1. Partnerships for Health Reform Utilization and Expenditures on Outpatient Health Care by HIV Positive Individuals in Rwanda PHR Rwanda - Abt Associates Inc. IAEN and AIDS Conference Durban July 2000 Abt Associates Inc. In collaboration with: s s Development Associates, Inc. s s Harvard School of Public Health s s Howard University International Affairs Center s s University Research Co., LLC

2. Background: NHA and HIV in Rwanda s PHR, Rwandan National Health Accounts Team, UNAIDS, PNLS, and MOH collaborating to examine the sources of uses of funding for HIV services in Rwanda using the NHA framework s National Health Accounts will clearly illustrate: Î Who (Private, Public, Donors) pays for what? Î How much do they pay?

3. Why National Health Accounts? s Effective method for compiling descriptive statistics of a nations health economy. s Represents the flow of funds throughout the system. s Can assist policy-makers in setting health care policy priorities. s Can assist governments in assessing the performance of their health sectors. s Can assist governments in identifying areas of inequity in the distribution of care.

4. NHA Data Collection s Data on sources and uses of HIV funds is collected through surveys from all levels of the health system including: Î Donors Î Hospitals Î Pharmaceutical Companies Î Ministry of Health Î NGOs Î Households*

5. Household Survey: Snapshot of Out-of -Pocket Expenditures s PHR with NHA team, UNAIDS, and MOH developed a survey to investigate the use of and expenditures on outpatient and inpatient health by HIV positive individuals in Rwanda s Findings on expenditures will contribute to understanding of out-of -pocket expenditures on health, and s contribute to existing limited body of literature looking at the impact of HIV on households

6. Outpatient Survey: Methodology s 350 HIV positive individuals were identified in four facilities Î 1 Hospital Î 1 Health Center Î 1 AIDS Association Î 1 meeting and testing facility s Interviews were conducted by social assistants who had a relationship with the patient

7. Data Limitations for the Study s Sample size Î 350 total Î 293 were women s Many facilities do not test, nor inform patients of their HIV status in Rwanda, which limits the sample size s Issue of self-selection: all patients knew their status s Findings are not representative of the universe of HIV positive individuals in Rwanda as most were identified from non-routine testing

8. Rwanda: Background s 7.8 million people in 1998 s Per Capita GDP in 1997: $242 s Service Sector: Î economically most productive with 7% of the population produces 43% of GDP s 70% of population lives below the poverty line

9. Rwanda NHA 1998 Results

10. HIV/AIDS in Rwanda s Estimated that 11% of the adult population is sero-positive s Highest prevalence in service sector population (19%) s Testing takes place in few facilities and often status is not revealed to those tested s Government of Rwanda has a clearly articulated multi-sectoral approach to combating the HIV epidemic

11. Socio-demographics of surveyed individuals: mainly women, widowed, without education, living in urban areas

12. s The following percentage of people indicated that they were with difficulty and unable to meet the following basic needs: Î food (73%) Î housing (57%) Î education (86%) Î clothing (82%) s Average Number of Work days lost in the past two weeks: : 4.8 NHA Finding: Households affected by HIV/AIDS suffer economically

13. NHA Finding: Sero-positive patients seek care more often s Annual per capita utilization rates Î 0.29 visits per general population Î 10.9 visits per sero-positive individual s Highest service use rates among sero-positive patients who are: Î urban, Î married, Î in highest expenditure quintiles

14. NHA Finding: Sero-positive individuals have higher per capita spending

15. How are health expenditures financed? s 66% receive assistance from church and family s 18% borrow from family/friends s Sero-positive low-income individuals did not perceive to have received donor and government assistance

16. Conclusions for Sample Group s Sero-positive individuals who are poor Î need care almost 10x more often than the general population Î have higher health care costs than the general population Î need assistance to pay out-of-pocket fees Î receive help from family, friends and church

17. Recommendations s Prevention: Î Strengthen efforts to prevent HIV/AIDS Î Provide extensive public information - IEC Î Broader, more extensive and routine testing for HIV s Improve access and equity for the poor with HIV Î increase government financing targeted to lower- income groups Î donor financed prepayment for poor households with access to health centers and district hospital Î international efforts lower the costs of AIDS treatments

18. Recommendations s Further Research Î effectiveness of alternative approaches to improve access and equity for the poor with HIV/AIDS

19. Partnerships for Health Reform Partnerships for Health Reform is implemented by Abt Associates Inc. under contract No. HRN-C-95-00024 with the U.S. Agency for International Development (USAID)