Rwanda
The 35th session of the African Regional Committee of the World Health Organization spurred Rwanda to adopt the Bamako Initiative of 1988, a health development strategy based on decentralization of management to the district-level to strengthen equity in access to health care. The process began with the development of provincial-level and district-level health offices for health system management, building on a history of community-based health insurance associations like Muvandimwe de Kibungo that dated back to the 1960s.
The 35th session of the African Regional Committee of the World Health Organization spurred Rwanda to adopt the Bamako Initiative of 1988, a health development strategy based on decentralization of management to the district-level to strengthen equity in access to health care. The process began with the development of provincial-level and district-level health offices for health system management, building on a history of community-based health insurance associations like Muvandimwe de Kibungo that dated back to the 1960s. This focus boosted community participation in financing health insurance. However, civil war and genocide in the early 1990s disrupted these efforts, decimating Rwanda’s fragile economic base. The death of 1,000,000 individuals and a shortage of health personnel due to mass exodus severely damaged human resources, leaving much of the country and the health system destroyed.
After the war, the government began rebuilding the health system with a focus on decentralizing management, building infrastructure, and strengthening communities’ role in managing and co-financing health-care. In an attempt to increase utilization rates the government abolished user fees between 1994 and 1996, making health care free to all. This system lacked accountability mechanisms, creating weak incentives for service providers to reach rural and poor populations and an under-resourced and poorly managed system, which negatively affected quality and availability of healthcare. In 1998 the government re-instituted user-fees to supplement the budget and improve the system, which led to a precipitous drop in utilization of health care services and increasingly deteriorating health outcomes; by 1999 health care utilization had dropped from 0.3 in 1997 to a national average of 0.2 consultations per person per year, well below the WHO recommendation of 1 health consultation per person per year, and fewer than 10% of the population had health insurance. This sharp drop in health service use combined with growing concerns about rising poverty, poor health outcome indicators, and a worrisome HIV prevalence among all population groups motivated the Rwandan government to develop a Community-Based Health Insurance (CBHI) system in an attempt to increase the use of healthcare services, expand health coverage, improve resource mobilization, improve community participation, and strengthen management capacities of health services.
In 1999 the Rwandan government initiated 54 CBHI pilot programs, implemented in 3 districts incorporating about 150,000 individuals, financed partially by donors with technical assistance provided by Partnerships for Health Reform, a project funded by USAID and run by Abt Associates. CBHI pilots drew on the policy of decentralization that was occurring concurrently in the financial and governmental sectors, working as local partnerships between communities and health centers. District federations of CBHI schemes were set up at the health district level to provide the institutional framework for risk pooling and social intermediation mechanisms between CBHI schemes and other actors including health providers, MOH, NGOs and donors. Rwanda already had a large network of community health workers (animateurs de santé), and these pilots provided an opportunity for defining the roles of the health sector. The pilot steering committee intended to develop a mixed provider payment modality including capitation and a quality payment based on performance, but was unable to due to the information requirements and possible system distortions were too daunting.
The Ministry of Health and its partners conducted a rigorous evaluation of the pilot phase and held a workshop in 2000 to discuss how lessons learned could be applied during the scale-up. Primary recommendations included adapting the system to the institutional environment of decentralization, enlarging the benefits package, and strengthening organizational and financial management in health facilities. Concurrent with the evaluation, in 2000 Rwanda held the first local elections which resulted in the establishment of new local government units. Acting on the recommendations, the newly elected officials assumed local leadership and expansion of CBHI schemes, leading to the adoption of CBHI schemes between 2001 and 2003 under the leadership of mayors and other local leaders.
Rwanda
Historical Context
The 35th session of the African Regional Committee of the World Health Organization spurred Rwanda to adopt the Bamako Initiative of 1988, a health development strategy based on decentralization of management to the district-level to strengthen equity in access to health care. The process began with the development of provincial-level and district-level health offices for health system management, building on a history of community-based health insurance associations like Muvandimwe de Kibungo that dated back to the 1960s. This focus boosted community participation in financing health insurance. However, civil war and genocide in the early 1990s disrupted these efforts, decimating Rwanda’s fragile economic base. The death of 1,000,000 individuals and a shortage of health personnel due to mass exodus severely damaged human resources, leaving much of the country and the health system destroyed.
