{"paper_id":"022556b9-8b9b-423d-a148-012ca050e2df","body_text":"Governance and Domestic Resource Mobilisation: Lessons from Rwanda’s mandatory corporate Contributions to Community-Based Health Insurance | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Governance and Domestic Resource Mobilisation: Lessons from Rwanda’s mandatory corporate Contributions to Community-Based Health Insurance Bridget Jolly Tusiime, Francesca Calo, Dinar Kale, Michael Ngoasong This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8057585/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract Low- and middle-income countries face persistent challenges in financing universal health coverage, making domestic resource mobilisation (DRM) a critical priority. Governance systems are increasingly recognised as central to ensuring effective and sustainable mobilisation of resources. It is also widely documented that governance systems in many developing countries are weak and fragmented. Rwanda is one of the few low income countries that performs well in governance indicators. This article examines how Rwanda’s governance structures support DRM through mandatory corporate contributions to the Community-Based Health Insurance (CBHI) scheme. Using a qualitative case study design, we conducted key informant interviews of relevant individuals from different government institutions, NGO representatives and multinational corporations from the telecommunications and Oil& gas sector. The analysis focused on governance dimensions including policy design, institutional arrangements, accountability mechanisms, and enforcement processes. Rwanda’s governance system demonstrates a clear legal mandate for corporate contributions, strong institutional coordination between government agencies, and accountability mechanisms that ensure compliance. These governance features have enabled consistent mobilisation of domestic resources, significantly strengthening CBHI financing. However, challenges remain, including balancing trade-offs with corporations and ensuring long-term sustainability. Governance plays a pivotal role in facilitating DRM for health. Rwanda’s experience with mandatory corporate contributions to CBHI offers valuable lessons signalling other low- and middle-income countries seeking to enhance domestic health financing to prioritise strengthening of governance frameworks. Health financing governance private sector Multinational corporations Domestic resource mobilisation Developing countries Figures Figure 1 Figure 2 1. Introduction 1.1 Overview of the health financing gap in LMICs Despite the recognised importance of investing in health, many countries still face challenges in finding the necessary resources to fund their health systems, lack of funding is particularly acute in developing countries, where the disease burden is high, and health systems are often weak (Oleribe et al., 2019 ). For developing countries, the WHO recommends that countries allocate a minimum of 15% of their total government budget to health (World Health Organisation, 2022 ). This is also in line with the 2001 Abuja Declaration by African Heads of State and Government to allocate at least 15% of their national budgets to the health sector (Oleribe et al., 2019 ; World Health Organisation, 2010 ). It's worth noting that by 2022 only three African countries had achieved the Abuja target including South Africa, Sudan and Madagascar (World Health Organisation, 2022 ). This problem, known as the \"fiscal space for health\" challenge, is a major barrier to achieving universal health coverage and the health-related Sustainable Development Goals. Limited funding capacity results from a combination of factors including weak health systems, limited tax revenues, competing demands on public resources, and poor health financing strategies (Ichoku & Okoli, 2015 ; Meheus & McIntyre, 2017 ). There is a documented reliance of foreign aid by many developing countries, and while aid has been used to fund critical health interventions like HIV/AIDS treatment, mass immunisation and malaria control through funding schemes such as PEPFAR and the Global Fund (Hontelez et al., 2025 ). It is not a long term solution to funding as sector as sensitive as health, this is because foreign aid is unreliable, fluctuating and out of control of the funded country (Abraham & Tao, 2021 ). Most of the funding priorities are dictated by the foreign policy and may at times not align with the priorities of the developing countries. For instance, the dismantling of USAID-funded health programs, particularly through cuts to PEPFAR, has severely disrupted HIV service delivery in sub-Saharan Africa. Studies warn that reductions in U.S. HIV funding could reverse decades of gains, with projections of up to 2 million additional infections and 350,000 AIDS-related deaths by 2030 if sustained (Brink et al., 2025 ). In countries like Uganda and Kenya, the withdrawal of PEPFAR support has resulted in immediate declines in HIV testing and treatment initiation, while thousands of community health workers previously funded through USAID grants have been retrenched (Brink et al., 2025 ; Hontelez et al., 2025 ). The ripple effects extend beyond HIV to broader health systems. In Kenya, Mozambique, and Malawi, PEPFAR resources historically underpinned health workforce salaries, laboratory systems, and supply chains for essential medicines. Funding cuts therefore not only reduce access to antiretroviral therapy but also weaken human resources for health, eroding primary health care delivery and system resilience (UNAIDS, 2025 ). These developments in the funding landscape show the fragility of donor-dependent health systems and emphasize the urgent need for countries to strengthen domestic financing mechanisms and integrate HIV programs into national health insurance and broader service delivery platforms. 1.2 Governance & Public Health Financing Policy. For low income countries, it goes beyond merely looking for funds, it is important to consider how the funds will effectively be utilised without leakage. This is due to the weak governance systems with limited accountability (Kutzin, 2013 ). Governance systems are critical for sustainable health financing. Domestic resource mobilisation is not only a matter of diversifying revenue streams, but it also fundamentally depends on effective governance. In the health sector, governance influences how financing reforms are designed, how compliance with mandatory contributions such as health taxes is enforced, and how trust is built among stakeholders (Barroy et al., 2018 ). Evidence shows that countries with robust governance systems are better able to sustain health financing innovations because they can institutionalise legal mandates, minimise leakage of funds, and maintain accountability across actors involved in revenue collection and pooling. Conversely, weak governance environments often lead to under-collection of revenues, misuse of funds, and erosion of public trust, undermining domestic resource mobilising efforts (Babor et al., 2023 ; Wright et al., 2017 ). Thus, governance serves as the enabling framework that translates policy intentions into tangible financial resources for health, while also shaping the legitimacy and sustainability of DRM strategies. 1.3 Why Rwanda as a case study Rwanda's governance system has undergone significant transformation since the 1994 genocide, positioning the country as a notable example of effective governance in sub-Saharan Africa. Rwanda ranks 41st out of 142 countries (World Justice Forum, 2021 ). According to the World Bank's 2023 data, Rwanda's government effectiveness index stands at 0.39, surpassing the global average of -0.04, indicating a high capacity in public service delivery and policy implementation (World Bank, 2024 ). In 2020, seeking to overcome a funding deficit for its Community Based Health Insurance scheme, Rwanda passed a policy that mandated Oil and Gas companies as well as corporations in the Telecommunications sector to contribute proportions of their revenue towards CBHI. Such a policy leverages finances from private sector to finance the Public health sector. There are limited examples of such policies in low income countries. 1.4 Aim of the Study: To Explore how governance influences corporate compliance with a health financing policy 2. Methods We utilised qualitative methods using in-depth key informant interviews to capture the experiences of key stakeholders involved in the implementation of the prime minister’s order on CBHI contributions. This involved in-depth interviews with government stakeholders, regulatory bodies, non-government organisations stakeholders, and corporations. The choice for qualitative methods to be the primary method of inquiry was due to the recency of the CBHI financing policy ( having been enacted in 2020 ), it is not expected that an investigation into the long-term impact of this policy will yield meaningful results at this early stage, as the policy has not been in place long enough to generate measurable long-term outcomes. The study was conducted in Kigali, Rwanda. Purposive sampling was employed to allow for the deliberate selection of participants with direct relevance to the research questions. This approach enabled me to include key informants with diverse experiences of the CBHI contributions policy, including stakeholders involved in its conception and implementation, as well as those affected by it. Table 1 below shows the Key informants interviewed. Table 1 Key Informants Interviewed institution Interviewee Broad role descriptor Corporations Telecom/Oil and gas Participant_2 Legal/compliance, company A Participant_3 Finance, company A Participant_4 Legal, Company A Participant_5 Legal, Company B Participant_12 Legal, Company C Participant_13 Finance, Company C Participant_16 Legal, Company D Participant_17 Legal, Company E Participant_18 Finance, company E Participant_23 Finance, Company F Rwanda Utility Regulatory Authority Participant_1 Economist Participant_10 Compliance Rwanda Social Security Board Participant_6 Economist Participant_22 Planner Ministry of Health Participant_7 Senior official Participant_19 Senior official Non-government Organisations Participant _9 Health financing advisor Participant_15 Economist Participant_20 Economist Participant_21 Public health advisor Interview guides were used to guide the data collection processes. The interviews were tape recorded and lasted between 30 min to 1 hour. Interviewees were asked questions about their knowledge of the policy as well as their involvement with policy development and implementation. Data collection continued until saturation was reached, meaning the point at which interviews did generate new insights. The interview data were supplemented with information from government documents and reports from the corporations. Interviews were then transcribed in MS Word and exported to NVivo for analysis. Data was analysed following Braun and Clarke’s Reflexive Thematic Analysis approach (Braun & Clarke, 2019; 2021). According to Braun and Clarke, themes are not inherent in the data but are actively constructed by the researcher through interpretation. The analysis was done using a deductive approach, organising data in pre-existing codes and themes while remaining open to themes emerging from the data. From the literature on governance, themes such as Rule of law, Accountability & monitoring systems and political will were used as deductive themes. Two inductive themes such as presence of an independent regulatory body and selective inclusion practices emerged from the data. This is represented in Fig. 1 below. 