Mutuelle de Santé: A Troubled Health Insurance Scheme

At Kagugu Health Center located in Kigali, Mukamusoni Martha has been there three times since August seeking remedy for a severe infection. The young woman has been given loads of medication. But the problem persists despite taking prescribed medicine.

In Rugengabali Sector, Burera District, Northern Province, at Mucaca Health Center, our reporter had been waiting for over two hours to get a service. It is 11am, and some other patients have been there since early morning. Some told him they had also been there the previous day.

Then, suddenly, a smartly dressed woman arrives and ignores the line of patients waiting and goes straight to the counter. Other patients grumble as to why the women who had just arrived was going from counter to another, and from one room to another with such ease when they had been waiting for hours without anyone attending to them. Within 22 minutes, she had already been attended to and left.

One of the angry patients says he knows the woman. “That one is VIP. She uses RAMA” the man says, referring to the insurance scheme for government employees.

The experiences at both Kigali and Burera health centers is typical for nearly all health centers in the country. The same is common at district hospitals and even national referral hospitals. The kind of health insurance you have determines whether you get good or poor quality generic medicines or branded medication, the nature of reception offered by the medical staff and how much time you spend at the health facility.

For starters, according to government data, 92% of the 12.3m Rwandans have health insurance, covered either by government or private schemes offered by insurance companies.

The government system is divided into: La Rwandaise d’Assurance Maladie or RAMA for government civilian employees, MMI for the security forces and Mutuelle de Santé which covers the rest – the vast majority of ordinary Rwandans.

An investigation conducted by The Chronicles since the beginning of September shows that owning a Mutuelle de Santé card, usually a paper card, makes little difference from not owning one. Nurses at health centers and doctors are district hospitals are prescribing medication well aware it will not work, but do so anyway, because they have no other medication available to offer under this insurance scheme.

Our Reporter spent time at four health centers and five hospitals in different districts and Kigali. He managed to obtain prescription booklets of 10 patients which show their illness and medication given. We then asked 5 Specialist Doctors to conduct a ‘Counter Prescription Analysis’ – to tell us what kind of treatment those patients should have received.

The results are shocking. After reviewing one of the prescription booklets, one of the Specialists asked: “Is this person still alive?”, as the medicine given doesn’t work at all for that particular illness.

At Ngoma health sector, Huye district, southern province, our reporter talked to Mukabunani Jacqueline with a sister who was sick. They have been here since 5:50am. At around noon, they come out. The nurse found no malaria as had been suspected. She is given Penicillin V and Paracetamol to relieve the fever and body pains.

However, they decide to visit a private clinic. Our reporter escorts them. There, the patient is diagnosed with malaria. Mukabunani narrates that she has come to this Ngoma health center several times only to be told she is fine. When they visit private clinics, they are told they are sick and indeed, they feel unwell. But because many private clinics don’t accept health insurance cards, these young women can’t keep going there due to lack of money.

These cases, at this point, raise more questions in our newsroom.

Our reporter is then asked to head to Nyamata ADEPR Hospital in Bugesera District. It was on September 30. He finds a 34 year-old man, who only accepts to speak to him if he promises anonymity. He came from Gashora, more than an hour’s drive away. The man says he has severe pain in the chest.

After several hours going through the hospital process, the doctor eventually meets him and says he needs Ultrasonography test (or what is commonly known as echography). The problem, though, is that the machine is not functioning, according to the doctor.

However, The Chronicles confirmed that the Ultrasonography test machine was in perfect condition on that day. Instead, we discovered that a patient can only get tested after paying cash of Rwf 10,000.

With this information, our reporter asks the patient to go back to the doctor and remind him that the test machine is working. The doctor tells him to return on October 16 and prescribed Paracetamol for pain relief. Feeling disappointed, the man says he cannot afford any more travel costs and will never come back.

