Abstract: Background: Rwanda's Community-Based Health Insurance (CBHI/Mutuelle de Santé), managed by the Rwanda Social Security Board (RSSB), stands as Africa's most successful community health insurance model, achieving over 86.6% national coverage. Despite this remarkable enrollment achievement, a gap between enrollment and active utilization at the point of inpatient care has been observed. This study aimed to determine the factors associated with CBHI utilization and its role in promoting equity among adult inpatients at Rwanda Military Referral and Teaching Hospital (RMRTH) in Kigali City.
Methods: A descriptive, cross-sectional mixed-methods study was conducted among 422 adult inpatients at RMRTH using structured questionnaires, key informant interviews, and focus group discussions. Sampling combined census, purposive, and prospective approaches. Descriptive statistics, chi-square tests, and multivariate logistic regression were used for quantitative analysis. Qualitative data were analyzed thematically using NVivo. Ethical approval was obtained from Mount Kigali University and RMRTH Institutional Review Board.
Results: The overall CBHI enrollment rate was 71.6% (n=302), with 64.2% of enrolled respondents actively using CBHI for current hospitalization. Non-enrollment was primarily attributed to premium unaffordability (43.3%), limited awareness (23.3%), and system distrust (15.0%). In multivariate logistic regression, satisfaction with CBHI services (aOR=6.84, 95% CI: 3.14–14.89, p<0.001), trust in CBHI coverage (aOR=5.24, 95% CI: 2.86–9.58, p<0.001), complete knowledge of covered services (aOR=3.82, 95% CI: 1.78–8.20, p<0.001), and perceived premium affordability (aOR=3.46, 95% CI: 1.88–6.36, p<0.001) were the strongest independent predictors of utilization. Gender (male AOR=2.14), education level, proximity to health facility, and absence of prior service denial also showed significant independent associations. Qualitative data from key informant interviews and focus group discussions, revealed that drug availability gaps, misalignment between premium collection schedules and beneficiaries' income cycles, and concerns about care quality standardization collectively shape CBHI engagement at the point of inpatient care.
Conclusion: CBHI, as administered by RSSB, provides critical financial protection for inpatients and demonstrates significant equity-promoting potential. Optimizing utilization requires targeted action in health literacy strengthening, flexible premium collection mechanisms, quality assurance at health facilities, gender-responsive programming, and administrative simplification. These findings offer an evidence base to guide Rwanda's continued progress toward universal health coverage.
Keywords: Community-Based Health Insurance; CBHI; Mutuelle de Santé; health equity; inpatients; Rwanda; RSSB; health insurance utilization; universal health coverage.
Title: Factors associated with community-based health insurance utilization and its role in promoting equity among hospital inpatients in Kigali city, Rwanda
Author: Christine Nyirantezimana, Emile Sebera, Maurice Silari
International Journal of Healthcare Sciences
ISSN 2348-5728 (Online)
Vol. 14, Issue 1, April 2026 - September 2026
Page No: 451-463
Research Publish Journals
Website: www.researchpublish.com
Published Date: 06-July-2026
