Joint Learning Network for Universal Health Coverage

Rwanda: Mutuelles de Sante

7.9 million

Funding

General government revenues, Donor funding
Formal Sector, Informal Sector
Premiums, Co-payments

Population Covered

Service delivery system

Both Public & Non-state
165
411

Institutional structure

Decentralized to district/local level
Central Government, District/Local Government
Central Government, District/Local Government
District/Local Government, Mutuelles
Mutuelles
Reform summary: 
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Mutuelles are highly decentralized, relying on existing community-based health structures at the district and local level to provide a majority of management and administration of services.In 2003 the Community-Based Health Insurance system (CBHI) was expanded from a pilot project to a national system. CBHI is comprised of three parts: Mutuelles de Sante; Military Medical Insurance; and Rwanda Health Insurance Scheme. The first, known as Mutuelles de Sante, is a modified version of social health insurance that provides health coverage through voluntary and affordable local insurance.

Mutuelles are highly decentralized, relying on existing community-based health structures at the district and local level to provide a majority of management and administration of services.In 2003 the Community-Based Health Insurance system (CBHI) was expanded from a pilot project to a national system. CBHI is comprised of three parts: Mutuelles de Sante; Military Medical Insurance; and Rwanda Health Insurance Scheme. The first, known as Mutuelles de Sante, is a modified version of social health insurance that provides health coverage through voluntary and affordable local insurance. Mutuelles are highly decentralized, relying on existing community-based health structures (such as rural co-operatives) at the district and local level to provide a majority of management and administration of services, with only top-level policy and administration coordinated by the central government. Enrollment in the Mutuelles system is voluntary and coordinated at the district and sector level. Members pay annual premiums of 1000 Rwandan francs (approximately US$1.80) per family member and a 10% co-payment fee for all services at the health care facility. Those classified as very poor are exempt from payments and their membership is subsidized through funds pooled at the local Mutuelle level, as well as funding from the government and donors. The expansion of the Mutuelles system led to a rapid uptake of coverage in 2003; by 2010 about 90% of the population had health insurance.

Specific benefits packages are determined by each local Mutuelle branch. All insured Rwandans receive comprehensive, subsidized preventative care through the Minimum Package of Activities (MPA), which covers all services and drugs provided at local health centers. A Comprehensive Package of Activities (MPA) covers a limited number of services at the district hospitals and select services in national hospitals that require referrals from local health centers. Mutuelle members are able to access curative (primary-, secondary-, and tertiary-level) care benefits at all public and private non-profit health centers, which excludes only 10% of the country’s health care facilities.

The Mutuelles system has a comprehensive financing framework that includes risk pooling, cross-subsidies, and substantial support from donors, NGOs, and tax-generated funding from the formal sector. Funding is comprised of annual member premiums organized on a per household basis. When a citizen cannot pay the premium up-front, community banks (Banques Populaires) provide individual loans with 15% interest. The poorest individuals, along with those infected with HIV/AIDs, have their fees subsidized by district and nationally organized Mutuelle solidarity funds financed primarily by the risk-pooling of fees, funding from the central government and external aid partners. A total of 1.5 million individuals enrolled in Mutuelles are subsidized by these funds.

In 2006, performance-based financing (PBF) was implemented, which provided a focus on progress and evaluation measures for both the Mutuelle system and the employer-based government schemes to strengthen the base of evidence and improve quality of care. Performance is monitored through quarterly evaluations and is based on a list of 13 services and 185 variables that measure facility outputs, quality, access to care, and administration. Analysis of results is then conducted by the district and sector levels and payment is then scaled to performance. PBF and CBHI align and reinforce incentives associated with provider payment modalities by putting pressures on providers to improve the quality of services to the satisfaction of CBHI members, which influences enrollment rates into CBHI.

Funding: 
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Rwanda has developed a comprehensive financing framework for health care that includes risk pooling, cross-subsidies, and substantial support from donors, NGOs, and tax-generated funding from the formal sector. In the Mutuelle system, funding is comprised of annual member premiums organized on a per household basis, with an annual payment of 1000 Rwandan francs (equivalent of approximately US$1.80) per family member, and a 10% service fee paid up-front for each visit to a health center or hospital.

