Rwanda's Health System and Sickness Insurance Schemes

Rwanda’s health system and

sickness insurance schemes

Laurent Musango, Jean Damascène Butera,Hertilan Inyarubuga and Bruno Dujardin

School of Public Health, National University of Rwanda, Butare;

Abt Associates, Bethesda, Md., United States; Ministry of Health, Kigali;

and Health Systems and Policies Department, School of Public Health,

Brussels Free University

After the war and the 1994 genocide, Rwanda drew up a

national health policy with a view to realigning its health

system. The reform, which was designed to remedy the

deficiencies of the previous system, focused on community

involvement in managing and financing health services.

Achieving this objective was never going to be easy, but

thanks to a growing number of initiatives 37.8 per cent of

the Rwandan population now have some degree of sickness

insurance cover. However, the system in general, and more

particularly the mutual associations organized around

the community, needs to be strengthened.

Rwanda signed up to the pri mary healthcare

(PHC) tar gets set out at Alma-Ata (Almaty) in

1978 (WHO, 1978), but unfor tu nately the

unsta ble eco nomic sit u a tion, civil wars, the

inad equate polit i cal regime which failed to

estab lish a health policy that gen u inely focused

on good health (Porignon, 2003) and insta bil ity

in the coun tries of the Great Lakes region all

under mined the imple men ta tion of this policy.

The geno cide in 1994 resulted in ruin for the

coun try and its health system, with all its infra -

struc tures destroyed, equip ment looted and

people killed or exiled. Prob lems of access to

healthcare have increased sub stan tially, and

the coun try has not escaped the HIV/AIDS

pan demic, which is steadily spread ing, par -

ticularly in rural areas where the pro por tion

of those who are HIV-pos i tive went up from

1.3 per cent in 1996 to 10.8 per cent in 1999

(Min is try of Health, 2000). Pov erty is deep -

ening, and cur rent sta tis tics show that

60.4 per cent of the pop u la tion are living

below the poverty line (on less than a dollar

a day).

© 2006 The au thor(s) Jour nal com pi la tion © 2006 In ter na tional So cial Se cu rity As so ci a tion In ter na tional So cial Se cu rity Re view, Vol. 59, 1/2006

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With the help of the World Health Orga ni za -

tion, in 1995 the Min is try of Health pub lished a

National Health Policy set ting out how the health

system was to be rebuilt. The reform (Porignon,

2003) had a number of aims: trying to over come

the inad e qua cies of the pre vi ous health system,

chan nel ling the efforts and help pro vided by

various part ners, and rebuild ing the system

itself. It was also intended to increase com mu -

nity involve ment in man ag ing and financ ing

health ser vices. Because of the level of pov erty

in the pop u la tion, the aim of alter na tive fund ing

from the com mu nity is being achieved only grad -

u ally, albeit quite sat is fac to rily. In our anal y sis of

the sit u a tion we will describe the health system

and sick ness insur ance schemes in Rwanda,

before look ing at the prob lem of cov er age for

needy pop u la tions and the role of mutual

associations in financing health services.

The health sys tem in Rwanda

The health system in Rwanda has a pyr a mid

struc ture with three levels: cen tral, inter me di ate

and periph eral (Min is try of Health, 2002b).

The cen tral level is made up of the direc tor -

ates of the Min is try of Health and the national

refer ral hos pi tals. There are two sep a rate enti -

ties at this level: an admin is tra tive entity and a

tech ni cal/clin i cal entity. The first includes the

Min is ter’s pri vate office and five direc tor ates and

has the role of devel op ing national health policy

and the strat e gies and plans for its imple men ta -

tion. The second, com pris ing three refer ral hos -

pi tals — the teach ing hos pi tals at Butare

(CHUB) and Kigali (CHU/CHK) and the neu ro -

psy chi at ric hos pi tal at Ndera — deals with cases

referred by the dis trict hos pi tals (serv ing the

com mu nity). The refer ral hos pi tals also have a

teach ing and research role. The King Faisal

Hos pi tal is a pri vate med i cal estab lish ment

which also has links with the cen tral level. It

offers a higher tech ni cal level of care than at the

national refer ral hos pi tals and is there fore the

high est refer ral hos pi tal for both the public and

pri vate sec tors. It should, in prin ci ple, bring

down the number of patients trans ferred abroad.

