COMMUNITY BASED HEALTH INSURANCE (CBHI) IN RWANDA

Caroline R. Kayonga, Permanent Secretary / Ministry of Health,

Rwanda

Ministerial Leadership for Global Womens Health Seminar

Madrid, 13 – 14 April, 2007

Economic and Health situation in Rwanda

Key Economic

Characteristics

Key Health Characteristi

cs

• Strong economic recovery since 1994 Genocide, but still low per capita income ($235) and widespread poverty (56% of population)

• Largest number of people active in agriculture (>90% of population)

• Landlocked country with high population density

• Very high under 5 mortality (152/1000) and maternal mortality (750/100,000) rates

• Primary causes of morbidity: malaria, respiratory infections and diarrhoeal diseases

• High fertility rates (6.1 children/mother) and low life expectancy (female: 46.8 years, male: 41.9 years)

• Low utilisation of health services (0.4 cases / capita / year)

Universal Health Insurance Coverage: the Goal

Key Social Health

Insurance Characteristics

• Formal sector employees are covered in health insurance schemes

• First community based health insurance (CBHI) schemes launched in 1999

• CBHI schemes launched in decentralised fashion during piloting phase

• Recent rapid growth in membership (9% of population in 2003 to 27% in 2004)

•Government initiative to achieve universal coverage of health insurance in Rwanda by the end of 2007

• Creation of a national support unit for Mutuelles and close coordination with development partners in creation of health insurance system

Challenges to Universal Health Insurance Coverage

GOALIncreased utilisation of health services leading to improved population health status

GOALIncreased utilisation of health services leading to improved population health status

Key Challenge 1Setting of CBHI contribution levels

Key Challenge 1Setting of CBHI contribution levels

Key Challenge 2Identification of poorest part of population for subsidisation

Key Challenge 2Identification of poorest part of population for subsidisation

Key Challenge 3Financing of gap between population’s contribution and financing needs

Key Challenge 3Financing of gap between population’s contribution and financing needs

Key Challenge 4Management of national framework and creation of local capacities

Key Challenge 4Management of national framework and creation of local capacities

A Contribution of 1000 rwf ($2) per capita

Key Challenge 1

Setting of CBHI contribution

levels

Key Challenge 1

Setting of CBHI contribution

levels

• The rural population in Rwanda is very cash constrained

• Median monthly household cash income is $6.6, mean monthly income $24.821)

• Mean household size of approx. 5 people

• Poorest population quintile is not able to pay for CBHI

1) Bucagu et al., 2004, including Kigali

A contribution of $2/capita/year will include 80% of the population and raise approximately

$13.4m

Uneven distribution of income creates a conflict between cost recovery (maximisation of revenue) and

inclusion of population

Community based self identification

Key Challenge 2

Identification of poorest part of population for subsidisation

Key Challenge 2

Identification of poorest part of population for subsidisation

• “Indigent” part of population coincides with poorest quintile

• With average household income of $.96 per household, indigents are unable to pay for health insurance

• Identification mechanism is needed to decide on eligibility for subsidisation of health insurance

Choice of eligible population is based on community decisions with elements of self

identification and receives good satisfaction ratings in surveys

Financing Gap: Contribution vs hospital (a Minimum) Services Package

Key Challenge 3

Financing of gap between

population’s contribution and financing needs

Key Challenge 3

Financing of gap between

population’s contribution and financing needs

• Community based health insurance should pay for a minimum package of activities for acute diseases and obstetric care

• Financial resources mobilised in the population are insufficient to cover cost of hospital services.

• Durable mechanisms are needed to finance the gap between resource needs and population contribution

• Financing of gap is based on domestic and international solidarity mechanisms

―Redistribution from formal sector to informal sector

Implementation of a national framework poses a capacity challenge

Key Challenge 4

Management of national

framework and creation of local

capacities

Key Challenge 4

Management of national

framework and creation of local

capacities

• Management at the national level was needed to define policies, norms and to check quality

• CBHI schemes had to be created in areas without current coverage

• Harmonisation of existing schemes and operational questions had to be resolved

• A dedicated national unit was created to manage CBHI in Rwanda

• Close cooperation with key development partners (GTZ, ILO, PHR, etc.) to jump start development of a national system

"

"

"

"

"

