Human Development 34342 256 November 2005 Findings reports on ongoing operational, economic, and sector work carried out by the World Bank and its member governments in the Africa Region. It is published periodically by the Knowledge and Learning Center on behalf of the Region. The views expressed in Findings are those of the author/s and should not be attributed to the World Bank Group. Community-Based Health Insurance in Rwanda Rwanda has lived one of the most needs in particular. Little atten- tragic moment of its history with tion has been paid in the past to the genocide of 1994, which re- these cultural traits of Rwanda's sulted in nearly one million deaths society within partnership and and the destruction of the social community involvement frame- fabric of the country. Since 1994, works in health development strat- however, the country is being re- egies. After the 1994 war, however, built: gross domestic production mutual aid initiatives have (GDP) has grown at a yearly rate emerged in the health sector as above 6 percent between 1995 and community responses to the rein- 2001, and social infrastructures troduction of user-fees in public and have been rebuilt with support mission health facilities. Building from the international community. on these community initiatives, Rwanda remains, however, one of health authorities and non-govern- the poorest countries in the world: ment organizations have moved per capita GDP is still under $300; these emerging strategies to a de- the incidence of poverty is as high liberate strategy of building com- as 60 percent of the population, and munity-based health insurance reaches 66 percent in the rural schemes in the health sector. areas where nearly 90 percent of the population live (Ministry of Fi- Community-based health insurance schemes (CBHI) nance and Economic Planning, 2002). Building on the experiences of Mutual aid and community soli- mutual health organizations which darity value systems have re- have emerged in the country, the mained resilient traits of Rwanda's Ministry of Health (MOH) initiated society and continue to be trans- in 1998 pilot experiments in the lated in coping strategies in the health districts of Byumba, Kabgayi health care area. In all local com- and Kabutare, which played a key munities, associations of hamac role in the design and organization carry the sick to health facilities. of CBHI schemes in the country. It Resources are specially collected Findings provided also a platform for the com- in neighborhoods and cells to face pilation of information to support emergencies; structured tontines the assessment of CBHI schemes, are more and more organized at and to familiarize health sector the cell level in order to face prior- actors and partners with the strat- ity needs in general, medical care egies needed to support their implementation on a large scale. tion plays other support functions, underway in the country, and part- CBHI schemes in Rwanda are such as training, advice and sup- nerships between local adminis- health insurance organizations port, information, for individual trative structures, grassroots as- based on a partnership between schemes. sociations, and micro-finance the community and health care Contributions to the CBHI schemes (banques populaires) to providers. The CBHI schemes de- scheme funds are on a yearly ba- strengthen local support systems velop their bylaws, organizational sis. Members have the option to of CBHI schemes and to increase structures including general as- sign up as a family with up to enrollment in the schemes. semblies, board of directors, sur- seven members, which costs veillance committees and execu- US$7.6 per family per year. Pay- CBHI and the poor tive bureaus to regulate contrac- ment of the yearly premium en- CBHI schemes have experienced tual relations between members titles covered family members to a an important growth during the and the mutual organization. Par- benefit package which includes all past five years in Rwanda. From ticipation in the CBHI scheme is preventive, curative services, pre- one CBHI scheme in 1998 to sixty voluntary and is based on a mem- natal care, delivery care and labo- in 2001. Starting in 2001, an ad- bership contract between the CBHI ratory exams, drugs on the MOH aptation phase drawing on lessons scheme and the member. In addi- essential drug list, and ambulance learned and recommendations tion, CBHI schemes develop con- transport to the district hospital from the pilot phase extended the tractual relations with health care provided by the partner health cen- number of CBHI schemes and in- provider organizations (health cen- ters. With a health center refer- creased enrollment rates in indi- ters, hospitals) for the purchasing ral, members also receive a lim- vidual schemes: consequently, on of health care. Bylaws of CBHI ited