Later, not the same day, our reporter puts this case to Nyamata hospital management. Dr. Rutagengwa William, the Director says: ”The services here are accessible to everyone no matter the kind of insurance they have. There are no services prescribed for private paying patients only.”

In Kigali, we toured different facilities. Uwacu Gaudence was having abdominal pains. Muhima Health Center prescribed Ibuprofen, Metronidazole + Albendazole, Ciprofloxacin, Buscopan and Dicofenac. Another patient Mukamurenzi Letitia, went to Kinyinya Health Center where they diagnosed malaria and prescribed different tablets including Prolamine and Albendazole – but no Coartem, which is a known malaria treatment.

Pascal Harelimana went to Kagugu Health Center with a running stomach. The nurse told him it was diarrhea and was given ORS, zinc, ziprofloxation and Indocid.

For Mukamusoni Martha, the case is more disturbing. She was also treated at Kagugu health center where she was diagnosed with Trichomoniasis vaginali, a sexually transmitted infection. The nurse there prescribed Brufen, Flagyl and Nystatine ovule.

When we met her, Mukamusoni Martha had spent over two-and-half months on treatment. However, the pain in her private parts had not gone away – a clear indication the treatment did not work. All the while, she had been getting packets and more packets of tablets.

At Muhima Health Center still, Uwingabire Anitha Claudine was diagnosed with malaria and given Prostamol.

For Rugero Pascal, who checked in at Kibagabaga Hospital, which is at an elevated level, was diagnosed with malaria, for which he was given different packets of medication including Coartem, Prastamol, Doxycycline. He was seemed to be recovering when we encountered him.

The reason all these people were being treated at Health Centers at sector level is because a district hospital cannot treat you unless you have been from the health center. So some patients may be close to a hospital, but have to go to the health center even if it is far away.

At health centers, there are no doctors, instead it is nurses and midwives who diagnose and prescribe medicines. Doctors, who are very few in the country, are only found at district level and other facilities like the national referral hospitals.

Our Specialists review the diagnosis and prescriptions

To understand the logic behind why the health facilities may have been prescribing a particular medication, we sought help from 5 Specialists from different hospitals, all in Kigali. We wanted them to do analysis of these patients’ records.

However, none of them would agree to be named in the story in order to speak freely. One said he works in government hospitals and will not criticise the treatment given there – saying he understands the difficult conditions in which nurses, doctors and other medical staff work in.

One Specialist at a private hospital in Nyarugenge hospital said it was against medical professional ethics to review diagnosis issued by another hospital unless with permission from the original hospital. He said our reporter first get recommendation from the hospitals before he can comment on their work.

He said: “It is illegal to use hospital documents as a journalist. How did you get those patient booklets? I see many mistakes [on] diagnosis and treatments, but I can only accept to comment if you have official recommendation from the hospital or government department responsible for hospitals.”

For those who agreed, we asked them to review booklets of 2 patients each as it would have consumed a lot of time to review all the 10 patients whose records we had acquired.

Concerning the case of Rugero Pascal e who was treated at Kibagabaga Hospital, one Specialist said that looking at the tests done and the results, the medicines given will take a long time to cure the patient. “Perusing through, I notice 3 kinds of medicine prescribed that have no relationship to the disease at all,” said the Specialist.

Both specialists agreed, separately, that Rugero’s treatment would take long to cure him. Remember that this patient has been treated by a doctor at a major hospital, and not a nurse at a health center.

On the case of Mukamusoni Martha, diagnosed as suffering from Trichomoniasis, which she still was yet to be cured from when we met her, our female Specialist was shocked at the kind of treatment the patient got.

”I am wondering how a doctor in their right mind who went through medical school can ask a patient to take those medicines,” said the Specialist. “All those medicines have a very low capacity to fight against infection.”

She added: “Is that patient still alive? All those medicines are actually a danger to the body of the patient.”

