1. 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

2. 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

4. I.Economic and Health situation in Rwanda in 2000
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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

5. 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

6. 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

7. 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

8. Organization NAT POOLING RISK Contributions from: MOH/
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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

9. 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

10. 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 ( )

11. 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

12. Obj2:Improve the Quality of Health Care services
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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

13. IV.CBHI Main results : Annualy increasing membership

14. Active vs passive Contribution to CBHI

15. Primary Health Care cost covered by CBHI

16. UTILIZATION OF CURATIVE CARE SERVICES IN RWANDA
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17. Proportionnal Malaria morbidity in Health Centres vs Health Utilization Rate

18. INFANT AND UNDER FIVE MORTALITY ( per 1000)

19. Pourcentage of delivery in health facilities

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

21. V.The requirement of a sustainable CBHI
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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

22. 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

23. THANK YOU FOR YOUR ATTENTION !
« YOU CAN NOT FIGHT SUCCESSFULY INFECTION DISEASES WITHOUT A STRONG HEALTH SYSTEM  »
THANK YOU FOR YOUR ATTENTION !