community based health insurance (cbhi) in rwanda
DESCRIPTION
COMMUNITY BASED HEALTH INSURANCE (CBHI) IN RWANDA. INYARUBUGA Hertilan CBHI Coordinator. Kampala, 15-16 june 2005. OUTLINE OF THE PRESENTATION. Introduction Evolution of health « mutuelles » Organization and management of health « mutuelles » Partners et Role of the goverment - PowerPoint PPT PresentationTRANSCRIPT
COMMUNITY BASED HEALTH COMMUNITY BASED HEALTH INSURANCE (CBHI) IN RWANDAINSURANCE (CBHI) IN RWANDA
INYARUBUGA HertilanINYARUBUGA HertilanCBHI Coordinator CBHI Coordinator
Kampala, 15-16 june 2005Kampala, 15-16 june 2005
OUTLINE OF THE PRESENTATIONOUTLINE OF THE PRESENTATION IntroductionIntroduction Evolution of health « mutuelles » Evolution of health « mutuelles » Organization and management of health « mutuelles » Organization and management of health « mutuelles » Partners et Role of the govermentPartners et Role of the goverment Keys resultatsKeys resultats OpportinitiesOpportinities CBHI challengesCBHI challenges Interventions strategiesInterventions strategies CBH and information for management and decision - CBH and information for management and decision -
makingmaking ConclusionConclusion
IntroductionIntroduction
The health « mutuelles » in The health « mutuelles » in Rwanda are associations which Rwanda are associations which are not for commercial purposes are not for commercial purposes and that are based on solidarity and that are based on solidarity of beneficiaries for forseing of beneficiaries for forseing financial risks in term of access financial risks in term of access to health care servicesto health care services
IntroductionIntroductionIn setting up the health »mutuelles », the In setting up the health »mutuelles », the
principal objectives are those principal objectives are those determined in rwanda government determined in rwanda government targets:. targets:.
To Improve the population financial To Improve the population financial access to the health care servicesaccess to the health care services
To Improve health state of the To Improve health state of the populationpopulation
To Improve the financial capacity of the To Improve the financial capacity of the health structureshealth structures
To Strengthen community participation To Strengthen community participation in health care managementin health care management
Health Financing Challenge 1: Health Financing Challenge 1: Health services are dependent on external resources Health services are dependent on external resources
and (household) out-of-pocket paymentsand (household) out-of-pocket payments
HEALTH FINANCING SOURCES IN RWANDA
32.5%
9.2%7.1% 0.7%
50.5%
Donors Household MOF Private sector Other Public sector
Source: NHA Rwanda (1998)
Health financing challenge 2:Health financing challenge 2: LLow financial access and utilization of modern health care as ow financial access and utilization of modern health care as
a consequence of the a consequence of the levelslevels of out-of-pocket payments of out-of-pocket payments
0.34
0.27
0.240.23
0.25
0.28 0.29
0.38
0
0.05
0.1
0.15
0.2
0.25
0.3
0.35
0.4
1997 1998 1999 2000 2001 2002 2003 2004
Evolution of health Evolution of health « mutuelles » in Rwanda« mutuelles » in Rwanda
Between 1996 and 1997, only one Between 1996 and 1997, only one « mutuelle » existing,« mutuelle » existing,
In 1998, 6 health « mutuelles » were In 1998, 6 health « mutuelles » were functionalfunctional
From 1999 to 2000, 54 « mutuelles » were From 1999 to 2000, 54 « mutuelles » were operatingoperating
From 2001 to 2004, 228 « mutuelles »From 2001 to 2004, 228 « mutuelles » Later in may 2006, 378 « mutuelles » were Later in may 2006, 378 « mutuelles » were
operationaloperational
RUHENGERI: 1 CBHI
BEFORE 1999: BEFORE 1999: RUHONDO CBHI: AN ISOLATED INITIATIVERUHONDO CBHI: AN ISOLATED INITIATIVE
BYUMBA22 CBHI
KABGAYI 17 CBHI
KABUTARE:15 CBHI
RUHENGERI: 1 CBHI
1999-2000: IMPLEMENTATION OF A PILOTE PHASE 1999-2000: IMPLEMENTATION OF A PILOTE PHASE
54 CBHIs IN 3 HEALTH DISTRICTS54 CBHIs IN 3 HEALTH DISTRICTS
Ruhengeri: 11 MS
Ngarama 5 MS
Mibilizi:1MSMushaka1MS
Gihundwe 4MSNyamasheke 3
Gitarama37 SPP
4 MS Gikongoro
Gakoma:4 MS
Kibilizi:7 MS
Nyanza:1 MS
Kabutare:15 SPP
Byumba28 SPP
Kibuye:7 MS
Umutara:1 MS
Ruli:10 MS
Nyamata: 10 MS
Rulindo9 MS
Kibungo:36 MS
2001-2001-2004: 2004: 228 CBHI : 2.500.000 BENEFICIARIES (March 2005)228 CBHI : 2.500.000 BENEFICIARIES (March 2005)
Later in May 2006: 378 « Mutuelles » with an enrollement rate at 47%.
