Debriefing for the Study Tour of the Malian and Senegalese Delegations to Rwanda October 25-30, 2009

Mission Objectives  Inquire about Rwanda’s experience with the following reforms:  Resource allocation systems, with special emphasis on performance-based financing;  Pooling risk in the health sector for community-based health insurance;  The organization and operation of health mutuelles;  Systems to identify and provide care for the indigent. 2

The Mission (1) Central level meetings  Director of Planning,  Community Based Health Insurance Support Unit (CTAMS) and Contractual Approach Support Unit (CAAC),  RAMA (Rwanda Health Insurance Scheme) and World Bank Field trips Two groups were formed:  Mali team  Senegal team 3

The Mission (2)  Mali Team  Gicumbi District: District hospital and district mutuelle, Bungwe section mutuelle, Bungwe Health Center.  Muhanga District: Kabgayi Hospital, district mutuelle, Gitarama section mutuelle, Gitarama Health Center. 4

The Mission (3)  Senegal Team  Gakenke District: District hospital and district mutuelle, Nemba section mutuelle, Nemba Health Center.  Rwamagana District: District hospital and district mutuelle, Rwamagana section mutuelle, Rwamagana Health Center. 5

HEALTH INSURANCE 6

Principal Findings (1)  A strong commitment to the President’s health insurance reforms by the political/ administrative authorities down to the decentralized level  The pivotal role of the district mayor  Strong provider involvement in promoting mutuelles  Incorporate mutuelle system performance into the performance contracts the President of the Republic signs with the mayors 7

Principal Findings (2)  Good coverage of Rwanda’s population (>90%) by combining health insurance systems: RAMA, military medical insurance (MMI), private insurance, insurance for school and university students, community-based health mutuelles  An attractive package of services that is consistent with the way the provision of care is organized (PMA and PCA)  Implement a coordination and monitoring system at every level 8

Principal Findings (3)  Establish structured management bodies and tools at the decentralized level  Decentralize the management system by setting up local decision-making centers  Involve RAMA in providing technical and financial support to the health mutuelles  Employee status for mutuelle managers 9

Principal Findings (4)  A citizen control system exists  RAMA is helping to improve coverage in dispensaries  The system enjoys good financial health under RAMA management  Formality is lacking in the relations between some mutuelles and the health facilities  RAMA is not providing care for retirees 10

Principal Findings (5)  RAMA territorial coverage is insufficient  The community-based mutuelle management system is not computerized  The financial balance of some mutuelles is tenuous 11

Lessons Learned (1)  Community health mutuelles are an appropriate approach to achieve universal health coverage  An ongoing commitment of the political- administrative authorities at all levels is required to make the system sustainable  Incorporating the mutuelle performance indicators into monitoring will ensure that their operations are properly monitored 12

Lessons Learned (2)  The existence of a complete package of service benefits contributes significantly to the people’s acceptance of mutuelles  Technical and financial support from the partners should be harmonized and made consistent with the national policy to be effective.  The organization of grass-roots mutuelle infrastructures around the health facilities strengthens beneficiary loyalty 13

Lessons Learned (3)  Solvency is key to ensuring access to services at every level of the pyramid  Combined public and private funding contributes to a more rapid expansion of health insurance coverage 14

Lessons Learned (4)  The effectiveness of the health insurance system depends on the existence of sufficient managerial capacities  Signing performance contracts and implementing them is an incentive measure 15

PERFORMANCE-BASED FINANCING 16

Principal Findings (1)  A minimum benefits package (PMA) is available at the health center level and a comprehensive benefits package (PCA) is available at the district hospital level  The activities targeted by PBF are the health sector priorities  PBF primarily finances personnel motivation  PBF also assists in funding FOSA (health structure) operations 17

Principal Findings (2)  The large number of skilled healthcare workers in the FOSAs and their ability to function are important outcomes of PBF  The monitoring/evaluation system has been implemented and is operational from the central level down to the FOSAs  The individual evaluation system implemented at the FOSA level has not yet been implemented at all levels  Individual evaluation is more complex for hospital personnel 18

Principal Findings (3)  The State is the principal donor and partner contributions are gradually on the decline  The same priorities are applied to all districts without taking their specific features into account  There is a real risk that PBF is neglecting the activities that are not targeted (not compensated) 19

Lessons Learned (1)  The decentralization of skilled healthcare worker positions at the district level fosters good healthcare worker coverage in rural areas  Implementing incentives is an effective way of encouraging workers to remain in rural areas  Having the State provide all the financing promotes the sustainability of PBF 20

Lessons Learned (2)  Financing community-based health through PBF is an effective strategy to improve performance, especially in the areas of Reproductive Health/Family Planning, acute respiratory infections and controlling diarrhea  Both quantitative and qualitative evaluation of services is an incentive for healthcare workers to place greater emphasis on the quality of services  PBF must continue to be dynamic and develop capacities to adjust to changes in priorities 21

Thank You 22