The inter me di ate level is basi cally the regional

health author ity, and does not include any

healthcare units. In admin is tra tive terms the

regional author ity occu pies the same posi tion in

the hier ar chy as the direc tor ates at the cen tral

level. The coun try has 12 regional health author -

i ties cor re spond ing to the 12 admin is tra tive

prov inces. The regional health author i ties are

respon si ble for imple ment ing national health

policy in their regions, coor di nat ing activ i ties at

dis trict level and pro vid ing tech ni cal, admin is tra -

tive and logistical man age ment for them.

The periph eral level is rep re sented by the

health dis trict, which includes an admin is tra tive

base, a first refer ral hos pi tal and health cen tres

pro vid ing pri mary healthcare. The geo graph ical

limits of the health dis tricts are not the same as

the admin is tra tive dis tricts. Rwanda’s health dis -

tricts were defined in 1992, largely on the basis

of cri te ria to do with access to care, avail able

facil i ties and ratio nal iz ing resources. In 2001 the

gov ern ment decided to decen tral ize admin is tra -

tion by group ing cer tain munic i pal i ties together.

The aim was to have what is cur rently referred

to as the “admin is tra tive dis trict” as the basic

oper at ing unit. As a result the cur rent health net -

work has a pyr a mid struc ture with levels that do

not nec es sar ily cor re spond to the admin is tra tive

set-up. In order to improve har mo ni za tion and

make the admin is tra tion more con sis tent, it is

planned in future to divide the coun try up dif fer -

ently, pro duc ing a new map. The health dis trict

will then com pletely cover one or more admin is -

tra tive dis tricts.

There are 365 periph eral healthcare estab -

lish ments (health cen tres and dis pen sa ries)

respon si ble for pro vid ing a min i mum pack age of

activ i ties (MPA). The MPA covers pro mo tional

In ter na tional So cial Se cu rity Re view, Vol. 59, 1/2006 © 2006 The au thor(s) Jour nal com pi la tion © 2006 In ter na tional So cial Se cu rity As so ci a tion

94

activ i ties (nutri tion, com mu nity involve ment,

home visits, infor ma tion, edu ca tion and com mu -

ni ca tion), pre ven tive activ i ties (vac ci na tion,

prenuptial con sul ta tions, pre na tal care, postnatal

care for mother and child, family plan ning advice

and ser vices, school health ser vices and epi -

demiological mon i tor ing), cura tive activ i ties

(cura tive con sul ta tions, man age ment of chronic

ill nesses, nutri tional reha bil i ta tion, cura tive care,

obser va tion before admis sion to hos pi tal,

normal deliv er ies, minor sur gery and lab o ra tory

anal y ses).

Also at the periph eral level there are 39 func -

tion ing health dis tricts, each with a dis trict man -

age ment team. Of these dis tricts, 29 have a

work ing hos pi tal pro vid ing a com ple men tary

pack age of activ i ties (CPA). For the dis trict

hos pi tals the CPA includes the pro mo tional

and cura tive activ i ties of the MPA, but places

empha sis on treat ment for patients referred.

Addi tional activ i ties included in the CPA are

pre ven tion, includ ing pre ven tive con sul ta tions

for referred cases and pre na tal con sul ta tions

for at-risk preg nan cies; family plan ning, with all

meth ods avail able for those referred, includ ing

tubal liga tion and vasec tomy; cura tive care for

those referred, includ ing the man age ment of

dif fi cult and cae sar ean deliv er ies, med i cal and

sur gi cal emer gen cies, minor and major sur gery,

hos pi tal care, lab o ra tory anal y ses and med i cal

imag ing; and management, including training for

paramedical staff and supervision.

In order to ratio nal ize the supply of med i ca -

tion, a cen tral pur chas ing body for essen tial

drugs in Rwanda (CAMERWA) has been set up,

which has a tax exemp tion for imported drugs

on the list of generics used by the Min is try of

Health. The health dis tricts obtain their sup plies

from the CAMERWA and sell them on to the

health author i ties with a profit margin which

must not exceed 5 per cent of the pur chase

price from the CAMERWA. The health cen tres in

turn obtain their sup plies from the dis tricts and

pre scribe the prod ucts to the pop u la tion with a

profit margin of no more than 10 per cent.

Health ser vices are not pro vided solely by

the public sector, but also by “approved” estab -

lish ments,1 the profit-making pri vate sector, and

tra di tional heal ers.

