Think of a situation where you earn less than 200USDollars a month, its mid-month and your child gets diagnosed with a tumor that needs urgent operation which can’t go less than 120 USDs.
Jean Claude Nsabimana went through such a situation; his 3 year old daughter (Sabrina) was hospitalized for one or two months after an operation, so doctors could monitor her recovery progress.
Nsabimana’s wife had taken their daughter for a medical checkup after realizing Sabrina’s neck was swollen, only for the medical staff at Kimironko to refer to the case as a complex one hence transferring the little girl to Kibagabaga hospital where the child was admitted immediately.
“An immediate operation had to be done on Sabrina’s chin. The medical staff at Kibagabaga asked if I had any kind of insurance,” narrates Nsabimana.
Nsabimana can’t be more thankful for the Mutuele de santé medical insurance that saved him a fortune he would have spent on his child surgery and recovery. Mutuele de santé provides a 10 per cent discount on medical bills.
“When I saw the bill, I was shocked and wondered where on earth would I get the money,” he recalls.
The hospital relieved his stress when they calculated the medical insurance coverage and Nsabimana paid only 19.000 francs of the hiked bill.
For many Rwandans of middle class and vulnerable groups (24.81 per cent of Rwandans) who cannot afford to pay for their medical bills in private clinics and hospitals, the Mutual health insurance has been more than just a policy or card; mutuele is salvation.
Lack of access to health care affects many developing countries.
The risks of total exclusion from health care or becoming destitute are higher among extremely poor populations.
Policy options to deal with these disparities in accessing health care are limited. Among them, alternate mechanisms of community financing based on pre-payment and on risk pooling, such as Community Based Health Insurance (CBHI) have proven to be strong options, reconciling an improvement in the financial accessibility to health care and the necessity to mobilize the internal resources necessary to ensure the financial viability of health services.
In Rwanda, CBHI was identified as a privileged channel for the growth of financial accessibility to health services in both rural settings and in the informal sector. CBHI, in particular allows the most vulnerable and poorest segments of the population to be fully integrated into the health insurance system, thus guaranteeing participation of the whole community and avoiding any stigmatization. As CBHI is a mechanism which aims to limit the exclusion of the most destitute segments of the population from health services, CBHI should play a key role in building and strengthening the foundations for the concept of equity in access to various packages supplied by the health system.
Mutual insurance companies are designed as a supplement to other existing health insurance systems. These include:
i) RAMA (Rwandaise d’Assurance Maladie) which currently covers civil servants and other Government agents, and is gradually expanding coverage to private sector workers involved in the formal economy; ii) the health insurance program for servicemen (MMI) which started at the end of 2005 and; iii) other private insurances which are encouraged to develop insurance products in Rwanda.
The unprecedented efforts by the Rwandan Government in the CBHI implementation process to date are a strong foundation for future success. The strong political investment by the Government is justified by the important role that can be played by CBHI in the financing of health services, in population access to health the care as well as in the wellbeing of families and the fight against poverty.
CBHI is strongly anchored in community ownership and management. Not only do communities massively subscribe to CBHI, but they are also involved in their management. A sense of urgency, the continuous involvement at all levels with the intervention of actors from the community, including administration and religious organizations, have played a major role in transforming communities and local authorities into active players in the CBHI system.
A development policy document for CBHI was elaborated in 2004 as a basic tool for the implementation and development of CBHI in Rwanda.
Andrew Makaka, the Director of the Health Financing Unit, Ministry of Health- (which oversees Mutuelle de Sante National programs), says that the CBHI program in Rwanda is similar to others in Africa, but has a dynamic that makes it so unique compared to others.
Makaka says that though Mutuelle de santé is not well published, it stands out (on the global measure) as one the most successful programs of health financing around the world. One of the reasons is that there are many teams of health experts from around the world who have Rwanda to study how the Rwandan programs works.
He notes that, apparently the Rwandan government is planning on a program of documenting the health system so that it is put out to the academic world in order to learn from it, critic or advice where necessary.
“The Rwandan community health program is unique because it is both national and community based program. It is community based, managed by the community in a sense that the community manages its own affairs. This has not happened anywhere else” Makaka says.
He also states that the success of Rwanda’s communal health insurance depends on the mandatory premium contribution of residents (who are put in three categories). This premium is mandatory and paid every fiscal year (from July).
“It is mandatory by the law that every person living in Rwanda owns a health insurance cover,” Makaka states.
He says that in other places (countries) such health programs are only pockets of the National Health Service which are tax-based or a formal social health insurance of which the formal sector contributed to was in place.
“For Rwanda’s case it is very unique. It is pulled from the informal- we have social health insurance (which is the formal sector- RAMA, MMI etc) -but these also contribute 1% of the total revenue into mutuelle de santé, so that the scale-up is so unique,” Makaka states.