3. Results 3.1 Rule of law and compliance The consensus among respondents was that the law is non-negotiable in Rwanda. Respondents expressed confidence in Rwanda’s approach to the rule of law, they contrasted Rwanda’s legal system with those in other countries, noting that in Rwanda, everyone, regardless of their status, is held accountable under the law. This is exemplified in the quote below “ personally, I have worked in both Africa and beyond, with all that we lack in-terms of finances, our strength lies in how strict we are with the law, nobody is above the law, no company is above the law. ……. compared to many countries on the continent and elsewhere when it come to the law, we are up there \" Participant_1, Economist. This reflects a strict enforcement of the law which is likely to affect how policies such as the CBHI contributions policy are enforced. When confronted with a question on lobbying, our corporate respondents reacted almost uniformly by asserting that there is “no room” for negotiation or push back on laws in Rwanda. “In the general practices that regulator just enforces, there is not much room for negotiation…[…] the position of the regulator is pay first and complain later.” said participant_5 a corporate lawyer. On whether they could possibly influence changes to the policy in the future, Participant_17 explained that there is limited opportunity to lobby against government initiatives. From the interviews we perceived a top-down approach by the government, where there is limited opportunity or culture for companies to push back strongly. This suggests that in Rwanda, the prevailing practice is for businesses to accept and adapt to government decisions rather than challenge them. “Well, to be honest, the political and economic environment in Rwanda doesn't really lend itself to aggressive lobbying against government policies, even if they have a significant impact on businesses like ours. The government tends to take a very top-down approach, and there isn't really a culture of companies pushing back too strongly against policies ”. Some interviewees stated that the country’s performance in terms of the rule of law builds trust in government. Such was the case of one of the interviewees Participant_9 who works for an international non-government agency, that stated the following: “I would think the investors, are probably driven to also contribute to the development of the country because they feel like they operate in a space that is well regulated, low corruption. So that can also drive them to be okay with the policies that the government has. […], but also, the fact that they feel like they operate in an environment that they trust”. From this statement two key observations emerge: the perception of a well-regulated and low-corruption environment influence investors' willingness to support and comply with government policies. Additionally, the trust investors place in the operational environment affect their overall satisfaction and long-term commitment to the country’s development. Participant_16 a non-Rwanda who has worked in multiple countries for the same company compared his experience in Rwanda with his experience in the United States and Uganda, where he worked for 10 years and 2 years respectively: ‘Firstly, law is equal for everybody, not like the US where the big companies will bankroll a political figure and get exemptions or lobby for changes at the expense of smaller companies with no influence. Secondly, it is clear, public, and stable. I have worked in Uganda where enforcement of laws was a mess, the people enforcing would not be aware of the laws themselves, a law will go redundant for 5 or so years due to lack of interest from the enforcer, then someone else takes office it comes back again, then the cycle continues. So, you see here we know what to expect, no informal payments. Legitimate businesses that are not looking to cut corners prefer to operate with this kind of certainty”. Another aspect that emerged in relation to rule of law was how “identity” as Rwandans also plays a persuasive role in the way Rwandans view and react to government policies, laws and regulations. There seemed to be a shared support for government policies among the interviewees not only in the government institutions but among the corporation and NGO staff too. The persuasive reach was visible in how the interviewees rationalised the policy. Participant_6 attributed obedience to the law to the normative culture of Rwandans that has been built overtime with participant_23 linking this culture directly to the dark genocide past: “I think that's coming from our Culture, If there is a law, everyone complies, I don't know if you have observed it, whether it is at a zebra crossing, if a pedestrian puts even one foot in the crossing, then no car will move forward until the pedestrian is on the other end of the road, we don’t need a red light to signal the car to stop, it is a culture…... If you see a piece of paper on the road, pick it up, It's implemented on a personal level. So, it has become a culture over years. So, people, they don't even, you don't even have to force them to do it, then if there is a law, they will comply with it.” Participant_6, Economist “So, this policy will only work if our people’s lives are made better because of it. Not by some words on paper, our people have to feel and experience that it is working. We have come a long way since the dark times [genocide period], and our health system has to reflect that. We progressively have to be getting better, when people see this, they get hope that better times are ahead. If it gets worse then you are reminding people of their past. We are constantly scratching our heads, all possible paths have to be explored.” Participant_23, Government staff From the statements, it is conceivable that Rwanda’s history has influenced the attitudes of Rwandans towards national laws. 3.2 Existence of independent regulatory and managing bodies Corporate participants expressed that the presence of RSSB as an independent body managing CBHI was a welcome aspect of this policy since RSSB is filled with technocrats which would reduce political influence over the scheme. “ …. also, RSSB an independent body handles the money, so that separation of powers makes me less sceptical of how the funds will be used, consider this government can have political appointees but such a body, they hire based on technical capacity, CBHI used to be under ministry of health but in 2015 or so it was handed over to RSSB and we can see the results ” Participant_5 Interviewees described improved quickness in decision making processes when dealing with RSSB, due to less bureaucracy: “ When you work with RSSB these days, you notice that decisions are being made much quicker than before. A lot of red tape is cut down and bureaucracy that used to slow things down, which makes the whole process much more efficient. ” (Participant_9, NGO health policy expert) Another independent body with relevance for the compliance behaviour the oil & gas and telecommunications industries is the regulating body in-charge of all utility corporation, The Rwanda Utility regulatory Authority (RURA). RURA has two roles related to this policy, the first responsibility is to collect the funds from the corporations and the second is to remit the funds to the CBHI account. That means that RURA is privy to compliance information related to these payments in real time and can possibly have a direct influence on a firm´s compliance behaviour by “revoking a licence” or “imposing fines”. Partcipant_15 explained how the presence of RURA motivates compliance; it emerged that corporations seek to maintain a good relationship with the regulating body to safeguard firm´s future operations. \" […] but there can also be a loss of good faith, so it will affect how RURA works with you going forward. Maybe they will be more cautious with you. Relationships are important in business, you don't want to be a non-trustworthy company, if they trust you then you will face less scrutiny when you submit a new product for example. There could be indirect benefits in terms of maintaining a good reputation with the authorities.” Participant_17. It seems likely that such compliance has some form “trust building effect” RURA’s side as well. When asked whether there has been a need for penalties so far, A RURA representative expressed that as a regulator they have not had the need to apply sanctions since all the corporations in the targeted industries have been fully compliant. 3.3 Accountability and monitoring systems The willingness to comply with mandatory levies among individuals within corporations seemed to increase when they perceived that their money was efficiently spent to provide public goods. As one corporate respondent alluded to using terms like “knowing the systems,” “trust,” and, “tangible”, “Verifiable” and “visibility,” these collectively imply positive sentiments about the systems: “Knowing the systems in Rwanda and how these funds are managed, I would say that 97% have trust in the government because we see the tangible results they are doing, they are verifiable. There's a lot of visibility. Yeah, there is visibility. And of course, there's something that maybe many people don't know about accountability. If you go to RSSB and ask them, how much have I contributed and how you're using this money, they will show you” participant_18 Another respondent echoed the same sentiments that similar past contributions lead to tangible benefits, such as improved infrastructure from the road levy and linked that to the developed sense of trust and obligation towards the state: “In the levies, for instance, for many years, in the point price structure, there was something for road constructions, which was a priority a few years back. And I believe it was 150 francs per litre. And that has been in the structure for a long time. And you can see the roads that have been constructed in Kigali and upcountry, which our industry has contributed in. So, the same can be applied to this sort of new and recent priorities”. Participant_13, Corporate finance manager When asked about the possibility of contribution evasion by the corporations, a senior official at RSSB explained that the system has controls in place to protect against that behaviour : “we have systems that protect against certain behaviour, they can't under-report or false report because they have to have also audited financials. We have no loopholes that can be manipulated.” Participant_6 The perception of low levels of corruption and waste seemed to foster a cooperative attitude towards the policy. From the responses, when systems are in place for interested parties to track their contributions, it reinforced the social contract between the government and corporations, resulting in higher compliance rates: “ You mean the money reaching the endpoint and not disappearing, in this country without doubt I have confidence in the government in that aspect, in other countries we operate in by the time a tank reaches our depot we would have paid so much in informal “kintu kidogo” (colloquial Swahili term for bribe/ petty corruption widely used in east Africa ), but here beyond the formal fees you do not lose any money. They have almost zero tolerance for that nonsense. For that I will give some credit .” Participant_17 A senior Ministry of Health official emphasized that while Rwanda has developed the necessary tools and mechanisms to ensure accountability in managing public funds, the real challenge lies in effectively using those tools. The official was confident in Rwanda's progress but stressed the importance of not just having systems in place, but actively using them to maintain accountability: “I think we do have most of the tools that we need to assure accountability. However, having tools is not enough. Having tools is one thing. But also using tools is something else. So, I can say, especially here in Rwanda, actually things are moving. The commitment is there. And there is high transparency and everything. Because the mechanism is there, There is enough information exchange between the agencies for people to be able to hold each other accountable in terms of leakages. You raised this much, and this much reached the CBHI fund.”. Participant_7, Ministry of Health Official 3.4 Stakeholder engagement 3.4.1 Inter-agency government and NGO collaboration The actors from all government agencies suggested that inter- agency relations are fairly effective and operate well. For instance, there was observed information sharing between the Ministry of Health, RURA and RSSB as explained by participant_7, a senior official in Ministry of health: “There is enough information exchange between the government agencies for people to be able to hold each other accountable in terms of leakages. We know each other, and every agency knows it’s role [….] Well, I know there is a clusters meeting from the Prime Minister's office where people who are in the same cluster needs and discuss all those kinds of things. So, there is those platform clusters that is inter-minister, inter-agencies and so on. Yeah, I mean, they're always involved as stakeholders in different angles. They are part of a team. We work as a team, just one government. We are serving one government.”