Publication: Synopsis of Results on the Impact of Community-Based Health Insurance on Financial Accessibility to Health Care in Rwanda
Loading...
Published
2001-09
ISSN
Date
2013-06-05
Author(s)
Editor(s)
Abstract
This paper evaluates the impact of prepayment schemes on access to health care for poor households, based on household survey data. Rwanda is one of the poorest countries in the world. After the genocide in 1994, public health care services were provided for free to patients, financed by donors and the government. In 1996, the Ministry of Health reintroduced prewar level user charges. By 1999, utilization of primary health care services had dropped from 0.3 in 1997 to a national average of 0.2 annual consultations per capita. This sharp drop in health service use combined with growing concerns about rising poverty, poor health outcome indicators, and a worrisome HIV prevalence among all population groups motivated the Rwandan government to develop community-based health insurance to assure access to the modern health system for the poor. The findings presented in this paper reveal that insurance enrollment is determined by household characteristics such as the health district of household residence, education level of household head, family size, distance to the health facility, and radio ownership, whereas health and economic indicators did not influence enrollment. Insurance members report up to five times higher health service use than nonmembers.
Link to Data Set
Citation
“Schneider, Pia; Diop, François. 2001. Synopsis of Results on the Impact of Community-Based Health Insurance on Financial Accessibility to Health Care in Rwanda. HNP discussion paper series;. © World Bank. http://hdl.handle.net/10986/13798 License: CC BY 3.0 IGO.”
Digital Object Identifier
Associated URLs
Associated content
Other publications in this report series
Journal
Journal Volume
Journal Issue
Related items
Showing items related by metadata.
Publication Social Inclusion and Financial Protection through Community Financing : Initial Results from Five Household Surveys(World Bank, Washington, DC, 2001-09)This paper provides empirical evidence regarding the performance of community-based health care financing in terms of (a) social inclusion and (b) financial protection. Five non-standardized household surveys were analyzed from India (two samples), Senegal, Rwanda, and Thailand. Common methodology was applied to the five data sets. Logistic regression was used to estimate the determinants of enrolling in a community financing scheme. A two-part model was used to assess the determinants of financial protection: part one used logistic regression to estimate the determinants of the likelihood of visiting a health care provider; part two used ordinary least-squares regression to estimate the determinants of out-of-pocket payments. The research finds: (a) Social inclusion. The findings suggest that community financing can be inclusive of the poorest even in the most economically deprived context. Nevertheless, this targeting outcome is not automatically attributable to the involvement of the community; rather it depends on key design and implementation characteristics of the schemes. (b) Financial protection. Community financing reduces financial barriers to health care as demonstrated by higher utilization and simultaneously lower out-of-pocket expenditure of scheme members controlling for a range of socioeconomic variables. The paper concludes: (a) Social inclusion. Design and implementation characteristics of community financing schemes matter to achieve good targeting outcome-community involvement alone does not guarantee social inclusion. Further research is needed to delineate which design and implementation characteristics allow better inclusion of the poor. (b) Financial protection. Prepayment and risk sharing, even on a small scale, reduce financial access barriers.Publication Philippines : Filipino Report Card on Pro-Poor Services(Washington, DC, 2001-05-30)The Report Card is a means by which citizens can provide credible and collective feedback to public agencies about their performance. It brings forth information on users' awareness, access, use, and satisfaction with public services. It is an important follow-up to the World Bank's Poverty Assessment for the Philippines. It complements the expert analyses and findings in the Poverty Assessment with a "bottom-up" assessment of pro-poor services in five key areas: health care, elementary education, water supply, housing, and subsidized rice distribution.The Report Card identifies the key constraints that Filipinos face in assessing public services, their appraisals of the quality and adequacy of public services, and the treatment they reeive in their interactions with service providers, especially government officials. It offers several recommendations on sector and sub-sector policies, strategies and programs to address constraints and improve service delivery, especially to the poor and under-served areas and groups. the Report Card is based on a national client satisfaction survey undertaken by the World Bank in collaboration