The Rwandan government and its partners have strongly promoted mutuelles de santé, community health insurance schemes that have proven to be a timely solution to the problem of access to quality health care.
Since Rwanda is a developing country and has a big percentage of relatively poor people, this health Policy depends purely on their community premium contributions. The government annually subsidizes this mutual health insurance program with 13% of the total budget- that is 1.8billion Rwandan francs every year, the contribution of the people is about 15billions, while the donor community contributes 2.8bilions (but this money is used to contribute to the health care of persons in category 1- the poor).
Before the new policy of mutuelle de santé was revisited in 2010 each person was supposed to pay 1000 Rwandan Francs a year (about 2 USD) for health care coverage. This however was limited to medical access to only in the region or health sector in which the member registered. That means that one could not access health care away from the region in which they registered.
Due to the demands of health care and propelling the health care access program, the government of Rwanda, revisited the policy. The new policy has been approved and now operational. Unlike in the past, it now suits the convenience of patients accessing medical care at any point or any region- this is called ‘Patient roaming’.
Another unique factor about the mutuelle de santé program is the ‘gate-keeper system’- this is a very strict referral system where one can only access medical care after you have a referral. That means from health centers to district hospital to Referral hospital (such as University teaching hospital of Kigali -CHUK, and King Faisal hospitals) – which is different from other health systems where patient go everywhere they want.
However, in cases of emergency cases, For example, if one got involved in an accident, they can be treated at the nearest health center, and even if patient did not carry with them the health insurance card, they would be first treated and logistics followed later on.
The new Mutuelle policy provides that only 24.81 percent of Rwandans fall under category 1 of Mutuelle policy and their contributions are catered for by the government since they fall largely within the abject poverty category.
The remaining percentage of population is within categories 2 and 3 and is obliged to make their own contribution, at least every fiscal year not later than January 31, 2012.
Those in category two pay Rwf 3,000 while people in the third category are supposed to pay Rwf7, 000, according to the new mutuelle policy.
Today, 90 percent of Rwandans have registered for mutuelle de santé, and the program is considered a success according to the ministry of health. Addressing a news conference to highlight key achievements and challenges in the course of 2011, the Minister of Health Dr Agnes Binagwaho attributed the quick response to the value and contribution that Rwandans have seen in this health insurance scheme.
Binagwaho said that the adherence to the new policy on Mutuelle de santé is very impressive,” the minister said. “Even in some areas where we had problems on data verification, these issues have since been resolved and the population is responding positively.”
“Mutuelles are very important for us,” says Chantal Murebwayire, whose baby was born prematurely at Muhima Hospital. “I’m no longer afraid to come to be treated or have my children be treated. With my mutuelles card I am sure to have all the care needed. If I weren’t a mutuelles member, I would have had problems paying the bill after such a long hospitalization stay.”
Presently, all operational health centers of the country shelter a CBHI section; which presumes 100 % geographic coverage. CBHI is regulated under the law n°62 / 2007 of 30/12/2007 relating to the creation, organization, functioning and management of CBHI and published on March 20th, 2008 in the official gazette.
Population adhesion to CBHI was progressive but the dynamics really started in 2004. As demonstrated in table 1 below, adhesion rates increased rapidly from 7% in 2003 to 85% at the end of June 2008.
The growth of CBHI, along with malaria and HIV programs, performance-based financing, community health and quality assurance program, have led to dramatic improvements in key health indicators as shown in the 2007-08 IDHS: i) the assisted deliveries rate rose from 39% in 2000 to 52% in 2008; ii) the infant mortality rate declined from 139/1000 in 2005 to 62/1000 in 2008; the under five mortality rate from 152/1000 in 2005 to 103/1000 in 2008.
The policy was formulated on the following five axes of implementation;
setting up management structures;
strengthening the legal framework;
strengthening the financing mechanisms;
strengthening the partnership with CBHI;
strengthening national and provincial capacities
The general objective of this policy is to give guidance which will allow the development and strengthening of the CBHI system in Rwanda, with the larger goal of improving the financial accessibility of populations to health care, protecting households against the financial risks associated with diseases, and strengthening social inclusion in the health sector. To reach this goal, the development policy is based on solidarity and equity principles. Furthermore, all interventions are aimed at strengthening intersectoral coordination, community participation, decentralization, and partnership principles.