. According to participant_6, the role sharing made implementation easier especially in the beginning when there was some uncertainty. RURA in turn worked with the Rwanda Revenue Authority (RRA) and utilised revenue collection infrastructure to track and collect the contributions, rather than building new and cost intensive systems from scratch: “We have had challenges at the beginning. So, people had so many questions in the beginning, like how we remit, when do we remit. But that is expected, what we did was work with our partners because we deal with RURA and RURA deals with the companies. For the petrol and gas, the contributions are levied at the time of import, [….] they are paid at the customs through RRA system, which we have also access. […..] So, for us, what we do is kind of reconciliation, why re-invent the wheel when a sister organisation has the tools you need. And we already knew RRA has a high compliance rate, so it was cost saving for us ” Participant_6, RSSB The same collaboration was also noted between the government agencies and international NGOs especially those the health system strengthening sub-sector. A representative for one of the major NGOs explained the close relationship between the government and NGOs while also noting that the private sector is often not as closely engaged: “Yes, we development partners are part of the technical working groups, we work closely with government in an advisory role, [….] the TWG does not as far as I know have private sector representation, so no active role in the formulation from them but wider stakeholder dissemination workshops were held with the representative for the health of private health providers in attendance, but that person does not represent the corporations in the telecom sector for example.” Participant_19, NGO representative 3.4.2 Limited Corporations’ involvement during formulation Perspectives of on involvement of the corporations in the policy formulation process were split with many government actors reflecting on an overall consultative process during which corporations were consulted, while corporate interviewees rebuffed any kind of consultative engagement with the government prior to the policy roll-out. The presence of a consultative policy making was exemplified in comments made by participant_6 a representative from RSSB, although he added that only two corporations were consulted from the telecommunications sector, “No, when it comes to telecoms, we only talked to two of them, the big ones,, so as to come to come to an agreement. [….]For example, for this we had like 5% and after negotiation, we came up with 2.5%. So, at the start, we had the proposal. So, we engaged each and every party that was involved in that. ” Participant_6, Economist Participant_16 expressed some frustration that his corporation found out about the policy at the same time the general public did when it was passed and published. “Well, it definitely caught us off guard. There was a lot of scrambling initially to understand the implications and figure out how we were going to navigate this new requirement. We thought surely, they will talk to us before rolling out something this big. It is funny that we kept hearing rumours that something like that was on the way, but officially we found out about it the same time as everyone else when it got published. There's definitely a sense of frustration, I won't deny that. We would have appreciated being consulted or at least having a chance to provide input before such significant policies are finalized”. Participant_16 strongly felt some of the initial challenges faced during implementation could have been avoided through a consultative process: one of our main challenges has been the lack information and guidance surrounding the implementation of the policy. Without prior consultation, there were uncertainties about interpretation, how are they defining telecom companies. We know none of the internet service providers are paying anything, my counterpart there says they did not apply the definition to them, is government saying only call companies are telecom, that does not make sense. Why not just tell us the thought process. By the way all this comes from them not talking to us, we would have advised them. A government representative linked the limited consultation to the timing of the policy that was released at the height of the COVID pandemic in 2020. Respondents pointed to the need for better information to corporations, not only about their responsibilities, but also about the impact of their contributions. Another issue brought up was the “arm’s length” relationship between the corporations and government and proposed that it would be beneficial if the government treated the corporations as development partners and not just as a funding source. Additionally, the lack of incentives for the corporations emerged given the limited publicity from government about the contribution of the businesses which takes away the public relations incentives they would have received as a result. In this scenario, the government reaps the rewards of the businesses' contribution, while the businesses themselves miss out on the potential reputational gains. 3.5 Political will Strong leadership and political will, at the highest level, were commonly mentioned out as a key facilitator of the CBHI contributions policy. Sharing the opinion that the prioritisation of the health sector reflects what the Government truly values, participant_7 a senior ministry of health official emphasised how senior leadership support ensures ideas are pursued beyond planning: I think the crucial success of everything is the leadership because the leadership willing to make change are the most important. If there is political will, then people will find an alternative way of achieving the target. But if there is no will, whatever alternative we the technocrats are bringing in, we will not contribute. The leadership is crucial in understanding that this is a priority, thinking that people have to reduce the hardship of people accessing the quality health services. So, for me, that's one is attributed to the leadership. If the leadership is good, then everything will be much easier. If the leadership is not good, whatever ideas you have, will just remain on paper. When discussing if the corporations employed any pushback strategies when the policy was launched, Participant_16 a corporate lawyer for one of the targeted companies, attributed lack of push back to the united front country leadership has towards health: By the way the leadership of this country seems united on anything health, you can’t push back even if you wanted. This theme of strong political supported by evidence from Front Patriotique Rwandais (FPR)’s historical campaign manifestos over the years exemplified by the 2024 manifesto below. The FPR political party was re-elected back into power in July 2024 with Paul Kagame as the president of the republic of Rwanda. As shown in Fig. 2 above, FPR’s 2024–2029 manifesto mirrors its predecessor in highlighting Community Based Health Insurance as a key priority for his government. 4. Discussion The findings reveal that governance plays a pivotal role in influencing compliance, while governance systems are often weak in developing countries, with challenges such as limited enforcement, corruption, and judicial inefficiencies (Nwoke et al., 2023 ), this study presents a contrasting case. In Rwanda, systems that support the rule of law have been effectively established, and this strength significantly influences corporate compliance with mandatory CSR policies. Many corporations expressed that once a mandate is embedded in law. However, evidence from both low- and middle-income countries (LMICs) and high-income countries (HICs) shows that the rule of law is often uneven in practice, and powerful corporate actors may still find avenues to bypass, dilute, or influence the application of mandates.(Favotto & Kollman, 2021 ; Yousfi et al., 2022 ). Some respondents expressed that the cultural respect for the law is deeply rooted in Rwanda’s post-genocide history, there seemed to be a collective desire to maintain national stability and progress, this translates into an almost institutionalized loyalty to state directives. Past literature supports the possibility that Rwanda’s genocide history, influences tradition and contributes to accountability at community level (Chemouni, 2018 ; Kamuzinzi & Rubyutsa, 2019 ). Corporate respondents also expressed confidence in the accountability and monitoring systems, citing examples such as road levies, where visible outcomes such as the construction of roads which reinforced trust that the funds collected would be used as intended, encouraging organizations to comply willingly. This finding aligns withOsei Afriyie et al. ( 2021 ) who in exploring the factors that affected implementation of health reforms in Tanzania found accountability to be a building block to mutual trust. The presence of an independent regulatory body was acknowledged as a factor that strengthened compliance. However, collaboration among stakeholders was highlighted as a mixed area. The differentiated levels of stakeholder engagement observed in this study align closely with the conceptual categories outlined by the Stakeholder Dialogue Ladder (Bjørgen et al., 2021 ). Interviews revealed strong inter-agency coordination, suggesting that public sector institutions were involved in shared decision-making processes and strategic alignment. This is consistent with prior research emphasising the effectiveness of cross-sector collaboration in complex policy environments (Bryson, Crosby, & Stone, 2015). NGOs and subject matter experts were actively consulted and played advisory roles during the formulation and operationalisation of the policy. A advisory engagement can enhance both the technical quality and legitimacy of policy interventions (Edelenbos & Klijn, 2005; Newig & Fritsch, 2009). In stark contrast, corporate stakeholders largely experienced one-sided information flow . Many reported first encountering the policy through indirect channels such as media reports or informal networks. This unilateral mode of communication reflects minimal engagement and a missed opportunity for leveraging private sector insights. Prior studies have shown that marginalising such actors in policy dialogues can lead to implementation friction, reduced compliance, or unintended consequences (Boaz et al., 2018; Mitchell, Agle, & Wood, 1997). This stratification has implications not only for the perceived legitimacy of the policy but also for its long-term sustainability and responsiveness. Although this did not have an immediate impact on compliance levels, it created dissatisfaction among businesses, businesses expressed a desire to be treated as development partners similar to how NGOs are involved in policy discussions rather than merely as funding sources. This lack of engagement also led to misinformation, as illustrated by one respondent who mistakenly believed that CBHI contributions were a temporary COVID-19 resource mobilization measure. Finally, political will was seen as a critical enabler of compliance. Respondents highlighted strong governmental support for the policy, aligning with the broader agenda of the ruling party. Strong political leadership can help overcome institutional inertia, navigate resistance from powerful interest groups, and mobilise the bureaucratic and financial tools necessary for policy implementation (Babor et al., 2023 ; Ezenduka et al., 2022 ; Wright et al., 2017 ). It also plays a key role in framing public problems and generating the legitimacy required to introduce new policy instruments, such as taxes or levies for social programmes. Studies from Ghana, for example, have documented how the successful rollout of a National Health Insurance Scheme was made possible by the active engagement and commitment of high-level political actors, who worked to align public messaging, financing, and institutional responsibilities (Fusheini, 2016 ; Novignon et al., 2021 ). Similarly, Thailand's journey toward universal health coverage was not solely a technocratic exercise, but the result of deliberate political prioritisation, championed by elected leaders and embedded within broader electoral platforms (Harris & Libardi Maia, 2022 ; Tangcharoensathien et al., 2019 , 2020 ). Rwanda’s own history of health system transformation has repeatedly hinged on strong political direction, especially in post-genocide rebuilding efforts where leadership prioritised equity in health access (Binagwaho et al., 2014). 5. Conclusion This study demonstrates that the success of public interest driven regulatory policies depends on the strength of the governance systems that support their implementation. In the case of mandatory corporate contributions to Community-Based Health Insurance (CBHI), robust governance mechanisms including strengthening rule of law, setting up accountability and monitoring systems, political buy-in, establishing and independent body for oversight are essential for ensuring compliance with national resource mobilisation strategies that seek to raise funds from the private sector. Stakeholder engagement (lack of) did not seem to affect compliance in the Rwanda case. However, this might not be the case for countries with weaker rule of law and other systematic incentives for compliance. Declarations Ethics approval and consent to participate This research was conducted in accordance with the ethical principles of the Declaration of Helsinki. Ethical approval for the research was obtained from the Human Research Ethical Committee of the Open University ( HREC reference number: 2023-0007-3) and a research permit no RP00000726 was issued by the Rwanda National Council of Science and Technology. Informed written consent was obtained from all participants, participant personal information was also anonymised for confidentiality and privacy. Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests No competing interests declared Funding Funding for this study was provided by The Open University , Faculty of Business and Law as part of a PhD studentship for B.J.T Conflicts of Interest: The authors declare no conflicts of interest. Author Contribution Research conceptualization: B.J.T., F.C., D.K., M.N.Data collection: B.J.T.Data analysis: B.J.T., F.C., D.K., M.N.Methodology: B.J.T., F.C., D.K., M.N.Writing original draft: B.J.T.All authors contributed to manuscript review & editing References Abraham, R., & Tao, Z. (2021). Funding health in developing countries: foreign aid, FDI, or personal remittances? International Journal of Social Economics , 48 (12), 1826–1851. https://libezproxy.open.ac.uk/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=bth&AN=153291260&site=ehost-live&scope=site Babor, T. F., Collin, J., & Monteiro, M. G. (2023). A Political Economy Analysis of Health Taxes. In Health Taxes: Policy and Practice . https://doi.org/10.1142/9781800612396_0015 Barroy, H., Kutzin, J., Tandon, A., Kurowski, C., Lie, G., Borowitz, M., Sparkes, S., Dale, E., Taylor, by, & el ene Barroy, H. (2018). Assessing Fiscal Space for Health in the SDG Era: A Different Story. 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Examining healthcare purchasing arrangements for strategic purchasing in Nigeria: a case study of the Imo state healthcare system. Health Research Policy and Systems , 20 (1). https://doi.org/10.1186/s12961-022-00844-z Favotto, A., & Kollman, K. (2021). Mixing business with politics: Does corporate social responsibility end where lobbying transparency begins? Regulation and Governance , 15 (2), 262–279. https://doi.org/10.1111/REGO.12275 Fusheini, A. (2016). The politico-economic challenges of ghana’s national health insurance scheme implementation. International Journal of Health Policy and Management , 5 (9). https://doi.org/10.15171/ijhpm.2016.47 Harris, J., & Libardi Maia, J. (2022). Universal healthcare does not look the same everywhere: Divergent experiences with the private sector in Brazil and Thailand. Global Public Health , 17 (9), 1809–1826. https://doi.org/10.1080/17441692.2021.1981973 Hontelez, J. A. C., Goymann, H., Berhane, Y., Bhattacharjee, P., Bor, J., Chabata, S. T., Cowan, F., Kimani, J., Knox, J., Lora, W. S., Lungu, C., Manne-Goehler, J., Mauti, J., Moshabela, M., Mpembeni, R. M., Wa Mwanza, M., Ndung’u, T., Omondi, E., Phiri, S., … Bärnighausen, T. W. (2025). The impact of the PEPFAR funding freeze on HIV deaths and infections: a mathematical modelling study of seven countries in sub-Saharan Africa. EClinicalMedicine , 83 , 103233. https://doi.org/10.1016/J.ECLINM.2025.103233 Ichoku, H. E., & Okoli, C. I. (2015). Fiscal Space for Health Financing in Nigeria. African Journal of Health Economics Xxx . Kamuzinzi, M., & Rubyutsa, J. M. (2019). When Tradition Feeds on Modern Accountability Mechanisms in Public Policy Implementation. The Case of “Imihigo” in Rwanda. Public Performance and Management Review , 42 (3). https://doi.org/10.1080/15309576.2018.1494018 Kutzin, J. (2013). Health financing for universal coverage and health system performance: concepts and implications for policy. Bull World Health Organ . https://doi.org/10.2471/BLT.12.113985 Meheus, F., & McIntyre, D. (2017). Fiscal space for domestic funding of health and other social services. Health Economics, Policy, and Law , 12 (2), 159–177. https://doi.org/10.1017/S1744133116000438 Novignon, J., Lanko, C., & Arthur, E. (2021). Political economy and the pursuit of universal health coverage in Ghana: a case study of the National Health Insurance Scheme. Health Policy and Planning , 36 . https://doi.org/10.1093/heapol/czab061 Nwoke, U., Ekwelem, C. M., & Agbowo-Egbo, H. C. (2023). Curbing corruption and promoting a more efficient corporate governance regime in Nigeria. Journal of Financial Crime , 30 (2), 536–548. https://doi.org/10.1108/JFC-01-2022-0025 Oleribe, O. O., Momoh, J., Uzochukwu, B. S. C., Mbofana, F., Adebiyi, A., Barbera, T., Williams, R., & Taylor-Robinson, S. D. (2019). Identifying key challenges facing healthcare systems in Africa and potential solutions. International Journal of General Medicine , 12 , 395–403. https://doi.org/10.2147/IJGM.S223882 Osei Afriyie, D., Hooley, B., Mhalu, G., Tediosi, F., & Mtenga, S. M. (2021). Governance factors that affect the implementation of health financing reforms in Tanzania: An exploratory study of stakeholders’ perspectives. BMJ Global Health , 6 (8). https://doi.org/10.1136/bmjgh-2021-005964 Tangcharoensathien, V., Patcharanarumol, W., Kulthanmanusorn, A., Saengruang, N., & Kosiyaporn, H. (2019). The Political Economy of UHC Reform in Thailand: Lessons for Low- and Middle-Income Countries. Health Systems and Reform , 5 (3). https://doi.org/10.1080/23288604.2019.1630595 Tangcharoensathien, V., Thammatach-Aree, J., Witthayapipopsakul, W., Viriyathorn, S., Kulthanmanusorn, A., & Patcharanarumol, W. (2020). Political economy of Thailand’s tax-financed universal coverage scheme. Bulletin of the World Health Organization , 98 (2). https://doi.org/10.2471/BLT.19.239343 UNAIDS. (2025). Impact of US funding cuts on HIV programmes in East and Southern Africa | UNAIDS . https://www.unaids.org/en/resources/presscentre/featurestories/2025/march/20250331_ESA-region_fs?utm_source=chatgpt.com World Bank. (2024). Rwanda | Data . https://data.worldbank.org/country/rwanda World Health Organisation. (2010). The Abuja Declaration: Ten Years On 2001 Promises of commitment and solidarity . http://www.oecd.org/document/11/0,3746,en_2649_34447_44981579_1_1_1_1,00.html World Health Organisation. (2022). Global Health Expenditure Database . https://apps.who.int/nha/database/country_profile/Index/en World Justice Forum. (2021). Rule of Law Around the World. In The World Justice Project . www.worldjusticeproject.org. Wright, A., Smith, K. E., & Hellowell, M. (2017). Policy lessons from health taxes: A systematic review of empirical studies. In BMC Public Health (Vol. 17, Issue 1). BioMed Central Ltd. https://doi.org/10.1186/s12889-017-4497-z www.rpfinkotanyi.rw . (2024). https://rpfinkotanyi.rw/amatora/wp-content/uploads/2024/06/20240311_Portrait-Pamplet_14x17cm_Engl-2.pdf Yousfi, O., Mbarek, I., Omri, A., Yousfi, O., Mbarek, I., & Omri, A. (2022). CSR and Corporate Lobbying: From an Environmental Perspective . https://doi.org/10.5772/INTECHOPEN.106936 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 16 Dec, 2025 Reviewers invited by journal 07 Dec, 2025 Editor invited by journal 12 Nov, 2025 Editor assigned by journal 11 Nov, 2025 Submission checks completed at journal 11 Nov, 2025 First submitted to journal 07 Nov, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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10:12:06\",\"extension\":\"png\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":47831,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eGovernance factors influencing implementation of the Rwanda CBHI financing policy.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"1.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8057585/v1/bcaf9f5bee37b3acf9c7213f.png\"},{\"id\":97870393,\"identity\":\"4b15bcbe-71bb-4ad9-b8b3-d0f541bb4946\",\"added_by\":\"auto\",\"created_at\":\"2025-12-10 10:12:06\",\"extension\":\"png\",\"order_by\":2,\"title\":\"Figure 2\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":332231,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eAn extract from the ruling political (FPR)’s 2024-2029 manifesto. Source: \\u003cem\\u003e(www.rpfinkotanyi.rw, 2024)\\u003c/em\\u003e\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"2.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8057585/v1/edd7efb1e90b4676ecc62204.png\"},{\"id\":97903376,\"identity\":\"2d53d382-b2cd-49a4-b7b2-08afe4d2748c\",\"added_by\":\"auto\",\"created_at\":\"2025-12-10 15:55:12\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":1060656,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8057585/v1/886b7cb2-0129-449c-ba51-081e210b9f98.pdf\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"Governance and Domestic Resource Mobilisation: Lessons from Rwanda’s mandatory corporate Contributions to Community-Based Health Insurance\",\"fulltext\":[{\"header\":\"1. Introduction\",\"content\":\"\\u003cdiv id=\\\"Sec2\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003e1.1 Overview of the health financing gap in LMICs\\u003c/h2\\u003e\\u003cp\\u003eDespite the recognised importance of investing in health, many countries still face challenges in finding the necessary resources to fund their health systems, lack of funding is particularly acute in developing countries, where the disease burden is high, and health systems are often weak (Oleribe et al., \\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e2019\\u003c/span\\u003e). For developing countries, the WHO recommends that countries allocate a minimum of 15% of their total government budget to health (World Health Organisation, \\u003cspan citationid=\\\"CR25\\\" class=\\\"CitationRef\\\"\\u003e2022\\u003c/span\\u003e). This is also in line with the 2001 Abuja Declaration by African Heads of State and Government to allocate at least 15% of their national budgets to the health sector (Oleribe et al., \\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e2019\\u003c/span\\u003e; World Health Organisation, \\u003cspan citationid=\\\"CR24\\\" class=\\\"CitationRef\\\"\\u003e2010\\u003c/span\\u003e). It's worth noting that by 2022 only three African countries had achieved the Abuja target including South Africa, Sudan and Madagascar (World Health Organisation, \\u003cspan citationid=\\\"CR25\\\" class=\\\"CitationRef\\\"\\u003e2022\\u003c/span\\u003e). This problem, known as the \\\"fiscal space for health\\\" challenge, is a major barrier to achieving universal health coverage and the health-related Sustainable Development Goals. Limited funding capacity results from a combination of factors including weak health systems, limited tax revenues, competing demands on public resources, and poor health financing strategies (Ichoku \\u0026amp; Okoli, \\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e2015\\u003c/span\\u003e; Meheus \\u0026amp; McIntyre, \\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e2017\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cp\\u003eThere is a documented reliance of foreign aid by many developing countries, and while aid has been used to fund critical health interventions like HIV/AIDS treatment, mass immunisation and malaria control through funding schemes such as PEPFAR and the Global Fund (Hontelez et al., \\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e2025\\u003c/span\\u003e). It is not a long term solution to funding as sector as sensitive as health, this is because foreign aid is unreliable, fluctuating and out of control of the funded country (Abraham \\u0026amp; Tao, \\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e2021\\u003c/span\\u003e). Most of the funding priorities are dictated by the foreign policy and may at times not align with the priorities of the developing countries. For instance, the dismantling of USAID-funded health programs, particularly through cuts to PEPFAR, has severely disrupted HIV service delivery in sub-Saharan Africa. Studies warn that reductions in U.S. HIV funding could reverse decades of gains, with projections of up to 2\\u0026nbsp;million additional infections and 350,000 AIDS-related deaths by 2030 if sustained (Brink et al., \\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e2025\\u003c/span\\u003e). In countries like Uganda and Kenya, the withdrawal of PEPFAR support has resulted in immediate declines in HIV testing and treatment initiation, while thousands of community health workers previously funded through USAID grants have been retrenched (Brink et al., \\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e2025\\u003c/span\\u003e; Hontelez et al., \\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e2025\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cp\\u003eThe ripple effects extend beyond HIV to broader health systems. In Kenya, Mozambique, and Malawi, PEPFAR resources historically underpinned health workforce salaries, laboratory systems, and supply chains for essential medicines. Funding cuts therefore not only reduce access to antiretroviral therapy but also weaken human resources for health, eroding primary health care delivery and system resilience (UNAIDS, \\u003cspan citationid=\\\"CR22\\\" class=\\\"CitationRef\\\"\\u003e2025\\u003c/span\\u003e). These developments in the funding landscape show the fragility of donor-dependent health systems and emphasize the urgent need for countries to strengthen domestic financing mechanisms and integrate HIV programs into national health insurance and broader service delivery platforms.