Mitigating Catastrophic Health Expenditure: An Action Research Inquiry into Rwanda’s Community-Based Health Insurance in Rural Districts

{ "background": "Catastrophic health expenditure (CHE) remains a critical barrier to universal health coverage in sub-Saharan Africa. Rwanda’s community-based health insurance (mutuelle de santé) is a prominent policy mechanism designed to provide financial protection, yet its efficacy in preventing CHE in the most vulnerable rural populations requires deeper, context-specific investigation.", "purpose and objectives": "This action research study aimed to collaboratively assess and enhance the capacity of mutuelle de santé schemes to mitigate CHE in selected rural districts. Its objectives were to identify systemic barriers to enrolment and utilisation, and to co-design interventions with community stakeholders to improve financial risk protection.", "methodology": "Employing a cyclical action research approach, the study integrated quantitative surveys of household health expenditure with qualitative focus group discussions and participatory workshops. Community members, local officials, and healthcare providers were engaged as co-researchers across iterative phases of diagnosis, action planning, intervention, and evaluation.", "findings": "Preliminary survey data indicated a 40% reduction in the incidence of CHE among enrolled households compared to non-enrolled counterparts in the study districts. Participatory analysis identified a key theme: that complex administrative renewal procedures and perceived poor service quality at local health centres were primary deterrents to sustained enrolment.", "conclusion": "The mutuelle de santé scheme demonstrates significant potential to shield rural households from CHE, but its effectiveness is undermined by operational and perceptual barriers at the community level. Sustainable protection requires adaptive management responsive to local realities.", "recommendations": "Policy should streamline enrolment and renewal processes through decentralised, mobile platforms. Furthermore, parallel actions to improve the perceived quality of care at affiliated health centres are essential to bolster trust and encourage sustained insurance uptake.", "key words": "catastrophic health expenditure, community-based health insurance, action research, Rwanda, universal health coverage, financial protection", "contribution statement": "This paper provides novel empirical evidence on the specific operational mechanisms within Rwanda’s mutuelle that influence CHE outcomes, and demonstrates the utility of participatory action research