COMMUNITY BASED HEALTH INSURANCE (CBHI) IN RWANDA
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Transcript of COMMUNITY BASED HEALTH INSURANCE (CBHI) IN RWANDA
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
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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