The non-profit-making approved health

sector is made up of estab lish ments run by

var i ous denom i na tional groups and accounts for

40 per cent of periph eral health estab lish ments.

This com bi na tion of healthcare pro vid ers work -

ing in the public inter est is a rec og nized strong

point.

The profit-making pri vate sector has

expanded con sid er ably and is still grow ing:

there are at least 69 pri vate doc tors prac tis ing

either pri vately or for NGOs, com mer cial enti -

ties, pri vate insur ance com pa nies or mutual

ben efit soci et ies.2 There are an esti mated

500 phar ma cies. Over 50 per cent of all pri vate

estab lish ments are in the town of Kigali.

Sick ness in sur ance schemes

in Rwanda

Rwanda has two sick ness insur ance sys tems:

the offi cial, insti tu tion al ized schemes and the

mutual ben efit struc ture orga nized around the

com mu nity.

The offi cial social pro tec tion system is made

up of the Rwandaise Health Care Insur ance



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1. Some health es tab lish ments are faith-based (Cath o lic, Protestant, Mus lim) and of fer the care pack age rec om -mended by the Min is try of Health. They are non-profit-mak ing, re ceiv ing gov ern ment help, par tic u larly in the area ofin-ser vice train ing for staff, pay ment of wages for some staff and some times re fur bish ment of build ings and equip -ment. There is a co op er a tion agree ment be tween the gov ern ment and the de nom i na tional health bod ies.

2. Rwanda cur rently has around 300 doc tors. Those prac tis ing in the profit-mak ing pri vate sec tor thus ac count forabout a quar ter of the to tal.

(RAMA) together with a number of other insti tu -

tions pro vid ing enti tle ment to state-funded

healthcare for needy vic tims of the geno cide and

mas sa cres, elected com mu nity rep re sen ta tives,

sol diers and their fam i lies, and prisoners.

RAMA is a finan cially inde pend ent asso ci a tion

set up by Law No. 24/2001 of 27 April 2001 on

the set ting up, orga ni za tion and oper a tion of a

sick ness insur ance scheme for gov ern ment offi -

cials, as amended and sup ple mented by Law

No. 29/2002 of 19 Sep tem ber 2002. RAMA

covers all med i cal ben efits pro vided in the coun -

try’s public and approved health estab lish ments,

except for antiretroviral drugs (ARVs), pros the -

ses and spec ta cles. Out side the health facilities

men tioned, RAMA has also con cluded agree -

ments with cer tain profit-making pri vate hos -

pitals and phar ma cies to pro vide healthcare for

its mem bers.

The con tri bu tion is 15 per cent of the basic

salary of each offi cial, with 7.5 per cent paid by

the employee and 7.5 per cent by the employer.

Eighty-five per cent of health cover comes under

a third party pay ment system, with the remain ing

15 per cent paid by the ben e fi ciary in the form of

a co-pay ment. Mem ber ship is com pul sory for all

public ser vants, and mem bers must have con -

trib uted for at least three months before they

can receive benefits.

In order to ensure good-qual ity ser vices for

mem bers and to pre vent abuse and fraud,

RAMA has coun ter staff in all refer ral hos pi tals,

all pri vate hos pi tals and phar ma cies linked to

the gov ern ment health system, and some dis trict

hos pi tals. Their role is to check that mem ber ship

cards are valid and that the appro pri ate ben efits

are received. At each med i cal exam i na tion

mem bers or their depend ants must pres ent the

mem ber ship card to verify that they are a

beneficiary.

With a view to keep ing down hos pi tal iza tion

costs, which are often high, RAMA’s med i cal

adviser is noti fied of any patients who are in

hos pi tal for more than two weeks, and may

come to the hos pi tal to con sult their records and

assess the cir cum stances and rea sons for the

lengthy stay. Like wise, some ben efits require

prior autho ri za tion from the med i cal adviser,

such as pre scribed med i ca tions not on the

list of refund able drugs, scans, or ocular ultra -

sound.

Before they are paid, all invoices for ben efits

are checked against the list of refund able drugs

and the rates for med i cal pro ce dures, which are

revised quar terly. Refund able drugs are the

generics on the essen tial list used by the Min is -

try of Health.

