1. Community Based Health Insurance Mutuelles de Santé Rwanda Case 1 Presented by Nicole Curti Kanyoko and Willy Janssen

2. Outline of Presentation  Overview of RW health Financing Structure  Evolution of Community Based Health Insurance  Enrollment and System Mangement  CBHI Key factor of Success  Challenges  Discussion 2

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4. Overview of the health Financing Structure  Population10.4 million; >90% are in the informal sector  45% living under poverty line  Over 90% health insurance coverage  Per capita income 2010 = US$ 520  Health Budget as % of Total Budget: 16%  Foreign financing in health = 53% of total budget 4

5. Rwanda Health Financing Architecture 5

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8. Evolution of CBHI Free care for all Poor exemptions Poor coverage under CBHI CBHI Pilots 19961999-2001 2004 Out of Pocket Payment for Services 2005 2010 Health Financing Policy (2009) CBHI New Policy (2010) National Health Insurance law drafted (2010) CBHI Law 2007 CBHI Expansion CBHI schemes nationwide Civil servants and private formal sector(RAMA 2001) CBHI Policy introduced 2005 CBHI Challenges 2008 Military Medical Insurance,2006 Private health insurance, 2006 8

9. Enrollment and System Management  Funding for CBHI operations management comes mainly from membership fees  Members consist of :  Contributing Members (active members of CBHI)  Assited members (indigents assisted by governement and DPs who pay for a targeted category of the population)  Services Providers are paid by Mutuelles directly:  through monthly capitation rates on a fee-for-service basis or  via performance-based payments 9

10. Contributions per member  Mutuelles uses a policy of household subscription with individual contribution per family member  Enrollees must wait one month to utilize covered services  The annual member premium is determined according to the category of the member:  Category I contribution is set to Rwf 2000/person/year- USD 3.18 (covered by the Government of Rwanda and DPs)  Category II contribution is set to Rwf 3000 /person/year- USD 4.77 (covered by members of this category)  Category III contribution is set to Rwf 7000 Frw/person/year-USD 11.12 (covered by members of this category) 10

11. Significative Affiliation (%) Utilization of services (%) 11

12.  Political Leadership – performance contract, Presidential commitment  Establishment of a legal Framework – 2007 Law  Selection and coverage of indigent (vulnerable groups)  Resource Mobilisation Mechanisms – Ibimina & Sensitization of communities on CBHI  Motivated Human Resources at all levels  Decentralisation of functions & referral mechanism Strengthening  Mobilization of additional financial resources – cross subsidisation, earmarked govt transfers  Synergy between health insurance schemes and other health financing mechanisms – PBF, CHW, Ubudehe, Ibimina, Imihigo (Performance Contract) CBHI key factor of Success 12

13. Challenges  Ensuring institutional, financial sustainability and equity in financing  Establishment of a regulatory body: RHIC ( Rwanda Health Insurance Council)  Effectiveness and accuracy of management and information systems  Technical capacity of CBHI managers including the implementation of the new stratified premium contribution  Expensive Referral system  Chronic diseases uncovered  Regular updating of socio-economic database 13

14. Challenges cont’d  Adequate representation of community and civil society in oversight bodies  Administrative burden at “mutuelles”sections need to be kept to a realistic minimum (simplified)  Subsidies for vulnerable groups need to be pooled at national level (to reduce administrative costs and fiduciary risks)  Need for appropriate (electronic) administrative tools for management  Differential rate should be introduced for “mutuelles” schemes (redistribution of burden /capacity of payment) –established in 2012 14

15. 1.How to decrease patient spending per episode when referred at secondary and tertiary levels? 2.How to deal with the increasing needs of managing Capacity and catastrophe protection for CBHI members? 3.How to maintain equity if the sustainability of the CBHI for Indigent rely mainly on external resources? 4.How to expand the use of CBHI in Private Health Services? Discussion 15