Mapping of HealthFinancing Schemes

in Rwanda

Alex HakuzimanaMPH/HSMP

Health Pol icy

July 2, 2014

Antwerpen, Belgium

1

Introduction

Growing evidence on low access to health care and catastrophic payments.

Every year,

• 1,300 million people with no access to affordable health services

• 150 million people suffer financial catastrophe

• 100 million pushed into poverty because of out-of-pocket payments at the entry point seeking healthservices.

2Xu K, Evans DB, Carrin G, Aguilar-Rivera AM, Musgrove P, Evans T. Protecting households from catastrophic health spending. Health Aff

(Millwood ) 2007 Jul;26(4):972-83

3

Path towards Universal Health Coverage (UHC)

WHO. The World Health Report 2010. Health systems financing: the path to universal coverage.

Ensure all people have

access to needed

services

Without risk of financial catastrophe

Well-functioning Health Financing

System

4

Where do we stand now?

Feasible in high income countries

Major reforms: BRICS, LICs e.g. Rwanda, Ghana, Georgia

No “one-fits-all”

Lessons & experiences e. g. Rwanda

“Know before you go”

Study on

UHC

Multicountry descriptive study on UHC

5

Mapping health care financing fragmentation

12 countries

Two CoPs: PBF & FAHSSame challenge: fragmentation

Hypothesis: many actors, different objectives

0

50

100

150

200

250

300

1990 1995 2000 2005 2010 2015MDG Target

Probability of child dying by age 5 per

1,000 live births

Child Mortality in Rwanda, 1990 – 2011

Rwanda

Sub-Saharan Africa

World

87 8273

6353 51

156

275

183

108

6054

178170

154

133

112109

29

5259

Farmer PE, Nutt CT, Wagner CM, Sekabaraga C, Nuthulaganti T, et al. (2013). “Reduced Premature Mortality in Rwanda: Lessons

from Success.” British Medical Journal 346(f65)

Rwanda, one of top performers to reach MDGs

6

7

Outcomes

. Whole architecture

. Process

Goal

Contribute to the Rwanda UHC path by

providing a comprehensive

overview on existing health care financing

schemes

Specific

List, describe, & analyse schemes

Compare with findings of multi-

country descriptive study on UHC

Recommendations on Rwanda & mapping

8

Objectives

Universal health Coverage: 3 dimensions

Population coverage

Fin

anci

al c

ove

rage

9

Hypothetical country: Health financing architecture

EPI

Pregnant women, under five children, poor, employees + affiliates to

schemes

Co-payment,

reimbursement

by a scheme

according to

user’s income,

salary, supply,

trainings, etc.

Primary care,

exempted services,

emergency and

referral services

SHICBHI

Private

10

Public input financing

Health Care Financing Scheme

• Building blocks or subsystems of a health financing system

• Financing arrangement through which people can getaccess to health care

• Features: coverage, resource collection, pooling andpurchasing

• Patterns: legal basis, institutional agent, source of fundsand time-bound

11

12

Document review: secondary data

Sources: policy documents, reports, websites,

databases, expert opinions, key informants, own

experience

Description and analysis of interaction/canvas:

conceptual framework.

Comparison with multi-country study: UHC

dimensions

Methods

13

Conceptual Framework

Kutzin J. A descriptive framework for country-level analysis of health care financing arrangements. Health Policy

2001 Jun;56(3):171-204

Funding flows

Benefit flows

14

General Government

Budget

Exemption Schemes (5)

Health Insurance

Schemes (4)

Performance-Based Financing

(PBF)

Through all other

schemes

- EPI- HIV/AIDS- TB- Malaria- MCH

- MedicalScheme

- MilitaryMedicalInsurance

- Community-Based HealthInsurance

- Private sector

Facility andcommunity-level

Actually, 11 schemes in Rwanda

Many health care financing schemes

2132

20

20

18

28

30

24

19

23

27

28

Source: Multi-country study report

Average= 23.8

15

16

C B H I - M u t u e l l e s d e s a n t e

Benefit package & coverage

Primary care package and referral care countrywide

Target population

Informal sector & rural

Financing

Premium contributions, subsidies (government & Global Fund) on a

fee-for-service schedule

Management & implementation:

Central entity, three-level pooling system

17

Financial protection

Mandatory health

insurance: 11% OOP in

2009/10

. Costly Co-payment and

referrals

. Spending gradient between schemes

Resource collection,

pooling and purchasing

.Reduction of transaction

costs

. Efficiency

. High external dependence

. Low contribution collection.

. Weak active purchasing

Provision of services

. Geographical access: good

. Benefit package

. More beneficial for

better-off

. Unmet need FP, chronic conditions,

referral abroad

Institutional arrangements

. Legal frameworks

. Aid Policy

. SWAp

. Merging

. Synergy

. High administrative

costs

. Still parallel systems

. Law enforcement

18

Financial protection, collection, pooling &

purchasing

Mandatory health insurance

and decline of OOP: 11%

No mandatory insurance

High OOP:

e.g. 65% Burundi

Population coverage

Universal insurance coverage

. No institutionalized

scheme

. Non operational pro-poor targeting

programs

Benefit package

Minimum essential

package & referral care

MDG & DCP-specific services

Rwanda

12 countries

Women and

< five children

High donor funding, mixed provider payment methods

Better-off, chronic care, NCD, referral abroad

19

Conclusion

Rwanda UHC cube not yet filled

Decline OOP but

expensive referral care

High external funding

Universal insurance

coverage with CLLC & NCD

Ownership & alignment

Research tools to be adapted to

context

Lessons for multi-country study participating

countries

20

Insufficient info for some schemes

Some data out of date

OOP excluded

Only national scale schemes included

21

Health Financing Strategy

Discuss on choices on UHC

Sustainability strategy

Improve pooling (CBHI to RSSB)

Review provider payment methods

22

Thank you for your attention