One Less Worry: More Rwandans Than Ever Before Are Finding Affordable Health Care Options

Rwanda’s health leaders are working to strengthen their country’s health system and boost the health of its 12 million citizens.

Charlotte Niwemusa and son Justin wait to see a doctor at Manyange Health Centre. / Riccardo Gangale for USAID, Courtesy of Photoshare

Charlotte Niwemusa is one of dozens of patients waiting to be seen at the Mayange Health Centre, located approximately one hour south of Kigali, the capital city of Rwanda.

Her one-and-a-half-year-old son Justin woke up in the middle of the night with a high temperature that she fears could be a sign of malaria. “I want him to be seen by a nurse and tested for malaria,” says the 32-year-old mother.

Over the last 15 years, maternal and child mortality rates in Rwanda have declined by more than 70 percent. This is due in part to innovative health reforms introduced by the government, including the Community Based Health Insurance (CBHI) plan, known as Mutuelle de Santé in French or Mituweli in the local Kinyarwanda language.

This insurance plan was piloted in 1999 and scaled up nationwide in 2005, with the goal to provide equitable and affordable healthcare to all Rwandans and to prevent people from incurring catastrophic health care costs. It is based on a sliding scale fee system based on income and is disseminated by the Rwandan Government through the Ubudehe database, a national system developed by USAID’s prior health systems strengthening work.

Jeanette Nzayikoreza, 20, came to the Manyange Health Centre with her medical insurance card for a checkup. She is 6 months pregnant. / Riccardo Gangale for USAID, Courtesy of Photoshare

Niwemusa has been enrolled in the CBHI for the past five years and doesn’t mind paying 15,000 Rwandan Francs (about $18) per year to cover her household of five. This is about 2.3 percent of $754, the average per capita income in Rwanda according to the International Monetary Fund.

“If I did not have Mituweli, my copayment would be around 2000 Rwandan Francs (a little over $ 2) each visit instead of 200 Rwandan Francs (25 cents). I like it because I get all the health services that I need for myself and my family in very little time. All my three children were born here, including Justin.”

Making Health Care Accessible to All

“Expanding access to quality and affordable health services requires building strong health systems — the benefits of which accrue across all health programs and help foster sustainability, putting countries on a path toward making healthcare more accessible and affordable to all,” says Kelly Saldana, director of the USAID Office of Health Systems.

Insurance plans like the CBHI can lower out-of-pocket health costs and expand coverage of basic services, which is in line with the health goals outlined in Rwanda’s Vision 2020, the country’s strategy for becoming a middle-income country over the next three years.

Rose Maniraguha and her baby Kelia wait to see a doctor at Manyange Health Centre. / Riccardo Gangale for USAID, Courtesy of Photoshare

“USAID supports the Rwandan Ministry of Health in building its health system through five core components: health information, health finance, human resources for health, quality improvement and decentralization,” explains Jesse Joseph, health office deputy director at USAID’s mission in Rwanda.

Rwanda’s national CBHI plan is now one of the largest public health insurance plans in sub-Saharan Africa. On average, between 75 to 80 percent of the population is enrolled in this health insurance scheme. But getting people to buy into the CBHI was not without its challenges.

Mutuelle medical insurance card. / Riccardo Gangale for USAID, Courtesy of Photoshare

“Changing people’s mindset around Mutuelle has not been easy,” says Francis Nkurunziza, executive secretary of Mayange Sector, which is where the Mayange Health Centre is located.

The government of Rwanda has used a variety of tools to promote participation in the Community-Based Health Insurance scheme, including social media, as well as print and broadcast public service announcements. The prime minister and other high ranking politicians, both at the national and local level, have directly encouraged people to sign up.

“We had to convince people to pay a small amount of money toward their health,” he said. “This area suffers from drought so there was no extra money to pay for the health insurance. We mobilized the population bit by bit. The first year, 72 percent of the population could pay; the second year it was 85 percent, and now it is 100 percent. Of course, there are still people who cannot pay, but they are covered by the government. I believe it is the responsibility of local leaders like myself to transform the minds of the people.”