\\u003c/p\\u003e\\u003c/div\\u003e\\u003cdiv id=\\\"Sec3\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003e1.2 Governance \\u0026amp; Public Health Financing Policy.\\u003c/h2\\u003e\\u003cp\\u003eFor low income countries, it goes beyond merely looking for funds, it is important to consider how the funds will effectively be utilised without leakage. This is due to the weak governance systems with limited accountability (Kutzin, \\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e2013\\u003c/span\\u003e). Governance systems are critical for sustainable health financing. Domestic resource mobilisation is not only a matter of diversifying revenue streams, but it also fundamentally depends on effective governance. In the health sector, governance influences how financing reforms are designed, how compliance with mandatory contributions such as health taxes is enforced, and how trust is built among stakeholders (Barroy et al., \\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e2018\\u003c/span\\u003e). Evidence shows that countries with robust governance systems are better able to sustain health financing innovations because they can institutionalise legal mandates, minimise leakage of funds, and maintain accountability across actors involved in revenue collection and pooling. Conversely, weak governance environments often lead to under-collection of revenues, misuse of funds, and erosion of public trust, undermining domestic resource mobilising efforts (Babor et al., \\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2023\\u003c/span\\u003e; Wright et al., \\u003cspan citationid=\\\"CR27\\\" class=\\\"CitationRef\\\"\\u003e2017\\u003c/span\\u003e). Thus, governance serves as the enabling framework that translates policy intentions into tangible financial resources for health, while also shaping the legitimacy and sustainability of DRM strategies.\\u003c/p\\u003e\\u003c/div\\u003e\\u003cdiv id=\\\"Sec4\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003e1.3 Why Rwanda as a case study\\u003c/h2\\u003e\\u003cp\\u003eRwanda's governance system has undergone significant transformation since the 1994 genocide, positioning the country as a notable example of effective governance in sub-Saharan Africa. Rwanda ranks 41st out of 142 countries (World Justice Forum, \\u003cspan citationid=\\\"CR26\\\" class=\\\"CitationRef\\\"\\u003e2021\\u003c/span\\u003e). According to the World Bank's 2023 data, Rwanda's government effectiveness index stands at 0.39, surpassing the global average of -0.04, indicating a high capacity in public service delivery and policy implementation (World Bank, \\u003cspan citationid=\\\"CR23\\\" class=\\\"CitationRef\\\"\\u003e2024\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cp\\u003eIn 2020, seeking to overcome a funding deficit for its Community Based Health Insurance scheme, Rwanda passed a policy that mandated Oil and Gas companies as well as corporations in the Telecommunications sector to contribute proportions of their revenue towards CBHI. Such a policy leverages finances from private sector to finance the Public health sector. There are limited examples of such policies in low income countries.\\u003c/p\\u003e\\u003c/div\\u003e\\u003cdiv id=\\\"Sec5\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003e1.4 Aim of the Study:\\u003c/h2\\u003e\\u003cp\\u003eTo Explore how governance influences corporate compliance with a health financing policy\\u003c/p\\u003e\\u003c/div\\u003e\"},{\"header\":\"2. Methods\",\"content\":\"\\u003cp\\u003eWe utilised qualitative methods using in-depth key informant interviews to capture the experiences of key stakeholders involved in the implementation of the prime minister\\u0026rsquo;s order on CBHI contributions. This involved in-depth interviews with government stakeholders, regulatory bodies, non-government organisations stakeholders, and corporations. The choice for qualitative methods to be the primary method of inquiry was due to the recency of the CBHI financing policy (\\u003cem\\u003ehaving been enacted in 2020\\u003c/em\\u003e), it is not expected that an investigation into the long-term impact of this policy will yield meaningful results at this early stage, as the policy has not been in place long enough to generate measurable long-term outcomes.\\u003c/p\\u003e\\u003cp\\u003eThe study was conducted in Kigali, Rwanda. Purposive sampling was employed to allow for the deliberate selection of participants with direct relevance to the research questions. This approach enabled me to include key informants with diverse experiences of the CBHI contributions policy, including stakeholders involved in its conception and implementation, as well as those affected by it. Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e below shows the Key informants interviewed.\\u003c/p\\u003e\\u003cp\\u003e\\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab1\\\" border=\\\"1\\\"\\u003e\\u003ccaption language=\\\"En\\\"\\u003e\\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 1\\u003c/div\\u003e\\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\u003cp\\u003eKey Informants Interviewed\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/caption\\u003e\\u003ccolgroup cols=\\\"3\\\"\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e\\u003cthead\\u003e\\u003ctr\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003einstitution\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eInterviewee\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eBroad role descriptor\\u003c/p\\u003e\\u003c/th\\u003e\\u003c/tr\\u003e\\u003c/thead\\u003e\\u003ctbody\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\" morerows=\\\"9\\\" rowspan=\\\"10\\\"\\u003e\\u003cp\\u003e\\u003cspan type=\\\"Underline\\\" class=\\\"Underline\\\" name=\\\"Emphasis\\\"\\u003eCorporations Telecom/Oil and gas\\u003c/span\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eParticipant_2\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eLegal/compliance, company A\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eParticipant_3\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eFinance, company A\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eParticipant_4\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eLegal, Company A\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eParticipant_5\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eLegal, Company B\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eParticipant_12\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eLegal, Company C\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eParticipant_13\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eFinance, Company C\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eParticipant_16\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eLegal, Company D\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eParticipant_17\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eLegal, Company E\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eParticipant_18\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eFinance, company E\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eParticipant_23\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eFinance, Company F\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\" morerows=\\\"1\\\" rowspan=\\\"2\\\"\\u003e\\u003cp\\u003eRwanda Utility Regulatory Authority\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eParticipant_1\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eEconomist\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eParticipant_10\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eCompliance\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\" morerows=\\\"1\\\" rowspan=\\\"2\\\"\\u003e\\u003cp\\u003eRwanda Social Security Board\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eParticipant_6\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eEconomist\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eParticipant_22\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003ePlanner\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\" morerows=\\\"1\\\" rowspan=\\\"2\\\"\\u003e\\u003cp\\u003eMinistry of Health\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eParticipant_7\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eSenior official\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eParticipant_19\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eSenior official\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\" morerows=\\\"3\\\" rowspan=\\\"4\\\"\\u003e\\u003cp\\u003eNon-government Organisations\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eParticipant _9\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eHealth financing advisor\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eParticipant_15\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eEconomist\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eParticipant_20\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eEconomist\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eParticipant_21\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003ePublic health advisor\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003c/tbody\\u003e\\u003c/colgroup\\u003e\\u003c/table\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003eInterview guides were used to guide the data collection processes. The interviews were tape recorded and lasted between 30 min to 1 hour. Interviewees were asked questions about their knowledge of the policy as well as their involvement with policy development and implementation. Data collection continued until saturation was reached, meaning the point at which interviews did generate new insights. The interview data were supplemented with information from government documents and reports from the corporations. Interviews were then transcribed in MS Word and exported to NVivo for analysis. Data was analysed following Braun and Clarke\\u0026rsquo;s Reflexive Thematic Analysis approach (Braun \\u0026amp; Clarke, 2019; 2021). According to Braun and Clarke, themes are not inherent in the data but are actively constructed by the researcher through interpretation. The analysis was done using a deductive approach, organising data in pre-existing codes and themes while remaining open to themes emerging from the data. From the literature on governance, themes such as Rule of law, Accountability \\u0026amp; monitoring systems and political will were used as deductive themes. Two inductive themes such as presence of an independent regulatory body and selective inclusion practices emerged from the data. This is represented in Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e below.\\u003c/p\\u003e\\u003cp\\u003e\\u003c/p\\u003e\"},{\"header\":\"3. Results\",\"content\":\"\\u003cdiv id=\\\"Sec8\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003e3.1 Rule of law and compliance\\u003c/h2\\u003e\\u003cp\\u003eThe consensus among respondents was that the law is non-negotiable in Rwanda. Respondents expressed confidence in Rwanda\\u0026rsquo;s approach to the rule of law, they contrasted Rwanda\\u0026rsquo;s legal system with those in other countries, noting that in Rwanda, everyone, regardless of their status, is held accountable under the law. This is exemplified in the quote below\\u003c/p\\u003e\\u003cp\\u003e\\u0026ldquo;\\u003cem\\u003epersonally, I have worked in both Africa and beyond, with all that we lack in-terms of finances, our strength lies in how strict we are with the law, nobody is above the law, no company is above the law. \\u0026hellip;\\u0026hellip;. compared to many countries on the continent and elsewhere when it come to the law, we are up there\\u003c/em\\u003e\\\" Participant_1, Economist.\\u003c/p\\u003e\\u003cp\\u003eThis reflects a strict enforcement of the law which is likely to affect how policies such as the CBHI contributions policy are enforced. When confronted with a question on lobbying, our corporate respondents reacted almost uniformly by asserting that there is \\u0026ldquo;no room\\u0026rdquo; for negotiation or push back on laws in Rwanda.\\u003c/p\\u003e\\u003cp\\u003e\\u003cem\\u003e\\u0026ldquo;In the general practices that regulator just enforces, there is not much room for negotiation\\u0026hellip;[\\u0026hellip;] the position of the regulator is pay first and complain later.\\u0026rdquo;\\u003c/em\\u003e said participant_5 a corporate lawyer.\\u003c/p\\u003e\\u003cp\\u003eOn whether they could possibly influence changes to the policy in the future, Participant_17 explained that there is limited opportunity to lobby against government initiatives. From the interviews we perceived a top-down approach by the government, where there is limited opportunity or culture for companies to push back strongly. This suggests that in Rwanda, the prevailing practice is for businesses to accept and adapt to government decisions rather than challenge them.