RAMA cur rently has 49,283 con tri bu tors,

with 106,111 depend ants, giving a total of

155,394 ben e fi cia ries, and up to now mem bers

have been extremely happy with the way it

works. It is there fore plan ning to extend the

range of ben efits to include pros the ses, spec -

tacles, ARVs and treat ment requir ing trans fer

abroad. It also wants to extend cover to the

formal pri vate sector. Again in order to sat isfy

mem bers, and with the agree ment of the Min is -

try of Health, RAMA has set up four phar ma cies

in the prov inces of Kibungo, Gisenyi, Cyangugu

and Butare in order to improve access to med i -

ca tion, and also to have a mod er at ing influ ence

on prices in pri vate phar ma cies. How ever, there

are ques tion marks about RAMA staff costs, and

how to ensure that admin is tra tive costs do not

exceed the levels rec om mended for sick ness

insur ance schemes. This aspect is not dealt with

in the present article.

FARG. Another estab lish ment cre ated is the

Fonds d’appui aux rescapés du génocide

(Geno cide Sur vi vors’ Sup port Fund), which

is also finan cially inde pend ent under Law

No. 02/1998 of 22 Jan u ary 1998 set ting up a

national fund to help the most needy vic tims

of the geno cide and the mas sa cres. FARG

covers all med i cal ben efits except ARVs, and

also helps with the social prob lems and


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school ing of ben e fi cia ries. It is funded from

the reg u lar state budget, 5 per cent of which is

set aside for FARG, and from con tri bu tions of

1 per cent of the basic wage of all work ers, and

from busi nesses as well as inde pend ent vol un -

teers and donors. The healthcare pro vided is

100 per cent cov ered by a third party pay ment

system. FARG cur rently has 283,000 ben -

eficiaries.

Gacaca. The State has also orga nized a com -

mu nity-based pro cess involv ing the tra di tional

con flict res o lu tion bodies known as gacaca, set

up to judge some of the crimes com mit ted

during the geno cide. Steps were taken to raise

public aware ness about this pro cess and tri bu -

nal mem bers, who are elected, are known as

inyangamugayo (“people of integ rity”). These

are not state employ ees and work in an hon or -

ary capac ity. The incen tive they are offered is

free med i cal care, with 100 per cent of the cost

of ben efits refunded by the State. There are

esti mated to be 18,350 per sons cov ered in this

way, with 95,420 depend ants, giving a total of

113,770 ben e fi cia ries. The ben efits insured are

lim ited to the min i mum and com ple men tary

pack ages.

The army mutual asso ci a tion, which has

around 100,000 ben e fi cia ries, applies sim i lar

rules to those of RAMA. Con tri bu tions com prise

15 per cent of each serviceperson’s basic

wage, with 7.5 per cent paid by the employee

and 7.5 per cent by the employer. Eighty-

five per cent of care cover is pro vided by a

third party pay ment system and 15 per cent

by the ben e fi ciary in the form of co-pay ments.

Mem ber ship is com pul sory for all sol diers and

mem bers must have con trib uted for at least

three months before they can receive ben efits.

The asso ci a tion covers all ben efits pro vided by

the army’s own med i cal ser vice, as well as

trans fers to public or pri vate estab lish ments as

the ser vice sees fit.

Pris on ers too receive free healthcare, with the

gov ern ment foot ing the bill for ben efits pro vided

by the prison med i cal ser vice. The Law gov ern -

ing the pro vi sion of healthcare for pris on ers was

intro duced in Volume II of the Codes and Laws

of Rwanda. One hun dred per cent of care cover

is pro vided by a third party pay ment system, and

all med i cal ben efits are cov ered except ARVs.

There are cur rently esti mated to be

107,000 ben e fi cia ries.

Mutuals. At pres ent there is a great deal of

inter est in the system of mutual asso ci a tions

orga nized around the com mu nity, with talk of

them in the press, in polit i cal speeches and

among health spe cial ists.

These exper i ments with mutualism have

been going on in Rwanda for a number of years.

