Exploring Rwanda's health insurance scheme

A resolution on universal health coverage that was adopted by the United Nations compels governments to move towards providing all people with access to affordable and quality healthcare services. Taking such a solid stand is a clear message that health is an important cross-cutting issue on the international scene. UN member states are, therefore, compelled to adopt approaches that reduce inequities in providing sustainable health services. For a country that had been shattered by the Genocide against the Tutsi, most health systems were defunct until 11 years ago when Rwanda introduced the community-based insurance known as Mutuelle de santé. What is Mutuelle de santé? Mutelle de santé is a health insurance scheme financed both by the state and individuals’ contributions through insurance and direct fees for services. Members pay annual premiums of approximately $6 per family member (increased in 2011 from $2 per person) with a 10 per cent service fee paid for each visit to a health centre or hospital. However, subscription for membership is voluntary and payment of premiums is based on economic status, but coverage excludes private health centres. In a paper published in the Lancet, titled, “Rwanda 20 years on: Investing in life”, health minister Dr Agnes Binagwaho says infant mortality fell and life expectancy doubled following the scale up of health systems. “Investments in health have stimulated shared economic growth and citizens live longer with greater capacity to pursue the lives they value,” she says. And holders of Mutuelle de santé have particular health centres where they access services. The system operates under a decentralised community-based health system. There are 18 dispensaries for primary healthcare, outpatient, referral, 16 prison dispensaries and 34 health posts for outreach activities for immunisations, antenatal care and family planning. There are also 430 health centres for prevention, primary healthcare, inpatient, maternity, 39 district hospitals for inpatient and outpatient)and four national referral hospitals for specialised inpatient and outpatient treatment. On the other hand, there are four referral hospitals, namely; University Teaching Hospital Kigali (CHUK), University Hospital of Butare (CHUB), King Faisal Hospital (KFH) and Kanombe Military Hospital. At any time, holders of Mutuelle de santé can receive services from any of these hospitals. Despite Mutuelle de santé covering 91 per cent of people, the scheme recently received a shake up to iron out mismanagement. Mothers receive medical care at Kabusunzu health centre in Nyarugenge District. Health insurance has cut down infant mortality. (Dennis Agaba) Ironing out mismanagement The first move was that all management shifts from the Ministry of Health to Rwanda Social Security Board (RSSB). Then, managers of community health insurance at the health centres received instructions to deposit funds collected from beneficiaries, to the RSSB bank account. According to a Ministry of Health report, the earlier scheme was characterised by mismanagement, delayed subscriptions - which had fallen from 73 per cent in 2014 to around 63 percent, meaning that more people remained uncovered and a lot of premiums went uncollected. For example, in Gatsibo District, Rwf32.9 million went missing, while in Bugesera Rwf4.1 million, Kirehe Rwf22.4 million, Nyagatare Rwf33.9 million and Ngoma Rwf2.9 million went missing too, according to the ministry report. With the coming of the new management, Rwandans are hopeful that improvement will translate into better health services. Hope in the new management The Ministry of Health and RSSB officials maintain that with the ongoing sensitisation campaigns about the new management, there is no need for fear. Jonathan Gatera, the director-general of RSSB, reaffirms that systems are in place to fix the challenges faced previously such as embezzlement. “The systems that we have put in place discourage embezzlement but encourage timely refunds,” says Gatera. Meanwhile, Alexis Rulisa, the head of Mutuelle de santé at RSSB, is confident that such sensitisation campaigns are helping the public to appreciate health insurance better. “We are planning on massive awareness campaigns within communities. This will enable registration services for the scheme to get closer to the people,” says Rulisa. Under Mutuelle de santé, government pays for categories one and two of the Ubudehe classification since they are considered extremely poor. Members in these categories receive a contribution of Rwf2,000. With such a contribution, a significant percentage of the population is tapping into the advantages of the community-based health insurance despite the challenges that existed before the uptake by RSSB. Care-takers on a routine visit to the patients’ ward. (Solomon Asaba) Maureen Uwase, a resident of Remera, says without Mutuelle de santé, hospital bills would be unmanageable. “The first thing you are asked for at the hospital is your insurance. My bills without the insurance were too high,” she says. Simon Dusengimana, a father of two in Gisozi, says health insurance subscriptions are necessary because medication is still expensive. “You realise you wont find all drugs at the hospital. It means that you have to dig deeper in your pockets to meet the cost else where at pharamacies,” Dusengimana says. The affordability of Mutuelle de santé is a sign of progress in the health sector and the latest Rwanda demographic and health survey shows that there was a significant drop in infant mortality rate, decreasing from 107 deaths per 1,000 live births to 32 deaths. Rwanda ranked among the top countries who slashed both infant and maternal mortality to achieve the targeted Millennium Development Goals. Other health insurance schemes Although community-based health insurance is widely used, there are other options within the country for those who can afford. Rwanda’s health insurance is also provided by other players such as SORAS, UAP, Radiant, Britam and Corar, among others. Reuben Kibiru, the chief executive officer of Britam, explains that although medical insurance has not been fully explored, there are packages that would be beneficial to Rwandans. “Most people are comfortable with Mutuelle de santé because of the thorough sensitisation about its advantages,” Kibiru explains. He adds that uptake of health insurance would improve for other packages if more awareness is created. “For other packages, the uptake is small but if people receive sufficient awareness about medical insurance, this will improve,” he adds. Your say... Stratton Gakara Stratton Gakara, parent: Health insurance is helpful to us Rwandans. Whenever someone is sick, it is easy to get medical treatment. Health insurance has eased access quality healthcare services at a very low cost. Eugene Turikumana Eugene Turikumana, parent: Health insurance is a cheap and effective way of protecting us from health hazards. It’s very costly to get treatment when one is not subscribed to health insurance. I encourage everyone to embrace it. Potien Twizeyimana Potien Twizeyimana, motorcyclist: With health insurance, we don’t spend sleepless nights worrying about the cost of treatment like we used to do in the past. In case of an accident or any hazard, you are assured of medical care from the hospital. Victoire Mukunda Victoire Mukunda, parent: Health insurance helps me and family members to access medical care. My children get sick several times in a year. I wouldn’t manage the cost if my family was not subscribed to health insurance. I appreciate the system for promoting good healthcare in our communities. Margaret Usanase Margaret Usanase, parent: Whoever subscribes to health insurance can’t lose hope or live in fear of any health hazard. I can personally attest to its benefits basing on the three years and six months I spent in the hospital. I would have paid millions, which I couldn’t afford, but I paid less because I was insured. Also, my daughter spent over one month in the hospital, but we paid only Rwf 15,000. Health insurance is a blessing to the country. David Karangwa David Karangwa, parent: Health insurance is like an association where people help one another. Expensive drugs are being bought at relatively low prices and to a large extent patients have been able to access good treatment. Compiled by Frederic Byumvuhore