Rwanda has developed a comprehensive financing framework for health care that includes risk pooling, cross-subsidies, and substantial support from donors, NGOs, and tax-generated funding from the formal sector. In the Mutuelle system, funding is comprised of annual member premiums organized on a per household basis, with an annual payment of 1000 Rwandan francs (equivalent of approximately US$1.80) per family member, and a 10% service fee paid up-front for each visit to a health center or hospital. When a citizen cannot pay the premium up-front, microfinance institutions from community banks (Banques Populaires) provide individual loans to be repaid within a year of disbursement with 15% interest. Due to the high degree of poverty in Rwanda, the poorest individuals, as determined by community leaders, along with those infected with HIV/AIDs, are not required to pay the membership or service fees, rather their fees are subsidized by district and nationally organized solidarity funds financed primarily by the central government and external aid partners. A total of 1.5 million individuals enrolled in Mutuelles are subsidized by these funds.

Rwandan Health Financing Sources

Funding for the insurance scheme is coordinated at the central, district, and local levels. At the central level, two bodies exist to coordinate funding: the National Health Insurance Fund and the National Guarantee Fund of the Mutuelles. Financing for both these Funds comes primarily from external aid partners and the Central Government, though MMI, RAMA, and Mutuelle branches provide a small percentage of the financing as well. A substantial amount of funding for the National Funds comes from 16 bilateral and multi-lateral donors and external aid partners: approximately $700 million per year or a third of the central government’s total health spending. Though donor funds are generally funneled through the national Funds, some donors channel funds through NGOs. These funds are largely earmarked for specific purposed such as Tuberculosis, Malaria, and HIV/AIDS, rather than the national care system. The ear-marking of funds and diversion through third parties creates administrative challenges to the central government and often skews the focus of the health system, by placing an emphasis on disease-specific care.

The National Funds allocate and disburse funds to the sector and district level Mutuelle solidarity funds through block transfers to the district and sector level Mutuelle bodies as well as separately providing other subsidies to sector level solidarity funds for coverage of indigent Mutuelle members. The National Funds also reimburse two national referral teaching hospitals and one psychiatric hospital for care of Mutuelle members who are referred by district hospitals.

At the district level, a district Mutuelle acts as a risk-pooling mechanism for all Mutuelles in the district and acts to reimburse the costs of district hospital care for the Mutuelle members referred by local health centers. Several sources contribute to the district Mutuelle funds: the National Guarantee Fund of Mutuelles, the sector level Mutuelle organizations, the district, and external partners. At the sector level, the Mutuelles perform a risk-pooling function for high-risk events at the sector level. Sector level Mutuelles are financed primarily by user fees, while the rest of the fees are from NGOs and development partners, interest generated from their bank accounts, and the Government of Rwanda to co-finance and subsidize membership fees.

The government sponsored program Rwanda Health Insurance Scheme (La Rwandaise d’Assurance Maladie or RAMA) is financed by monthly contributions of 15% of the member’s base salary with the employer paying 7.5% and the employee paying the difference. Members of the government sponsored Military Medical Insurance (MMI) contribute 5% of their base salary and the government adds 17.5% of the members’ base salary. Beneficiaries also contribute a 15% direct co-payment for services and pharmacies.

The table below summarizes the recipients of donor aid for health in Rwanda:

Financing agentShare of donor aid
NGO55%
Development partner direct management19%
Central government14%
Direct to local government or health district12%
Total100%
Population covered: 
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Enrollment in the Mutuelle system is voluntary and is primarily coordinated at the district and sector level. Each community-based Mutuelle is responsible for increasing enrollment, maintaining re-enrollment, educating the population about the program, verifying the number of participants in each household, and collecting membership contributions. Outreach is done most frequently at the community level via church services, radio broadcasts, etc, and tends to focus largely on the rural and informal sector in order to most effectively target those individuals unable to access formal health insurance through other means.