with the Social Weather Stations (SWS), a survey research organization in the Philippines that is independent, non-partisan, and credible.Publication Health Financing for Poor People : Resource Mobilization and Risk Sharing(Washington, DC: World Bank, 2004)Most community financing schemes have evolved in the context of severe economic constraints, political instability, and lack of good governance. Usually government taxation capacity is weak, formal mechanisms of social protection for vulnerable populations absent, and government oversight of the informal health sector lacking. In this context of extreme public sector failure, community involvement in the financing of health care provides a critical albeit insufficient first step in the long march towards improved access to health care by the poor and social protection against the cost of illness. Health Financing for Poor People stresses that community financing schemes are no panacea for the problems that low-income countries face in resource mobilization. They should be regarded as a complement to - not as a substitute for - strong government involvement in health care financing and risk management related to the cost of illness. Based on an extensive survey of the literature, the main strengths of community financing schemes are the extent of outreach penetration achieved through community participation, their contribution to financial protection against illness, and increase in access to health care by low-income rural and informal sector workers. Their main weaknesses are the low volume of revenues that can be mobilized from poor communities, the frequent exclusion of the very poorest from participation in such schemes without some form of subsidy, the small size of the risk pool, the limited management capacity that exists in rural and low-income contexts, and their isolation from the more comprehensive benefits that are often available through more formal health financing mechanisms and provider networks. The authors conclude by proposing concrete public policy measures that governments can introduce to strengthen and improve the effectiveness of community involvement in health care financing.Publication Using Rapid City Surveys to Inform Municipal Social Policy: An Application in Cali, Colombia(World Bank, Washington, D.C., 2004-08)Many developing countries assign local governments increasing responsibilities in fighting poverty. This requires local social policy to go beyond the execution of centrally designed and funded education and health programs. Hence, local governments and their partners have both an opportunity and a need to analyze key local bottlenecks for poverty reduction and social development. Drawing on an example from Cali, Colombia, The author describes a tool for such policy formulation at the local level-a rapid city household survey. Although the survey uses pre-coded and closed- ended questions, it is contextual in the sense that it is tailor-made to social and economic conditions in Cali. The survey places particular emphasis on collecting key quantitative information, such as household welfare and service access, as well as qualitative information, such as service evaluations and population priorities. Combining the quantitative and qualitative data allows, for example, the mapping of population budget priorities or service satisfaction levels by welfare group. Rapid city household surveys could provide an important tool for the development of local social policies.Publication Community-Based Health Insurance in Rwanda(World Bank, Washington, DC, 2005-11)Rwanda has lived one of the most tragic moments of its history with the genocide of 1994, which resulted in nearly one million deaths, and the destruction of the social fabric of the country. Mutual aid and community solidarity value systems have remained resilient traits of Rwanda's society, and continue to be translated in coping strategies in the health care area. After the 1994 war, however, mutual aid initiatives have emerged in the health sector as community responses to the reintroduction of user-fees in public, and mission health facilities. Building on these community initiatives, health authorities, and non-government organizations have moved these emerging strategies to a deliberate strategy of building community-based health insurance schemes in the health sector. Community-based health insurance schemes (CBHI) provided also a platform for the compilation of information to support the assessment of CBHI schemes, and to familiarize health sector actors, and partners with the strategies needed to support their implementation on a large scale. CBHI schemes in Rwanda are health insurance organizations based on a partnership between the community and health care providers. As consensus built-up on the benefits of the CBHI schemes, a multi-level leadership developed in the country to provide support to the adaptation, and extension of the schemes. Political leaders at the central level, starting from the Presidency, called for the mobilization of all actors to support the implementation of CBHI schemes throughout the country.
