each
district within the country. CBHI was tried to be initiated at Mugonero hospital in Karongi district
by the establishment of christian mutual health insurance. At that time, it finally came to be a
national CBHI program in 2000 after the initiatives from the agriculture sector workers. Even
though Rwanda attempted a Community-Based Health Insurance (CBHI) program around 2000,

2
war halted its progress. After the war, efforts to revive a sustainable CBHI program were made but
haven’t resulted in significant impact on the health sector. In 2004, a pilot program for a national
CBHI scheme called ”Mutuelle de santé” was initiated in three districts ?. Building on the principles
of community solidarity and mutual aid, this program aimed to provide affordable health insurance
coverage for a broader population Bucagu et al. (2012); ? .The new CBHI proposition launched
on January 1, 2005, was considered to adapt and improve the community-based insurance for all
citizens in Rwanda. Rwanda’s CBHI program underwent a significant transformation after the pilot
program’s success. A government decree in 2007 paved the way for a nationwide rollout in 2008,
supported by global health funds ? Coverage targets were ambitious, exceeding 80% by 2012 and
reaching an impressive 91% at its peak. This achievement surpassed the global indicator of 60% but
fell short of the program’s ideal 80% membership rate for long-term sustainability Bucagu et al.
(2012); ? . Under the new CBHI, able-bodied individuals in categories one and two pay an annual
contribution of RWF2000 (US$3). Government and development partners/NGOs usually pay for
the very poor and vulnerable individuals in the first category. For individuals and families in the
third and fourth categories, the annual subscription fee is RWF3000 (US$4.5) per year, while a
fee of RWF7000 (US$10.5) is to be paid annually by those in the two wealthiest categories (MOH
2010). According to the 2007 law, it is mandatory for all Rwandans to be enrolled in Ubudehe
health insurance. The main purpose of categorizing Community-Based Health Insurance (CBHI)
payments under the Ubudehe system is to support the most vulnerable populations and identify
those in extreme poverty. In the 2011/12 period, 24.8% of the population was classified into CBHI
category 1, while 65.9% and 0.04% were placed in categories 2 and 3, respectively. During its
initial implementation year from July 2011 to June 2012, CBHI achieved a high enrolment rate of
90.7% Mohd-Zaki et al. (2014). This success is attributed to the Ubudehe categorization, which
made the annual premiums more affordable for many citizens and ensured that their financial
capacities were considered in determining their premiums. Additionally, this system allowed NGOs,
development partners, and philanthropic individuals to more easily identify and assist the most
vulnerable members of the community ?. Despite this, the program has demonstrably increased
health insurance coverage in Rwanda. The future of CBHI in Rwanda lies in further expanding
risk-pooling to cover the entire population, eliminating out-of-pocket payments, and transitioning
to value-based healthcare financing models. Recognizing the need for a sustainable healthcare
financing system, the Rwandan government initiated a multi-year process. This involved research,
policy discussions, and consultations, culminating in the approval of two key policies in 2010: social
protection and health financing. The health financing policy specifically led to the establishment of
a legal framework for CBHI through a law passed in late 2010 and implemented in 2011.

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1.2 Problem statement

Rwanda’s healthcare system has undergone a remarkable transformation since the 1994 genocide.
The country has made significant strides in expanding access to basic healthcare services, with a large
portion of the population now covered under the successful Community-Based Health Insurance
(CBHI) scheme. This program has demonstrably improved overall healthcare utilization rates
Habimana et al. (2023). However, despite these achievements, a critical challenge remains: ensuring
equitable access to quality healthcare services for all Rwandans. While CBHI has undoubtedly
improved access, questions linger about its impact on the quality of care received. This study aims
to investigate a critical issue for Rwanda’s healthcare system: does having a large number of people
covered by health insurance necessarily translate to better quality healthcare for them? Examining
this question is crucial for the Rwandan government, as they strive to achieve universal health
insurance coverage. Understanding the link between insurance and quality of care will inform future
policies and ensure that expanding coverage translates into tangible improvements in healthcare
experiences for the Rwandan population.

1.3 Study objective

1.3.1 Main objective

The main goal of this study is to evaluate how health insurance, specifically, community-based
health insurance (CBHI), affects accessibility of quality healthcare services in Rwanda

1.3.2 Specific objective

Specific objectives of this study include:

• Compare the social, demographic, and economic profiles of participants enrolled in health
insurance plans with those who are not enrolled.

• Study how health insurance (or lack thereof) is connected to the quality of healthcare received.

1.3.3 Organisation of the dissertation

This dissertation will be organized into five parts. The first will be containing background of the
study, research questions and objectives. The second part of this dissertation will summarize the
past research and findings of other researchers on the topic of interest. The third part will discuss
how reports and articles were employed to gather needed materials for our study. The fourth part

4
of this dissertation will focus on the procedure to obtain major results of the study. The fifth part
of this dissertation will come to an end of all other previous parts, and it will summarize all work,
show findings and provide recommendations to future researchers.

1.3.4 RESEARCH QUESTIONS

this project will address the following research questions:

• What are the social, demographic, and economic characteristics of participants enrolled in
health insurance plans with those who are not enrolled?

