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in total health expenditure had fallen from 27per cent in 2002 to 14 per cent. Service utilizationhas increased among the previously uninsured,especially poor women of childbearing age andtheir infants. 174 This dramatic progress is not onlythe result of the UCS as investment in the expansionof primary health-care centres, particularlyin rural areas, has also ensured that universalcoverage translates into access to services onthe ground. 175 Despite being formally coveredunder the UCS, however, some groups continueto experience access barriers. These include olderwomen, women living in remote areas, as well aswomen and men from ethnic minority and migrantcommunities. 176Scaling up community-based healthinsurance in RwandaIn contrast to tax- or social insurance-financedschemes at the national level, community-basedhealth insurance (CBHI) targets lower-incomepopulations with weak contributory capacity,often at the local level. CBHI schemes varyconsiderably but are usually based on solidarityamong individuals with common geographic,occupational, ethnic, religious or gendercharacteristics, with risk being shared within thatspecific community. Membership is voluntary and,in most cases, CBHI schemes are run on a nonprofitand participatory basis. 177CBHI schemes typically offer limited servicepackages and often exclude key health needssuch as routine sexual and reproductive healthservices. 178 Progress in extending coverage canalso be painfully slow. In the United Republicof Tanzania, for example, it took social andcommunity-based insurance schemes a decade toenrol only 17 per cent of the population. 179 In Ghana,where community-based plans were absorbed intothe National Health Insurance Scheme (NHIS) from2003 onwards, almost two thirds of the populationremained without coverage in 2011. 180 Even whenpremiums are set at low levels, CBHI schemes oftenfail to reach the poorest groups: 39 per cent ofwomen and 32 per cent of men in Ghana reportedthat they had not registered with the NHIS becausethe premium was too expensive. 181The experience of CBHI in Rwanda has beenmore positive. CBHI schemes have been partof an overall strategy of the Government torebuild the country’s health system after the1994 genocide. Mutuelles de Santé were pilotedin three districts in 1999 and later extendedto other districts. The Mutuelles enrol entirehouseholds and provide a minimum servicepackage at the primary care level as well asa complementary services package at districtlevel. Users contribute through co-payments, 182but the poorest quarter of the population isexempt thanks to international donor funding.The service package includes family planning,antenatal and postnatal care, childbirth, HIVtesting and treatment as well as prescribeddrugs. By 2011/2012, the coverage of theMutuelles had reached 91 per cent of thepopulation. 183 Together with pre-existing privateand social insurance schemes, this has broughtRwanda close to universal coverage within adecade.The reforms in Rwanda have significantlyreduced financial barriers to health-care accessfor women and expanded their uptake ofservices. The share of women who reported lackof money as the main barrier to accessing healthcare declined from 71 per cent in 2005 to 53 percent in 2010. In the same period, skilled birthattendance increased from 39 per cent to 69 percent and women’s use of modern contraceptivemethods from 10 per cent to 25 per cent. Gapsin access between women from rural andurban areas and between women from higherandlower-income groups have narrowedsubstantially and access has expanded for allgroups. 184 Box 3.9 highlights the dramatic impactof these changes on maternal mortality rates.These achievements have been bolstered bysignificant investments in health infrastructureand service delivery, heavily supported byinternational donors. 185 A performance-basedfinancing system rewards service providers forbetter patient follow-up. Improved indicatorsand monitoring systems track progress in healthoutcomes, including, for example, the proportionof women delivering at health facilities. 186163