COMMUNITY BASED HEALTH INSURANCE (CBHI) IN RWANDA

1. COMMUNITY BASED HEALTH INSURANCE (CBHI) IN RWANDA Caroline R. Kayonga, PermanentSecretary / Ministry of Health, Rwanda Ministerial Leadership for Global Womens Health Seminar Madrid, 13 – 14 April, 2007

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 (>90% 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 population’s 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 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

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 NATIONAL POOLING RISK Government; Civil Insurance; Military Insurance; Private Insurances; Donors Ministry of Health • Payment source of finance • Payment finance • Payment finance 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 afraid…Now, I present my card and get services.”

19. 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) Challenges and Strategic Interventions

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