• Is there connection between health insurance and the quality of healthcare received?

5
 CHAPTER 2

LITERATURE REVIEW

2.1 Introduction

A literature review involves examining academic sources related to a particular subject to gain an
understanding of current state of knowledge. This process helps in recognizing pertinent theories,
approaches, and areas where further research is needed Gosselin et al. (2023).Recent research on
Rwanda’s health system highlights the growing importance of Community-Based Health Insurance
(CBHI). Studies like ”The impact of mutual health insurance...”Saksena et al. (2011) and ”The
impact of community-based health insurance...” Binagwaho & Scott (2015) explore how CBHI
affects healthcare utilization and financial protection. These findings are directly provide valuable
insights into how health insurance, specifically CBHI, influences healthcare access and potentially
the quality of services used by Rwandans.

2.2 DEFINITION OF THE KEY CONCEPTS

2.2.1 Health insurance

Health insurance is a financial arrangement that acts as a safety net for individuals and groups
against the often-prohibitive costs of medical care (Kongstvedt, 2019). These costs encompass a
wide range of services, including hospital stays, doctor visits, prescription drugs, and other medical
interventions. The core function of health insurance lies in pooling financial resources from a large
population, enabling the sharing of risk and the distribution of costs (Council et al., 2007). This
mechanism allows individuals to access essential medical care without the burden of carrying the
full financial responsibility themselves.

2.2.2 Universal Health Coverage

Universal Health Coverage (UHC), defined as ensures everyone can access the full spectrum of
quality health services they need, regardless of financial hardship. This encompasses preventive
measures, treatment, and rehabilitation, delivered without creating financial burden P. Mishra et
al. (2020). Financial protection is a cornerstone of UHC, guaranteeing that cost is not a barrier

6
to seeking necessary healthcare stated by Organization et al. (2019). Other organizations like the
World Bank (2013) emphasize this financial accessibility, while The Lancet Commission on Health
in the 21st Century (2014) highlights primary care as a cornerstone of UHC.

2.2.3 Insurance for national or social health (NHI/SHI)

As described by the South African Department of Health (2020), the NHI is a health financing system
intended to pool resources in order to give all South Africans, regardless of their socioeconomic
status, access to high-quality and reasonably priced personal health services based on their health
needs. Risk pooling is essential to the funding and management of healthcare in a social health
insurance (SHI) system. This means that SHI combines the financial contributions from individuals,
households, businesses, and the government, as well as the population’s health risks Organization
(2022).

2.2.4 Community based health insurance

Community-Based Health Insurance (CBHI) is a voluntary health insurance scheme managed

locally World Bank, (2017) highlights its focus on financial protection by pooling resources within
communities Bank (2018). Meanwhile, the World Health Organization (WHO) emphasizes the
social aspect, describing CBHI as based on solidarity, risk-sharing, and mutual aidOrganization
et al. (2012). In Rwanda, this program is called ”Mutuelle de Santé” (MS) and is credited with
improving access to healthcare and health outcomes, playing a vital role in achieving Universal
Health Coverage (UHC)Nsabimana, Niyitanga, et al. (2021).

2.2.5 Total health expenditure

refers to the total amount a country spends on healthcare over a specific period, encompassing both
public and private funding. This expenditure covers a wide range of health activities, including
disease prevention, treatment (both curative and preventative), family planning, nutritional programs,
and emergency interventions. It’s important to note that investments in water sanitation, despite
their crucial role in public health, are not included. Bank (2018). Expressed as a percentage of
a country’s Gross Domestic Product (GDP) (e.g., Organization for Economic Co-operation and
Development Ahn (2024), Total health expenditure serves as a key indicator for researchers to assess
how a nation allocates resources towards healthcare relative to its overall economic production.

7
2.2.6 Out of pocket cost

Out-of-pocket expenses are a significant financial burden for many patients in the healthcare system.
These costs represent the portion of medical bills a patient pays directly, encompassing copays,
deductibles, and coinsurance for covered services, as well as any charges for services not covered
by insuranceBreslow et al. (1997). This financial burden can limit a patient’s ability to access
and utilize healthcare services effectively. While intended to promote responsible healthcare use
by requiring patients to share costs with insurance companies, high out-of-pocket expenses can
discourage people from seeking necessary treatments or preventive care Sinabell & Ammenwerth
(2024). Research by Bankrate (2023) highlights the strain these expenses can cause, with millions
of Americans spending over 5% of their annual income on healthcare, a significant portion of which
goes towards out-of-pocket costs. This burden can disproportionately affect low- and middle-income
families, potentially leading them to delay or forgo needed care. Fortunately, there are limitations
on out-of-pocket costs under the Affordable Care Act for most health insurance plans. Once a
patient reaches this annual out-of-pocket maximum, the insurance company becomes responsible
for covering the remaining costs of approved services Sinabell & Ammenwerth (2024).

