Partnershipsfor HealthReform

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: Development Associates, Inc. Harvard School of Public Health Howard University International Affairs Center University Research Co., LLC

Background: NHA and HIV in Rwanda

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

National Health Accounts will clearly illustrate: Who (Private, Public, Donors) pays for what? How much do they pay?

Why National Health Accounts? Effective method for compiling descriptive

statistics of a nation’s health economy. Represents the flow of funds throughout the

system. Can assist policy-makers in setting health care

policy priorities. Can assist governments in assessing the

performance of their health sectors. Can assist governments in identifying areas of

inequity in the distribution of care.

NHA Data Collection

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

Household Survey: Snapshot of Out-of -Pocket Expenditures

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

Findings on expenditures will contribute to understanding of out-of -pocket expenditures on health, and

contribute to existing limited body of literature looking at the impact of HIV on households

Outpatient Survey: Methodology

350 HIV positive individuals were identified in four facilities 1 Hospital 1 Health Center 1 AIDS Association 1 meeting and testing facility

Interviews were conducted by social assistants who had a relationship with the patient

Data Limitations for the Study

Sample size 350 total 293 were women

Many facilities do not test, nor inform patients of their HIV status in Rwanda, which limits the sample size

Issue of self-selection: all patients knew their status

Findings are not representative of the universe of HIV positive individuals in Rwanda as most were identified from non-routine testing

Rwanda: Background

7.8 million people in 1998 Per Capita GDP in 1997: $242 Service Sector:

economically most productive with 7% of the population produces 43% of GDP

70% of population lives below the poverty line

Rwanda NHA 1998 Results

HealthSpending

Per capitaExp. onHealth

HealthExp. as %of GDP

Distributionof Sources

Public $1.30 0.5% 12%

Private $2.70 1.1% 25%

Donors $6.80 2.7% 63%

HIV/AIDS in Rwanda

Estimated that 11% of the adult population is sero-positive

Highest prevalence in service sector population (19%)

Testing takes place in few facilities and often status is not revealed to those tested

Government of Rwanda has a clearly articulated multi-sectoral approach to combating the HIV epidemic

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

85%

50%

69%

43%

92%

41%

26%

0%

20%

40%

60%

80%

100%

FE

M

WID

O

UR

B

AG

E 2

6-35

<=

PR

IM E

DU

5+ Y

HIV

HH

2+

HIV

The following percentage of people indicated that they were “with difficulty” and “unable to meet” the following basic needs: food (73%) housing (57%) education (86%) clothing (82%)

Average Number of Work days lost in the past two weeks: : 4.8

NHA Finding: Households NHA Finding: Households affected by HIV/AIDS suffer affected by HIV/AIDS suffer economically economically

NHA Finding: Sero-positive patients seek care more often

Annual per capita utilization rates 0.29 visits per general population 10.9 visits per sero-positive individual

Highest service use rates among sero-positive patients who are: urban, married, in highest expenditure quintiles

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

$2.7

$63

$182

$0$20$40$60$80

$100$120$140$160$180$200

TOT POP HIV+SAMPLE

HIV+MARRIEDSAMPLE

Per Capita HealthSpending

How are health expenditures financed?

66% receive assistance from church and family

18% borrow from family/friends

Sero-positive low-income individuals did not perceive to have received donor and government assistance

Conclusions for Sample Group

Sero-positive individuals who are poor need care almost 10x more often than the

general population have higher health care costs than the

general population need assistance to pay out-of-pocket fees receive help from family, friends and church

Recommendations

Prevention: Strengthen efforts to prevent HIV/AIDS Provide extensive public information - IEC Broader, more extensive and routine testing for

HIV Improve access and equity for the poor with

HIV increase government financing targeted to lower-

income groups donor financed prepayment for poor households

with access to health centers and district hospital international efforts lower the costs of AIDS

treatments

Recommendations

Further Research effectiveness of alternative approaches to

improve access and equity for the poor with HIV/AIDS

Partnershipsfor HealthReform

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)