Rwanda is the country with the highest enrolment in health insurance in Sub-Saharan
Africa. Pivotal in setting Rwanda on the path to universal health coverage is the
community-based health insurance (CBHI), which covers three-quarters of the
population. Despite the importance of the Rwandan case, analyses of the history and
politics behind the scheme are largely absent. This article fills this gap by identifying
the political drivers behind its development. It engages in process-tracing of the
critical policy choices regarding the CBHI: the design of the first pilot, the decision to
make enrolment mandatory, the policies to ensure its adequate funding, and the
strategy of day-to-day implementation. It argues that the commitment to expanding
health coverage is part of the broader efforts of the ruling coalition to foster its
legitimacy based on rapid socio-economic development in a context of a dominant
political settlement. The paper also argues that CBHI was chosen as a solution to
expand access to healthcare over other approaches because it was the policy option
that was the most compatible with the ruling coalition core paradigmatic ideas of
popular participation, individual and national self-reliance.