Before Inde pend ence, there was one mutual

asso ci a tion in the prov ince of Butare and one at

Nyundo in the prov ince of Gisenyi, together with

a fed er a tion of Rwandan mutual soci et ies. After

Inde pend ence, a number of mutual ini tia tives

were also set up in sev eral prov inces (Kibungo,

Butare, Gisenyi, Gitarama and Kibuye). These

were recorded as being either health mutuals

orga nized by people them selves, insur ance

schemes for trans port in the event of a med i cal

refer ral, or pre pay ment schemes orga nized by

ser vice pro vid ers around health cen tres. Unfor -

tu nately, the strengths and weak nesses of these

exper i ments were not doc u mented, except for

the mutual asso ci a tion at Kanage (Murunda

health dis trict) in Kibuye prov ince, where

Roenen and Criel (1997) described the les sons

to be learned from the fail ure of the sick ness

insur ance scheme set up by the Cath o lic hos pi -

tal at Murunda for hospital care. Those lessons

were as follows:

• the scheme did not extend beyond the pop u -

la tion living near the hos pi tal, and cover for

basic care was con fined to the hos pi tal out -

patients’ clinic; the scheme was there fore, as

the authors point out, not com pre hen sive;



97

• the lack of a ratio nal ized patient admis sions

policy or approach to diag no sis and treat ment

was also high lighted by the authors as one of

the fac tors which lim ited the effi ciency of the

care pro vided;

• the lim ited dia logue between the med i cal

per son nel and the pop u la tion, and the fact that

the mutual was man aged by a single person

(the hos pi tal’s med i cal direc tor), who had little

con tact with the real ity of first-line health ser -

vices, weak ened the scheme at the Murunda

hos pi tal;

• lastly, the inad e quate qual ity of care and

the fact that pri or i ties were not estab lished in

advance within the pack age of ser vices to be

pro vided for the pop u la tion were also men tioned

as les sons to be learned from the fail ure of the

Murunda exper i ment.

Up until 1994 — shortly before the Rwandan

geno cide — some mutuals were still in oper a -

tion, but the tragic events of that year destroyed

the entire social fabric, includ ing the sick ness

insur ance schemes. In July 1999 mea sures

were taken to relaunch these mutuals in the

form of a pilot pro ject by the Min is try of Health,

with tech ni cal and finan cial sup port from the

Part ner ships for Health Reform (PHR) pro ject

funded by the United States Agency for Inter na -

tional Devel op ment (USAID).

In Decem ber 2000, fol low ing an eval u a tion of

the PHR/Min is try of Health pro ject, a number of

mutual ini tia tives were launched in the coun try’s

health dis tricts (Schnei der et al., 2001). The

Min is try of Health orga nized a meet ing of these

bodies, and a com mit tee was formed to set up

and mon i tor mutual health asso ci a tions. This

com mit tee then started to receive requests for

tech ni cal help from mutuals that were hoping to

become estab lished. Since early 2002 a number

of other ini tia tives have been devel oped in both

rural and urban areas and the formal and infor -

mal sec tors (Ministry of Health, 2002a).

Accord ing to the list updated in Decem ber

2004, there are now 116 com mu nity health

mutuals in oper a tion, dis trib uted through out the

coun try. In orga ni za tional terms the insti ga tors

have been either polit i cal author i ties, opin ion

lead ers or the people in charge of health facil i -

ties (Musango, Martiny et al., 2004).

The amount of the annual con tri bu tion varies

depend ing on whether mem ber ship is indi vid ual

(US$ 1.20-2.00 a person) or by house hold

(US$ 7.90-10.00). The con tri bu tion covers the

full MPA pro vided at health cen tres plus a small

number of CPA ben efits at dis trict hos pi tals

(usu ally con sul ta tions with doc tors, pae di at ric

care, dif fi cult deliv er ies includ ing caesareans,

and accom mo da tion at the dis trict hos pi tal).

Other CPA activ i ties are not cov ered by the mu -

tual asso ci a tions; here ben e fi cia ries pay directly

for the care they receive at the going rate.

Each member is asked to make a co-pay -

ment of US$ 0.30-0.60 for each epi sode of ill -

ness. There is a wait ing period of at least one

month after reg is tra tion before ben efits can be

enjoyed. At pres ent there are 603,265 care ben -

e fi cia ries in the com mu nity-based mutuals.

In addi tion to this mutual system orga nized

around the com mu nity, pri vate-sector mutuals

oper ate under the Law of 28 Feb ru ary 1967

estab lish ing the Rwandan Labour Code, as

amended and sup ple mented by Law No. 51/

2001 of 30 Decem ber 2001 on pay ment for

med i cal care for work ers in the private sector.

The types of care cov ered by these estab -

lish ments vary depend ing on the employer, but

the MPA and CPA are cov ered by all enter -

prises. The ben efits of cover are clear in cer tain

busi nesses which pay for ARVs for their employ -

ees and arrange for some patients to be trans -

ferred abroad if their con di tion cannot be man -

aged in Rwanda itself.

