Hospitals are calling for mechanisms such as the establishment of a fund meant to cover unpaid medical bills for healthcare provided to vulnerable people, after defaulting cases almost doubled from Rwf608 million in 2019 to Rwf1.14 billion in 2021.

According to the Auditor General (AG)’s report for 2020-2021, hospitals are persistently grappling with cases of patients who are unable to pay the cost of medical services they were provided, referred to as "social cases,” a situation that may threaten their service delivery.

The AG’s report noted a steady increase of unpaid medical services ‘for social cases’ as they increased almost by 100 per cent over a three-year period, from Rwf608 million in 2019 to Rwf1.148 billion in 2021. (They were over Rwf1.09 billion in 2020).

This issue, it indicated, was attributed to lack of a funding mechanism of social cases which negatively impacts service delivery of hospitals due to cash flow shortfalls.

Kibuye Referral Hospital Director General, Ayingeneye Violette, told The New Times that the unpaid medical bills for healthcare offered to vulnerable people is a major concern that should be solved.

She said that the number of cases of vulnerable people who received treatment at this hospital in Karongi District, Western Province, but did not pay the due amount, increased from 954 in the fiscal year 2019-2020 to 1,102 in 2020-2021, and 1,208 in 2021-2022.

Also, the funds that the hospital lost in the last three consecutive fiscal years, because vulnerable patients could not pay them, followed an increasing trend, rising from over Rwf83.5 million in 2019-2020, to Rwf103.6 million in 2020-2021, and Rwd129.4 million in 2021-2022.

"Overall, it was observed that there is an increase of over 20 per cent [of unpaid medical bills for the treated vulnerable patients] per year, representing an average of Rwf2 million per month,” she said.

This, she said, is a challenge for the hospital because it negatively affects its medicine procurement ability due to the outstanding bills.

Talking about the factors underlying this situation, she said that they include vulnerable people in the second or third Ubudehe category, who cannot pay the 10 per cent that remain after their community-based health insurance scheme – Mutuelles de Santé – covers 90 per cent of the cost.

But, there are also cases of patients who do not have Ubudehe categories – which are based on to determine the contribution one has to pay to Mutuelles de Santé. As such, they also do not have health insurance cover.

"The establishment of a fund meant for the payment of medical bills for vulnerable residents can be helpful,” she proposed.

Kibagabaga Hospital Director General, Ernest Munyemana told The New Times that the problem of patients not paying the due amount is a challenging issue at the hospital, which he said has a large rural area.

"We lose between Rwf2 and Rwf2.5 million per month,” he said, referring to the unpaid amount for the treatment offered under the social cases category including the vulnerable patients, with some patients not owning national identification cards (IDs).

On what should be done to address the issue, he said that local Government entities should carry out inspections to know the residents who do not have IDs, nor Ubudehe categories so that they get them.

Residents should be sensitised about the benefits of having Mutuelles de Santé insurance cover.

"The City (of Kigali) leadership should pay that (money in question) to the hospital so as to avoid drug shortage [which might result from that],” he said.

‘Fund might hinder community-based health insurance scheme’

The AG’s report recommended that "district hospital management should collaborate with the Ministry of Health to find a funding mechanism for patients who are unable to settle their medical bills”.

Dr. Corneille Killy Ntihabose, Head of Clinical and Public Health Services Department at the Ministry of Health, told the Parliament’s Public Accounts Committee (PAC) last month that some of the ‘social cases include mentally ill people and people who are picked by police [from the road,...] and taken to health facilities for remedy, yet they do not have insurance coverage.

"We also agree that it is a burden to health facilities and the Ministry of Health,” he said.

He disclosed that there was a proposal to set up a national-level social fund, "but we are worried that it could create a demand, and discourage people to pay their contributions to the community-based health insurance scheme (Mutuelles de Santé)”.

"The first area where we think hospitals can get financial means is from the social funds at the district level, though they are still inadequate. It is also a responsibility of a health facility to provide health services, but work with the local government entities in order to see how the resident [patient] could pay and ease the payment modality,” he observed.

MP Anita Mutesi said that it is understandable that the creation of such a fund could result in a higher number of people seeking support from it, and hinder the uptake of Mutuelles de Santé, but indicated that there are special cases that should be catered for.

"There are cases of mentally ill people who are taken from the streets and brought to hospital [for treatment]. The accident victims whose residence is not identified,” she said.