A joint research and capacity strengthening programme by Radboudumc and University College London

Rwanda

Overview

In Rwanda, we supported a comprehensive sectoral review of cancer services as part of the broader Health Benefits Package (HBP) reform under the Community-Based Health Insurance (CBHI) scheme from 2021 to 2025. Rather than reassessing the entire HBP, the government prioritised cancer as a high-burden and high-cost disease area requiring structured and evidence-informed prioritisation.

In collaboration with the University of Rwanda, the Rwanda Social Security Board (RSSB), Ministry of Health, the London School of Hygiene and Tropical Medicine, and other (inter)national stakeholders, we developed and applied adaptive Health Technology Assessment (aHTA) methods to assess 49 cancers, each divided into basic, core and enhanced service packages. The review generated cost-effectiveness evidence under significant time, data and capacity constraints. This represents the first large-scale assessment of multiple cancers simultaneously to inform HBP design in a low-income setting.

Context & Objectives

Cancer incidence in Rwanda has increased, with substantial pressure on CBHI reimbursement and national health budgets. While Rwanda has strong UHC coverage (over 80% insured through CBHI), expanding access to high-cost cancer treatments posed fiscal sustainability challenges.

The Ministry of Health initiated a multi-stakeholder prioritisation process assessing cancers against nine criteria, including:

Cost-effectiveness
Burden of disease
Financial risk protection
Budget impact
Feasibility
Equity considerations

The specific objectives of the cost-effectiveness component were to:

Select appropriate aHTA methods under local constraints
Identify or generate cost-effectiveness ratios (CERs) for all individual cancer services
Adjust for transferability across settings
Strengthen the methodological basis for future HBP prioritisation

Approach & Methods Used

Division of each cancer into basic, core and enhanced packages using NCCN resource stratification
Rapid review of the Tufts CEA Registry (12,000+ CEAs) to identify transferable evidence
Application of structured “knock-out” transferability criteria (intervention match, geography, study quality)
Recalculation of Average Cost-Effectiveness Ratios (ACERs) to ensure comparability
Purchasing power parity (PPP) adjustment for cross-country transfer
Structured Expert Elicitation (SEE) with 12 national cancer experts to fill evidence gaps
Delphi-based consensus scoring for interventions lacking published CEAs
Explicit categorisation of interventions by cost-effectiveness thresholds relative to GDP per capita.

Outcomes

The assessment demonstrated that large-scale sectoral cost-effectiveness review is feasible within 3–4 months using adaptive HTA methods. Access to pre-extracted CEA databases significantly reduced analytical burden, while structured expert elicitation filled critical evidence gaps.

Key findings include:

Strong publication bias toward common cancers (e.g. cervical, breast, lung)
Limited LMIC-specific CEAs for many cancer types
Need for better reporting standards in global CEA literature
Importance of clearly communicating uncertainty during appraisal

The Rwanda experience shows how adaptive HTA can support evidence-informed benefit package design in resource-constrained settings, particularly for complex and high-cost disease areas like cancer.