Enrollment in the Mutuelle system is voluntary and is primarily coordinated at the district and sector level. Each community-based Mutuelle is responsible for increasing enrollment, maintaining re-enrollment, educating the population about the program, verifying the number of participants in each household, and collecting membership contributions. Outreach is done most frequently at the community level via church services, radio broadcasts, etc, and tends to focus largely on the rural and informal sector in order to most effectively target those individuals unable to access formal health insurance through other means.

Enrollment for Rwanda Health Insurance Scheme (La Rwandaise d’Assurance Maladie or RAMA) and Military Medical Insurance (MMI) are coordinated through the government and employers. Initially only civil servants and their families were covered with RAMA, however, in 2003 coverage expanded to all those employed in both the public and the private sector. In 2006 RAMA only covered approximately 2.2% of the population. Coverage through MMI is provided for all members of the Rwandan Defense Force. Family members of MMI affiliates are covered under the same conditions as in RAMA. The exact number of beneficiaries is difficult to calculate due to national security issues but an estimated figure of 100,000 individuals or approximately 1.1% of the total Rwandan population is estimated to be covered. Combined, these programs insure less than 5% of the population.

The result of these health insurance programs has been an incredible upsurge in health insurance enrollment. USAID estimates that in 2010 approximately 92% of the population had health coverage, up from about 10% in 1999 since the implementation of the Community-Based Health Initiatives (CBHI). Geographically, enrollment has expanded from about 4 provinces to all 11 provinces. After national expansion of CBHI, participation increased coverage to 5.8 million persons, about 70% of the population. The Ministry of Health has stated that the rapid uptake seen in the early years of the program undoubtedly speaks to the communal and grassroots dynamics of the country.

Enrollment uptake in Health Insurance System from 2002 to 2006

Benefits package: 
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The benefits package in Rwanda has two primary parts: the Minimum Package of Activities (MPA) and the Complementary Package of Activities (CPA). The MPA covers all services and drugs provided at the health centers including pre- and post-natal care, vaccinations, family planning, minor surgical operations, and essential and generic drugs. All individuals in Rwanda with health insurance are entitled to comprehensive, subsidized preventative care through the MPA. The CPA covers a limited number of services at the district hospitals, including the cost of hospitalization, caesarian operations, minor and major surgical operations, medical imaging, and all diseases afflicting children ages 0 to 5 years.

The benefits package in Rwanda has two primary parts: the Minimum Package of Activities (MPA) and the Complementary Package of Activities (CPA). The MPA covers all services and drugs provided at the health centers including pre- and post-natal care, vaccinations, family planning, minor surgical operations, and essential and generic drugs. All individuals in Rwanda with health insurance are entitled to comprehensive, subsidized preventative care through the MPA. The CPA covers a limited number of services at the district hospitals, including the cost of hospitalization, caesarian operations, minor and major surgical operations, medical imaging, and all diseases afflicting children ages 0 to 5 years. As of 2006, the CPA benefits package was extended to cover select services in national hospitals. In order to receive these benefits, individuals must be referred from the health centers to district or national level hospitals.

Mutuelle members are entitled to comprehensive benefits for primary care, secondary care, and tertiary care provided through public or private non-profit contracted facilities. The scheme provides basic services such as family planning, pre-natal care, consultations, basic laboratory examinations, generic drugs, and hospital treatment. All medications from hospitals are also included in the benefits.

For those covered under RAMA, benefits include all the major preventative services in addition to all curative services and pharmaceuticals. The benefits package for MMI is the same as RAMA, with the addition of prostheses coverage added under MMI. Excluded are contact lenses and braces as well as cosmetic surgery for purely aesthetic reasons. RAMA and MMI have signed contracts with all public health centers and reference hospitals, as well as 16 private institutions. MMI has the added advantage of using military hospitals, thus, individuals covered under these plans are able to access health care benefits at almost all health centers in Rwanda.

