This chapter evaluates the impact of prepayment schemes on access to health care for poor households, based on household survey data. Rwanda is one of the poorest countries in the world. After the genocide in 1994, public health care services were provided free to patients, ?nanced by donors and the government. In 1996, the Ministry of Health reintroduced prewar level user charges. By 1999, utilization of primary health care services had dropped from 0.3 in 1997 to a national average of 0.2 annual consultations per capita. This sharp drop in health service use, combined with growing concerns about rising poverty, poor health outcome indicators, and a worrisome HIV prevalence among all population groups, motivated the Rwandan government to develop communitybased health insurance to assure access to the modern health system for the poor. In early 1999, the Rwandan Ministry of Health, in collaboration with the local communities and with the technical support of the USAID-funded Partnerships for Health Reform (PHR) project, began the process to pilot test 54 prepayment schemes in three districts. At the end of their ?rst operational year, the 54 schemes comprised more than 88,000 members. The ?ndings presented in this chapter reveal that insurance enrollment is determined by household characteristics such as the health district of household residence, education level of household head, family size, distance to the health facility, and radio ownership; health and economic indicators did not in?uence enrollment. Insurance members report up to ?ve times higher health service use than nonmembers. The analysis con?rms ?ndings reported by PHR based on provider data: health insurance has signi?cantly improved equity in health service use for members while out-of-pocket spending per episode of illness has decreased.