\\u003c/p\\u003e\\u003cp\\u003e\\u003cem\\u003e\\u0026ldquo;Well, to be honest, the political and economic environment in Rwanda doesn't really lend itself to aggressive lobbying against government policies, even if they have a significant impact on businesses like ours. The government tends to take a very top-down approach, and there isn't really a culture of companies pushing back too strongly against policies\\u003c/em\\u003e\\u0026rdquo;.\\u003c/p\\u003e\\u003cp\\u003eSome interviewees stated that the country\\u0026rsquo;s performance in terms of the rule of law builds trust in government. Such was the case of one of the interviewees Participant_9 who works for an international non-government agency, that stated the following:\\u003c/p\\u003e\\u003cp\\u003e\\u003cem\\u003e\\u0026ldquo;I would think the investors, are probably driven to also contribute to the development of the country because they feel like they operate in a space that is well regulated, low corruption. So that can also drive them to be okay with the policies that the government has. [\\u0026hellip;], but also, the fact that they feel like they operate in an environment that they trust\\u0026rdquo;.\\u003c/em\\u003e\\u003c/p\\u003e\\u003cp\\u003eFrom this statement two key observations emerge: the perception of a well-regulated and low-corruption environment influence investors' willingness to support and comply with government policies. Additionally, the trust investors place in the operational environment affect their overall satisfaction and long-term commitment to the country\\u0026rsquo;s development.\\u003c/p\\u003e\\u003cp\\u003eParticipant_16 a non-Rwanda who has worked in multiple countries for the same company compared his experience in Rwanda with his experience in the United States and Uganda, where he worked for 10 years and 2 years respectively:\\u003c/p\\u003e\\u003cp\\u003e\\u003cem\\u003e\\u0026lsquo;Firstly, law is equal for everybody, not like the US where the big companies will bankroll a political figure and get exemptions or lobby for changes at the expense of smaller companies with no influence. Secondly, it is clear, public, and stable. I have worked in Uganda where enforcement of laws was a mess, the people enforcing would not be aware of the laws themselves, a law will go redundant for 5 or so years due to lack of interest from the enforcer, then someone else takes office it comes back again, then the cycle continues. So, you see here we know what to expect, no informal payments. Legitimate businesses that are not looking to cut corners prefer to operate with this kind of certainty\\u0026rdquo;.\\u003c/em\\u003e\\u003c/p\\u003e\\u003cp\\u003eAnother aspect that emerged in relation to rule of law was how \\u0026ldquo;identity\\u0026rdquo; as Rwandans also plays a persuasive role in the way Rwandans view and react to government policies, laws and regulations. There seemed to be a shared support for government policies among the interviewees not only in the government institutions but among the corporation and NGO staff too. The persuasive reach was visible in how the interviewees rationalised the policy. Participant_6 attributed obedience to the law to the normative culture of Rwandans that has been built overtime with participant_23 linking this culture directly to the dark genocide past:\\u003c/p\\u003e\\u003cp\\u003e\\u003cem\\u003e\\u0026ldquo;I think that's coming from our Culture, If there is a law, everyone complies, I don't know if you have observed it, whether it is at a zebra crossing, if a pedestrian puts even one foot in the crossing, then no car will move forward until the pedestrian is on the other end of the road, we don\\u0026rsquo;t need a red light to signal the car to stop, it is a culture\\u0026hellip;... If you see a piece of paper on the road, pick it up, It's implemented on a personal level. So, it has become a culture over years. So, people, they don't even, you don't even have to force them to do it, then if there is a law, they will comply with it.\\u0026rdquo;\\u003c/em\\u003e \\u003cb\\u003eParticipant_6, Economist\\u003c/b\\u003e\\u003c/p\\u003e\\u003cp\\u003e\\u003cem\\u003e\\u0026ldquo;So, this policy will only work if our people\\u0026rsquo;s lives are made better because of it. Not by some words on paper, our people have to feel and experience that it is working. We have come a long way since the dark times [genocide period], and our health system has to reflect that. We progressively have to be getting better, when people see this, they get hope that better times are ahead. If it gets worse then you are reminding people of their past. We are constantly scratching our heads, all possible paths have to be explored.\\u0026rdquo;\\u003c/em\\u003e Participant_23, Government staff\\u003c/p\\u003e\\u003cp\\u003eFrom the statements, it is conceivable that Rwanda\\u0026rsquo;s history has influenced the attitudes of Rwandans towards national laws.\\u003c/p\\u003e\\u003c/div\\u003e\\u003cdiv id=\\\"Sec9\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003e3.2 Existence of independent regulatory and managing bodies\\u003c/h2\\u003e\\u003cp\\u003eCorporate participants expressed that the presence of RSSB as an independent body managing CBHI was a welcome aspect of this policy since RSSB is filled with technocrats which would reduce political influence over the scheme.\\u003c/p\\u003e\\u003cp\\u003e\\u0026ldquo; \\u0026hellip;. \\u003cem\\u003ealso, RSSB an independent body handles the money, so that separation of powers makes me less sceptical of how the funds will be used, consider this government can have political appointees but such a body, they hire based on technical capacity, CBHI used to be under ministry of health but in 2015 or so it was handed over to RSSB and we can see the results\\u003c/em\\u003e\\u0026rdquo; Participant_5\\u003c/p\\u003e\\u003cp\\u003eInterviewees described improved quickness in decision making processes when dealing with RSSB, due to less bureaucracy:\\u003c/p\\u003e\\u003cp\\u003e\\u0026ldquo;\\u003cem\\u003eWhen you work with RSSB these days, you notice that decisions are being made much quicker than before. A lot of red tape is cut down and bureaucracy that used to slow things down, which makes the whole process much more efficient.\\u003c/em\\u003e\\u0026rdquo; (Participant_9, NGO health policy expert)\\u003c/p\\u003e\\u003cp\\u003eAnother independent body with relevance for the compliance behaviour the oil \\u0026amp; gas and telecommunications industries is the regulating body in-charge of all utility corporation, The Rwanda Utility regulatory Authority (RURA). RURA has two roles related to this policy, the first responsibility is to collect the funds from the corporations and the second is to remit the funds to the CBHI account. That means that RURA is privy to compliance information related to these payments in real time and can possibly have a direct influence on a firm\\u0026acute;s compliance behaviour by \\u0026ldquo;revoking a licence\\u0026rdquo; or \\u0026ldquo;imposing fines\\u0026rdquo;.\\u003c/p\\u003e\\u003cp\\u003ePartcipant_15 explained how the presence of RURA motivates compliance; it emerged that corporations seek to maintain a good relationship with the regulating body to safeguard firm\\u0026acute;s future operations.\\u003c/p\\u003e\\u003cp\\u003e\\u003cem\\u003e\\\" [\\u0026hellip;] but there can also be a loss of good faith, so it will affect how RURA works with you going forward. Maybe they will be more cautious with you. Relationships are important in business, you don't want to be a non-trustworthy company, if they trust you then you will face less scrutiny when you submit a new product for example. There could be indirect benefits in terms of maintaining a good reputation with the authorities.\\u0026rdquo;\\u003c/em\\u003e Participant_17.\\u003c/p\\u003e\\u003cp\\u003eIt seems likely that such compliance has some form \\u0026ldquo;trust building effect\\u0026rdquo; RURA\\u0026rsquo;s side as well. When asked whether there has been a need for penalties so far, A RURA representative expressed that as a regulator they have not had the need to apply sanctions since all the corporations in the targeted industries have been fully compliant.\\u003c/p\\u003e\\u003c/div\\u003e\\u003cdiv id=\\\"Sec10\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003e3.3 Accountability and monitoring systems\\u003c/h2\\u003e\\u003cp\\u003eThe willingness to comply with mandatory levies among individuals within corporations seemed to increase when they perceived that their money was efficiently spent to provide public goods. As one corporate respondent alluded to using terms like \\u0026ldquo;knowing the systems,\\u0026rdquo; \\u0026ldquo;trust,\\u0026rdquo; and, \\u0026ldquo;tangible\\u0026rdquo;, \\u0026ldquo;Verifiable\\u0026rdquo; and \\u0026ldquo;visibility,\\u0026rdquo; these collectively imply positive sentiments about the systems:\\u003c/p\\u003e\\u003cp\\u003e\\u003cem\\u003e\\u0026ldquo;Knowing the systems in Rwanda and how these funds are managed, I would say that 97% have trust in the government because we see the tangible results they are doing, they are verifiable. There's a lot of visibility. Yeah, there is visibility. And of course, there's something that maybe many people don't know about accountability. If you go to RSSB and ask them, how much have I contributed and how you're using this money, they will show you\\u0026rdquo;\\u003c/em\\u003e participant_18\\u003c/p\\u003e\\u003cp\\u003eAnother respondent echoed the same sentiments that similar past contributions lead to tangible benefits, such as improved infrastructure from the road levy and linked that to the developed sense of trust and obligation towards the state:\\u003c/p\\u003e\\u003cp\\u003e\\u003cem\\u003e\\u0026ldquo;In the levies, for instance, for many years, in the point price structure, there was something for road constructions, which was a priority a few years back. And I believe it was 150 francs per litre. And that has been in the structure for a long time. And you can see the roads that have been constructed in Kigali and upcountry, which our industry has contributed in. So, the same can be applied to this sort of new and recent priorities\\u0026rdquo;.\\u003c/em\\u003e Participant_13, Corporate finance manager\\u003c/p\\u003e\\u003cp\\u003eWhen asked about the possibility of contribution evasion by the corporations, a senior official at RSSB explained that the system has controls in place to protect against that behaviour :\\u003c/p\\u003e\\u003cp\\u003e\\u003cem\\u003e\\u0026ldquo;we have systems that protect against certain behaviour, they can't under-report or false report because they have to have also audited financials. We have no loopholes that can be manipulated.\\u0026rdquo;\\u003c/em\\u003e Participant_6\\u003c/p\\u003e\\u003cp\\u003eThe perception of low levels of corruption and waste seemed to foster a cooperative attitude towards the policy. From the responses, when systems are in place for interested parties to track their contributions, it reinforced the social contract between the government and corporations, resulting in higher compliance rates:\\u003c/p\\u003e\\u003cp\\u003e\\u0026ldquo;\\u003cem\\u003eYou mean the money reaching the endpoint and not disappearing, in this country without doubt I have confidence in the government in that aspect, in other countries we operate in by the time a tank reaches our depot we would have paid so much in informal \\u0026ldquo;kintu kidogo\\u0026rdquo;\\u003c/em\\u003e \\u003cb\\u003e(colloquial Swahili term for bribe/ petty corruption widely used in east Africa\\u003c/b\\u003e\\u003cem\\u003e), but here beyond the formal fees you do not lose any money. They have almost zero tolerance for that nonsense. For that I will give some credit\\u003c/em\\u003e.\\u0026rdquo; Participant_17\\u003c/p\\u003e\\u003cp\\u003eA senior Ministry of Health official emphasized that while Rwanda has developed the necessary tools and mechanisms to ensure accountability in managing public funds, the real challenge lies in effectively using those tools. The official was confident in Rwanda's progress but stressed the importance of not just having systems in place, but actively using them to maintain accountability:\\u003c/p\\u003e\\u003cp\\u003e\\u003cem\\u003e\\u0026ldquo;I think we do have most of the tools that we need to assure accountability. However, having tools is not enough. Having tools is one thing. But also using tools is something else. So, I can say, especially here in Rwanda, actually things are moving. The commitment is there. And there is high transparency and everything. Because the mechanism is there, There is enough information exchange between the agencies for people to be able to hold each other accountable in terms of leakages. You raised this much, and this much reached the CBHI fund.