UMUTARA

GATSIBO

KAYONZA

KIREHE

KIBUYE

RUTSIRO

BUGESERA

BYUMBA

KIBUNGO

GIKONGORO

NYAMASHEKE

CYANGUGU

NYANZA

NYARUGURU

BURERA

GAKENKE

BUTARE

KAMONYI

GISAGARA

RULINDO

RUHANGO

GITARAMA

NYABIHU

NGORORERO

RWAMAGANA

GASABO

GISENYI

RUHENGERI

KICUKIRO

NYARUGENGE

.10 0 105 Kilometers

1:1 150 000

Legend" chefnvprov

Province de l'Est

Province du Nord

Province de l'Ouest

Province du Sud

Ville de Kigali

Lac

Parc

Limite de district

UMUSHINGA W'IMBIBI NSHYA Z'UTURERE TW'U RWANDA

Uganda

D.R. Congo

Burundi

Burundi

Tanzania

Payment source of finance

Payment finance

Payment financeHealth Center

Sector Level

District Hospital

Referral Hospital

District Level

Contributions-Sector Level-Donors

DISTRICT POOLING RISKDistrict-Section Mutuelle-National Pooling Risk -Donors

NATIONAL POOLING RISKGovernment; Civil Insurance;Military Insurance; Private Insurances; Donors

Ministry of Health

Organisation

Evolution of membership 2003 : 7 %

2004 : 27 %

2005 : 44.1%

2006 : 73 % March 2007 : 53 %

Key Results

Increased financial accessibility to health care( rate of utilization)

Improved financial sustainability of primary health services

Result 1: Average annual number of health facility visits in Rwanda

0

0,2

0,4

0,6

1988 2006

Members use preventive & curative services

0

0,5

1

1,5

2

2,5

Kabutare Kabgayi Byumba Bugesera

Non-Members

Members

Result 2 : Financial Result 2 : Financial sustainability of basic health sustainability of basic health care servicescare services

Sources of Financing (FRW per inhabitant) of HC by the level of enrollment in the CBHIs in 2003

HD of Kabutare, Kabgayi, Byumba, Bugesera [ 72 CBHIs and HC ]

0

50

100

150

200

250

300

350

400

450

500

Under 5 [5,10) [10, 15) [15, 20) [20, 25) [25, 30) [30, 35) [35, 40) 40 et +Level of enrollment %

Rwandan Francs\Capita

DirectPayment bynon-members

Copaymentsmembers ofMHO

Reimboursement by MHO

Other sources

State

Source:IntraHealth

Result 3: Satisfaction: beneficiary testimony The mutual health

Insurance is important for us,” said Chantal, a 24-year-old mother whose baby was born prematurely and required hospitalization I am no longer afraid to come to the health facility with my children, because I know when I show my card, I can get all of the care I need

Before becoming a member, I would spend sometimes even more than 10,000 rwf. I am not afraid…Now, I present my card and get services.”

Challenges and Strategic Interventions Gap between the premiums

of contribution and the care costs

Problem of quality of the care provided by some public medical staff

Strengthening Institutional Capacity for Managing the Mutuelle Health Insurance

Risk pooling system Study on the real costs of

providing health services Harmonization of tarifs Development of approaches

for the improvement of health care quality

Development of a policy and a strategic framework for the mutual insurance companies

Development of a legal framework

Development of a set of training modules on CBHI management and training of trainers (TOT)

Key success factors

Government ContributionGovernment Contribution

Development Partner

Contribution

Development Partner

Contribution

Evidence Based Policy Development

Evidence Based Policy Development

• Thorough piloting phase from 1999-2004

• Clear goal: to achieve universal coverage of health insurance

• Willingness to engage in institutional reform to achieve goals

• Providing specific budget for supporting CBHI management

• Strong program of community sensitization by local Government

• Strong engagement in Sector Wide Approach in health

• Strong technical contributions to development of health insurance

• Willingness to contribute financial and human resources

• Willingness to engage in long term projects

• Policy, strategic plan and laws development based

on strong

analytic foundations

• Triangulation methods using multiple studies and

assessments

• Policy development strongly influenced by

stakeholder consultation

• Regulation of user fees of heath care services

• Development of Quality assurance approaches

Conclusion The insurance mechanisms are a useful tool

for the provision of financial access to health services for the poor people, however, their sustainability and strengths depend on:

The existence of good quality health care services for the beneficiaries

The existence of an appealing package of health services for the beneficiaries

The existence of continued sensitization of the population and the utilization of the witness statements from the beneficiaries.

Thank you