In a context in which around 90% of the population makes a living from the informal economy, Community Based Health Insurance schemes play an important role in Rwanda and their development has been facilitated by strong government involvement and commitment towards providing access to health services to all.

Groundwork for the implementation and extension of mutual health organisations in Rwanda began in 1999, when the government initiated pilots at three sites in the Byumba, Kabutare and Kabgayi health districts respectively. In December 2004, the Government adopted a national policy on the development of mutual health organisations and a special unit to deal with these mutuelles was set up within the Ministry of Health, the CTAMS (Cellule technique d’appui aux Mutuelles de Santé). Mutual health organisations have since been set up at the district level (in each of the 30 health-districts) and sections de mutuelle are present at the level of the health centres (there are 403 of these smaller units).

The premium for a minimum healthcare packagebased at the level of the health centre was set at FRW 1.000 (less than 2 USD) per person per year as from January 2007 with a 200Frw co-payment due upon treatment at the health care centre. This premium is paid in full to the section de mutuelle which has signed contracts with its respective health centre and those in the surrounding area and acts as a third-party in paying the relevant health facility. Beneficiaries can seek treatment at any health centre in the country owing to the harmonisation of tariffs.

Though the 1000 FRW premium for a primary healthcare package is kept low in relation to the real costs of health care, it remains out of reach for many Rwandans living in extreme poverty. The Global Fund to Fight Aids Tuberculosis and Malaria (GFATM) along with other NGOs (e.g. The Red Cross, Oxfam, Caritas) and government programmes (e.g. FARG) have therefore opted to finance health insurance premiums for the poorest Rwandans, orphans and people living with HIV/AIDS.A Mid-term evaluation report of the GFATM project indicated that facilitating financial access to health care services through mutual health organisations in line with the government strategy had had a significant impact in terms of increasing the utilisation rates of health services.

The targeting process of beneficiaries for different government or donor supported programmes is led by the communities who identify the most vulnerable among them (a traditional approach called Ubudehe). The Ministry of Local Government (MINALOC) currently takes charge of collecting and recording data on indigents.

The structure and organisation of the district-level mutual health organisations has been standardised throughout the country and there is a notable presence of state civil servants within their management committees (3 out of 5 persons). The CTAMS has also taken measures to standardise the management of the sections de mutuelle (remuneration of personnel etc.) and these developments have recently been consolidated through the promulgation of Law No. 62/2007 of the 30/12/2007 on the Creation, Organisation, Functioning and Management of Mutual Health Organisations.

In April 2010, Rwanda has adopted a new policy about Community Based Health Insurance. In order to be more adapted to the current context, new orientations have been adopted to face the current challenges and to consolidate the successes of the system. The general objective is “to give guidance which will allow the development and strengthening of the CBHI system in Rwanda, with the larger goal of improving the financial accessibility of populations to health care, protecting households against the financial risks associated with diseases, and strengthening social inclusion in the health sector”[1]. Solidarity and equity are the fundamental principles. The document also aims at enhancing the coordination of CBHI with other sectors and increasing the participation of the community and the decentralization. More specifically, the policy also targets to strengthen the financial viability and management capacities of CBHI.

Among the main interventions foreseen in the new policy, there is the strengthening of the financial sustainability, equity and fairness of the system. Contribution will be paid according to the capacity to pay: members will be divided in 3 categories, based on the Ubudehe classification, and will pay a different contribution according to their category. The first category will gather the poorest and most vulnerable groups and will be supported by a third party to pay their contribution. This stratification will allow raising more resources and reducing dependence on external financing. A national database is currently developed by MINALOC in close collaboration with other ministries, including Ministry of Health, to classify all population of Rwanda according to their Ubudehe category.

Other major interventions planned include the following: strengthening of the management of the CBHI system (via capacity building, complementary human resources, revitalization of local CBHI committees, etc.), the strengthening of the management of patient roaming, the reinforcement of the participation of the community in the CHBI system and its ownership, etc.

To know more about CBHI: http://www.cbhirwanda.org.rw/