(17)
(14) (12)
(10)
(12)(14)
(11)
(16)
(11)(12)
(15)(8)
(15)(8)
(15)(19)
(20)
(13)(10)
(13)
(13)
(13)
(12)
(13)(12)
(11)
(16)
(12)
(5)
(6)
Organization and ManagemtOrganization and Managemt
At the cell and sector level there are health At the cell and sector level there are health « mutuelles » committees in charge of the « mutuelles » committees in charge of the sensitization and mobilizationsensitization and mobilization
At the health center level a agent is in At the health center level a agent is in charge of the administrative and financial charge of the administrative and financial management of the « mutuelle » ; at this management of the « mutuelle » ; at this level, a management committee elected level, a management committee elected among the members; this committee is among the members; this committee is mainly in charge of the monitoring. mainly in charge of the monitoring.
At the district level, an agent in charge of At the district level, an agent in charge of the coordination of the « mutuelles » within the coordination of the « mutuelles » within the districtthe district
Organization ManagementOrganization Management
At the national level, there is a technical At the national level, there is a technical support cell in charge of: support cell in charge of:
Of the capacity building for « mutuelles » Of the capacity building for « mutuelles » managersmanagers
Of the development of policy, strategies Of the development of policy, strategies and legal frameworks and legal frameworks
Of development of management modules Of development of management modules and toolsand tools
Of the MonitoringOf the Monitoring
Organization and Organization and ManagementManagement
HealthHealth Center Center levellevel: :
• Unlimited access to all services and drugsUnlimited access to all services and drugs
• Referral by (ambulance) to District Referral by (ambulance) to District HospitalHospital
District District HospitalHospital level: all healthcare level: all healthcare packagespackages
Reference Hopital: all healthcare Reference Hopital: all healthcare packagespackages
Organization and Organization and managementmanagement
Variables:Variables:
-Subscriptions of 2 to 7 households Subscriptions of 2 to 7 households vary between 2.500rwf and vary between 2.500rwf and 11500rwf11500rwf-Per capita subscriptions vary Per capita subscriptions vary between 600rwf and 1000rwfbetween 600rwf and 1000rwf- Ticket »moderateur » is Ticket »moderateur » is between 100rwf and 150rwf per between 100rwf and 150rwf per episode, and from 5% to 25% in episode, and from 5% to 25% in co-paymentsco-payments
The partners & role of Government.The partners & role of Government. Ministry of Health (MINISANTE)Ministry of Health (MINISANTE)
Ministry of Local Goverment (MINALOC)Ministry of Local Goverment (MINALOC) Donors and NGOsDonors and NGOs
Rwanda Popular BanksRwanda Popular Banks, , CooperativesCooperatives Health centers and districtsHealth centers and districts Role of government:Role of government:• Providing Management tools to Health Mutuelle.Providing Management tools to Health Mutuelle.
• Providing facilitating equipments to Health mutuelle.Providing facilitating equipments to Health mutuelle.• Providing Budget for Training and Monitoring.Providing Budget for Training and Monitoring.• Providing Budget for Indigenous.Providing Budget for Indigenous.• Providing Budget pooling risks.Providing Budget pooling risks.
Key AchievementsKey Achievements Increased financial accessibility to health Increased financial accessibility to health
carecare
Improved financial sustainability of primary Improved financial sustainability of primary health serviceshealth services
Strengthened community participation in Strengthened community participation in healthcarehealthcare
Level of Utilisation of Curative Care in 2003: Members of cbhis vs Non-Members
0
0.5
1
1.5
2
2.5
Kabutare Kabgayi Byumba Bugesera
Non-Members Memberssource:
IntraHealth/ABT Assoc.
