GAHARA – Nsengimana, a fiftysomething merchant from this town in eastern Rwanda, is ranting against his country's medical services. "Old Gerard died in May in the courtyard of Gahara's health center. The nurses refused to take care of him because he hadn't paid the health insurance fees for all of his family members," Nsengimana says.

As the anger rises in his voice, Nsengimana says that in Rwanda someone can be denied treatment even if just one family member has not paid for their health insurance card.

"The authorities lock us up in their offices for hours and demand that we sell our cattle so that we can pay for the card," adds Yoweri, a fellow merchant.

But just a few miles from here, across the border in neighboring Burundi, doctors and nurses don't ask any of that; the national health service is also much less expensive, and available both for Burundians and Rwandese.

"The Burundian health services are fast and efficient," says Yoweri. "One day, I noticed that they even took care of the Rwandese patients first because they had come from further away. I was stunned!"

Jacqueline Nyirahabimana, a nurse at Gahara's health center, says that a typical nurse can see as many as 300 patients in a day. "Some people go to Burundi for faster service," she admits. However, Nyirahabimana denies any mistreatment as far as her health center is concerned. "How could we refuse to take care of a poor, dying person because they don't have a health insurance card? But we don't automatically welcome those who can pay and don't have a card. If we did, the insurance system would collapse."

Bad citizens

Another advantage for the patients crossing the border is that several Burundian hospitals are close to the border with Rwanda. Going there costs less than being transferred to more distant Rwandese hospitals. Moreover, the subscription to a private insurance is optional in Burundi, as opposed to Rwanda where it is compulsory.

Finally, there is the role of the currency exchange rate in the medical exodus to Burundi. "One Rwanda franc is worth more than two Burundi francs. That's why it's cheaper there," explains Nyirahabimana.

The migration of Rwandese patients started as soon as the nation's private health insurance policy was launched, in 2009. The authorities did not understand why a large number of people living near the border had still not subscribed to this new method of universal access to health care. 

A police officer from Gahara remembers, "At the very beginning, they were branded as bad citizens. But later, we understood that it was just about the financial reality." He added that the poor people from the overpopulated region of the North, who came east searching for arable lands, were the first to go to the Burundian health services.

But for the inhabitants of Gahara, such as thrift shop owner Kamanzi, "this has become the norm for Rwandese people who live near the Burundian border. We are already so used it, we'll go over the border just for a stomach bug."