Abt Associates Inc. In collaboration with: Development Associates, Inc.

Utilization and Expenditures on Outpatient Health Care by HIV Positive Individuals in RwandaPHR Rwanda - Abt Associates Inc.IAEN and AIDS Conference DurbanJuly 2000 • Abt Associates Inc. • In collaboration with: • Development Associates, Inc. • Harvard School of Public Health • Howard University International Affairs Center • University Research Co., LLC

Background: NHA and HIV in Rwanda • PHR, Rwandan National Health Accounts Team, UNAIDS, PNLS, and MOH collaborating to examine the sources of uses of funding for HIV services in Rwanda using the NHA framework • National Health Accounts will clearly illustrate: • Who (Private, Public, Donors) pays for what? • How much do they pay?

Why National Health Accounts? • Effective method for compiling descriptive statistics of a nation’s health economy. • Represents the flow of funds throughout the system. • Can assist policy-makers in setting health care policy priorities. • Can assist governments in assessing the performance of their health sectors. • Can assist governments in identifying areas of inequity in the distribution of care.

NHA Data Collection • Data on sources and uses of HIV funds is collected through surveys from all levels of the health system including: • Donors • Hospitals • Pharmaceutical Companies • Ministry of Health • NGOs • Households*

Household Survey: Snapshot of Out-of -Pocket Expenditures • PHR with NHA team, UNAIDS, and MOH developed a survey to investigate the use of and expenditures on outpatient and inpatient health by HIV positive individuals in Rwanda • Findings on expenditures will contribute to understanding of out-of -pocket expenditures on health, and • contribute to existing limited body of literature looking at the impact of HIV on households

Outpatient Survey: Methodology • 350 HIV positive individuals were identified in four facilities • 1 Hospital • 1 Health Center • 1 AIDS Association • 1 meeting and testing facility • Interviews were conducted by social assistants who had a relationship with the patient

Data Limitations for the Study • Sample size • 350 total • 293 were women • Many facilities do not test, nor inform patients of their HIV status in Rwanda, which limits the sample size • Issue of self-selection: all patients knew their status • Findings are not representative of the universe of HIV positive individuals in Rwanda as most were identified from non-routine testing

Rwanda: Background • 7.8 million people in 1998 • Per Capita GDP in 1997: $242 • Service Sector: • economically most productive with 7% of the population produces 43% of GDP • 70% of population lives below the poverty line

Rwanda NHA 1998 Results

HIV/AIDS in Rwanda • Estimated that 11% of the adult population is sero-positive • Highest prevalence in service sector population (19%) • Testing takes place in few facilities and often status is not revealed to those tested • Government of Rwanda has a clearly articulated multi-sectoral approach to combating the HIV epidemic

Socio-demographics of surveyed individuals: mainly women, widowed, without education, living in urban areas

NHA Finding: Households affected by HIV/AIDS suffer economically • The following percentage of people indicated that they were “with difficulty” and “unable to meet” the following basic needs: • food (73%) • housing (57%) • education (86%) • clothing (82%) • Average Number of Work days lost in the past two weeks: : 4.8

NHA Finding: Sero-positive patients seek care more often • Annual per capita utilization rates • 0.29 visits per general population • 10.9 visits per sero-positive individual • Highest service use rates among sero-positive patients who are: • urban, • married, • in highest expenditure quintiles

NHA Finding: Sero-positive individuals have higher per capita spending

How are health expenditures financed? • 66% receive assistance from church and family • 18% borrow from family/friends • Sero-positive low-income individuals did not perceive to have received donor and government assistance

Conclusions for Sample Group • Sero-positive individuals who are poor • need care almost 10x more often than the general population • have higher health care costs than the general population • need assistance to pay out-of-pocket fees • receive help from family, friends and church

Recommendations • Prevention: • Strengthen efforts to prevent HIV/AIDS • Provide extensive public information - IEC • Broader, more extensive and routine testing for HIV • Improve access and equity for the poor with HIV • increase government financing targeted to lower-income groups • donor financed prepayment for poor households with access to health centers and district hospital • international efforts lower the costs of AIDS treatments

Recommendations • Further Research • effectiveness of alternative approaches to improve access and equity for the poor with HIV/AIDS

Partnerships for Health Reform is implemented by Abt Associates Inc. under contract No. HRN-C-95-00024 with the U.S. Agency for International Development (USAID)

Abt Associates Inc. In collaboration with: Development Associates, Inc.