package at the district hospi- July 2003, ninety-seven CBHI schemes and their contracts with tal. Sick members pay a co-pay- schemes, covering half a million health care providers include mea- ment of US$0.30 for each visit at Rwandans, were functional in the sures for minimizing risks asso- the health center. At the hospital, country. The development of CBHI ciated with health insurance (ad- refereed members have direct ac- schemes is currently in an exten- verse selection, moral hazard, cost cess to the hospital package with- sion phase: in 2004, two hundred escalation, and fraud). out any co-payment. Health cen- and fourteen CBHI schemes have The target population of indi- ters play a gatekeeper function to developed all over the country as a vidual CBHI schemes are inhabit- discourage the inappropriate use result of the combined effects of pro- ants of the catchment's area of of hospital services (Schneider et motional activities of central au- their partner health center: low al., 2001). thorities (Ministry of Health and risk events (health center pack- Since 1998, a cumulative pro- Ministry of Local Affairs), prov- age) which are included in the cess of learning in the community- inces, districts, local health per- CBHI benefit package are shared based health insurance area, in- sonnel, local opinion leaders and at the partner health center volving CBHI schemes of the pilot non-government organizations. In catchment's area population. CBHI districts and CBHI schemes in mid-2004, national coverage of schemes in a given health district, other districts, has been launched CBHI schemes is estimated at 1,7 however, establish a federation at in Rwanda. Such a learning envi- millions Rwandans: about 21 per- the district level which plays a ronment has facilitated the emer- cent of the Rwanda population are risk-pooling mechanism function gence of innovative strategies for currently benefiting from CBHI cov- for high-risk events (hospital pack- strengthening existing CBHI erage in the health sector age). The district federation also schemes in pilot districts and (Ndahinyuka, Jovit. 2004). plays social intermediation and implementation of new CBHI As a consequence of the removal representation roles for individual schemes in other parts of the of financial barriers to access to CBHI schemes in their interac- country. These local initiatives, health care by CBHI schemes, tions and contractual relations while maintaining the technical members of CBHI schemes are with health care providers and ex- design of the pilot phase, have built four times more likely to seek ternal partners. Finally, the federa- on the decentralization movement modern health care when sick than non-members (Diop, 2000). The household survey re- Greater access of the poor to CBHI scheme benefits sults of the pilot phase summarized in Figure 1 have are being promoted through two main strategies. First, been replicated based on routine data from health building on partnerships between CBHI schemes, centers during the pilot phase and recent results from grassroots associations and micro-finance schemes health centers in the same pilot districts and results (banques populaires), existing and newly formed from health centers in the districts which have grassroots associations are motivated to enroll as a implemented CBHI schemes between 2001 and 2003 group in the CBHI schemes under a financing scheme (Butera, 2004). CBHI schemes coverage has also in- where the micro-finance schemes provide small loans creased the use of reproductive health services, in- to the associations' members to pay for their yearly cluding prenatal care and delivery care; they had no contributions to the CBHI schemes. Such a financ- effect, however, on the use of family planning ser- ing scheme has boosted enrollment of the poor in the vices. CBHI schemes. In addition, it has opened opportuni- ties for poor CBHI members for greater access to larger micro-finance loans to finance income-generating activities. Such financial arrangements developed as a consequence of the institutional arrangements between CBHI schemes, micro-financing schemes and health centers, and innovations introduced by local actors. Second, non-government organizations and admin- istrative districts are building on the institutional bridges between the community, the CBHI schemes and health care providers to finance the enrollment of the poorest, indigents and vulnerable groups (or- As a result of their insurance function, CBHI phans, widows, people living with HIV/AIDS). Under schemes protect the income of their members these demand-based subsidy schemes, community against financial risks associated with illness leaders play administrative functions in the identifi- through two mechanisms. First, when sick, mem- cation of the poorest and indigents and vulnerable bers of CBHI schemes