Evidence shows that backing from local leaders has been critical to the success of the project, alongside more practical considerations like engaging community health workers (community partnerships) and facilitating access to health facilities.

In fact, local government officials are held accountable for the number of people who have health insurance. This is done largely through the local concept of Imihigo or “performance contracts,” a cultural practice that emphasizes notions of competition and accountability, which de facto puts pressure on local officials.

CBHI coverage is one of the indicators in their performance contracts put in place through the Ministry of Local Government.

“Supporting the CBHI, which is a community-owned, home-grown solution that responds to the needs of the population of Rwanda, means helping the government ensure equity of access to health care services, supporting them in monitoring service utilization patterns and customer satisfaction, and creating sustainable financial health systems,” adds Joseph.

With the national roll-out of CBHI, coverage expanded from less than 7 percent of the target population in 2003 to 74 percent in 2013. It is now close to 80 percent.

Rewarding Community Health Heroes

Another way to improve access to basic health care services is to bring them closer to where people live.

Athalia Mukamusoni is one of 45,000 community health workers spread throughout Rwanda and works in a village in Nyanza, in the southern province of the country.

Community health worker Athalia Mukamusoni, of the Dufitintego cooperative in Nyanza, cares for 1-year-old Fruit Irakoze, who is not feeling well. She meets with him and his mother, Gemma Niyigena, in their home. / Riccardo Gangale for USAID, Courtesy of Photoshare

“I have about 10 cases per week. I have learned to advise people, regardless of their ailment. The more serious cases, the ones I cannot treat, I refer to the nearest health facility,” says Mukamusoni, who does this work on a voluntary basis like all other community health workers in Rwanda.

“One of the main challenges I have is that when I see many patients I lose out on earning a living,” she explained. Like many Rwandan women, Mukamusoni is a subsistence farmer who sells her surplus produce at the local market.

Community health worker Athalia Mukamusoni sends a text message to the national health data center with the code that corresponds with the results of her visit to a sick child. / Riccardo Gangale for USAID, Courtesy of Photoshare

To address this potential loss of income, the Rwandan Government has encouraged community health workers to establish business cooperatives to earn extra income. There are now about 475 spread across the country. These cooperatives receive quarterly payments from the government in a pay-for-performance approach that provides compensation based on results.

Cooperative members decide how to invest that money, with about 70 percent plowed into income-generating activities and the rest split between cooperative members. Rwanda is now a pioneer of performance-based financing for the health sector and serves as a model for other developing countries.

Cooperative Chairman Cyprien Ngarambe stands inside the piggery run by community health workers in Kigali. / Riccardo Gangale for USAID, Courtesy of Photoshare

Mukamusoni is a member of the Dufitintego cooperative, which means “we have a vision.” Her cooperative, supported by the Association François-Xavier Bagnoud, a local organization, now has 174 members and in 2012 they decided to raise goats.

“We started off by planting cassava but we soon realized that it was not a profitable venture so we decided to invest in goats,” says Sarah Mukamurara, president of the Dufitintego cooperative.

“We now have 30 goats and have also invested in this community building, which we rent out for weddings and public meetings,” she said. “We are booked for weddings several months ahead of time. Every weekend we have at least one and we collect about 50,000 Rwandan Francs (about $60).”

Community health workers members of the Dufitintego cooperative in Nyanza gather outside their meeting hall they built as investment. They also bought some goats which are roaming outside the building. / Riccardo Gangale for USAID, Courtesy of Photoshare

“The business cooperatives are meant to be an incentive for volunteer health workers,” says Randy Wilson, team leader for health information system strengthening at USAID’s implementing partner, Management Sciences for Health in Rwanda. “If the cooperative is successful, they will receive a dividend from the investment they made. Some of the challenges we face are retention of community health workers and access to credit, particularly in rural areas.”

About the Author

Beatrice M. Spadacini is a senior communications advisor in USAID’s Bureau for Global Health.