Service delivery system: 
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Mutuelle members are able to access health care through all public and private non-profit health centers in Rwanda, which excludes only 10% of the country’s health care facilities that are private and for-profit. A recent law titled the Patient Roaming System was passed allowing any Mutuelle member to seek health care at any health center throughout the country. However, this has not been realized in practice as the capacity to transfer bills and funds is still limited, despite ambitions for more e-health solutions.

Mutuelle members are able to access health care through all public and private non-profit health centers in Rwanda, which excludes only 10% of the country’s health care facilities that are private and for-profit. A recent law titled the Patient Roaming System was passed allowing any Mutuelle member to seek health care at any health center throughout the country. However, this has not been realized in practice as the capacity to transfer bills and funds is still limited, despite ambitions for more e-health solutions.

Rwanda has about 411 private and public health centers in total, which deliver primary and secondary care at the sector and district level. Facilities are run by for-profit entities, traditional healers, non-governmental agencies, and governmentally-assisted health organizations. Public Governmentally Assisted Health Facilities (GAHFs) are run by NGOs, religious groups, and other third parties and are partially funded by the central government. These account for approximately 40% of all primary and secondary care facilities.

Primary care includes out-patient services, in-patient services, and preventive services such as immunizations, while secondary care is provided by district hospitals, which are responsible for more specialized procedures such as surgery, management of complicated cases such as severe malaria, organization of health services in health centers, administrative functioning and logistics—including the management of resources and supply of drugs— as well as supervision of community health workers. In addition, six mental health operational poles in district hospitals have been established and 30 district hospitals have integrated mental healthcare into the system. Each district health center serves approximately 200,000 people, with an average of one bed per every 1,000 people. However, these figures mask substantial variation between districts and provinces, which range from 70,000 to 480,000 people served per district. In 2006 Rwanda purchased 51 ambulances and 270 motorcycles for the district level health centers.

Tertiary care is delivered at the national level at one of the few specialized, national medical institutions. There are only 4 tertiary care hospitals in Rwanda, 3 public and 1 private. While national hospitals should primarily serve as referral hospitals, in reality there is substantial overlap due to unclear delineation of responsibilities.

Currently, individuals are considered to have access to medical centers if services can be reached within one and half hours by foot; approximately 85% of the population falls into this category. For the 15% of individuals living in rural areas, telemedicine is currently being used to reach geographically isolated regions.

Pharmacies make generic medications available through the independent purchasing supply house called the Central Purchasing of Essential Drugs, Medical Consumables and Equipment in Rwanda (Centrale d’Achat des Medicaments Essentiels au Rwnda or CAMERWA), a non-profit organization that sells medications to district pharmacies and health facilities as a means of financing the activities of CAMERWA. The government fully finances vaccines and immunizations with the Expanded Programme on Immunizations.

The table below summarizes the growth in the number of health facilities in Rwanda since the 1980s.

Year1982199020002007
Hospitals27292938
Health centers, dispensaries, and health posts208302348411
Institutional structures: 
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The health system is organized on a 3-tier pyramid system composed of central, district, and sector levels. The central government is managed by the Ministry of Health (MOH) and is responsible for the stewardship of the Mutuelles program, focusing on policy development, capacity building, monitoring and evaluation of operational programs, and resource mobilization. The central level monitors and coordinates technical and logistic support and training at the district and sector levels. The central level is also in charge of the payment to national tertiary care hospitals.

The health system is organized on a 3-tier pyramid system composed of central, district, and sector levels. The central government is managed by the Ministry of Health (MOH) and is responsible for the stewardship of the Mutuelles program, focusing on policy development, capacity building, monitoring and evaluation of operational programs, and resource mobilization. The central level monitors and coordinates technical and logistic support and training at the district and sector levels. The central level is also in charge of the payment to national tertiary care hospitals.