The specific objectives of this policy are to:
1) Favor the membership in CBHI for people in the non-public sector and rural areas
2) Strengthen the financial viability of CBHI;
3) Strengthen management capacities of the CBHI system
The positive development of the CBHI system in Rwanda is based on several advantages, namely:
Strong political commitment by central and decentralized government (CBHI coverage is an important indicator in district performance contracts);
a decentralized health system;
an excellent network of health facilities in all districts;
Although the extension of the CBHI system to the national level in Rwanda has been done at a very fast pace, it still faces the following challenges:
Insufficient funds at both district and national risk pooling level;
Weak pooling mechanisms;
Insufficient staff and limited management capabilities;
Possible abuse at different levels in the system (beneficiaries and providers);
Large numbers of people in the informal sector with limited capacity to make contributions and who are difficult to identify;
The CBHI system is linked to several key policies in Rwanda.
Vision 2020 summarizes the long-term objectives of the Rwandan Government. It aims to increase the well-being of the population by increasing production and reducing poverty in a context of good governance. To realize this vision, the Government of Rwanda endeavors to develop a proactive and successful health system capable of identifying the health needs of the population and of bringing appropriate answers.
The poverty reduction strategy is the mid-term policy reference framework that guide Rwanda towards attainment of the Vision 2020 objectives, as well as international development objectives, such as the MDGs. An evaluation of the first poverty reduction strategy in Rwanda (PRSP 2002-2007) demonstrated a remarkable improvement in health indicators.
Health and poverty are very closely related, as falling ill is one of the biggest risk factors leading to poverty, and, conversely, poverty can be the root of many health problems. Thus, ensuring an adequate standard of health care by setting up a health insurance system which offers coverage against financial, social and health risks connected to diseases constitutes a very important element in the fight against the poverty. This is reflected in the new mid-term strategy (EDPRS, 2008-2012) which has a stronger emphasis on poverty reduction through strengthening economic growth policy with components focusing on the most vulnerable segments of the population.
Considering the environmental, socio-sanitary and administrative dynamism in the six years following CBHI development, the orientations of the aforementioned policy deserved to be updated. Following the rapid change and expansion of the Rwandan CBHI scheme, it was necessary to adapt the CBHI policy document to the current context. This revised policy contains new orientations relating to the consolidation of the current success of the system but especially devices adapted to the challenges presently facing CBHI. The implementation and management of the CBHI is under the responsibility of the Ministry of Health (MOH).
Some of the success stories of Mutuelle de santé are indicated in the Demographic and Health Survey (DHS)-2010, the establishment of Mutuelle de santé has contributed to the increased access to health services, reduction in Infant Mortality rates (reduced by more than half) and made health care services affordable with a Rwandan only 4.6dollars instead of 34 dollars in 2005 (saving at least 30 dollars spent by an average Rwandan), hospital utilization has doubled since 2005 (from 0.6 to 1.8 times)- meaning that Rwandans today frequent hospitals more than ever because it is affordable.
The success of Mutuelle de santé has been attributed to the strong political will, decentralization and involvement of the communities. The program is stipulated in the political system of the government and it does take center stage as one of the ways of achieving the countries development programs which are stipulated in Rwanda’s Economic Development and Poverty Reduction Strategy (EDPRS), Vision 2020 and the Millennium Development Goal (MDG).
Though the Rwandan health program has attracted international attention and interest of global health care experts, Andrew Makaka says that the program is still a learning process and continues to develop.
The objectives of the development policy of CBHI are clearly defined and well shared. They strongly reflect the ambition of the Rwandan government towards promote the accessibility of quality health care to all Rwandans, particularly the most destitute.
This determination is shown by the implication of local authorities in the improvement of the coverage by CBHI and the involvement of development partners in the development of CBHI. The challenges are certainly numerous, but the adherence and participation of Rwandans in the development of this policy will favor its success.
Public Health Policy
Since the 1980s, the Government of Rwanda has implemented primary health care as the key strategy for improving the health of the population. In February 1995, the Ministry of Health began making reforms in the health sector in accord with the Lusaka declaration; these reforms were later adopted by the Government of National Unity in March 1996. The new policy was based upon three main strategies: (1) the decentralization of the health system using the health district as the basic operational unit; (2) the development of the primary health care system through its eight core components; and (3) the reinforcement of community participation in the management and financing of services.
The Ministry of Health has laid down seven major policy objectives for the health sector: (1) to improve the availability of human resources; (2) to improve the availability of quality drugs, vaccines, and consumables; (3) to expand geographical accessibility to health services; (4) to improve financial accessibility to health services; (5) to improve the quality of services in the control of disease; (6) to strengthen national referral hospitals and research and treatment institutions; and (7) to strengthen institutional capacity.
Characteristics of Rwandan health care services include decentralization, continuous provision, flexibility, and efficiency. The health system consists of three levels of provision: central, intermediary, and peripheral. The central level includes the central directorates and programs of the Ministry of Health and the national referral hospitals. It elaborates policies and strategies, ensures monitoring and evaluation, and regulates the health sector. It organizes and coordinates the intermediary (at the provincial level) and peripheral (at the health district level) levels of the health system and provides them with administrative, technical, and logistical support.