2.3 Conceptualizing Health Insurance

Health insurance acts as a financial safety net in Rwanda, where high out-of-pocket costs hinder
healthcare access Nsabimana, Li, et al. (2021). It reduces financial burdens and allows people
to seek necessary care. The type of coverage also matters. Comprehensive plans that include
preventive services encourage proactive healthcare, while limited coverage can restrict access and
lead to delayed or inadequate care. As Rwanda strives for Universal Health Coverage (UHC), health
insurance is a key strategy to ensure everyone can access needed services without financial hardship.
Expanding coverage and ensuring affordability are crucial steps towards achieving this goal. The
following are the process of health insurance.

8
 Figure 2.1: the health insurance process (source: Health systems Resources Centre)

An analysis of the health insurance system in a particular nation reveals an intricate network of
players with varying goals. A complex environment is produced by the roles played by individuals,
organizations, governments, and private businesses Mills et al. (2020).The governing structure
of health insurance funds adds to this complexity. Depending on the particular system, several
organizations may be in charge of managing these funds. A vertically integrated system may
result from the fund’s management company’s ownership or operation of healthcare facilities in
certain cases Edwards & Saltman (2017). Possible conflicts of interest may arise as a result of this
vertical integration. A vital component of this intricacy is the extent to which health insurance
provide coverage. According to Oliver et al. (2023), coverage can vary from restrictive plans that
concentrate on catastrophic illnesses to all-inclusive plans that cover regular medical procedures and
preventative care. The use of healthcare services and patient outcomes are directly impacted by this
variance in coverage. A life insurance policy involves recurring payments to the insurance company
in exchange for a predetermined sum of money that will be distributed to the beneficiaries, typically
a member of your family upon your death. Insurance expires if the policyholder passes away within
the terms of the agreement. You designate beneficiaries, and the company pays the authorized sum
to them M. Mishra & Mishra (2011). Individual marketing plays a major part in the quick and
selective distribution channel that life insurance is specifically supplied through. The market may
be observed using both direct (workers, distance promotion) and indirect (agents, brokers, banks)
distribution channels Phipps et al. (2020). Health insurance can raise quality by expanding access
to essential and preventive medical treatment. This makes it possible to intervene early and possibly

9
achieve better health results. Also according to Basi (2022), health insurance can give patients
financial stability so they can finish their prescribed treatment regimens without worrying about
money. Better adherence and better health outcomes may result from this Basi (2022). Investing
in health insurance is like investing in a country’s human resources. A workforce in good health
is more productive and makes a larger economic contributionCunning et al. (2019). Risk pooling
is emphasized byBernard et al. (2020). People with health insurance can distribute the financial
load of future medical expenses among a sizable group. In addition to offering comfort, this shields
people against financial ruin brought on by unforeseen medical expenses Bernard et al. (2020).
Access to essential and preventive healthcare services is facilitated by health insurance. Better health
outcomes and maybe lower future medical costs can result from this early intervention Song et al.
(2023). Health insurance lowers the possibility of bad debt from patients unable to pay for essential
services and gives healthcare providers a steady stream of revenue Basi (2022). This enables them
to concentrate on providing high-quality care. Health insurance can be a useful tool for businesses
to draw in and keep skilled workers, as suggested by ?. Providing health benefits to workers can be
a big incentive, increasing their job satisfaction and possibly lowering attrition ?. Empirical data
from multiple Sub-Saharan African countries indicates that those with limited resources face the
highest rates of illness and catastrophic medical expenses. Since social health insurance (SHI) offers
financial support, it is regarded as a crucial tactic for achieving universal healthcare. Protection.
Social health insurance plans combine resources and permit cross-siding between the rich and the
poor, as well as between the healthy and the ill, in order to protect individuals from unaffordable
medical expenses. A number of African countries have introduced social health insurance programs
to guarantee access to health care for all income levels, especially the poor, in reaction to public
dissatisfaction with the high costs paid by healthcare providers. However, not much is known
about how the countries that have adopted this health finance system have addressed the issue of
guaranteeing insufficient coverage Fenny et al. (2018). In order to provide ideas for practitioners,
scientists, and other experts, the International Social Security Association seeks to promote a
broader exchange of experience among various regions, countries, and health insurance systems.
Some countries, like Nigeria, Guinea, Benin, and Cameroon, have prioritized obtaining local quality
improvements and providing basic medical care above undergoing comprehensive health insurance
system reform. At the moment, only employees in these countries’ formal paid sectors are covered.
The Dutch Act on the Extension of the Duty for Employers to Maintain Salary Payments in Case
of Illness has ”privatize” the health insurance scheme for covered individuals engaged in regular
employment.

10
2.4 Theoretical Literature Review

2.4.1 Premium Rating Regulations and Community Rating

In the US, health insurance companies can set premiums based on various factors, including Le et
al. (2023). where Younger individuals typically pay lower premiums than older adults due to their
statistically lower healthcare utilization, Individuals with pre-existing conditions may face higher
premiums, creating a potential barrier to coverage, Smokers and users of other tobacco products
typically pay higher premiums due to the increased healthcare costs associated with these habits,
Premiums can vary depending on the cost of healthcare services in a particular area. The Affordable
Care Act (ACA) introduced modifications to the premium rating system. While insurers can still
consider age, the allowed variation is limited. Insurers can charge older adults no more than three
times the premium charged to young adults Warrier et al. (2024). This modification aims to ensure
affordability for individuals with pre-existing conditions who may be more susceptible to higher
premiums under a pure premium rating system. A 2022 report by the Kaiser Family Foundation
suggests that average silver plan premiums in the ACA marketplaces increased by approximately
24% between 2016 and 2022. This increase likely reflects various factors, including healthcare cost
inflation, not solely changes in age rating. The three-to-one age rating limit established by the ACA
has remained constant since its implementation in 2014. This signifies a significant reduction in the
variation allowed compared to the pre-ACA era.