The district level is composed of about 5 sectors, with roughly 250,000-500,000 people each (Rwanda has 30 districts in total), and at least one hospital and secondary care facility. A board of directors governs the district Mutuelle and a permanent salaried agent conduct audits and overviews. At the district level, the Mutuelle Fund manages member premium subsidies and disburses funds to the appropriate district and sector level facilities based on need and service utilization. Districts guide and facilitate the administrative, logistical, technical, and political supervision, training, and management of the sector level Mutuelles. The district level is also responsible for contractual relations with the district hospital, hospital reimbursement, and quality-of-care supervision at the district hospital levels.

The sector-level includes roughly 50,000 people, with at least one health center for primary care. Each sector has a Mutuelle that is managed by community elected officials. At the sector level, Mutuelles are owned and privately managed by their members. Sector level Mutuelle organizations adopt a Constitution and By-laws, through which they define the organizational structure, roles and functions of management, and election of organizational leaders. These leaders then determine benefit packages, annual premiums and periodicity of the subscriptions, establish conventions on care and health services, service providers and reimbursement. In addition, these sector-level Mutuelles are responsible for recruitment of members and membership collections, as well as monitoring and evaluation of local health and reimbursing health centers.

In 2009 the government created the Rwanda Social Security Board which merges Rwanda Health Insurance Scheme (RAMA) and Military Medical Insurance (MMI) with the Society Security Fund with the objective of improving performance and decision-making.

Reformed Rwandan Health System

Provider payment mechanisms: 
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The health insurance system in Rwanda has two main channels for financing: the demand side – the insurance programs, and the supply side – transfers from the treasury to districts and health facilities. On the demand side, services are financed through three main channels: demand-based user payments, demand-based payments from Mutuelles, and demand-based payments from RAMA and MMI.

The health insurance system in Rwanda has two main channels for financing: the demand side – the insurance programs, and the supply side – transfers from the treasury to districts and health facilities. On the demand side, services are financed through three main channels: demand-based user payments, demand-based payments from Mutuelles, and demand-based payments from RAMA and MMI.

  • Demand Based User Payments: These amount to approximately 20% of total health expenditures in Rwanda. These stem from personal payments for treatment from individuals who have health coverage. Those insured by RAMA and MMI pay 15% upon treatment for all services and pharmaceuticals. Those covered by the Mutuelles system pay 10% for all services.
  • Demand based payments from Mutuelles: Payments are made directly to health facilities based on a fee-for-service or a capitation basis depending on the region.
  • Demand Based payments from RAMA and MMI: Payments are made to the health centers by the insurance system RAMA and MMI on a fee-for-service or a capitation basis. Many of the health centers receive capitation payments, while district and national hospitals are paid on a fee-for-service basis.

On the supply side, financing flows from the central government towards health providers through multiple block grants, which provide hospitals with greater degrees of autonomy.

A key issue on the supply-side financing is the equity of the needs based transfers against the historical criteria. The government hopes to progressively move towards increasing the importance of needs-based transfers and decreasing historical transfers.

  • Needs-based transfers are delivered in the form of a monthly block grant from the government to individual district-level health centers, in amounts that are calculated based on a formula which includes population and poverty levels as a weighing factor.
  • Performance based transfers or Pay for performance (PFP), instituted in 2006, links measurable indicators with financial incentives for district level health centers that are paid according to performance, rather than actual costs of service or operation. Hospital budgets are determined prospectively based on an annual value of beds. Each quarter, performance is reviewed by the district level peer review system with indicators that gauge facility outputs, quality, and administration. Based on the scores, each hospital receives payment that correlates to the performance review. Incentives are included for workers in rural areas and hospitals that offer HIV/AIDS services in order to maintain qualified health personnel. Results from independent studies of 16 health centers indicated that income was 22.7% higher and health outcomes improved in health centers that had PFP mechanisms. The same study found that family planning was 28% higher in provinces with PFP.
  • History based transfers delivered from the government to health centers for facilities to maintain their assets.
  • Investment grants which are provided from the government for construction and equipment to health centers
  • Fragmented Donors’ Transfers from a group of bilateral and multi-lateral organizations to specific facilities, some of which are made in kind. Rwanda receives a substantial amount of funding from donors, approximately $700 million per year. Donor funding is generally funneled either through a single framework coordinated by the central government or through NGOs and administrative districts. Of those diverted through NGOs, a large percentage are earmarked for specific purposes such as HIV/AIDS, which creates administrative challenges for the government and often skews the focus of the health system.