After the war, the government began rebuilding the health system with a focus on decentralizing management, building infrastructure, and strengthening communities’ role in managing and co-financing health-care. In an attempt to increase utilization rates the government abolished user fees between 1994 and 1996, making health care free to all. This system lacked accountability mechanisms, creating weak incentives for service providers to reach rural and poor populations and an under-resourced and poorly managed system, which negatively affected quality and availability of healthcare. In 1998 the government re-instituted user-fees to supplement the budget and improve the system, which led to a precipitous drop in utilization of health care services and increasingly deteriorating health outcomes; by 1999 health care utilization had dropped from 0.3 in 1997 to a national average of 0.2 consultations per person per year, well below the WHO recommendation of 1 health consultation per person per year, and fewer than 10% of the population had health insurance. This sharp drop in health service use combined with growing concerns about rising poverty, poor health outcome indicators, and a worrisome HIV prevalence among all population groups motivated the Rwandan government to develop a Community-Based Health Insurance (CBHI) system in an attempt to increase the use of healthcare services, expand health coverage, improve resource mobilization, improve community participation, and strengthen management capacities of health services.
In 1999 the Rwandan government initiated 54 CBHI pilot programs, implemented in 3 districts incorporating about 150,000 individuals, financed partially by donors with technical assistance provided by Partnerships for Health Reform, a project funded by USAID and run by Abt Associates. CBHI pilots drew on the policy of decentralization that was occurring concurrently in the financial and governmental sectors, working as local partnerships between communities and health centers. District federations of CBHI schemes were set up at the health district level to provide the institutional framework for risk pooling and social intermediation mechanisms between CBHI schemes and other actors including health providers, MOH, NGOs and donors. Rwanda already had a large network of community health workers (animateurs de santé), and these pilots provided an opportunity for defining the roles of the health sector. The pilot steering committee intended to develop a mixed provider payment modality including capitation and a quality payment based on performance, but was unable to due to the information requirements and possible system distortions were too daunting.
The Ministry of Health and its partners conducted a rigorous evaluation of the pilot phase and held a workshop in 2000 to discuss how lessons learned could be applied during the scale-up. Primary recommendations included adapting the system to the institutional environment of decentralization, enlarging the benefits package, and strengthening organizational and financial management in health facilities. Concurrent with the evaluation, in 2000 Rwanda held the first local elections which resulted in the establishment of new local government units. Acting on the recommendations, the newly elected officials assumed local leadership and expansion of CBHI schemes, leading to the adoption of CBHI schemes between 2001 and 2003 under the leadership of mayors and other local leaders.
The unified front on health care and social security by the government has had a large impact on how effectively the program has developed. The Government of Rwanda has played a very important role in the establishment of the health insurance. Under the leadership of President Paul Kagame, the program was designated as a high priority. In 2005, the Rwandan Ministry of the Public Sector and Labour produced a detailed review of existing social security schemes and set out plans for reform in a draft National Social Security Policy report (Politique nationale de sécurité sociale au Rwanda).
The unified front on health care and social security by the government has had a large impact on how effectively the program has developed. The Government of Rwanda has played a very important role in the establishment of the health insurance. Under the leadership of President Paul Kagame, the program was designated as a high priority. In 2005, the Rwandan Ministry of the Public Sector and Labour produced a detailed review of existing social security schemes and set out plans for reform in a draft National Social Security Policy report (Politique nationale de sécurité sociale au Rwanda). The Ministry of Science, Technology, and Scientific Research was created in 2006 as a way to supplement the Kigali Institute of Science and Technology, to better develop the technology sector in the health care system. This unified front on health care and social security by the government has had a large impact on how effectively the program has developed.
By channeling money to specific programs and diseases, donor organizations have helped to promote the e-health agenda, designed policies for technology use, and developed connectivity in programs, as well as a focus on diseases such as HIV/AIDs. In addition, donor organizations have heavily influenced the expansion of health insurance. After the war in the 1990s, donor groups played a large role in rebuilding capacity and infrastructure, especially within the health sector. As such, groups such as the Center for Treatment and Research on HIV/AIDS, Malaria, Tuberculosis and other epidemics (TRACplus) and Global Funds Against Aids, Tuberculosis and Malaria (GTFAM), have been heavily involved in the implementation, shaping, and monitoring of health insurance programs. USAID has been particularly important, financing technical assistance of the pilot phase as well as the development of the scale-up strategy. By channeling money to specific programs and diseases, donor organizations have helped to promote the e-health agenda, designed policies for technology use, and developed connectivity in programs, as well as a focus on diseases such as HIV/AIDs.