2.4.2 Consumer theory

consumer theory, applied to the realm of insurance, sheds light on how individuals make decisions
about purchasing insurance policies Shim et al. (2019). It posits that consumers are rational actors
striving to maximize their expected utility (satisfaction) by carefully evaluating the trade-offs
between the costs and benefits of insurance. Two key concepts within consumer theory significantly
influence insurance purchase decisions: risk aversion and expected value. Risk aversion refers to
an individual’s inherent dislike for uncertainty, even if it means sacrificing some potential gains
Örtqvist (2014). In the context of insurance, risk-averse individuals are more likely to purchase
coverage because it acts as a financial safety net against unforeseen events like accidents or illnesses.
The expected value of an insurance policy, on the other hand, represents the average outcome an
individual can anticipate over time, factoring in both the ongoing cost of premiums and potential
payouts from claims.

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2.4.3 Expected utility theory (EU)

Expected utility theory (EU) builds on consumer theory by considering how people make decisions
about insurance ?. Consumer theory focuses on maximizing satisfaction, but EU recognizes
diminishing marginal utility, meaning the extra satisfaction you get from each dollar decreases
as you get wealthier Rabin (2023). EU theory says people choose options based on the expected
utility they expect from each. In insurance, this means weighing the expected utility of having
insurance versus not having it Gollier (2001). With insurance, you consider the satisfaction you have
from money left after premiums, balanced with the satisfaction from getting a payout if something
happens. Without insurance, you have all your money initially, but risk a big drop in satisfaction
if an accident occurs and you have to pay for it yourself. According to EU theory, someone who
dislikes risk (risk-averse) would value having insurance more because the potential loss of happiness
from an accident is worse than the cost of premiums. This person would likely buy insurance to
maximize their expected happiness. Overall, expected utility theory provides a powerful tool for
understanding how people make rational decisions about insurance by considering how they weigh
potential gains and losses based on their risk tolerance and diminishing marginal utility.

2.4.4 Poverty literature

Poverty literature highlights the complex relationship between insurance and health quality for
low-income individuals ?. While insurance grants access to healthcare, its impact on overall health
is multifaceted. On one hand, insurance can improve health quality by increasing preventive
care utilization Basa et al. (2019), allowing for early detection and treatment of health problems.
Additionally, it can help manage chronic conditions through better access to medications and
treatments Van Bavel et al. (2022), potentially leading to a better quality of life. However, challenges
exist. Affordability remains a concern, with premiums, deductibles, and co-pays potentially causing
people to forgo necessary care despite having insurance Wammes et al. (2020). Limited access
to qualified providers in low-income areas can further restrict the positive impact of insurance
Wammes et al. (2020).A recent Rwandan study examining health quality in households with and
without Community-Based Health Insurance (CBHI) – the country’s national program – sheds
light on these complexities. The study found that households with CBHI demonstrated increased
healthcare utilization compared to those without insurance, suggesting CBHI effectively removes
financial barriersBinagwaho et al. (2021). Additionally, they reported a higher prevalence of
preventive care, aligning with findings from other studies Basa et al. (2019). However, the study also
highlights limitations. While CBHI increased healthcare utilization, it did not establish a direct link
to improved health outcomes. This could be due to the study’s design or the fact that out-of-pocket

12
costs and limited access to specialists, particularly in rural areas, can still hinder positive health
impacts Binagwaho et al. (2021).

2.4.5 State dependent utility theory

State-dependent utility theory provides a deeper understanding of the link between insurance and
health quality compared to traditional models ?. Traditional models focus on average outcomes,
while state-dependent theory acknowledges that the value placed on healthcare fluctuates with a
person’s health state Dhami & Hajimoladarvish (2020). This is important because the benefit you
get from each dollar (marginal utility) actually increases when you’re in poor health Dhami &
Hajimoladarvish (2020). In other words, money becomes more valuable when you’re sick. This
explains why people might be more willing to pay for insurance when they are unhealthy, as the
potential financial ruin from a major illness outweighs the ongoing cost of premiums, especially
when money holds greater value in a poor health state Dehez & Drèze (1984). Furthermore, this
theory suggests that insurance can influence health behaviors. Studies show people with insurance
in poor health are more likely to seek preventive care or stick to treatment plans Loewenstein et al.
(2003). This might be because insurance removes the financial burden, allowing them to prioritize
health even with financial limitations. Additionally, knowing they have coverage can reduce anxiety
about medical bills, potentially improving overall well-being and encouraging healthier choices
Dhami & Hajimoladarvish (2020).

