Political economy as strategy: Lessons from Rwanda’s community-based health insurance reforms
Rwanda’s community-based health insurance (CBHI) evolved into a compulsory, nationally pooled, and largely government-financed scheme that achieved high population coverage but developed persistent fiscal deficits, prompting major reforms in 2020–2021. We examine how those reforms became politically feasible and argue that Rwanda’s reform strategy reflected political economy in practice through mutually reinforcing approaches: anchoring the financing response in central fiscal institutions, linking revenue mobilisation to visible expansion of the benefits package, framing sustainability as a national fiscal priority, and institutionalising more transparent, rule-based benefits-package decisions. Rwanda’s experience illustrates how political economy considerations can shape health financing reforms by influencing where authority is located, how costs and benefits are distributed, and how politically sensitive decisions are managed.
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