COMMUNITY BASED HEALTH COMMUNITY BASED HEALTH INSURANCE (CBHI) IN RWANDAINSURANCE (CBHI) IN RWANDA

INYARUBUGA HertilanINYARUBUGA HertilanCBHI Coordinator CBHI Coordinator

Kampala, 15-16 june 2005Kampala, 15-16 june 2005

OUTLINE OF THE PRESENTATIONOUTLINE OF THE PRESENTATION IntroductionIntroduction Evolution of health « mutuelles » Evolution of health « mutuelles » Organization and management of health « mutuelles » Organization and management of health « mutuelles » Partners et Role of the govermentPartners et Role of the goverment Keys resultatsKeys resultats OpportinitiesOpportinities CBHI challengesCBHI challenges Interventions strategiesInterventions strategies CBH and information for management and decision - CBH and information for management and decision -

makingmaking ConclusionConclusion

IntroductionIntroduction

The health « mutuelles » in The health « mutuelles » in Rwanda are associations which Rwanda are associations which are not for commercial purposes are not for commercial purposes and that are based on solidarity and that are based on solidarity of beneficiaries for forseing of beneficiaries for forseing financial risks in term of access financial risks in term of access to health care servicesto health care services

IntroductionIntroductionIn setting up the health  »mutuelles », the In setting up the health  »mutuelles », the

principal objectives are those principal objectives are those determined in rwanda government determined in rwanda government targets:. targets:.

To Improve the population financial To Improve the population financial access to the health care servicesaccess to the health care services

To Improve health state of the To Improve health state of the populationpopulation

To Improve the financial capacity of the To Improve the financial capacity of the health structureshealth structures

To Strengthen community participation To Strengthen community participation in health care managementin health care management

Health Financing Challenge 1: Health Financing Challenge 1: Health services are dependent on external resources Health services are dependent on external resources

and (household) out-of-pocket paymentsand (household) out-of-pocket payments

HEALTH FINANCING SOURCES IN RWANDA

32.5%

9.2%7.1% 0.7%

50.5%

Donors Household MOF Private sector Other Public sector

Source: NHA Rwanda (1998)

Health financing challenge 2:Health financing challenge 2: LLow financial access and utilization of modern health care as ow financial access and utilization of modern health care as

a consequence of the a consequence of the levelslevels of out-of-pocket payments of out-of-pocket payments

0.34

0.27

0.240.23

0.25

0.28 0.29

0.38

0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

0.4

1997 1998 1999 2000 2001 2002 2003 2004

Evolution of health Evolution of health « mutuelles » in Rwanda« mutuelles » in Rwanda

Between 1996 and 1997, only one Between 1996 and 1997, only one « mutuelle » existing,« mutuelle » existing,

In 1998, 6 health « mutuelles » were In 1998, 6 health « mutuelles » were functionalfunctional

From 1999 to 2000, 54 « mutuelles » were From 1999 to 2000, 54 « mutuelles » were operatingoperating

From 2001 to 2004, 228 « mutuelles »From 2001 to 2004, 228 « mutuelles » Later in may 2006, 378 « mutuelles » were Later in may 2006, 378 « mutuelles » were

operationaloperational

RUHENGERI: 1 CBHI

BEFORE 1999: BEFORE 1999: RUHONDO CBHI: AN ISOLATED INITIATIVERUHONDO CBHI: AN ISOLATED INITIATIVE

BYUMBA22 CBHI

KABGAYI 17 CBHI

KABUTARE:15 CBHI

RUHENGERI: 1 CBHI

1999-2000: IMPLEMENTATION OF A PILOTE PHASE 1999-2000: IMPLEMENTATION OF A PILOTE PHASE

54 CBHIs IN 3 HEALTH DISTRICTS54 CBHIs IN 3 HEALTH DISTRICTS

Ruhengeri: 11 MS

Ngarama 5 MS

Mibilizi:1MSMushaka1MS

Gihundwe 4MSNyamasheke 3

Gitarama37 SPP

4 MS Gikongoro

Gakoma:4 MS

Kibilizi:7 MS

Nyanza:1 MS

Kabutare:15 SPP

Byumba28 SPP

Kibuye:7 MS

Umutara:1 MS

Ruli:10 MS

Nyamata: 10 MS

Rulindo9 MS

Kibungo:36 MS

2001-2001-2004: 2004: 228 CBHI : 2.500.000 BENEFICIARIES (March 2005)228 CBHI : 2.500.000 BENEFICIARIES (March 2005)

Later in May 2006: 378 « Mutuelles » with an enrollement rate at 47%.