2.5 REVIEW OF PREVIOUS STUDIES

Rwanda’s Community-Based Health Insurance (MHI) program has undoubtedly expanded access
to healthcare; recent studies highlight areas for improvement to achieve its full potential. Research
by Priyanka et al. (2023). indicates that despite MHI coverage, over 40% of insured individuals still
face unmet healthcare needs. Additionally, one-fifth of insured households seeking care experience
significant financial burdens exceeding 10% of their income. These findings suggest limitations
in the current MHI benefit package. Expanding coverage to encompass a wider range of services
and potentially reducing out-of-pocket costs could significantly improve access and utilization of
healthcare, particularly for low-income households. Studies like Card et al. (2007).demonstrate
a strong correlation between insurance coverage and treatment intensity, case disposition, and
health outcomes. Uninsured patients often receive less intensive treatment and are more likely
to be discharged home prematurely, potentially compromising their recovery. This underscores
the importance of MHI in ensuring patients receive appropriate care and have a better chance of

13
achieving positive health outcomes. Continued efforts to strengthen MHI and expand coverage
can contribute to improved health equity in Rwanda. Research in other African countries like
Ethiopia Wellay et al. (2018). suggests a potential link between low healthcare utilization and the
absence of prepayment schemes like MHI. While studies from specific regions might show lower
overall demand for modern healthcare, it’s crucial to consider factors like education levels and
cultural preferences. MHI can play a key role in promoting health awareness and encouraging
people to seek modern medical care, particularly in rural areas. Expanding outreach programs and
community engagement initiatives can further bridge the gap between traditional practices and
modern medicine. Studies like Abuosi et al. (2016). in Ghana suggest that insurance status might
not always be a determining factor in the overall quality of care received at hospitals. However,
ensuring consistent quality across the healthcare system remains crucial. Furthermore, research by
?. in Nepal highlights the importance of a strong support structure for community-based health
insurance programs to ensure sustainability. Rwanda can learn from these experiences by investing
in quality improvement initiatives for healthcare providers and fostering collaboration between MHI
and the broader healthcare system.

2.6 SUMMARY REVIEW

A life insurance policy involves recurring payments to the insurance company in exchange for a
predetermined sum of money that will be distributed to the beneficiaries, typically a member of
your family upon your death. This review explores the complex relationship between insurance,
health quality, and various economic and behavioral factors. Consumer theory and expected utility
theory provide frameworks for understanding how individuals make decisions about purchasing
insurance, highlighting risk aversion and the balancing of costs and benefits. Poverty literature
presents a nuanced view, acknowledging the potential of insurance to improve access to care and
preventive measures for low-income individuals, while also recognizing challenges like affordability
and limited access to qualified providers. A recent study in Rwanda aligns with these complexities.
While Community-Based Health Insurance (CBHI) increased healthcare utilization, the link to
definitive health improvements remains unclear. This could be due to limitations of the study
design, out-of-pocket costs, and uneven access to specialists, especially in rural areas. Finally,
state-dependent utility theory offers a fresh perspective. It acknowledges that the value of health
insurance fluctuates depending on an individual’s health state. When unhealthy, the perceived value
of money increases, making insurance more attractive despite the ongoing cost. This theory also
suggests that insurance can encourage preventative behaviors by mitigating financial burdens and
reducing anxiety around healthcare costs. In conclusion, achieving optimal health outcomes through

14
insurance requires a multifaceted approach. Addressing affordability concerns, ensuring access to
quality providers, and considering the psychological impact of insurance on health behaviors are all
crucial factors.

15
 CHAPTER 3

RESEARCH METHODOLOGY

3.1 Introduction

This chapter dives deep into the research methods used for this dissertation, specifically exploring
how the study was designed, the area of focus within healthcare in Rwanda, who participated in the
research, and the sources of data. It will also address the crucial aspects of ensuring data accuracy
and trustworthiness, the chosen methods for analyzing the information, and any limitations inherent
to the research. Finally, the chapter will discuss strategies implemented to mitigate these limitations.
This methodological approach will provide a comprehensive framework for assessing the impact of
health insurance on access to quality healthcare services in Rwanda.

3.2 Research Design

This dissertation will employ quantitative approaches, to comprehensively assess the effects of
health insurance on the accessibility of quality health services in Rwanda. The quantitative arm will
utilize a predictive modeling approach, similar to the study by Leisman et al. (2020), to analyze data
from the National Institute of Statistics of Rwanda (NISR). This data will allow us to explore the
relationship between health insurance coverage and access to quality healthcare services. Predictive
modeling is particularly suited for this research question as it can identify patterns and trends within
the data, enabling us to assess if the significant increase in Rwandans covered by health insurance
has translated into improved access to quality care.

3.3 Study Area

This research delves into the Rwandan context to explore how health insurance programs influence
citizen engagement. It aligns with Rwanda’s national goals by examining how insurance policies
shape citizen behaviors towards utilizing healthcare services. By understanding these interactions,
the study aims to contribute to the development of more effective strategies that encourage citizens
to actively participate in and benefit from Rwanda’s health insurance system.

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3.4 Study Population

To fulfill the research aims which is to investigate the relationship between health insurance
status and the quality of healthcare services received in Rwanda. We will analyze secondary data,
specifically from the 2019-2020 Rwanda Demographic and Health Survey (RDHS), to address
this question. The analysis will focus on the entire Rwandan population to draw generalizable
conclusions about the country.