\\u0026rdquo;.\\u003c/em\\u003e Participant_7, Ministry of Health Official\\u003c/p\\u003e\\u003c/div\\u003e\\u003cdiv id=\\\"Sec11\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003e3.4 Stakeholder engagement\\u003c/h2\\u003e\\u003cdiv id=\\\"Sec12\\\" class=\\\"Section3\\\"\\u003e\\u003ch2\\u003e3.4.1 Inter-agency government and NGO collaboration\\u003c/h2\\u003e\\u003cp\\u003eThe actors from all government agencies suggested that inter- agency relations are fairly effective and operate well. For instance, there was observed information sharing between the Ministry of Health, RURA and RSSB as explained by participant_7, a senior official in Ministry of health:\\u003c/p\\u003e\\u003cp\\u003e\\u003cem\\u003e\\u0026ldquo;There is enough information exchange between the government agencies for people to be able to hold each other accountable in terms of leakages. We know each other, and every agency knows it\\u0026rsquo;s role [\\u0026hellip;.] Well, I know there is a clusters meeting from the Prime Minister's office where people who are in the same cluster needs and discuss all those kinds of things. So, there is those platform clusters that is inter-minister, inter-agencies and so on. Yeah, I mean, they're always involved as stakeholders in different angles. They are part of a team. We work as a team, just one government. We are serving one government.\\u0026rdquo;.\\u003c/em\\u003e\\u003c/p\\u003e\\u003cp\\u003eAccording to participant_6, the role sharing made implementation easier especially in the beginning when there was some uncertainty. RURA in turn worked with the Rwanda Revenue Authority (RRA) and utilised revenue collection infrastructure to track and collect the contributions, rather than building new and cost intensive systems from scratch:\\u003c/p\\u003e\\u003cp\\u003e\\u003cem\\u003e\\u0026ldquo;We have had challenges at the beginning. So, people had so many questions in the beginning, like how we remit, when do we remit. But that is expected, what we did was work with our partners because we deal with RURA and RURA deals with the companies. For the petrol and gas, the contributions are levied at the time of import, [\\u0026hellip;.] they are paid at the customs through RRA system, which we have also access. [\\u0026hellip;..] So, for us, what we do is kind of reconciliation, why re-invent the wheel when a sister organisation has the tools you need. And we already knew RRA has a high compliance rate, so it was cost saving for us \\u0026rdquo; Participant_6, RSSB\\u003c/em\\u003e\\u003c/p\\u003e\\u003cp\\u003eThe same collaboration was also noted between the government agencies and international NGOs especially those the health system strengthening sub-sector. A representative for one of the major NGOs explained the close relationship between the government and NGOs while also noting that the private sector is often not as closely engaged:\\u003c/p\\u003e\\u003cp\\u003e\\u003cem\\u003e\\u0026ldquo;Yes, we development partners are part of the technical working groups, we work closely with government in an advisory role, [\\u0026hellip;.] the TWG does not as far as I know have private sector representation, so no active role in the formulation from them but wider stakeholder dissemination workshops were held with the representative for the health of private health providers in attendance, but that person does not represent the corporations in the telecom sector for example.\\u0026rdquo;\\u003c/em\\u003e Participant_19, NGO representative\\u003c/p\\u003e\\u003c/div\\u003e\\u003cdiv id=\\\"Sec13\\\" class=\\\"Section3\\\"\\u003e\\u003ch2\\u003e3.4.2 Limited Corporations\\u0026rsquo; involvement during formulation\\u003c/h2\\u003e\\u003cp\\u003ePerspectives of on involvement of the corporations in the policy formulation process were split with many government actors reflecting on an overall consultative process during which corporations were consulted, while corporate interviewees rebuffed any kind of consultative engagement with the government prior to the policy roll-out. The presence of a consultative policy making was exemplified in comments made by participant_6 a representative from RSSB, although he added that only two corporations were consulted from the telecommunications sector,\\u003c/p\\u003e\\u003cp\\u003e\\u003cem\\u003e\\u0026ldquo;No, when it comes to telecoms, we only talked to two of them, the big ones,, so as to come to come to an agreement. [\\u0026hellip;.]For example, for this we had like 5% and after negotiation, we came up with 2.5%. So, at the start, we had the proposal. So, we engaged each and every party that was involved in that. \\u0026rdquo; Participant_6, Economist\\u003c/em\\u003e\\u003c/p\\u003e\\u003cp\\u003eParticipant_16 expressed some frustration that his corporation found out about the policy at the same time the general public did when it was passed and published.\\u003c/p\\u003e\\u003cp\\u003e\\u003cem\\u003e\\u0026ldquo;Well, it definitely caught us off guard. There was a lot of scrambling initially to understand the implications and figure out how we were going to navigate this new requirement. We thought surely, they will talk to us before rolling out something this big. It is funny that we kept hearing rumours that something like that was on the way, but officially we found out about it the same time as everyone else when it got published. There's definitely a sense of frustration, I won't deny that. We would have appreciated being consulted or at least having a chance to provide input before such significant policies are finalized\\u0026rdquo;.\\u003c/em\\u003e\\u003c/p\\u003e\\u003cp\\u003eParticipant_16 strongly felt some of the initial challenges faced during implementation could have been avoided through a consultative process:\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003e\\u003cem\\u003eone of our main challenges has been the lack information and guidance surrounding the implementation of the policy. Without prior consultation, there were uncertainties about interpretation, how are they defining telecom companies. We know none of the internet service providers are paying anything, my counterpart there says they did not apply the definition to them, is government saying only call companies are telecom, that does not make sense. Why not just tell us the thought process. By the way all this comes from them not talking to us, we would have advised them.\\u003c/em\\u003e\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003eA government representative linked the limited consultation to the timing of the policy that was released at the height of the COVID pandemic in 2020. Respondents pointed to the need for better information to corporations, not only about their responsibilities, but also about the impact of their contributions. Another issue brought up was the \\u0026ldquo;arm\\u0026rsquo;s length\\u0026rdquo; relationship between the corporations and government and proposed that it would be beneficial if the government treated the corporations as development partners and not just as a funding source. Additionally, the lack of incentives for the corporations emerged given the limited publicity from government about the contribution of the businesses which takes away the public relations incentives they would have received as a result. In this scenario, the government reaps the rewards of the businesses' contribution, while the businesses themselves miss out on the potential reputational gains.\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv id=\\\"Sec14\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003e3.5 Political will\\u003c/h2\\u003e\\u003cp\\u003eStrong leadership and political will, at the highest level, were commonly mentioned out as a key facilitator of the CBHI contributions policy. Sharing the opinion that the prioritisation of the health sector reflects what the Government truly values, participant_7 a senior ministry of health official emphasised how senior leadership support ensures ideas are pursued beyond planning:\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003eI think the crucial success of everything is the leadership because the leadership willing to make change are the most important. If there is political will, then people will find an alternative way of achieving the target. But if there is no will, whatever alternative we the technocrats are bringing in, we will not contribute. The leadership is crucial in understanding that this is a priority, thinking that people have to reduce the hardship of people accessing the quality health services. So, for me, that's one is attributed to the leadership. If the leadership is good, then everything will be much easier. If the leadership is not good, whatever ideas you have, will just remain on paper.\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003eWhen discussing if the corporations employed any pushback strategies when the policy was launched, Participant_16 a corporate lawyer for one of the targeted companies, attributed lack of push back to the united front country leadership has towards health:\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003eBy the way the leadership of this country seems united on anything health, you can\\u0026rsquo;t push back even if you wanted.\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003eThis theme of strong political supported by evidence from Front Patriotique Rwandais (FPR)\\u0026rsquo;s historical campaign manifestos over the years exemplified by the 2024 manifesto below.\\u003c/p\\u003e\\u003cp\\u003e\\u003c/p\\u003e\\u003cp\\u003eThe FPR political party was re-elected back into power in July 2024 with Paul Kagame as the president of the republic of Rwanda. As shown in Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e above, FPR\\u0026rsquo;s 2024\\u0026ndash;2029 manifesto mirrors its predecessor in highlighting Community Based Health Insurance as a key priority for his government.\\u003c/p\\u003e\\u003c/div\\u003e\"},{\"header\":\"4. Discussion\",\"content\":\"\\u003cp\\u003eThe findings reveal that governance plays a pivotal role in influencing compliance, while governance systems are often weak in developing countries, with challenges such as limited enforcement, corruption, and judicial inefficiencies (Nwoke et al., \\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e2023\\u003c/span\\u003e), this study presents a contrasting case. In Rwanda, systems that support the rule of law have been effectively established, and this strength significantly influences corporate compliance with mandatory CSR policies. Many corporations expressed that once a mandate is embedded in law. However, evidence from both low- and middle-income countries (LMICs) and high-income countries (HICs) shows that the rule of law is often uneven in practice, and powerful corporate actors may still find avenues to bypass, dilute, or influence the application of mandates.(Favotto \\u0026amp; Kollman, \\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e2021\\u003c/span\\u003e; Yousfi et al., \\u003cspan citationid=\\\"CR29\\\" class=\\\"CitationRef\\\"\\u003e2022\\u003c/span\\u003e). Some respondents expressed that the cultural respect for the law is deeply rooted in Rwanda\\u0026rsquo;s post-genocide history, there seemed to be a collective desire to maintain national stability and progress, this translates into an almost institutionalized loyalty to state directives. Past literature supports the possibility that Rwanda\\u0026rsquo;s genocide history, influences tradition and contributes to accountability at community level (Chemouni, \\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e2018\\u003c/span\\u003e; Kamuzinzi \\u0026amp; Rubyutsa, \\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e2019\\u003c/span\\u003e). Corporate respondents also expressed confidence in the accountability and monitoring systems, citing examples such as road levies, where visible outcomes such as the construction of roads which reinforced trust that the funds collected would be used as intended, encouraging organizations to comply willingly. This finding aligns withOsei Afriyie et al. (\\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e2021\\u003c/span\\u003e) who in exploring the factors that affected implementation of health reforms in Tanzania found accountability to be a building block to mutual trust.