This paper evaluates the impact of prepayment schemes on access to health care for poor households, based on household survey data. Rwanda is one of the poorest countries in the world. After the genocide in 1994, public health care services were provided for free to patients, financed by donors and the government. In 1996, the Ministry of Health reintroduced prewar level user charges. By 1999, utilization of primary health care services had dropped from 0.3 in 1997 to a national average of 0.2 annual consultations per capita. This sharp drop in health service use combined with growing concerns about rising poverty, poor health outcome indicators, and a worrisome HIV prevalence among all population groups motivated the Rwandan government to develop community-based health insurance to assure access to the modern health system for the poor. In early 1999, the Rwandan Ministry of Health, in collaboration with the local communities, and the technical support of the USAID-funded Partnerships for Health Reform project (PHR) started the process to pilot test prepayment schemes in three districts. At the end of their first operational year, the 54 schemes counted more than 88,000 members. The findings presented in this paper reveal that insurance enrollment is determined by household characteristics such as the health district of household residence, education level of household head, family size, distance to the health facility, and radio ownership, whereas health and economic indicators did not influence enrollment. Insurance members report up to five times higher health service use than nonmembers. The analysis confirms findings reported by PHR based on provider data: health insurance has significantly improved equity in health service use for members while at the same time out-of-pocket spending has gone down per episode of illness.