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Key Text Evaluation of NPA’s Support to Mutuelle, a Voluntary Health Insurance Scheme in Rwanda

Author: M Hatlebakk and Ø Olsen
Date: 2005
Size: 46 pages (165 KB)

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Summary

Declining demand for health services in Rwanda prompted the introduction of community-based health insurance schemes called Mutuelles in 1999. Mutuelles have been supported by international donors such as the Norwegian People’s Aid (NPA) as instruments for increasing access to health services. This report by the Chr. Michelson Institute evaluates NPA’s support to health services in the Gisenyi district of Rwanda, focusing on its support to Mutuelles. Reform of the Mutuelles is recommended to increase their financial sustainability.

Mutuelles are risk-sharing health insurance schemes, where people make a prepayment (premium) to cover the costs of health services, or treatment at the local health centre and the district hospital. Maintaining financial viability is a problem for such community-based insurance schemes. The financial sustainability of Mutuelles is reliant on the payment system and a high membership rate. If the payment system is based on the full payment of user fees for health services, it creates a tendency for over-use of those services by members. High membership in turn depends on the payment scheme (for instance, the level of prepayment) and the quality of health services provided.

The present low membership rate and the fee and payment structure of Mutuelles are not sustainable. The payment structure needs to be reformed and the membership rate increased. Improvements in the quality of health services are required to increase enrolment. The assessment of NPA supported health services and Mutuelles shows that:

The quality of the infrastructure (such as building and equipment) of health centres is generally acceptable.
The range of health services needs improvement. Treatments focus on the most common infectious diseases but do not include other prevalent diseases like diabetes.
Health centres lack qualified human resources. For instance, some had no doctors.
Members of Mutuelles receive free treatment at health centres. If the Mutuelles pay the health centres for each visit, they have no incentive to reduce excessive treatment.
Prepayments do not cover the entire costs of hospital treatment. Members are charged a fifty per cent co-payment.

Mutuelles have the potential to improve access to health services but this is contingent on several necessary reforms. It is essential to introduce the capitation system, in which prepayments to the Mutuelles are transferred automatically to the health centre and district hospital. This ensures financial sustainability as the risk of over-use of health facilities by members is transferred to the health centres. Further recommendations for reforms include:

If health centres are only paid the sum of the premiums and not per consultation, the incentive is to keep treatment costs low. Monthly member meetings are important as a way for users to exercise control over the centres and avoid the danger of under-treatment.
In addition to the prepayment, small co-payments must be applied to limit excessive use of the health services.
There should be a second voluntary contract, where the prepayment is higher and the co-payment is smaller. The choice of payment schemes will also attract more members to the Mutuelles.
NPA or other agencies should pay the premiums for very poor households that cannot afford the prepayment.
A sound reporting system, that clearly states the actual membership rate as well as types of income and expenditure.

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Source: Hatlebakk, M. and Eujen Olsen, O., ‘Evaluation of NPA’s Support to Mutuelle, a Voluntary Health Insurance Scheme in Rwanda’, Chr. Michelsen Institute, Bergen
Author: Chr. Michelsen Institute (CMI), http://www.cmi.no