Rwanda
Political Context
The unified front on health care and social security by the government has had a large impact on how effectively the program has developed. The Government of Rwanda has played a very important role in the establishment of the health insurance. Under the leadership of President Paul Kagame, the program was designated as a high priority. In 2005, the Rwandan Ministry of the Public Sector and Labour produced a detailed review of existing social security schemes and set out plans for reform in a draft National Social Security Policy report (Politique nationale de sécurité sociale au Rwanda). The Ministry of Science, Technology, and Scientific Research was created in 2006 as a way to supplement the Kigali Institute of Science and Technology, to better develop the technology sector in the health care system. This unified front on health care and social security by the government has had a large impact on how effectively the program has developed.
By channeling money to specific programs and diseases, donor organizations have helped to promote the e-health agenda, designed policies for technology use, and developed connectivity in programs, as well as a focus on diseases such as HIV/AIDs. In addition, donor organizations have heavily influenced the expansion of health insurance. After the war in the 1990s, donor groups played a large role in rebuilding capacity and infrastructure, especially within the health sector. As such, groups such as the Center for Treatment and Research on HIV/AIDS, Malaria, Tuberculosis and other epidemics (TRACplus) and Global Funds Against Aids, Tuberculosis and Malaria (GTFAM), have been heavily involved in the implementation, shaping, and monitoring of health insurance programs. USAID has been particularly important, financing technical assistance of the pilot phase as well as the development of the scale-up strategy. By channeling money to specific programs and diseases, donor organizations have helped to promote the e-health agenda, designed policies for technology use, and developed connectivity in programs, as well as a focus on diseases such as HIV/AIDs.
Mutuelles are highly decentralized, relying on existing community-based health structures at the district and local level to provide a majority of management and administration of services, with only top-level policy and administration coordinated by the central government.In 2003 the Community-Based Health Insurance system (CBHI) was expanded from a pilot project to a national system. CBHI is comprised of three parts: Mutuelles de Sante; Military Medical Insurance; and Rwanda Health Insurance Scheme. The first, known as Mutuelles de Sante, is a modified version of social health insurance that provides health coverage through voluntary and affordable local insurance. Mutuelles are highly decentralized, relying on existing community-based health structures (such as rural co-operatives) at the district and local level to provide a majority of management and administration of services, with only top-level policy and administration coordinated by the central government.
Mutuelles are highly decentralized, relying on existing community-based health structures at the district and local level to provide a majority of management and administration of services, with only top-level policy and administration coordinated by the central government.In 2003 the Community-Based Health Insurance system (CBHI) was expanded from a pilot project to a national system. CBHI is comprised of three parts: Mutuelles de Sante; Military Medical Insurance; and Rwanda Health Insurance Scheme. The first, known as Mutuelles de Sante, is a modified version of social health insurance that provides health coverage through voluntary and affordable local insurance. Mutuelles are highly decentralized, relying on existing community-based health structures (such as rural co-operatives) at the district and local level to provide a majority of management and administration of services, with only top-level policy and administration coordinated by the central government. Enrollment in the Mutuelles system is voluntary and coordinated at the district and sector level. Members pay annual premiums of 1000 Rwandan francs (approximately US$1.80) per family member and a 10% co-payment fee for all services at the health care facility. Those classified as very poor are exempt from payments and their membership is subsidized through funds pooled at the local Mutuelle level, as well as funding from the government and donors. The expansion of the Mutuelles system led to a rapid uptake of coverage in 2003; by 2010 about 90% of the population had health insurance.
Specific benefits packages are determined by each local Mutuelle branch. All insured Rwandans receive comprehensive, subsidized preventative care through the Minimum Package of Activities (MPA), which covers all services and drugs provided at local health centers. A Comprehensive Package of Activities (MPA) covers a limited number of services at the district hospitals and select services in national hospitals that require referrals from local health centers. Mutuelle members are able to access curative (primary-, secondary-, and tertiary-level) care benefits at all public and private non-profit health centers, which excludes only 10% of the country’s health care facilities.
The Mutuelles system has a comprehensive financing framework that includes risk pooling, cross-subsidies, and substantial support from donors, NGOs, and tax-generated funding from the formal sector. Funding is comprised of annual member premiums organized on a per household basis. When a citizen cannot pay the premium up-front, community banks (Banques Populaires) provide individual loans with 15% interest. The poorest individuals, along with those infected with HIV/AIDs, have their fees subsidized by district and nationally organized Mutuelle solidarity funds financed primarily by the risk-pooling of fees, funding from the central government and external aid partners. A total of 1.5 million individuals enrolled in Mutuelles are subsidized by these funds.
