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 tripsTwo 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