seek care earlier resulting in groups, the CBHI schemes manage the consumption efficiency gains in the consumption of health care of health care for these groups, while the subsidies services. Second, sick members pay small out-of- are financed by non-government organizations and pocket co-payments at the health centers. Conse- administrative districts who serves as intermediar- quently, out-of-pocket payments are reduced signifi- ies for primary sources of finance (state, external aid). cantly among CBHI scheme members as demon- Main Lessons strated by the comparison of members and non-mem- bers of CBHI schemes' out-of-pocket payments in While the extension of CBHI in Rwanda is still un- Figure 2. derway, the experience of the past five years provides valuable lessons for the development of micro health insurance schemes in developing countries. First, the development of CBHI in Rwanda built on an in- cremental approach which drew lessons from inter- nal experiences and external experiences of prepay- ment schemes in Southern Africa and mutual health organizations in Western Africa. The MOH provided the leadership to initiate the pilot phase, and secured technical assistance from USAID\Rwanda and Abt As- sociates Inc., which improved on the technical de- sign and organization of CBHI schemes in the coun- try. The MOH kept a respectable distance from the design and management of the ment organizations in CBHI pro- Project, Abt Associates Inc. schemes to ensure the autonomy motion activities under a policy Ministry of Finance and Economic and the appropriation of the environment where community Planning, "A Profile of Poverty in schemes by communities and lo- development was a central Rwanda: A Report Based on the cal health providers. It generated theme, mobilized intersectoral Results of the Household Living information on the performance of action, resulting in local initia- Standards Survey." Republic of the schemes and convened mul- tives which improved access of Rwanda: February 2002. tiple forums for stakeholders to the poor to CBHI benefits. Part- Ndahinyuka, Jovit. Etude de cas sur exchange experiences and to de- nerships between local micro-fi- les rôles des acteurs dans le bate on the consequences and im- nance schemes, CBHI schemes, développement des mutuelles de plications of the CBHI schemes on and grassroots associations have santé au Rwanda. Projet AWARE- the Rwanda health system. Such widened opportunities for the RH, 2004. an incremental approach provided poor to access CBHI and micro- Schneider, Pia, François Diop, a platform for learning and draw- finance credit. Access of the poor- Daniel Maceira, and Damscene ing policy directions for the devel- est and indigents to CBHI ben- Butera. Utilization, Cost, and Fi- opment of CBHI in the country. efits is being strengthened, due nancing of District Health Services Second, as consensus built-up on to the use of CBHI schemes as in Rwanda. Technical Report No. the benefits of the CBHI schemes, intermediate local solidarity 61 (March 2001). Bethesda, MD: a multi-level leadership developed funds in the targeting of demand- Partnerships for Health Reform in the country to provide support based subsidies to the poorest and Project, Abt Associates Inc. to the adaptation and extension of indigents in the health sector by the schemes. Political leaders at non-government organizations the central level, starting from the and administrative districts. Presidency, called for the mobili- zation of all actors to support the This article was written by implementation of CBHI schemes François Pathé Diop and Jean throughout the country. Local com- Damascene Butera, of Abt Associ- munities were motivated by the ates Inc. MOH support in designing and es- tablishing CBHI schemes; such support was boosted by the Minis- try of Local Affairs involvement in References: promotion activities. At the prov- ince and district levels, prefects Butera, Jean Damascene and and mayors continue to play a key Francois Diop. Systèmes role in coordinating promotional d'Assurance Basée sur la activities. At the grassroots levels, Communauté : Utilisation, Coûts cell and sector representatives are et Financement des Soins de playing a key role in sensitization Santé de Base au Rwanda. activities, along with health per- PRIME II\Rwanda Rapport Tech- sonnel and local opinion leaders. nique (July 2004). Such a multi-level leadership has Diop, Francois, Pia Schneider, strengthened the legitimacy of Damascene Butera. Summary CBHI in the country and enabled of Results: Prepayment Schemes the mobilization of intersectoral in the Rwandan Districts of support for the development of the Byumba,Kabgayi,andKabutare. schemes. Technical Report No. 59 (Sep- Third, the involvement of decen- tember 2000). Bethesda, MD: tralized entities and non-govern- Partnerships for Health Reform