# Health insurance and the distribution of healthcare use in Rwanda’s Vision Umurenge Programme: evidence from the Seventh Integrated Household Living Conditions Survey

## TL;DR

Rwanda's health insurance program increases healthcare use, but wealthier people still use more services, showing that financial barriers aren't the only issue.

## Contribution

The study reveals that non-financial barriers, like transport and income loss, limit equitable healthcare access despite high insurance coverage.

## Key findings

- Health insurance in Rwanda increases healthcare utilization by 12-14.6 percentage points.
- Healthcare use remains more concentrated among wealthier households than insurance coverage.
- Social protection programs like VUP help reduce inequities by supporting service readiness and direct assistance.

## Abstract

Rwanda’s community-based health insurance (CBHI) has achieved near-universal enrollment, yet inequities in healthcare use remain. Understanding whether coverage translates into equitable utilization is critical for advancing universal health coverage (UHC). This study aims to examine how social protection complements health insurance in promoting equitable healthcare access.

To examine the relationship between insurance coverage and healthcare utilization in sectors targeted by the Vision Umurenge Programme (VUP), assess socioeconomic inequities, and evaluate the complementary role of social protection.

This study analyzed cross-sectional data from 15,039 households in VUP sectors using the 2023–2024 Seventh Integrated Household Living Conditions Survey. Socioeconomic inequality was measured using Erreygers-corrected concentration indices and need-standardized horizontal inequity analysis. Insurance effects were estimated using survey weighted logistic regression, propensity score matching, and doubly robust inverse-probability-weighted regression adjustment.

Insurance coverage was 85.8%, yet only 25.5% reported any formal healthcare utilization in the 12 months preceding the survey, including outpatient visits, inpatient admissions and preventive services. Utilization showed stronger pro-rich concentration (E =  +0.066) than coverage (E =  +0.026) and need-standardized analysis confirmed residual inequity. Insurance increased utilization by +14.6% points in regression models and ~+12% points in causal estimators. Participation in VUP components, particularly direct support, was consistently associated with higher service use.

In a high coverage setting, persistent pro-rich inequities highlight the role of non-financial barriers such as indirect costs and service readiness. Layering social protection with insurance and strengthening primary care delivery is critical to convert nominal coverage into equitable healthcare access.

Main findings: In sectors covered by Rwanda’s Vision Umurenge Programme (VUP), health insurance significantly increases the likelihood of seeking formal care, but utilization remains disproportionately concentrated among wealthier households.Added knowledge: Even after adjusting for health need, pro-rich inequities in utilization persist, highlighting that barriers beyond premiums such as transport costs, lost income, and other indirect expenses limit access for the poorest.Global health impact for policy and action: Integrating health insurance with targeted social protection and investments in supply-side readiness can help reduce non-financial barriers, strengthen effective coverage, and promote more equitable progress toward universal health coverage.

Main findings: In sectors covered by Rwanda’s Vision Umurenge Programme (VUP), health insurance significantly increases the likelihood of seeking formal care, but utilization remains disproportionately concentrated among wealthier households.

Added knowledge: Even after adjusting for health need, pro-rich inequities in utilization persist, highlighting that barriers beyond premiums such as transport costs, lost income, and other indirect expenses limit access for the poorest.

Global health impact for policy and action: Integrating health insurance with targeted social protection and investments in supply-side readiness can help reduce non-financial barriers, strengthen effective coverage, and promote more equitable progress toward universal health coverage.