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COMMUNITY BASED HEALTH INSURANCE (CBHI) IN RWANDA

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Title: COMMUNITY BASED HEALTH INSURANCE (CBHI) IN RWANDA


1
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
2
(No Transcript)
3
Economic and Health situation in Rwanda
Key Economic Characteristics
  • 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
    (gt90 of population)
  • Landlocked country with high population density

Key Health Characteristics
  • 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)

4
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

5
Challenges to Universal Health Insurance Coverage
Key Challenge 1 Setting of CBHI contribution
levels
Key Challenge 2 Identification of poorest part of
population for subsidisation
Key Challenge 3 Financing of gap between
populations contribution and financing needs
Key Challenge 4 Management of national framework
and creation of local capacities
GOAL Increased utilisation of health services
leading to improved population health status
6
A Contribution of 1000 rwf (2) per capita
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

Uneven distribution of income creates a conflict
between cost recovery (maximisation of revenue)
and inclusion of population
A contribution of 2/capita/year will include 80
of the population and raise approximately 13.4m
1) Bucagu et al., 2004, including Kigali
7
Community based self identification
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
8
Financing Gap Contribution vs hospital (a
Minimum) Services Package
Key Challenge 3 Financing of gap between
populations 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

9
Implementation of a national framework poses a
capacity challenge
  • 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

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

10
Uganda
D.R. Congo
Tanzania
Burundi
Burundi
11
Organisation
  • Payment
    source of finance
  • Payment finance

NATIONAL POOLING RISK Government Civil
Insurance Military Insurance Private
Insurances Donors
Ministry of Health
Referral Hospital
District Hospital
District Level
DISTRICT POOLING RISK District -Section
Mutuelle -National Pooling Risk -Donors
Sector Level
Health Center
Contributions -Sector Level -Donors
12
Evolution of membership
  • 2003 7
  • 2004 27
  • 2005 44.1
  • 2006 73
  • March 2007 53

13
Key Results
  • Increased financial accessibility to health care(
    rate of utilization)
  • Improved financial sustainability of primary
    health services

14
Result 1 Average annual number of health
facility visits in Rwanda
15
Members use preventive curative services
16
Result 2 Financial sustainability of basic
health care services
17
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

18
Before becoming a member, I would spend sometimes
even more than 10,000 rwf. I am not afraidNow,
I present my card and get services.
19
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)

20
Key success factors
Government Contribution
  • 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

Development Partner Contribution
  • 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

Evidence Based Policy Development
21
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.

22
  • Thank you
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