Early last week, at a workshop held in Accra Ghana, Rwanda was recognised internationally as one of the countries in Africa that had successfully implemented its health insurance policy.

The workshop, organised by international organisations such as USAID, World Bank, World Health Organization, International Labour Organization, and the Rockefeller Foundation, was especially focused on encouraging nations to scale up health insurance coverage in Africa.

Rwanda, together with Ghana, were showcased to other countries attending as countries that were proving that indeed this service could actually be delivered.

As it is well documented, after1994, Rwanda was left with a devastated health care infrastructure and a society largely morbid and plagued by a high rate of mortality.

Due to being under-resourced, the quality and availability of the services were highly affected.

A community based health insurance scheme known as Mutuelle de Santé which was voluntary and non-profit was then initiated in 1999 as a pilot project.

However, in 2001, a survey found that only 23 percent of the population was using primary care and that there was a worsening trend in health outcomes with HIV and other infectious diseases being on the rise.

That same year the Ministry of Health decided to overhaul the system with a new vision that had three pillars.

The three pillars based on the new vision were: 1. Strong investment in preventive interventions, 2.

Access to curative care through voluntary, pre-paid health insurance and 3, Performance-based financing to improve quality of care.

Thereafter in 2004-2005, the schemes uptake accelerated greatly after the government’s adoption of a national policy on it. Its rollout was also facilitated with financial and technical support from development partners.

The scheme which covered 74 percent of the population by 2007 is now mandatory for all and it covers curative services at the primary, secondary and tertiary levels.

It is delivered at clinics at sector level which are either run by government, NGOs and at district hospitals or at the few national medical institutions.

Its financing is very interesting. About 50 percent of it is from member premiums where members pay about USD 1.81 annually per year.

The remaining 50 percent is obtained via charitable organizations, NGOs, other national insurance funds, development partners and the government of Rwanda.

Rwanda especially stands out in the area of governance where it is graded at 34 percent on its effectiveness, which is higher than its regional and income-group peers.
A donor coordination mechanism is also one of the features this system prides in.

This helps to avoid duplication of health projects and the effective use of this donor funding. Rwanda has been also found to be effective in the control of corruption where it performed better than 44 percent of the countries surveyed.

Although Rwanda is ranked at the bottom 20 percent by UN in the area of voice and accountability, political stability and rule of law as compared to other sub-Saharan and low income countries, it was found to perform much better than these countries in government effectiveness and regulatory quality.

Other positives is that the scheme is managed at sector level by people elected by the community. Each district has at least one hospital or secondary care facility.

A unique aspect is that its services are delivered through public or private non-profit contracted facilities and not at profit driven health facilities.

As regards to the quality of care delivered, this is maintained via stringent performance based financing for public and private providers.

All district mayors who sign performance contracts with the president go on to ensure that these standards are adhered to. In turn these institutions benefit from subsidies and some financing contingent.

Looking at operations, once the member premiums are collected at sector level, the funds are then pooled and distributed by the Mutuelle management entities to the different facilities based on need and service utilization.

However, it has been found that the cost of care is usually higher than what the Mutuelle payments are able to cover. Regarding this, Rwanda is undertaking a costing study in partnership with USAID in order to understand the costs of service delivery.

According to a country brief by USAID on Rwanda’s Health Systems, It reports that donor support has been increasing and it states that Rwandans are more protected from out of pocket spending on health.

The brief also states that the GOR uses performance-based financing to motivated the health personnel, but it cites the need for extra measures to encourage retention bearing the fact that there is a huge deficit of human resource. 

In fact, Rwanda’s physician to population ratio was found to be greatly lagging behind at a ratio of 5 per 100,000. Way under WHO recommendation of 20 per 100,000.

In this area, Rwanda is therefore encouraged to make significant effort in creating incentives for professionals to remain in the country and to work where they are most needed not according to where resources are concentrated.

As for the service delivery indicators, Rwanda performs favourably as compared to other sub-Saharan and low-income countries.

For instance in Immunization in 2004, 9 out of 10 children received DPT3 immunization as compared to other comparable nations that registered 7 0f 10 in immunizations.

Similarly 9 of 10 pregnant women received at least one ante-natal care visit as compared to 8 out of 10 and 7 out of 10 in sub-Saharan Africa.

Some of the major challenges Rwanda’s Health care scheme is facing is in the area of financing.

Although the government of Rwanda increased spending on health, the country is still highly dependent on donor funding.

It accounts for 55% of the total spending on health, a much greater percentage as compared to other sub-saharan and low income countries.

Also, need has arisen for Rwanda to build its own Health Information system in order to support crucial evidence-based decision making and priority setting.

This will also help Rwanda to pool, integrate and maintain all data and studies undertaken in order to avoid overlapping studies and thus facilitate a knowledge base for health care and thus facilitate efficiency.

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