(17)

(14) (12)

(10)

(12)(14)

(11)

(16)

(11)(12)

(15)(8)

(15)(8)

(15)(19)

(20)

(13)(10)

(13)

(13)

(13)

(12)

(13)(12)

(11)

(16)

(12)

(5)

(6)

Organization and ManagemtOrganization and Managemt

At the cell and sector level there are health At the cell and sector level there are health « mutuelles » committees in charge of the « mutuelles » committees in charge of the sensitization and mobilizationsensitization and mobilization

At the health center level a agent is in At the health center level a agent is in charge of the administrative and financial charge of the administrative and financial management of the « mutuelle » ; at this management of the « mutuelle » ; at this level, a management committee elected level, a management committee elected among the members; this committee is among the members; this committee is mainly in charge of the monitoring. mainly in charge of the monitoring.

At the district level, an agent in charge of At the district level, an agent in charge of the coordination of the « mutuelles » within the coordination of the « mutuelles » within the districtthe district

Organization ManagementOrganization Management

At the national level, there is a technical At the national level, there is a technical support cell in charge of: support cell in charge of:

Of the capacity building for « mutuelles » Of the capacity building for « mutuelles » managersmanagers

Of the development of policy, strategies Of the development of policy, strategies and legal frameworks and legal frameworks

Of development of management modules Of development of management modules and toolsand tools

Of the MonitoringOf the Monitoring

Organization and Organization and ManagementManagement

HealthHealth Center Center levellevel: :

• Unlimited access to all services and drugsUnlimited access to all services and drugs

• Referral by (ambulance) to District Referral by (ambulance) to District HospitalHospital

District District HospitalHospital level: all healthcare level: all healthcare packagespackages

Reference Hopital: all healthcare Reference Hopital: all healthcare packagespackages

Organization and Organization and managementmanagement

Variables:Variables:

-Subscriptions of 2 to 7 households Subscriptions of 2 to 7 households vary between 2.500rwf and vary between 2.500rwf and 11500rwf11500rwf-Per capita subscriptions vary Per capita subscriptions vary between 600rwf and 1000rwfbetween 600rwf and 1000rwf- Ticket    »moderateur » is Ticket    »moderateur » is between 100rwf and 150rwf per between 100rwf and 150rwf per episode, and from 5% to 25% in episode, and from 5% to 25% in co-paymentsco-payments

The partners & role of Government.The partners & role of Government. Ministry of Health (MINISANTE)Ministry of Health (MINISANTE)

Ministry of Local Goverment (MINALOC)Ministry of Local Goverment (MINALOC) Donors and NGOsDonors and NGOs

Rwanda Popular BanksRwanda Popular Banks, , CooperativesCooperatives Health centers and districtsHealth centers and districts Role of government:Role of government:• Providing Management tools to Health Mutuelle.Providing Management tools to Health Mutuelle.

• Providing facilitating equipments to Health mutuelle.Providing facilitating equipments to Health mutuelle.• Providing Budget for Training and Monitoring.Providing Budget for Training and Monitoring.• Providing Budget for Indigenous.Providing Budget for Indigenous.• Providing Budget pooling risks.Providing Budget pooling risks.

Key AchievementsKey Achievements Increased financial accessibility to health Increased financial accessibility to health

carecare

Improved financial sustainability of primary Improved financial sustainability of primary health serviceshealth services

Strengthened community participation in Strengthened community participation in healthcarehealthcare

Level of Utilisation of Curative Care in 2003: Members of cbhis vs Non-Members

0

0.5

1

1.5

2

2.5

Kabutare Kabgayi Byumba Bugesera

Non-Members Memberssource:

IntraHealth/ABT Assoc.

