Coordinator of Project management Unit of Global fund and MAP projects 11/20/00 NATIONAL HEALTH CARE IN RWANDA THE COMMUNITY BASED HEALTH INSURANCE (CBHI) NGAMIJE Daniel Coordinator of Project management Unit of Global fund and MAP projects 1 Mexico , 03 – 8 AUGUST , 2008

Outline of the Presentation 1. Economic and Health situation in Rwanda in 2000 2. Why did the Government set up a Universal CBHI in 2000 ? 3. Principal objectives and organisation of the CBHI 4. CBHI Main results 5. The sustainability of CBHI in Rwanda 6. Conclusion

I.Economic and Health situation in Rwanda in 2000 11/20/00 Key Economic Characteristics Economic recovery since 1994 Genocide, but still low per capita income ($235) and widespread poverty (60% of population) Largest number of people active in agriculture (>90% of population) with high population density Very high under 5 mortality (196/1000) and maternal mortality (1071/100,000) Primary causes of morbidity: malaria, respiratory infections and diarrhoeal diseases and low utilization of health services . Formal sector employees are covered in health insurance First community based health insurance (CBHI) schemes launched in 1999 as pilots Key Health Characteristics Rate of utilization was very low 30% and studies showed that the first reason was finance – the population couldnot afford health care The health center had many debt of the patient The health financing was in difficult 4

Rwanda Health System : Programs and sub-programs To Guarantee the Wellbeing of the Population Goal of the Health System To Ensure and Promote the Health Status of the Population IMCI Reproductive Health EPI Nutrition Malaria HIV / AIDS / STI Tuberculosis Epidemics and Disasters Mental Health Blindness & Phys. Hand. Environmental Health IEC / BCC Public Health Services and High Impact Health Interventions Quality of and Demand for Health Services and Efforts to Control Disease The Health System Human Resource Development Drugs, Vaccines and Consumables Infrastructure, Equipment & Laboratory Network National Referral Hospitals & Treatment and Research Centres Infrastructure, human- and material resources, and health care financing In Rwanda we have a HSSP is and how it is linked to the mandate of the global, the basis of the Round 5, we based on the HSSP, what could be solved by vertical projects and what was cross-cutting and could be solved vertical and looked at the linked betwe Health Care Financing Public Health Functions Institutional Capacity

II.Why did the Government set up a Universal CBHI ? Rate of medical utilization was very low(30%) and study showed that the main cause was the finance aspect Health facilities had accumulated debts from patients with impact to their financing system especially after the progressive withdraw of post Genocide Health Donations Equity issue after launching of health insurance for the formal sector Low level of population ownership to health facilities management’s issues

III.Principal objectives and organization of the CBHI To Improve health status of the population by supporting the financial access to the health services To Improve the financial capacity of the health facilities To Strengthen community participation in health facilities management

Organization NAT POOLING RISK Contributions from: MOH/ 11/20/00 Organization Payment source of finance Payment finance NAT POOLING RISK Contributions from: MOH ; Civil Insurance; Military Insurance; FARG Private Insurances; Donors MOH/ Desk CBHI Referral Hospital DISTRICT POOLING RISK Contribution from: - Sections of CBHI of HCs - District revenu -National Pooling Risk -Donors District Hospital District Level Sector Level Health Center Contributions from: -Voluntary contribution of Pop -Sector revenu -Donors 8

Organization : How the CHBI is financed ? Subscription1000rwf( 2$ US) per capita per year Ticket « moderateur» is 0.4 $ US per episode at the health center level , and 10 % for co-payment Hospital ‘s bill. District Pooling risk fund : Budget is 2 $ US per member who paid his Subscription: 0.4 $ US from district revenu and Health Center 1.02 $ US from Donors and the national poling risk National Pooling risk fund: Budget is 1$ US per member by the paiement of 1% of annual revenu of national public and private insurances

Organization : Roles of Partners in CBHI Technical assistance during pilot period :GTZ ,PH Mobilisation of funds: The Global fund case “Assuring Access to Quality Care: The Missing Link to Combat AIDS, Tuberculosis and Malaria in Rwanda” Budget 33,945,080 USD (2006-2010)

Obj 1: Improve Access to health care to vulnerable groups Pay membership fees for the very poor( indigents); Pay 50% of membership fees for the District pooling risk Pay membership fees for PLHIV and Orphans

Obj2:Improve the Quality of Health Care services 11/20/00 1. Strengthen Capacity for medical students (Pre – service training) 2. In-service training of health providers and managers 3. Revising Policies 4. Operational Research/M&E 5. Infrastructure and equipment 1. Capacity Creation (Pre – service training) Strengthened institutions that train General MD, Nurses and Paramedics, Public Health Supported the internship program (revising the curricula to integrate new norms, procdures for HIV, TB and Malaria programs, they come to the system when they are full equipped to serve) , HIV, will benefit, Malaria benefit , which would not have happened with vertical programs 2. In-service training District hospital managers; health district supervisors; Health Center managers;deputy mayors i/c of health affairs. 12

IV.CBHI Main results : Annualy increasing membership

Active vs passive Contribution to CBHI

Primary Health Care cost covered by CBHI

UTILIZATION OF CURATIVE CARE SERVICES IN RWANDA 11/20/00 16 16

Proportionnal Malaria morbidity in Health Centres vs Health Utilization Rate

INFANT AND UNDER FIVE MORTALITY ( per 1000)

Pourcentage of delivery in health facilities

Maternal mortality ( Per100.000) Source DHS 2000 &2005

V.The requirement of a sustainable CBHI 11/20/00 Central and local Government Contribution Clear goal: to achieve universal coverage of health insurance Commitment to engage in institutional reform & Policy to achieve goals Specific budget for supporting CBHI by C.Gvt and local Gvt contribution Conduct Studies on the real costs of health services provided at different levels Development Partner Contribution Strong engagement in Sector Wide Approach in health Strong technical contributions Engage in long term projects addressing CBHI issues 21

Right choice at right time and Solidarity with vulnerable groups Conclusion “Health Insurance for all” : Right choice at right time and Solidarity with vulnerable groups

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