3.5 Data source

This research leverages secondary data analysis to investigate the potential link between health
insurance status and the quality of healthcare services received. The analysis will utilize data sets
from the Rwanda Demographic and Health Survey Baziga (2022). The RDHS gathers information
on a broad spectrum of topics related to demographics, health, and social factors. These areas
include family composition, the health of mothers and children, breastfeeding habits, deaths of young
children, deaths related to childbirth, the nutritional well-being of women and young children, birth
rates, marriage patterns, preferences for family size, knowledge and use of birth control methods,
sexual activity, and awareness and behaviors surrounding AIDS and other sexually transmitted
diseases. The survey also outlines the data collection process.

3.6 Validity and Reliability

While prior research byBinagwaho et al. (2012), investigated the effect of Mutuelle de Santé (MHI)
enrollment on child health in Rwanda using secondary data from the National Institute of Statistics
of Rwanda, this study seeks to leverage more recent data to explore this relationship further. Recent
findings from the 2020 Rwanda Demographic and Health Survey (RDHS) conducted by the National
Institute of Statistics of Rwanda Sserwanja et al. (2022). provide valuable insights into current
trends in child health and MHI coverage. Notably, the 2020 RDHS indicates a significant increase in
MHI enrollment compared to previous surveys Sserwanja et al. (2022). This aligns with Rwanda’s
commitment to achieving Universal Health Coverage (UHC), a goal echoed by the World Health
Organization (WHO) Organization (2022).

3.7 Hypothesis

This research posits a positive influence of health insurance on access to quality healthcare. We
will explore this by examining the relationship between insurance coverage (independent variable)

17
and two key factors impacting access: financial burden (money for treatment) and geographic
accessibility (distance to health facility) - both considered dependent variables.

3.8 Method of Data analysis

This dissertation employs a quantitative research design, relying on numerical data analysis to
examine the relationships between variables. STATA version 14, widely used statistical software,
will be the primary tool for data analysis. The analysis will encompass both descriptive and
inferential statistics. Descriptive statistics, including frequency distributions, means, and standard
deviations, will be used to summarize and characterize the socio-economic and demographic
features of the study population. To assess differences in health insurance coverage and healthcare
utilization, a t-test will be employed. Finally, a logistic regression analysis will be conducted to
explore the association between health insurance and the quality of care received. By presenting the
findings through tables and graphs, this quantitative approach will enable a clear and comprehensive
understanding of how Health Insurance affects the Accessibility of Quality Health Services in
Rwanda.

3.9 Limitation of the study

The study implementation encountered several challenges. One particular hurdle involved access to
necessary academic resources. Unlike freely available online sources, some articles and publications
require purchase, creating a cost barrier. This limited the ability to gather a comprehensive and
diverse range of materials for the study.

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 CHAPTER 4

DATA ANALYSIS AND FINDINGS

4.1 Introduction

4.1.1 INTRODUCTION

This chapter focuses on an empirical study investigating the potential link between health insurance
coverage and the quality-of-care patients receive. The study employs cross-sectional data and
descriptive statistics to characterize the variables of interest (insurance coverage and quality of
care). To determine the significance of the relationship between these variables, a logistic regression
analysis is conducted. This analysis provides coefficients and odds ratios, which help us understand
the strength and direction of the association between insurance and quality of care.

4.2 DESCRIPTIVE STATISTICS

Nearly all (77.32%) of the household heads who participated in the survey were men, with women
comprising the remaining 22.68%. The distribution of participants across age groups was uneven.
The 15-19 age group had the smallest representation at 1.54%, while the 30-34 age group boasted the
highest participation rate at 26.01%. Marital status exhibited a clear skew, with married participants
comprising a dominant 51.25% of the sample. In contrast, the category ’widowed’ had the lowest
representation, accounting for only 1.37% of respondents. Health insurance status showed a
significant disparity. A substantial majority (81.18%) of respondents reported having insurance,
while the remaining 18.82% were uninsured. The study created a ”quality of care” variable based on
two factors related to accessing healthcare: financial burden (money spent) and physical accessibility
(distance to facilities). Participants were asked how these factors hinder their ability to receive
quality care. The majority (76.41%) reported these challenges as not a big problem, while the
remaining 23.59% considered them a significant barrier. The study categorized participants by
region: Kigali City and the rest of the provinces. This reflects the potential disparity in access
to infrastructure, particularly healthcare facilities, between urban and rural areas. While Kigali
City residents make up a smaller portion of the sample (11.72%), it’s expected they might have
better access to these resources compared to those living in the provinces (88.28%). Educational
attainment was categorized into two groups: ’not educated’ and ’educated.’ The ’not educated’