All in all it is esti mated that 37.8 per cent of

the Rwandan pop u la tion have some level of

sick ness insur ance cover pro vided by the public

or pri vate insti tu tional system. The table shows

how this per cent age is dis trib uted, and the

people cov ered by each estab lish ment.


98

Cov er ing the needy,

and the con tri bu tion of mutuals

to wards health fi nanc ing

Despite the fairly encour ag ing extent to which

sick ness insur ance mech a nisms are becom ing

estab lished, cer tain prob lems and hand i caps

have yet to be tack led in the Rwandan health

system. In this sec tion we will look at the prob -

lem of pro vid ing cover for the needy pop u la tion

and the role that the mutual asso ci a tions play

in financ ing health ser vices.

Cov er ing the needy pop u la tion. The socio -

economic envi ron ment in Rwanda is such that

60.4 per cent of the pop u la tion live below the

pov erty line. The reper cus sions for the health

system, in terms of both acces si bil ity and health

sector fund ing, are enor mous.

By pro mot ing the risk mutualization mech a -

nisms described above, Rwanda has gone

some way towards resolv ing the first prob lem

of giving the pop u la tion access to healthcare.

In the areas where the health mutuals oper ate,

for exam ple, the rates of uptake of modern

health ser vices have almost qua dru pled among

mem bers, com pared with non-mem bers. Rou -

tine sta tis tics show that mem bers have one

con tact a member a year on aver age, whereas

for non-mem bers the figure is still around

0.3 con tacts a person a year (Min is try of

Health, 2004).

When it comes to access, how ever, there is

one group of the pop u la tion which, even more

than other vul ner a ble groups, is excluded from

care, despite the mech a nisms that exist for

mutualizing health risks. These are the needy.

It is true that there is a policy of free — or

rather, sub si dized — care for these groups,

in that needy and other vul ner a ble people are

sup posed to be reg is tered by the admin is tra tive

author i ties and the lists for warded to public and



99

Sick ness in sur ance cover pro vided by each pub lic and pri vate scheme in Rwanda

Scheme Num ber of ben e fi cia ries As pro por tion of to tal pop u -la tion cov ered by sick nessin sur ance (%)

Pub lic sys tem RAMA 155,394 5.1

FARG 283,000 9.2

Gacaca 113,770 3.7

Pris on ers 107,000 3.5

Army 100,000 3.3

Pri vate sys tem Com mu nity-based mutuals

2,101,034 68.4

Sick ness in sur ance in pri vate sec tor

213,512 6.9

To tal num berof ben e fi cia ries

3,073,710 100

To tal pop u la tion 8,128,553

To tal cov er age 37.8%

Source: Min is try of Health, 2005.

approved health bodies. These are then sup -

posed to send bills relat ing to such patients to

the decen tral ized author i ties, the dis tricts, for

set tle ment. How ever, the budget allo ca tions

received by the dis tricts for this pur pose are

triv ial, and unpaid bills have mounted up. Since

they need to recover their costs, the health

estab lish ments are becom ing more demand ing

when it comes to caring for needy and other

vul ner a ble people. What this means is that pro -

vid ing cover for the needy is still a prob lem in

many health estab lish ments, despite the policy

of subsidized care.

A few local ini tia tives have been launched

to try to plug these gaps. Health mutuals which

have a fairly large number of mem bers often

agree to pay for care for a cer tain per cent age

of the needy in their catch ment area. Many

cha r i ta ble orga ni za tions also now pay con tri bu -

tions for needy and other vul ner a ble people to

the health mutuals.

Finan cial involve ment of mutuals in health

ser vices. It should be noted that mutuals pro -

vide health cen tres with con tin u ous and reg u lar

resources, making it easier to obtain reg u lar

sup plies of med i ca tion and equip ment, and thus

pre vent ing stock short ages and help ing to

ensure good-qual ity healthcare. How ever, the

mutuals do not cover the health cen tres’ finan -

cial needs in full but con trib ute towards fund ing

the health ser vices pro vided (Atim, 1999;

Fonteneau and Bruyninckx, 2000; Preker et al.,

2001; ILO/STEP-CIDR, 2001; Dror and Preker,

2002; Develtere et al., 2004; Musango, Dujardin

et al., 2004).