In 2006, performance-based financing (PBF) was implemented, which provided a focus on progress and evaluation measures for both the Mutuelle system and the employer-based government schemes to strengthen the base of evidence and improve quality of care. Performance is monitored through quarterly evaluations and is based on a list of 13 services and 185 variables that measure facility outputs, quality, access to care, and administration. Analysis of results is then conducted by the district and sector levels and payment is then scaled to performance. PBF and CBHI align and reinforce incentives associated with provider payment modalities by putting pressures on providers to improve the quality of services to the satisfaction of CBHI members, which influences enrollment rates into CBHI.
The Mutuelle system functions in conjunction with the small number of private insurance companies in Rwanda, as well as two the government and employer based insurance programs known as Rwanda Health Insurance Scheme (La Rwandaise d’Assurance Maladie or RAMA) and Military Medical Insurance (MMI). RAMA is a health insurance scheme for public servants and individuals working in the formal sector and their dependents. MMI provides health insurance for members of the Rwanda Defense Force and their dependents. Originally MMI was established as a part of RAMA, however separated in 2005 due to concerns about financial risk. RAMA and MMI require 15% copayment for services and pharmaceuticals, and receive preventative and curative care through health facilities affiliated with their insurance scheme.
Rwanda
Summary of Reforms
Mutuelles are highly decentralized, relying on existing community-based health structures at the district and local level to provide a majority of management and administration of services, with only top-level policy and administration coordinated by the central government.In 2003 the Community-Based Health Insurance system (CBHI) was expanded from a pilot project to a national system. CBHI is comprised of three parts: Mutuelles de Sante; Military Medical Insurance; and Rwanda Health Insurance Scheme. The first, known as Mutuelles de Sante, is a modified version of social health insurance that provides health coverage through voluntary and affordable local insurance. Mutuelles are highly decentralized, relying on existing community-based health structures (such as rural co-operatives) at the district and local level to provide a majority of management and administration of services, with only top-level policy and administration coordinated by the central government. Enrollment in the Mutuelles system is voluntary and coordinated at the district and sector level. Members pay annual premiums of 1000 Rwandan francs (approximately US$1.80) per family member and a 10% co-payment fee for all services at the health care facility. Those classified as very poor are exempt from payments and their membership is subsidized through funds pooled at the local Mutuelle level, as well as funding from the government and donors. The expansion of the Mutuelles system led to a rapid uptake of coverage in 2003; by 2010 about 90% of the population had health insurance.
Specific benefits packages are determined by each local Mutuelle branch. All insured Rwandans receive comprehensive, subsidized preventative care through the Minimum Package of Activities (MPA), which covers all services and drugs provided at local health centers. A Comprehensive Package of Activities (MPA) covers a limited number of services at the district hospitals and select services in national hospitals that require referrals from local health centers. Mutuelle members are able to access curative (primary-, secondary-, and tertiary-level) care benefits at all public and private non-profit health centers, which excludes only 10% of the country’s health care facilities.
The Mutuelles system has a comprehensive financing framework that includes risk pooling, cross-subsidies, and substantial support from donors, NGOs, and tax-generated funding from the formal sector. Funding is comprised of annual member premiums organized on a per household basis. When a citizen cannot pay the premium up-front, community banks (Banques Populaires) provide individual loans with 15% interest. The poorest individuals, along with those infected with HIV/AIDs, have their fees subsidized by district and nationally organized Mutuelle solidarity funds financed primarily by the risk-pooling of fees, funding from the central government and external aid partners. A total of 1.5 million individuals enrolled in Mutuelles are subsidized by these funds.
In 2006, performance-based financing (PBF) was implemented, which provided a focus on progress and evaluation measures for both the Mutuelle system and the employer-based government schemes to strengthen the base of evidence and improve quality of care. Performance is monitored through quarterly evaluations and is based on a list of 13 services and 185 variables that measure facility outputs, quality, access to care, and administration. Analysis of results is then conducted by the district and sector levels and payment is then scaled to performance. PBF and CBHI align and reinforce incentives associated with provider payment modalities by putting pressures on providers to improve the quality of services to the satisfaction of CBHI members, which influences enrollment rates into CBHI.
The Mutuelle system functions in conjunction with the small number of private insurance companies in Rwanda, as well as two the government and employer based insurance programs known as Rwanda Health Insurance Scheme (La Rwandaise d’Assurance Maladie or RAMA) and Military Medical Insurance (MMI). RAMA is a health insurance scheme for public servants and individuals working in the formal sector and their dependents. MMI provides health insurance for members of the Rwanda Defense Force and their dependents. Originally MMI was established as a part of RAMA, however separated in 2005 due to concerns about financial risk. RAMA and MMI require 15% copayment for services and pharmaceuticals, and receive preventative and curative care through health facilities affiliated with their insurance scheme.
