March 4, 2019

Rwanda’s Health Insurance Scheme Favours the Rich – Says IMF Study


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A young woman displays her health insurance card at an RPF party campaign rally during the 2018 parliamentary polls (Photo by Kigali Today)

The International Monetary Fund (IMF) says in a new study on Rwanda’s heavily subsidized health insurance scheme that even the little paid by the poor has a huge impact on their incomes.

The study released last week compares ‘Community Based Health Insurance Schemes’ from various countries including China, Vietnam, Mexico and Ghana.

The IMF researchers found that on average, Rwandans incur ‘out-of-pocket’ expense of Rwf4.212 on hospital bills.

“We find that the scheme significantly reduce[d] annual per capita out-of-pocket spending by about 3,600 Rwandan Franc (about US$12) or about 83 percent of average per capita healthcare expenditure…” says the report.

Rwanda’s program was singled out for in-depth review by the IMF team due to its success in reducing the burden on patients.

The Rwandan CBHI or simply known as ‘Mutuelle’ was first introduced in 1999 as a pilot project in three districts. In 2004, implementation begun across the country.

Prior to 2007, enrollment was on a household basis where a household with up to seven family members paid premiums ranging from RWF2,500 to RWF11,000 per year and co-pays of up to RWF150 for services provided at health clinics and up to 50 percent of the cost at hospitals.

Since 2012, however, enrollment has been on individual basis with each member paying a flat rate of RWF2,000 per year.

Participation in ‘Mutuelle’ is voluntary. When the financial year ends around June, there are usually nationwide campaigns to encourage people to pay their contribution – which is managed by the Rwanda Social Security Board (RSSB).

Government says some 72 percent of Rwandans get their services from ‘Mutuelle’. Government employees have their own scheme called RAMA.

The well-to-do Rwandans pay for their health insurance cover with private insurance companies.

In general, a very small number of Rwandans don’t have health insurance, according to data regularly published.

“The [‘Mutuelle’] program also reduces the incidence of catastrophic healthcare spending significantly,” the IMF report further indicates.

Informatively, although the perception on ‘Mutuelle’ has been overwhelmingly positive from ordinary Rwandans and observed broadly, the IMF study shows that even the small amount paid out has huge impact on the already small incomes of many peasants.

“The impacts…favor the rich as compared to the poor,” says the study.

“If “inclusiveness” is one of the objectives, there is little or no evidence that the Rwandan CBHI program has succeeded in providing affordable health insurance for the poor.”

In other words, what the study says is that for somebody with a reliable income in the village, the small percentage paid at the hospital is not felt in the pocket. But for families struggling to put food on the table, going to hospital is something they would rather not to do.

In practice, reports abound of individuals and families that fail to pay hospital bills and are held at hospitals.

Yet, with Rwandans paying too little into the scheme, the government is covering a large portion to subsidize the scheme, which is causing a big drain on state coffers.

Two weeks ago, the Health Minister Dr Diane Gashumba told parliament that she needs between Rwf10-12billion for ‘Mutuelle’ – some of which will go to covering losses being incurred by the scheme.

Together with Local Government Minister Prof Anastase Shyaka, they are proposing a package of new measures to increase ‘Mutuelle’ fund.

Currently, the government math is that beneficiaries are supposed to pay Rwf 5,000 every year – of which the state covers Rwf3,000.

However, the cost of treatment goes up to Rwf 7,000 for each individual, which is squeezing the government budget.

As a result, the finance ministry finds itself with no money to reimburse hospitals for expenses incurred when giving services to patients.

Under the new proposals yet to be approved by cabinet and forwarded to parliament, beneficiaries may be asked to pay more; a factor that will eat further into the limited finances of the very poor as the IMF report shows.

The finance ministry is also planning to impose a 2% tax increase on drugs that are imported into Rwanda; perhaps as a way to find a more reliable source of funding for this important health scheme.

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