19
 DESCRIPTIVE STATISTICS
Variable Freq. Percent Cum.
bf Gender
Male 6,257 77.32 77.32
Female 1,835 22.68 100
Age
15-19 125 1.54 1.54
20-24 1,162 14.36 15.9
25-29 1,844 22.79 38.69
30-34 2,105 26.01 64.71
35-39 1,820 22.49 87.2
40-44 832 10.28 97.48
45-49 204 2.52 100
Marital Status
Never in union 719 8.89 9
Married 4,147 51.25 60
Living with partner 2,587 31.97 92.1
Widowed 111 1.37 93.48
Divorced 183 2.26 95.74
Separated 345 4.26 100
covered by health insurance
No 1,523 18.82 18.82
Yes 6,569 81.18 100
Quality of healthcare( Money for treatment and Distance to health facility)
Big problem 1,909 23.59 23.59
Not a big problem 6,183 76.41 100
Region
Other regions 7,144 88.28 88.28
Kigali 948 11.72 100
Education level
Not educated 918 11.34 11.34
Educated 7,174 88.66 100
Wealth status
Poor 3,766 46.54 46.54
Middle 1,568 19.38 65.92
Rich 1,443 17.83 83.75

Table 4.1: Descriptive statistics

20
group comprised the majority of participants (88.66%), encompassing those with no education or
incomplete primary education. The remaining 11.34% fell into the ’ educated’ category, which
included individuals who completed primary school, attended secondary school, or attained higher
levels of education. Wealth status, a variable used to categorize respondents as “poor”, “middle “and
“rich”. 46.54 percent of the respondents are the poor, middle are 19.38 and 17.83 of the respondents
are rich.

4.3 Empirical results and discussion

Covered by health insurance sex of household head

Male Female Total
No N 1,068 455 1,523
% 70.12 29.88 100.00
Yes N 5,189 1,380 6,569
% 78.99 21.01 100.00
Total N 6,257 1,835 8,092
% 77.32 22.68 100.00
Pearson chi2(1) = 55.4439 Pr = 0.000

Table 4.2: Tabulation of coved by health insurance by gender

The table above displays the distribution of health insurance coverage by participant gender. The
p-value associated with this analysis is well below the commonly accepted significance level of 0.05.
This statistically significant result suggests a relationship between gender and insurance coverage.
The data reveals a gender disparity in insurance coverage. Uninsured participants are more likely
to be male 70.12% compared to female 29.88%. This trend is less pronounced among insured
participants, where males represent around 78.99% and females’ 21.01%. This is a result of there
being more heads of household than there are female heads of households.
Insured respondents Name of main type of health insurance
Mutuelle/CBHI RAMA/RSSB MMI Pri
Yes N 6,025 63 114
% 74.46 0.78 1.041
Total N 8,092 8,092 8,092
% 100.00 100.00 100.00

Table 4.3: Tabulation of insured respondents and type of insurance

The table shows a clear dominance of community-based health insurance, also known as Mutuelles
de santé, among Rwandan respondents. An overwhelming 74.46% rely on this scheme for their

21
health coverage. This dominance can be attributed to government efforts to make healthcare
accessible through affordable insurance, especially for those with lower incomes. RAMA comes in
second with regards to the number of insured Rwandans, covering around 6% of the population. This
program specifically targets both government employees and those in the private sector. The results
reach a level of statistical significance (p-value of 0.0), meaning it’s very unlikely this relationship
arose by chance. In other words, with a significance level of 0.05, we can confidently reject the idea
that no relationship exists between the variables. This implies a statistically significant association
between them.

4.4 Logistic regression

Quality of healthcare services Odds Ratio Std. Err. z P>z [95% Conf. Interval]
Covered by health insurance 0.8229285 0.0546689 -2.93 0.003 0.7224618 0.937366
Gender 1.017245 0.0646892 0.27 0.788 0.8980399 1.152274
Age 1.021431 0.0206897 1.05 0.295 0.9816743 1.062798
Region 0.4927485 0.0505668 -6.9 0 0.4029707 0.602528
Education level 0.6792504 0.0536877 -4.89 0 0.58177 0.793065
Wealth status 0.8372486 0.017844 -8.33 0 0.8029953 0.872963
Constant 0.7038023 0.1074237 -2.3 0.021 0.5218298 0.949232

Number of Obs = 8,092

LR chi2(6) = 225.33
Prob > chi2 = 0.0000
Pseudo r-squared = 0.0255
Log likelihood = -4308.1693
∗ ∗ ∗p < .01, ∗ ∗ p < .05, ∗p < .1

Table 4.4: Dependent variable: Quality of healthcare services

The study looked at how much money spent on treatment and how far people have to travel to a health
facility affect the overall quality of care. The results are pretty clear: both factors are linked to quality
of care, and this connection is statistically significant. In other words, spending more money and
having a closer health facility are both associated with better quality of care. The analysis showed a
statistically significant relationship (p-value ¡ 0.05) between all independent variables (money spent
and distance to facility) and the dependent variable (quality of care). This suggests that both factors
are likely to have a measurable impact on the perceived quality of healthcare services. The study
found that having health insurance didn’t necessarily make it easier to access healthcare. In fact,
insured people were surprisingly 0.822928 times more likely to report problems getting the care they