Result 1: Improvement of financial accessibility: Result 1: Improvement of financial accessibility: Members of CBHI seek care earlier and use services more Members of CBHI seek care earlier and use services more

frequently than non-membersfrequently than non-members

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

ResultResult 2 2 Financial sustainability of basic health care Financial sustainability of basic health care servicesservices

FINANCFINANCING OF ING OF BUNGWEBUNGWE HC BY THE CBHI HC BY THE CBHI

11568973

12992017

15674751

17781765

11785786

9116120

6450495

5059928

0

2000000

4000000

6000000

8000000

10000000

12000000

14000000

16000000

18000000

20000000 Total Revenues of Bungwe HC Revenues from Mutuelle

44% 50% 58% 66%

2000 2001 2002 2003

OpportunitiesOpportunities - the existence of the culture of social - the existence of the culture of social

solidarity in the country (protective solidarity in the country (protective sacking, pastoral hammock, work jointly) sacking, pastoral hammock, work jointly)

- the existence of political will - the existence of political will - the existence of the development of the - the existence of the development of the

co-operatives co-operatives - the existence of at least a medical - the existence of at least a medical

structure in a district structure in a district - facility of communication (language, - facility of communication (language,

road, radio etc.)road, radio etc.)

MMain challengesain challenges Gap between the premiums of contribution Gap between the premiums of contribution

and the care costs and the care costs A large number of « indigents »A large number of « indigents » Problem of quality of the care provided by Problem of quality of the care provided by

the public medical staffthe public medical staff

Lack of mobile access to healthcare services Lack of mobile access to healthcare services throughout the countrythroughout the country

Strategic InterventionsStrategic Interventions Study on the real costs of providing health Study on the real costs of providing health

services services Development of a policy and a strategic Development of a policy and a strategic

framework for the mutual insurance companiesframework for the mutual insurance companies Development of a legal frameworkDevelopment of a legal framework Development of a set of training modules on Development of a set of training modules on

CBHI management and training of trainers CBHI management and training of trainers (TOT)(TOT)

Harmonization des tariffsHarmonization des tariffs

Strategic Interventions Strategic Interventions (cont(cont))

Development of approaches for the Development of approaches for the improvement of health care qualityimprovement of health care quality (PAQ, Quality assurance and (PAQ, Quality assurance and

contractual approach) contractual approach) Development of a risk pooling system for Development of a risk pooling system for

support to mutuelles for district and support to mutuelles for district and reference hospitalsreference hospitals

Increase health services packages in Increase health services packages in hospitals hospitals

CBHI and Information for CBHI and Information for management and decision management and decision

makingmaking

Up to now three indicators are used Up to now three indicators are used for decision-making at the for decision-making at the community, and institutions levels:community, and institutions levels:

1. Number of mutuelles beneficiaries 1. Number of mutuelles beneficiaries 2. Enrollement rate2. Enrollement rate 3. Health services utilization rate3. Health services utilization rate

CBHI and Information for CBHI and Information for management and decision management and decision

makingmakingSoon, with the BIT/STEP,we will implement a Soon, with the BIT/STEP,we will implement a

software before the end of this year . This software before the end of this year . This software will allow us to capture indicators software will allow us to capture indicators on :on :

Mutuelles FinancesMutuelles Finances- Premium recover ratesPremium recover rates- Health care costsHealth care costs- Re-enrollement ratesRe-enrollement ratesThese indicators would allow an appropriate These indicators would allow an appropriate

management of the systemmanagement of the system

ConclusionConclusionThe health « mutuelles » are a useful tool for the The health « mutuelles » are a useful tool for the

provision of financial access to health services for provision of financial access to health services for the poor people, however, its sustainability and the poor people, however, its sustainability and strength sare focused on:strength sare focused on:

The existence of a good quality of health care services The existence of a good quality of health care services for the beneficiariesfor the beneficiaries

The existence of an appealing package of health The existence of an appealing package of health services for the beneficiairiesservices for the beneficiairies

The existence of a continued sensitization of the The existence of a continued sensitization of the population and the utilization of the witness statements population and the utilization of the witness statements from the benficiairies.from the benficiairies.

ConclusionConclusion de la participation des beneficiaires dans la de la participation des beneficiaires dans la

gestion des mutuelles de santégestion des mutuelles de santé

de la bonne gestion administrative et de la bonne gestion administrative et financière du systèmefinancière du système

MERCIMERCI