A key issue on the supply-side financing is the equity of the needs based transfers against the historical criteria. The government hopes to progressively move towards increasing the importance of needs-based transfers and decreasing historical transfers. In addition, the substantial amount of donor funding incurs high overhead costs and involves a lack of clarity.

Monitoring and evaluation: 
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Performance is monitored through quarterly evaluations and the analysis of results in annual reports conducted by a district and sector level peer-review that gauges facility outputs, quality, and administration through a list of 13 services and 185 variables. Information has been gathered with the help of information technology, particularly electronic health records and national reporting systems. District and sector level health centers use technologically advanced health-surveillance systems

Performance is monitored through quarterly evaluations and the analysis of results in annual reports conducted by a district and sector level peer-review that gauges facility outputs, quality, and administration through a list of 13 services and 185 variables. Information has been gathered with the help of information technology, particularly electronic health records and national reporting systems. District and sector level health centers use technologically advanced health-surveillance systems such as:

  • OPENMRS-an open-source Medical Records System that tracks patient level data for clinics
  • TracPlus and TRACnet- implemented in 1997, this system monitors infectious diseases including HIV/AIDS, TB, and Malaria on a monthly or biweekly basis into a repository known as the Health Management Information System (HMIS) managed by the Central Government in order to integrate data collection, processing, reporting, and use of the information necessary for improving and monitoring health
  • CAMERWA- Drug and medical supply management system
  • Health Management Information Systems- systems that integrate data collection processing, reporting and use of information for programmatic decision making
  • E-learning- Use of information and communication technology in instruction of A2-Level nurses for promotion to A1status

Despite these measures, there is still insufficient capacity within the local and central levels to effectively aggregate, analyze or report national level data. However, these systems are open to all donors, which have done a large degree of independent evaluation.

Results of the reform: 
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The impressive expansion of health coverage, decentralization of services, and performance-based-financing in Rwanda has had a number of positive results. Since 1999 there has been a substantial reduction in health-care costs and user fees and an increase in the use of health-care services. Consultation rates increased from .25 in 2001 to .86 in 2008. Studies indicate that in 2004, Mutuelle members had better access to care, with a utilization probability of 0.45, compared to 0.15 for the uninsured. Between 2005 and 2007 there was a 20% increase in health insurance participation, use of modern contraceptives jumped 20%, infant mortality decreased 28% and under-5 mortality decreased 33%. In addition, since the beginning of the program, Malaria and Tuberculosis infection rates have decreased.

The impressive expansion of health coverage, decentralization of services, and performance-based-financing in Rwanda has had a number of positive results. Since 1999 there has been a substantial reduction in health-care costs and user fees and an increase in the use of health-care services. Consultation rates increased from .25 in 2001 to .86 in 2008. Studies indicate that in 2004, Mutuelle members had better access to care, with a utilization probability of 0.45, compared to 0.15 for the uninsured. Between 2005 and 2007 there was a 20% increase in health insurance participation, use of modern contraceptives jumped 20%, infant mortality decreased 28% and under-5 mortality decreased 33%. In addition, since the beginning of the program, Malaria and Tuberculosis infection rates have decreased.

The results of the health insurance program have made Rwanda a leader in performance-incentive programs that target provider behavior where hospitals with incentives achieved higher-quality scores than hospitals without incentives.

The table below summarizes key health indicators in Rwanda over the 15 year period from 1992-2007.

Indicator1992200020052007
Infant mortality (<1 year)851078662
Child mortality (<5 years)150196152103
Antenatal care (1st visit)94%92%94%95%
Skilled birth attendance26%31%39%53%
Total fertility rate6.25.86.15.5
Contraceptive prevalence13%4%10%27%

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