Does Universal Health Coverage Improve Access to Healthcare? Insights from Rwanda’s National Health System

Does Universal Health Coverage Improve Access to Healthcare? 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Insights from Rwanda’s National Health System Musinga Abdulswamad This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7978334/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Universal Health Coverage (UHC) ensures that all individuals receive the health services they need without financial hardship. Rwanda has made significant progress toward achieving UHC through community-based health insurance, health financing reforms, and expanded service delivery. This study assesses how UHC has influenced healthcare utilization in Rwanda, with a focus on equity and access across different population groups. Few studies have combined long- term quantitative trends with qualitative insights to comprehensively assess UHC impact. This study evaluates healthcare utilization patterns in Rwanda between 2015 and 2025, examining both achievements and persistent barriers. Methods: A secondary data analysis was conducted using the Rwanda Demographic and Health Survey (DHS) data, the national Ministry of Health reports, and the World Health Organization UHC service coverage indices. Descriptive and comparative methods were applied to examine healthcare utilization trends across income quintiles, rural vs. urban areas, and key demographic groups. Key indicators included skilled birth attendance, outpatient visit rates, and access to basic health services. Results: Mean outpatient visits per capita increased from 1.5 in 2015 to 2.3 in 2023, and skilled birth attendance rose to 94%, reflecting substantial service coverage gains. However, disparities persisted: utilization was higher in higher Ubudehe categories (Category 3: 91% vs Category 1: 74%, p < 0.01). Primary survey respondents reported barriers including medicine stock-outs, long wait times, co-payment burdens, and transport limitations. Qualitative findings highlighted supply-chain issues, workforce constraints, and limited awareness of entitlements. The analysis revealed notable improvements in healthcare utilization over the last decade, particularly among rural populations and low-income households. Utilization of skilled maternal care and essential health services increased nationally. However, disparities persist, especially among the poorest quintile and informal sector workers, with some populations continuing to face barriers due to indirect costs and service availability. Financial protection remains uneven, despite high insurance coverage levels. Conclusions: To a certain point, Rwanda's UHC strategy has reduced utilization inequality and improved access to healthcare services. But there are still gaps in financial protection and equity. To improve cross-subsidization mechanisms, boost service delivery, and guarantee that no one is left behind on the journey to UHC, more policy interventions are needed. Clinical trial number : not applicable. Universal Health Coverage Healthcare Utilization Rwanda Equity Access to Care Public Health Policy DHS Health Insurance Full Text Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted 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. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7978334","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":537729480,"identity":"7bf30aec-5803-4780-956a-522d895fe5f7","order_by":0,"name":"Musinga Abdulswamad","email":"data:image/png;base64,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","orcid":"","institution":"","correspondingAuthor":true,"prefix":"","firstName":"Musinga","middleName":"","lastName":"Abdulswamad","suffix":""}],"badges":[],"createdAt":"2025-10-29 09:53:24","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7978334/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7978334/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":95009037,"identity":"bc85a8cb-d379-4762-b8dc-e5801eb69fd8","added_by":"auto","created_at":"2025-11-03 10:07:15","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":4162,"visible":true,"origin":"","legend":"","description":"","filename":"cc0ad5120a3e491695c84506dc4e0560.json","url":"https://assets-eu.researchsquare.com/files/rs-7978334/v1/a43bf70915da3e54d81d4e44.json"},{"id":106068623,"identity":"2a5dc72b-ee54-410b-b6eb-4b3aded4f29f","added_by":"auto","created_at":"2026-04-03 06:11:16","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":320126,"visible":true,"origin":"","legend":"","description":"","filename":"Manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7978334/v1_covered_0cef724e-2950-4fee-a34a-988505d6e3c9.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Does Universal Health Coverage Improve Access to Healthcare? Insights from Rwanda’s National Health System","fulltext":[],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":false,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":true,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":true,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Universal Health Coverage, Healthcare Utilization, Rwanda, Equity, Access to Care, Public Health Policy, DHS, Health Insurance","lastPublishedDoi":"10.21203/rs.3.rs-7978334/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7978334/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUniversal Health Coverage (UHC) ensures that all individuals receive the health services they need without financial hardship. Rwanda has made significant progress toward achieving UHC through community-based health insurance, health financing reforms, and expanded service delivery. This study assesses how UHC has influenced healthcare utilization in Rwanda, with a focus on equity and access across different population groups. Few studies have combined long- term quantitative trends with qualitative insights to comprehensively assess UHC impact. This study evaluates healthcare utilization patterns in Rwanda between 2015 and 2025, examining both achievements and persistent barriers.\u003c/p\u003e\n\u003cp\u003eMethods:\u003c/p\u003e\n\u003cp\u003eA secondary data analysis was conducted using the Rwanda Demographic and Health Survey (DHS) data, the national Ministry of Health reports, and the World Health Organization UHC service coverage indices. Descriptive and comparative methods were applied to examine healthcare utilization trends across income quintiles, rural vs. urban areas, and key demographic groups. Key indicators included skilled birth attendance, outpatient visit rates, and access to basic health services.\u003c/p\u003e\n\u003cp\u003eResults:\u003c/p\u003e\n\u003cp\u003eMean outpatient visits per capita increased from 1.5 in 2015 to 2.3 in 2023, and skilled birth attendance rose to 94%, reflecting substantial service coverage gains. However, disparities persisted: utilization was higher in higher Ubudehe categories (Category 3: 91% vs Category 1: 74%, p \u0026lt; 0.01). Primary survey respondents reported barriers including medicine stock-outs, long wait times, co-payment burdens, and transport limitations. Qualitative findings highlighted supply-chain issues, workforce constraints, and limited awareness of entitlements.\u003c/p\u003e\n\u003cp\u003eThe analysis revealed notable improvements in healthcare utilization over the last decade, particularly among rural populations and low-income households. Utilization of skilled maternal care and essential health services increased nationally. However, disparities persist, especially among the poorest quintile and informal sector workers, with some populations continuing to face barriers due to indirect costs and service availability. Financial protection remains uneven, despite high insurance coverage levels.\u003c/p\u003e\n\u003cp\u003eConclusions:\u003c/p\u003e\n\u003cp\u003eTo a certain point, Rwanda's UHC strategy has reduced utilization inequality and improved access to healthcare services. But there are still gaps in financial protection and equity. To improve cross-subsidization mechanisms, boost service delivery, and guarantee that no one is left behind on the journey to UHC, more policy interventions are needed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e: not applicable.\u003c/p\u003e","manuscriptTitle":"Does Universal Health Coverage Improve Access to Healthcare? 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