22
needed compared to those without insurance. This highlights the unexpected finding that having
insurance doesn’t translate to easier access to quality healthcare. It emphasizes the fact that insured
respondents were more likely to face issues related to affordability of treatment and travel distance
to facilities compared to the uninsured group. The analysis indicates that the 15-19 age group has a
1.021431 times greater odds of encountering problems with quality healthcare access compared to
individuals in other age categories. The findings indicate a protective effect associated with being
married. Married individuals have a likelihood of 1.017744 compared to other marital statuses
in terms of facing issues with accessing quality healthcare. The analysis revealed a statistically
significant association between poverty status and quality healthcare access. Those classified
as ”middle and rich” have a likelihood of 0.8372486 compared to poor respondents regarding
encountering difficulties in accessing quality healthcare services. This translates to individuals who
are not poor being approximately 83.7% less likely to face such problems compared to their poorer
counterparts. Compared to other regions, Kigali City shows a significantly lower likelihood (factor
of 0.4927485) of residents encountering problems with quality healthcare access. This indicates
a substantial advantage for Kigali residents in terms of obtaining necessary medical care. The
analysis revealed an unexpected association between education level and quality healthcare access.
Individuals with higher education were 0.6792504 times more likely to experience difficulties in
obtaining quality healthcare services compared to their less educated counterparts. The analysis
revealed a statistically significant association between gender and quality healthcare access. Women
have a likelihood of 1.017245 compared to men regarding encountering difficulties in accessing
quality healthcare services. This translates to women being approximately 40% less likely to face
such problems compared to men.

23
 CHAPTER 5

SUMMARY, CONCLUSION, AND RECOMMENDATION

5.1 Introduction

This chapter wraps up the research by presenting the key discoveries, overall conclusions, and
suggestions for both future policy changes and further investigations.

5.2 Summary

This research investigated the link between health insurance status and the quality of healthcare
received. It specifically focused on analyzing this connection and examining the social, demographic,
and economic characteristics of both insured and uninsured participants. To achieve these goals,
the study utilized cross-sectional data collected between 2019 and 2020. Drawing on a literature
review, various variables were identified and incorporated into the study design to address the
research objectives effectively. Since the study focused on the relationship between a binary
outcome (quality of healthcare) and several independent variables (sociodemographic and economic
factors), logistic regression analysis was chosen as the primary statistical method. This aligns with
previous research and allows for a clear understanding of the impact of these variables. Additionally,
cross-tabulations were used to provide a more descriptive picture of how social, demographic, and
economic characteristics are distributed among insured and uninsured individuals. The analysis
revealed that several factors, including age, gender, region of residence, health insurance status,
marital status, education level, and wealth status, significantly influence the quality of healthcare
received. This quality was measured by two key aspects: financial burden (money spent on
treatment) and accessibility (distance to healthcare facilities). These findings were further confirmed
by the logistic regression analysis. The logistic regression analysis identified statistically significant
relationships between quality of healthcare, measured by money spent on treatment and distance to
facilities, and factors like health insurance status. While the study confirms a link between insurance
and quality of care, it also reveals a concerning finding: a large number of insured individuals still
struggle to access appropriate quality healthcare. This suggests that having insurance alone may not
be enough to guarantee high-quality care for everyone.

24
5.3 conclusion

This research confirms a strong link between health insurance and the quality of healthcare received
in Rwanda. Interestingly, the study goes beyond just insurance status, demonstrating that all the
social, demographic, and economic factors investigated significantly influence quality of care.
The analysis revealed a particularly concerning finding: even with insurance, respondents were
82.29 times more likely to experience challenges accessing quality healthcare. These challenges
were measured by two key factors: financial burden (money spent on treatment) and accessibility
(distance to healthcare facilities). This suggests that having health insurance alone may not be
sufficient to guarantee high-quality care for everyone in Rwanda. The study highlights a critical
limitation of Rwanda’s government-mandated community health insurance scheme, despite its
success in expanding coverage. While a large portion of the population benefits from this affordable
plan, it may not cover certain high-cost treatments. This suggests a potential gap in access to
specialized care, even for insured individuals. The survey results show an impressive 81.18%
health insurance coverage rate among respondents. This achievement underscores the importance of
expanding health insurance access. However, despite this progress, Rwanda still faces a challenge
in distributing healthcare facilities like hospitals and health posts more evenly. This suggests a need
to prioritize geographical accessibility of healthcare services alongside insurance coverage.

5.3.1 Recommendation

Based on the study’s conclusions, we recommend the following actions to be considered for
future health policy formulation and planning to ensure greater effectiveness. Policymakers should
prioritize improving the quality of healthcare services for all Rwandans, especially considering the
high insurance coverage, particularly through community-based schemes. The study highlights
concerns regarding financial burden (money spent on treatment) and accessibility (distance to
facilities) as key factors impacting insured individuals’ perception of quality care. the Ministry of
Health, in collaboration with local governments, should prioritize expanding healthcare infrastructure.
This includes increasing the number of distributed health posts to reduce the distance barrier for
many Rwandans. empowering community health workers is crucial. This can be achieved by
providing them with access to and the ability to distribute essential medications, particularly those
covered by the community health insurance scheme. Additionally, exploring ways to empower the
community health insurance scheme to address uncovered treatments is vital. This could involve
strategies for negotiating better coverage with pharmaceutical companies or exploring alternative
financing mechanisms.

25
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