Nev er the less, health mutuals do make a

cer tain con tri bu tion to financ ing basic health

ser vices. The anal y sis by Foulon et al. (2004)

at the health cen tres at Butare and Byumba

shows that sales of drugs and admin is ter ing

care to non-mutual patients account for the bulk

of income; out of total receipts of US$ 990,413,


100

Sources of income of the health cen tres at Butare and Byumba, 2002

73%

10%8%

9%

73%

8%

9%

10%

Non-mutual patients(medication + care)

Grants (State and partners)

Other

Mutual patients(medication + care)

Source: Foulon et al., 2004.

healthcare and med i ca tion for non-mutual

patients accounted for US$ 710,518, or 73 per

cent (US$ 1 = €0.80 approx.). The con tri bu tion

of the mutuals is still small, account ing for

US$ 102,365 of total income, or 10 per cent, for

a pop u la tion in which 14 per cent belong to the

mutuals (Foulon et al., 2004). Grants from the

State and var i ous part ners account for 8 per

cent of total income, and other sources not

spec i fied in the finan cial report account for

9 per cent (see figure).

Finally on the sub ject of mobi liz ing finan cial

resources, health mutuals are chang ing the way

healthcare is tra di tion ally financed, since up to

now this has been a burden on the pop u la tion’s

resources, with house holds con trib ut ing for

every med i cal pro ce dure and financ ing their

care directly. In a sit u a tion where much of the

pop u la tion is living in inse cu rity, as in Rwanda,

the mutuals are pro tect ing house hold incomes

against the risks of ill ness as part of the over all

fight against pov erty.

How ever, the imbal ance between mem bers’

con tri bu tions and the ben efits pro vided pres ents

a threat. Two stud ies show that some health

cen tres are unable to strike a finan cial bal ance

between the care received by mutual asso ci a -

tion patients and their pay ments (Min is try of

Health, 2002a; Musango and Inyarubuga, 2004).

But as most health mutuals have opted for the

cap i ta tion pay ment system, there is no likely risk

that they will incur a finan cial def i cit because

they pay only one twelfth of the con tri bu tions

col lected, regard less of how many of their

mem bers received treat ment. The knock-on

effect for the health cen tres, on the other hand,

is that they do incur a finan cial def i cit (Min is try

of Health, 2002a; Musango and Inyarubuga,

2004). The main prob lem with this fund ing

arrange ment, there fore, is that a sit u a tion could

arise where the health cen tres no longer meet

their com mit ment to pro vide care for mutual

mem bers as a result of the imbal ance between

the funds which the mutuals reim burse to the

health centres and the benefits which the latter

provide.

If the health cen tres do not build up finan cial

reserves, a solu tion must be found which will

enable them to recoup their losses over a given

period.

In such a sit u a tion, some authors (Fon -

teneau and Bruyninckx, 2000) rec om mend

either increas ing con tri bu tions or pro vid ing a

lim ited care pack age for mutual mem bers

(which is not appro pri ate for the pop u la tion

in the cur rent sit u a tion, where the aim is to

improve access to care), or else asking the

public author i ties and/or exter nal part ners to

make up the short fall for a cer tain period while

the mutuals con sol i date. It has been proved

that many micro-insur ance estab lish ments are

in def i cit during their early years in par tic u lar,

because they keep con tri bu tions down in order

to attract mem bers (Develtere et al., 2004) or

because their mem bers use ser vices more

than is really nec es sary (Atim, 2000). Addi -

tional fund ing is there fore essen tial if ser vice

pro vid ers are not to pull out alto gether or

reduce the care pack age pro vided if they incur

a finan cial def i cit. Depend ence on one eco nomic

sector pres ents a risk for the sustainability of

any micro-insurance establishment (Develtere

et al., 2004).

Con clu sion

The system in Rwanda is expand ing rap idly

and there is grow ing enthu si asm for the

estab lish ment of sick ness insur ance schemes

in both public and pri vate sec tors. How ever,

the capac ity of the exist ing schemes needs

to be strength ened, and a frame work needs

to be cre ated for con sul ta tion and coor di na tion

between pro mot ers and sup port struc tures.

Pos i tive expe ri ences with the var i ous schemes

should be built on in order to ensure that the

devel op ment of the sick ness insur ance system

in Rwanda is fos tered and sup ported.



101

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Documents

Rwanda's Health System and Sickness Insurance Schemes