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