\\u003c/p\\u003e\\u003cp\\u003eThe presence of an independent regulatory body was acknowledged as a factor that strengthened compliance. However, collaboration among stakeholders was highlighted as a mixed area. The differentiated levels of stakeholder engagement observed in this study align closely with the conceptual categories outlined by the Stakeholder Dialogue Ladder (Bj\\u0026oslash;rgen et al., \\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e2021\\u003c/span\\u003e). Interviews revealed strong inter-agency coordination, suggesting that public sector institutions were involved in shared decision-making processes and strategic alignment. This is consistent with prior research emphasising the effectiveness of cross-sector collaboration in complex policy environments (Bryson, Crosby, \\u0026amp; Stone, 2015). NGOs and subject matter experts were actively consulted and played advisory roles during the formulation and operationalisation of the policy. A advisory engagement can enhance both the technical quality and legitimacy of policy interventions (Edelenbos \\u0026amp; Klijn, 2005; Newig \\u0026amp; Fritsch, 2009). In stark contrast, corporate stakeholders largely experienced \\u003cem\\u003eone-sided information flow\\u003c/em\\u003e. Many reported first encountering the policy through indirect channels such as media reports or informal networks. This unilateral mode of communication reflects minimal engagement and a missed opportunity for leveraging private sector insights. Prior studies have shown that marginalising such actors in policy dialogues can lead to implementation friction, reduced compliance, or unintended consequences (Boaz et al., 2018; Mitchell, Agle, \\u0026amp; Wood, 1997). This stratification has implications not only for the perceived legitimacy of the policy but also for its long-term sustainability and responsiveness. Although this did not have an immediate impact on compliance levels, it created dissatisfaction among businesses, businesses expressed a desire to be treated as development partners similar to how NGOs are involved in policy discussions rather than merely as funding sources. This lack of engagement also led to misinformation, as illustrated by one respondent who mistakenly believed that CBHI contributions were a temporary COVID-19 resource mobilization measure.\\u003c/p\\u003e\\u003cp\\u003eFinally, political will was seen as a critical enabler of compliance. Respondents highlighted strong governmental support for the policy, aligning with the broader agenda of the ruling party. Strong political leadership can help overcome institutional inertia, navigate resistance from powerful interest groups, and mobilise the bureaucratic and financial tools necessary for policy implementation (Babor et al., \\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2023\\u003c/span\\u003e; Ezenduka et al., \\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e2022\\u003c/span\\u003e; Wright et al., \\u003cspan citationid=\\\"CR27\\\" class=\\\"CitationRef\\\"\\u003e2017\\u003c/span\\u003e). It also plays a key role in framing public problems and generating the legitimacy required to introduce new policy instruments, such as taxes or levies for social programmes. Studies from Ghana, for example, have documented how the successful rollout of a National Health Insurance Scheme was made possible by the active engagement and commitment of high-level political actors, who worked to align public messaging, financing, and institutional responsibilities (Fusheini, \\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e2016\\u003c/span\\u003e; Novignon et al., \\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e2021\\u003c/span\\u003e). Similarly, Thailand's journey toward universal health coverage was not solely a technocratic exercise, but the result of deliberate political prioritisation, championed by elected leaders and embedded within broader electoral platforms (Harris \\u0026amp; Libardi Maia, \\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e2022\\u003c/span\\u003e; Tangcharoensathien et al., \\u003cspan citationid=\\\"CR20\\\" class=\\\"CitationRef\\\"\\u003e2019\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR21\\\" class=\\\"CitationRef\\\"\\u003e2020\\u003c/span\\u003e). Rwanda\\u0026rsquo;s own history of health system transformation has repeatedly hinged on strong political direction, especially in post-genocide rebuilding efforts where leadership prioritised equity in health access (Binagwaho et al., 2014).\\u003c/p\\u003e\"},{\"header\":\"5. Conclusion\",\"content\":\"\\u003cp\\u003eThis study demonstrates that the success of public interest driven regulatory policies depends on the strength of the governance systems that support their implementation. In the case of mandatory corporate contributions to Community-Based Health Insurance (CBHI), robust governance mechanisms including strengthening rule of law, setting up accountability and monitoring systems, political buy-in, establishing and independent body for oversight are essential for ensuring compliance with national resource mobilisation strategies that seek to raise funds from the private sector. Stakeholder engagement (lack of) did not seem to affect compliance in the Rwanda case. However, this might not be the case for countries with weaker rule of law and other systematic incentives for compliance.\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003ch2\\u003e\\u003cstrong\\u003eEthics approval and consent to participate\\u003c/strong\\u003e\\u003c/h2\\u003e\\n\\u003cp\\u003eThis research was conducted in accordance with the ethical principles of the Declaration of Helsinki.\\u0026nbsp;Ethical approval for the research was obtained from the Human Research Ethical Committee of the Open University (\\u003cem\\u003eHREC reference number: 2023-0007-3)\\u003c/em\\u003e and a research permit no RP00000726 was issued by the Rwanda National Council of Science and Technology.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eInformed written consent was obtained from all participants, participant personal information was also anonymised for confidentiality and privacy.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003ch2\\u003e\\u003cstrong\\u003eAvailability of data and materials\\u003c/strong\\u003e\\u003c/h2\\u003e\\n\\u003cp\\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\\u003c/p\\u003e\\n\\u003ch2\\u003e\\u003cstrong\\u003eCompeting interests\\u003c/strong\\u003e\\u003c/h2\\u003e\\n\\u003cp\\u003eNo competing interests declared\\u003c/p\\u003e\\n\\u003ch2\\u003e\\u003cstrong\\u003eFunding\\u003c/strong\\u003e\\u003c/h2\\u003e\\n\\u003cp\\u003eFunding for this study was provided by The Open University , Faculty of Business and Law as part of a PhD studentship for B.J.T\\u003c/p\\u003e\\n\\u003ch2\\u003eConflicts of Interest:\\u0026nbsp;\\u003c/h2\\u003e\\n\\u003cp\\u003eThe authors declare no conflicts of interest.\\u003c/p\\u003e\\u003ch2\\u003eAuthor Contribution\\u003c/h2\\u003e\\u003cp\\u003eResearch conceptualization: B.J.T., F.C., D.K., M.N.Data collection: B.J.T.Data analysis: B.J.T., F.C., D.K., M.N.Methodology: B.J.T., F.C., D.K., M.N.Writing original draft: B.J.T.All authors contributed to manuscript review \\u0026amp; editing\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\n \\u003cli\\u003eAbraham, R., \\u0026amp; Tao, Z. 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The politico-economic challenges of ghana\\u0026rsquo;s national health insurance scheme implementation. \\u003cem\\u003eInternational Journal of Health Policy and Management\\u003c/em\\u003e, \\u003cem\\u003e5\\u003c/em\\u003e(9). https://doi.org/10.15171/ijhpm.2016.47\\u003c/li\\u003e\\n \\u003cli\\u003eHarris, J., \\u0026amp; Libardi Maia, J. (2022). Universal healthcare does not look the same everywhere: Divergent experiences with the private sector in Brazil and Thailand. \\u003cem\\u003eGlobal Public Health\\u003c/em\\u003e, \\u003cem\\u003e17\\u003c/em\\u003e(9), 1809\\u0026ndash;1826. https://doi.org/10.1080/17441692.2021.1981973\\u003c/li\\u003e\\n \\u003cli\\u003eHontelez, J. A. C., Goymann, H., Berhane, Y., Bhattacharjee, P., Bor, J., Chabata, S. T., Cowan, F., Kimani, J., Knox, J., Lora, W. S., Lungu, C., Manne-Goehler, J., Mauti, J., Moshabela, M., Mpembeni, R. M., Wa Mwanza, M., Ndung\\u0026rsquo;u, T., Omondi, E., Phiri, S., \\u0026hellip; B\\u0026auml;rnighausen, T. W. 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(2024). https://rpfinkotanyi.rw/amatora/wp-content/uploads/2024/06/20240311_Portrait-Pamplet_14x17cm_Engl-2.pdf\\u003c/li\\u003e\\n \\u003cli\\u003eYousfi, O., Mbarek, I., Omri, A., Yousfi, O., Mbarek, I., \\u0026amp; Omri, A. (2022). \\u003cem\\u003eCSR and Corporate Lobbying: From an Environmental Perspective\\u003c/em\\u003e. https://doi.org/10.5772/INTECHOPEN.106936\\u003c/li\\u003e\\n\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":true,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-health-services-research\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"bhsr\",\"sideBox\":\"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/BHSR/default.aspx\",\"title\":\"BMC Health Services Research\",\"twitterHandle\":\"BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true},\"keywords\":\"Health financing, governance, private sector, Multinational corporations, Domestic resource mobilisation, Developing countries\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-8057585/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-8057585/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003eLow- and middle-income countries face persistent challenges in financing universal health coverage, making domestic resource mobilisation (DRM) a critical priority. Governance systems are increasingly recognised as central to ensuring effective and sustainable mobilisation of resources. It is also widely documented that governance systems in many developing countries are weak and fragmented. Rwanda is one of the few low income countries that performs well in governance indicators. This article examines how Rwanda\\u0026rsquo;s governance structures support DRM through mandatory corporate contributions to the Community-Based Health Insurance (CBHI) scheme.\\u003c/p\\u003e\\u003cp\\u003eUsing a qualitative case study design, we conducted key informant interviews of relevant individuals from different government institutions, NGO representatives and multinational corporations from the telecommunications and Oil\\u0026amp; gas sector. The analysis focused on governance dimensions including policy design, institutional arrangements, accountability mechanisms, and enforcement processes. Rwanda\\u0026rsquo;s governance system demonstrates a clear legal mandate for corporate contributions, strong institutional coordination between government agencies, and accountability mechanisms that ensure compliance. These governance features have enabled consistent mobilisation of domestic resources, significantly strengthening CBHI financing. However, challenges remain, including balancing trade-offs with corporations and ensuring long-term sustainability.\\u003c/p\\u003e\\u003cp\\u003eGovernance plays a pivotal role in facilitating DRM for health. Rwanda\\u0026rsquo;s experience with mandatory corporate contributions to CBHI offers valuable lessons signalling other low- and middle-income countries seeking to enhance domestic health financing to prioritise strengthening of governance frameworks.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Governance and Domestic Resource Mobilisation: Lessons from Rwanda’s mandatory corporate Contributions to Community-Based Health Insurance\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2025-12-10 10:12:01\",\"doi\":\"10.21203/rs.3.rs-8057585/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"reviewerAgreed\",\"content\":\"238238633174053811875033687929580796539\",\"date\":\"2025-12-16T10:13:08+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewersInvited\",\"content\":\"\",\"date\":\"2025-12-08T03:34:23+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvited\",\"content\":\"\",\"date\":\"2025-11-12T09:34:32+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2025-11-12T04:56:04+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2025-11-12T04:54:49+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"BMC Health Services Research\",\"date\":\"2025-11-07T13:22:19+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-health-services-research\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"bhsr\",\"sideBox\":\"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/BHSR/default.aspx\",\"title\":\"BMC Health Services Research\",\"twitterHandle\":\"BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"322f47ec-0c5c-4318-9270-52ab54f7e930\",\"owner\":[],\"postedDate\":\"December 10th, 2025\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"under-review\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2025-12-10T10:12:01+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2025-12-10 10:12:01\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-8057585\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-8057585\",\"identity\":\"rs-8057585\",\"version\":[\"v1\"]},\"buildId\":\"8U1c8b4HqxoKbykW_rLl7\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}