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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 (UHC) is the community-based health insurance (CBHI), which covers more than three-quarters of the population. The paper seeks to explain how Rwanda, one of the poorest countries in the world, managed to achieve such performance by understanding the political drivers behind the CBHI design and implementation. Using an analytical framework relying on political settlement and ideas, it engages in process-tracing of the critical policy choices of the CBHI development. The study finds that the commitment to expanding health insurance coverage was made possible by a dominant political settlement. CBHI is part of the broader efforts of the regime to foster its legitimacy based on rapid socio-economic development. Yet, CBHI was chosen over other …