Rwanda is an exemplary case of a low-income country implementing a health system with widespread and affordable coverage. However, despite substantial achievements to date, there are still a number of issues that must be focused on in the future. Institutional capacity and management ability is still limited. There are tremendous human-resource constraints at every level. At the national level, there is a lack of institutional management capacity to govern the nation and develop the private sector. At the local level, there is a lack of advanced-level specialized medical professionals, as Rwanda only has one medical university.
Rwanda is an exemplary case of a low-income country implementing a health system with widespread and affordable coverage. However, despite substantial achievements to date, there are still a number of issues that must be focused on in the future. Institutional capacity and management ability is still limited. There are tremendous human-resource constraints at every level. At the national level, there is a lack of institutional management capacity to govern the nation and develop the private sector. At the local level, there is a lack of advanced-level specialized medical professionals, as Rwanda only has one medical university. District and sector level health facilities do not have sufficient trained health staff and most districts only have two doctors per 100,000 people.
System financing is also potentially unsustainable. Currently, the cost of care is often higher than the Mutuelle payments are able to cover and funding for the program is heavily dependent on international donors. Studies show that more than half the health sector funding comes from donors or NGOs, which is unsustainable and also has high operational and administrative costs. An estimated 27% of all government and donor resources for health are spent on administration. Rwanda government staff members spend 3 days a year servicing each aid mission. There are 168 missions per year and 55% of donor projects end within a year, leading to continual renegotiation. Additionally, donor aid leads to an uneven spread of aid. For example, funding is heavily skewed towards disease prevention with less investment in health systems. In 2006, $47 million was spent on HIV/AIDS, which has a low prevalence in Rwanda, but only $1 million was spent on the Integrated Management of Childhood Illness program, though child mortality is very high. In order to decrease this dependence on aid and make the program more sustainable, Rwanda will need to receive increased long-term aid flows, increase health spending, and implement stronger, complementary, insurance coverage packages for the population.
While the government of Rwanda is committed to internet connectivity and information and health technology, within Sub-Saharan Africa, Rwanda has the fewest number of telephone subscribers, fewer internet users, and fewer personal computers (per 100 people) than all the surrounding countries. This is partially because Rwanda is not connected to the fiber-optic system and thus must use satellite for all broadband connections. This has detrimental impacts on the ability of Rwanda to effectively monitor and report data.
Rwanda
The Way Forward
Rwanda is an exemplary case of a low-income country implementing a health system with widespread and affordable coverage. However, despite substantial achievements to date, there are still a number of issues that must be focused on in the future. Institutional capacity and management ability is still limited. There are tremendous human-resource constraints at every level. At the national level, there is a lack of institutional management capacity to govern the nation and develop the private sector. At the local level, there is a lack of advanced-level specialized medical professionals, as Rwanda only has one medical university. District and sector level health facilities do not have sufficient trained health staff and most districts only have two doctors per 100,000 people.
System financing is also potentially unsustainable. Currently, the cost of care is often higher than the Mutuelle payments are able to cover and funding for the program is heavily dependent on international donors. Studies show that more than half the health sector funding comes from donors or NGOs, which is unsustainable and also has high operational and administrative costs. An estimated 27% of all government and donor resources for health are spent on administration. Rwanda government staff members spend 3 days a year servicing each aid mission. There are 168 missions per year and 55% of donor projects end within a year, leading to continual renegotiation. Additionally, donor aid leads to an uneven spread of aid. For example, funding is heavily skewed towards disease prevention with less investment in health systems. In 2006, $47 million was spent on HIV/AIDS, which has a low prevalence in Rwanda, but only $1 million was spent on the Integrated Management of Childhood Illness program, though child mortality is very high. In order to decrease this dependence on aid and make the program more sustainable, Rwanda will need to receive increased long-term aid flows, increase health spending, and implement stronger, complementary, insurance coverage packages for the population.
While the government of Rwanda is committed to internet connectivity and information and health technology, within Sub-Saharan Africa, Rwanda has the fewest number of telephone subscribers, fewer internet users, and fewer personal computers (per 100 people) than all the surrounding countries. This is partially because Rwanda is not connected to the fiber-optic system and thus must use satellite for all broadband connections. This has detrimental impacts on the ability of Rwanda to effectively monitor and report data.