A 2020 maternal death in Karongi District which was recently revisited by President Paul Kagame has triggered lasting changes in how Rwanda’s healthcare system handles emergencies, with authorities now enforcing a "treatment first” approach to prevent patients from being turned away over administrative barriers.

Speaking on March 23 during a high-level consultative meeting with central and local government leaders, Kagame recalled the case of a pregnant woman who died after reportedly being denied care at a health centre due to issues related to her community-based health insurance, Mutuelle de Santé.

"It is a story I will never forget,” he said.

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Nearly four years on, the case is no longer just about accountability; it has become a turning point in efforts to ensure that emergency cases are handled immediately, regardless of insurance status or procedural requirements.

From tragedy to reform

Recounting the incident, Kagame said the woman, who was in critical condition and close to giving birth was turned away and asked to first resolve an insurance issue. She was later sent home and died without receiving care.

"They should have treated her first and followed up on payment later,” Kagame said, stressing that mechanisms already exist to address financial matters after emergency treatment has been provided.

That principle now underpins reforms introduced by the Ministry of Health and its partners.

A review of the case found that administrative bottlenecks, not clinical negligence, were the primary cause of delayed care. At the time, mandatory waiting periods for newly subscribed CBHI members, combined with a "verification-first” approach, meant patients could be denied immediate treatment.

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Those rules have since been overhauled. Health authorities say emergency care must now be provided immediately, with insurance verification and payment processes handled afterward.

Waiting periods for Mutuelle de Santé coverage have also been removed, eliminating a key barrier that previously delayed access to care. At the same time, accountability measures have been strengthened to ensure frontline health workers prioritise patient safety over administrative procedures.

"At the time, protocols prevented immediate treatment. Today, the system is designed to ensure that no patient in an emergency is denied care,” said Dr Oreste Tuganeyezu, Acting Head of the Department of Clinical and Public Health Services at the Ministry of Health.

Local authorities in Karongi say the reforms have been reinforced through closer supervision of health facilities and continued training of healthcare workers, particularly in handling maternal emergencies.

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"The goal is that no patient is turned away because of financial or administrative barriers,” said Patrice Akumuntu, Head of Biguhu Health Centre. "Women in labour or emergencies must always be prioritised.”

The case that prompted change

The incident at the centre of the reforms involved Belancilla Musanabera, a resident of Rugabano Sector, who visited Biguhu Health Centre on February 10, 2020, while nearing delivery.

At the facility, her Mutuelle de Santé status was checked and found to be inactive due to a waiting period, despite payment having been made. She was advised to return once coverage became effective and left without receiving medical attention.

On February 22, she gave birth at home. The following morning, she developed severe complications, including excessive bleeding, and died at her residence. Her newborn was later taken to Kirinda District Hospital but also died.

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The case was investigated and prosecuted. While a lower court initially found one staff member guilty of failing to assist a person in danger, the Intermediate Court in Karongi later acquitted the accused, ruling that their actions did not directly cause the death.

Beyond the courtroom

Although the judicial process has largely concluded, the case continues to shape policy and practice.

The Ministry of Justice has confirmed that it is reinvestigating the matter to determine whether any errors occurred in how it was handled, reflecting ongoing efforts to strengthen accountability.

More broadly, the case has become a reference point in discussions about service delivery in Rwanda, highlighting the risks of rigid systems that fail to respond to urgent, real-life situations.

For Kagame, the lesson is clear: systems must work for people, especially in moments of crisis.

"You cannot say you don’t know,” he said, urging leaders to stay attuned to the realities citizens face.

A system recalibrated

The government has made significant progress in expanding healthcare access through initiatives such as Mutuelle de Santé. But the Karongi case exposed critical gaps at the point of care—gaps that reforms now seek to close.

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Health sector stakeholders say the focus going forward is on ensuring that policies translate into practice, through continuous training, stronger supervision, and better coordination between institutions such as health facilities and the Rwanda Social Security Board (RSSB).

As the country pushes toward high-quality, citizen-centred healthcare, the legacy of the Karongi case lies in a fundamental shift: in emergencies, treatment comes first.