Users also downloaded
Showing related downloaded files
Publication The Impact of Health Insurance on the Access to Health Care and Financial Protection in Rural Developing Countries : The Example of Senegal(World Bank, Washington, DC, 2001-09)Community-based health insurance schemes are becoming increasingly recognized as an instrument to finance health care in developing countries. Taking the example of "les mutuelles de santes" (mutual health organization) in rural Senegal this paper analyzes whether or not members in a mutual health insurance scheme have better access to health care than nonmembers. A binary probit model is estimated for the determinants of participation in a mutual and a logit/log linear model is used to measure the impact on health care utilization and financial protection. The results show that, while the health insurance schemes reach otherwise excluded people, the very poorest in the communities are not covered. Regarding the impact on the access to health care, members have a higher probability of using hospitalization services than nonmembers and pay substantially less when they need care. Given the results of this study, community financing schemes have the potential to improve the risk-management capacity of rural households. To reduce identified limitations of the schemes, an enlargement of the risk pool and a scaling up or linking of the schemes is, however, a prerequisite. Appropriate instruments to be further tested should include reinsurance policies, subsidies for the poorest and developing linkages to the private sector via the promotion of group insurance policies. All these instruments call for a stronger role of public health policy.Publication Income Inequality and Violent Crime : Evidence from Mexico's Drug War(World Bank, Washington, DC, 2014-06)The relationship between income inequality and crime has attracted the interest of many researchers, but little convincing evidence exists on the causal effect of inequality on crime in developing countries. This paper estimates this effect in a unique context: Mexico's Drug War. The analysis takes advantage of a unique data set containing inequality and crime statistics for more than 2,000 Mexican municipalities covering a period of 20 years. Using an instrumental variable for inequality that tackles problems of reverse causality and omitted variable bias, this paper finds that an increment of one point in the Gini coefficient translates into an increase of more than 10 drug-related homicides per 100,000 inhabitants between 2006 and 2010. There are no significant effects before 2005. The fact that the effect was found during Mexico's Drug War and not before is likely because the cost of crime decreased with the proliferation of gangs (facilitating access to knowledge and logistics, lowering the marginal cost of criminal behavior), which, combined with rising inequality, increased the expected net benefit from criminal acts after 2005.Publication Achieving Universal Health Coverage through Voluntary Insurance(BioMed Central, 2013-12-17)The Government of Lao Peoples’ Democratic Republic (Lao PDR) has embarked on a path to achieve universal health coverage (UHC) through implementation of four risk-protection schemes. One of these schemes is community-based health insurance (CBHI) – a voluntary scheme that targets roughly half the population. However, after 12 years of implementation, coverage through CBHI remains very low. Increasing coverage of the scheme would require expansion to households in both villages where CBHI is currently operating, and new geographic areas. In this study we explore the prospects of both types of expansion by examining household and district level data.Publication Digital Africa(Washington, DC: World Bank, 2023-03-13)All African countries need better and more jobs for their growing populations. "Digital Africa: Technological Transformation for Jobs" shows that broader use of productivity-enhancing, digital technologies by enterprises and households is imperative to generate such jobs, including for lower-skilled people. At the same time, it can support not only countries’ short-term objective of postpandemic economic recovery but also their vision of economic transformation with more inclusive growth. These outcomes are not automatic, however. Mobile internet availability has increased throughout the continent in recent years, but Africa’s uptake gap is the highest in the world. Areas with at least 3G mobile internet service now cover 84 percent of Africa’s population, but only 22 percent uses such services. And the average African business lags in the use of smartphones and computers as well as more sophisticated digital technologies that catalyze further productivity gains. Two issues explain the usage gap: affordability of these new technologies and willingness to use them. For the 40 percent of Africans below the extreme poverty line, mobile data plans alone would cost one-third of their incomes—in addition to the price of access devices, apps, and electricity. Data plans for small- and medium-size businesses are also more expensive than in other regions. Moreover, shortcomings in the quality of internet services—and in the supply of attractive, skills-appropriate apps that promote entrepreneurship and raise earnings—dampen people’s willingness to use them. For those countries already using these technologies, the development payoffs are significant. New empirical studies for this report add to the rapidly growing evidence that mobile internet availability directly raises enterprise productivity, increases jobs, and reduces poverty throughout Africa. To realize these and other benefits more widely, Africa’s countries must implement complementary and mutually reinforcing policies to strengthen both consumers’ ability to pay and willingness to use digital technologies. These interventions must prioritize productive use to generate large numbers of inclusive jobs in a region poised to benefit from a massive, youthful workforce—one projected to become the world’s largest by the end of this century.Publication Safety of Commercial Motorcycles: Guidelines and Good Practices for Governments and the Private Sector(Washington, DC: World Bank, 2025-09-15)The report highlights safety challenges across several areas and ways to address them. Key challenges include the limited availability and affordability of certified helmets, widespread counterfeit gear, and poor public awareness of helmet standards and proper usage. Riders juggling multiple platforms and shifts are more susceptible to fatigue and risky behavior. Motorcycle fleets often rely on vehicles that may not conform to adequate standards, with inconsistent safety features and limited periodic maintenance. Weak insurance enforcement, limited coverage for commercial use, socioeconomic barriers, and limited adoption of telematics to monitor safety performance further hinder safety efforts. For instance, in some countries, low-powered commercial use two-wheelers are exempt from standard two-wheeler regulations. Addressing these challenges is a shared responsibility requiring active participation from the government, companies, riders, and the insurance sector.