Result 1: Improvement of financial accessibility: Result 1: Improvement of financial accessibility: Members of CBHI seek care earlier and use services more Members of CBHI seek care earlier and use services more
frequently than non-membersfrequently than non-members
Sources of Financing (FRW per inhabitant) of HC by the level of enrollment in the CBHIs in 2003
HD of Kabutare, Kabgayi, Byumba, Bugesera [ 72 CBHIs and HC ]
0
50
100
150
200
250
300
350
400
450
500
Under 5 [5,10) [10, 15) [15, 20) [20, 25) [25, 30) [30, 35) [35, 40) 40 et +Level of enrollment %
Rwandan Francs\Capita
DirectPayment bynon-members
Copaymentsmembers ofMHO
Reimboursement by MHO
Other sources
State
Source:IntraHealth
ResultResult 2 2 Financial sustainability of basic health care Financial sustainability of basic health care servicesservices
FINANCFINANCING OF ING OF BUNGWEBUNGWE HC BY THE CBHI HC BY THE CBHI
11568973
12992017
15674751
17781765
11785786
9116120
6450495
5059928
0
2000000
4000000
6000000
8000000
10000000
12000000
14000000
16000000
18000000
20000000 Total Revenues of Bungwe HC Revenues from Mutuelle
44% 50% 58% 66%
2000 2001 2002 2003
OpportunitiesOpportunities - the existence of the culture of social - the existence of the culture of social
solidarity in the country (protective solidarity in the country (protective sacking, pastoral hammock, work jointly) sacking, pastoral hammock, work jointly)
- the existence of political will - the existence of political will - the existence of the development of the - the existence of the development of the
co-operatives co-operatives - the existence of at least a medical - the existence of at least a medical
structure in a district structure in a district - facility of communication (language, - facility of communication (language,
road, radio etc.)road, radio etc.)
MMain challengesain challenges Gap between the premiums of contribution Gap between the premiums of contribution
and the care costs and the care costs A large number of « indigents »A large number of « indigents » Problem of quality of the care provided by Problem of quality of the care provided by
the public medical staffthe public medical staff
Lack of mobile access to healthcare services Lack of mobile access to healthcare services throughout the countrythroughout the country
Strategic InterventionsStrategic Interventions Study on the real costs of providing health Study on the real costs of providing health
services services Development of a policy and a strategic Development of a policy and a strategic
framework for the mutual insurance companiesframework for the mutual insurance companies Development of a legal frameworkDevelopment of a legal framework Development of a set of training modules on Development of a set of training modules on
CBHI management and training of trainers CBHI management and training of trainers (TOT)(TOT)
Harmonization des tariffsHarmonization des tariffs
Strategic Interventions Strategic Interventions (cont(cont))
Development of approaches for the Development of approaches for the improvement of health care qualityimprovement of health care quality (PAQ, Quality assurance and (PAQ, Quality assurance and
contractual approach) contractual approach) Development of a risk pooling system for Development of a risk pooling system for
support to mutuelles for district and support to mutuelles for district and reference hospitalsreference hospitals
Increase health services packages in Increase health services packages in hospitals hospitals
CBHI and Information for CBHI and Information for management and decision management and decision
makingmaking
Up to now three indicators are used Up to now three indicators are used for decision-making at the for decision-making at the community, and institutions levels:community, and institutions levels:
1. Number of mutuelles beneficiaries 1. Number of mutuelles beneficiaries 2. Enrollement rate2. Enrollement rate 3. Health services utilization rate3. Health services utilization rate
CBHI and Information for CBHI and Information for management and decision management and decision
makingmakingSoon, with the BIT/STEP,we will implement a Soon, with the BIT/STEP,we will implement a
software before the end of this year . This software before the end of this year . This software will allow us to capture indicators software will allow us to capture indicators on :on :
Mutuelles FinancesMutuelles Finances- Premium recover ratesPremium recover rates- Health care costsHealth care costs- Re-enrollement ratesRe-enrollement ratesThese indicators would allow an appropriate These indicators would allow an appropriate
management of the systemmanagement of the system
ConclusionConclusionThe health « mutuelles » are a useful tool for the The health « mutuelles » are a useful tool for the
provision of financial access to health services for provision of financial access to health services for the poor people, however, its sustainability and the poor people, however, its sustainability and strength sare focused on:strength sare focused on:
The existence of a good quality of health care services The existence of a good quality of health care services for the beneficiariesfor the beneficiaries
The existence of an appealing package of health The existence of an appealing package of health services for the beneficiairiesservices for the beneficiairies
The existence of a continued sensitization of the The existence of a continued sensitization of the population and the utilization of the witness statements population and the utilization of the witness statements from the benficiairies.from the benficiairies.
ConclusionConclusion de la participation des beneficiaires dans la de la participation des beneficiaires dans la
gestion des mutuelles de santégestion des mutuelles de santé
de la bonne gestion administrative et de la bonne gestion administrative et financière du systèmefinancière du système
MERCIMERCI