Districts across the country have devised different mechanisms in a bid to ensure 100 per cent subscription to communal health insurance, scheme commonly known as Mutuelle de Santé.Among the mechanisms adopted is the creation of communal associations known as ibimina, (Cooperatives) through which, families pool resources, and ensure all members pay their respective premiums.The money collected is saved at a local Sacco until all the families have paid up. Mutuelle, unlike other health insurance schemes where a single premium takes care of all family members, is paid on individual basis.Figures from the Ministry of Health indicate that last fiscal year that ended in June, countrywide compliance was at 80 per cent.District mayors have pledged achieving 100 per cent compliance in their performance contracts for 2013-2014, with view to having all Rwandans irrespective of their social status access to health care. They have also come up with different measures – including door to door sensitisation for people to either pay the full amount to Mutuelle or make regular deposits through their cooperative.But local leaders have been warned against forcing people to pay up. Collection creativity Nyamagabe District dedicated the week of August 19 to 26 to a campaign aimed  at reaching out to all households to explain to them the benefits of subscribing to the insurance.The campaign involved a delegation made of a community health worker, an officer from local authorities at cell level and a member of a local cooperative. "Before this campaign, we had already covered 17 per cent in health insurance, but now the number has increased up to 25 per cent,” said Vedaste Nsanzimana, the executive secretary of Musange Sector in Nyamagabe.In Musange, he said, they organised people of the same village in groups of 30-50 members as part of the cooperative. The groups chose a treasurer amongst themselves who will be charged with collecting premiums and depositing them on the cooperative’s account.Kirehe District currently has subscription of up to 65 per cent just two months into the new fiscal year.Jacqueline Murekatete, the district vice mayor in charge of social affairs, said; "since June, a campaign, dubbed ‘Healthy Spirit in Healthy Body’ played a significant role to ensure more people pay their premiums at the beginning of the fiscal year in July.Ladislas Ngendahimana, Director of communication in the Ministry of Local Government said Karongi and  Kirehe  districts are ahead of others in Mutuelle de Santé subscription. According to Jean Louis Mukunzi, the in charge of health financing in the Ministry of Health, cooperatives have become an ideal method to collect subscription without any conflict. ChallengesMutuelle de Santé is arguably one of the country’s most successful policies. But it has not been with challenges.Bonaventure Kubarahe from Jomba Sector was convicted late last month to life imprisonment after he was found guilty of  killing a six-year old child of a local leader who was on the team that had visited his family to collect health insurance premiums for his family of eight.Other cases involve overzealous leaders who use highhandedness in collecting the premiums, including confiscation of people’s property like domestic animals.A Nyamagabe District resident said, on condition of anonymity, that they fear to go to the market, when they do not have the health insurance card because "if you take your products to the market, the local leaders will confiscate them.”But Nsanzimana refuted the allegation.In other areas, they allege that local leaders sell their goats to get the money, or deny people services to force them to pay for Mutuelle de Santé. Lazy leaders Paul Jabo, the Executive Secretary of Western Province faults leaders who use coercive measures to collect Mutuelle de Santé funds. He blasted such leaders as lazy."Sensitisation has proven to be an effecient tool to bring people on board without using force,” he said.The Minister for Local Government, James Musoni, has also previously condemned such approach, saying it is against good governance principles.Edouard Munyamariza, the Executive Secretary of civil society platform of Rwanda, attributes these problems to the increase in subscription. He said, "The health insurance fee was increased from Rwf1,000 to Rwf2,000 and above.”However, Mukunzi, said the government did everything to facilitate the citizens, including allowing people to pay in installments.He said one can pay the first installment by September, and the second one by December.  The government has divided the citizens into different social categories under the ed Ubudehe programme, on which  varied social protection programmes base.Category 1 and 2 constitute the very poor and their premium of Rwf 2,000 per individual is paid by government. The other categories pay Rwf 3,000 and Rwf 7,000 per each individual.Also some hospitals or health centres are blamed for referring Muteulle subscribers to private pharmacies, instead of getting them medicine from their stores.”"We had heard about those allegations but our field inspectors report that such issues no longer exist,” said Mukunzi adding the ministry has stocked every health facility with essential medicine to help tackle the issue. Mukunzi took the opportunity to remind any patient who meets any problem to dial the hotline 114 through which any complaint on health care can be communicated.