The cost of safe abortion care in Rwanda: What new evidence reveals

A recent study by Health Development Initiative (HDI) Rwanda, in partnership with the Guttmacher Institute, has revealed that the financial burden of obtaining safe abortion care (SAC) services remains significant, despite Rwanda’s recent legal reforms.

The study draws on hospital billing data from 236 patients who received a SAC service between June 2022 and December 2024. The cost analysis offers the first detailed look at the direct costs of legally provided abortion services in selected healthcare facilities in Kigali . The findings highlight both affordability challenges and systematic inefficiencies that inflate costs, raising urgent questions about equity in safe abortion service accessibility.

Legal access, but financial barriers persist

Although abortion is still criminalized in Rwanda, the abortion law has been liberalized over the past decade. The 2018 Penal Code revision and the 2019 ministerial order permitted abortion under specific circumstances, including rape, defilement, incest, forced marriage, or risk to the health of the woman or fetus. Most recently, a 2024 order decentralized SAC provision, authorizing health centers, polyclinics and other eligible clinics to perform procedures that were once restricted to hospitals.

Yet, as the study notes, “legal abortion is not truly accessible if it is not affordable.” The median cost of safe abortion care in the participating facilities was 62,353 Rfw (about US$50), with charges ranging from as little as 282 Rfw to as high as 256,100 Rfw. For many women, this represents a substantial burden. With Rwanda’s rural living wage estimated at 217,987 Rfw per month, a single abortion care episode can consume the equivalent of 8-9 days of income.

Inpatient care driving costs

Perhaps the most striking finding is the reliance on inpatient treatment. Two-thirds of patients (66.1 %) were admitted as inpatients, with an average stay of 3.1 days. Inpatient cases cost more than double those treated as outpatients: 96,572 Rfw vs 47,167 Rfw.

This practice runs counter to World Health Organization (WHO) guidance, which recommends outpatient provision for most abortion care (either procedural or medication abortion) due to the well-established safety profile of these methods. Routine hospitalization not only inflates costs but also imposes additional burdens: lost wages, childcare challenges, and unwanted disclosure of abortion status.

The study concludes that “requiring multiple days of inpatient care can place unnecessary burdens on women who are seeking safe abortion,” underscoring the need to align clinical practices with international standards.

What really drives the bills

The analysis breaks down costs across nine categories. Consultations fees and drugs were nearly universal, incurred by more than 90% of patients. Laboratory tests (70.8%), imaging (75.4%) and medical acts (76.3%) were also common. Hospitalization charges affected more than half of patients.

Interestingly, counselling, though less frequent (8.5%), carried some of the highest median costs, averaging over 30,000 Rfw. Private facilities, though few in the sample, consistently reported higher charges across nearly all categories, particularly pharmaceuticals and imaging.

Policy implications

The absence of a standardized national tariff for SAC appears to be a major factor behind cost variability. Currently, abortion services are absorbed into the general gynecology and obstetrics schedule, leaving facilities to classify and bill procedures inconsistently.

The authors argue that Rwanda would benefit from a dedicated SAC tariff within the national health insurance scheme. Such a measure could reduce unpredictability, strengthen financial protection, and prevent inequities between public and private providers.

They also call for regulatory oversight of private-sector pricing to prevent cost escalation, and for updated clinical guidelines and provider training to expand outpatient models of care.

A health system in transition

Rwanda’s health system is still adapting to rapid legal change and evolution in international standards.. While reforms have expanded eligibility for abortion services, this study shows that affordability remains a major barrier.

For women, the result is a service that is legally available but financially daunting. For policymakers, the challenge is to ensure that affordability keeps pace with availability.

You can read the full study report (pre-print) here.