With reviews from Specialists, we decided to go back to the original nurses who conducted the diagnosis and issued prescriptions. We visited Kagugu Health Center to ask about the diagnosis issued from there. We were denied access to the offices of the nurse who treated the patients by staff at the reception.

When we asked Joseph Mushatsi, the Acting Director of Kagugu health center to give us access to the nurses or comment on the cases himself, he said: “It is illegal to discuss our work. Besides, if it is to be done, it can only be done with RBA not an unknown media.”

RBA is the state broadcaster with national TV; Radio Rwanda and a host of other FM stations.

He added: “You have to bring a letter signed by Executive Secretary of Kinyinya Sector. If I give such information without permission from my superiors, I could be punished.”

The Chronicles moved up the chain. We contacted Umuhoza Rwabukamba, Executive Secretary of Kinyinya Sector, asking for permission to interview medical staff at Kagugu Health Center about Mutuelle de santé services.

Rwabukumba responded; “For anything you want from the health center, ask me, including Mutuelle de Santé, instead of seeking to talk to staff at the facility. You need permission from higher authority to speak to staff.”

Why government pharmacies have no adequate medicine

So what is going on at our public health centers and hospitals? How come Mutuelle de Santé patients are getting medication ineffective to cure their illnesses? Can anything be done to reverse the trend?

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

Our probe found the problems facing Mutuelle de Santé are far reaching and, under present conditions, beyond the ability of health facilities and the nurses and midwives who operate these health centers, and even doctors at hospitals.

According to two Specialists interviewed and government officials who deal with the distribution of medicine, one major reason health centers give less effective medications is because that is what is available. At health centers, there is usually a small adjacent room where medicine is given to patients.

And here is how medication travels from importation to particular to drug room at health center or district pharmacy. There are private pharmacies which are spread all over the country, and government pharmacies which are at district levels: these then provide supplies to rural health centers.

All district pharmacies and district hospitals are supplied with both essential and branded medicines by the Medical Procurement and Production Division (MPPD), a health ministry agency that manages the import of medical materials.

Essential medications are materials that every health facility must have at all times including various antibiotics and painkillers. It is these basic medicines that are available at the health center.

The other entity that imports medical materials is the Bureau des Formation Médicales Agréées du Rwanda or BUFMAR, which is partly associated with the Apostolic church.

According to Harelimana Gaspard, coordinator of Gasabo District pharmacy, under whose authority falls dozens of health facilities, the district pharmacies are only able to get about 45% of the medicines they need.

In other words, on a list of say 100 types of medicines which the hospitals need, the government pharmacy finds only 45 types available. If the district pharmacy needs more, they have to buy from private importers. But no official does that because it means they have to pay on their own.

Even getting the supplies from private medical stores, it is not an automatic process. A district pharmacy coordinator has to file requests detailing all needed medicines with the Ministry of Health. It takes up to three weeks for permission to come through, which could come when many medicines requested have been removed.

So the first reason patients on Mutuelle insurance get ‘low quality medicines’ is because that is what government allows you to have. As result, a patient in rural areas goes to a health center or a district hospital and they are prescribed a dose that is less effective simply because the nurses at health centers or doctors at higher level facilities know that is what a government pharmacy has in stock and can be provided under this scheme.

When The Chronicles visited Nemba Hospital in Gakenke district, on September 24, we found about 50 people lined at the hospital’s pharmacy. An elderly woman stood there, looking disoriented and unsure of what to do. Our inquiry discovered she had been diagnosed with Typhoid, but the medication prescribed by the nurse was not in the hospital pharmacy.

According to her, the medicine is in a private pharmacy and she was told it costs Rwf 5,600 ($6). The problem though, the private pharmacy doesn’t supply that medication to people with Mutuelle de Santé insurance as its not subscribed.

Which brings us to the second factor why mutuelle insurance patients are given low-level medicines. The Rwanda Social Security Board (RSSB), is the government agency in charge of managing civilian insurance schemes. RSSB covers 85 percent of treatment costs. The patient on Mutuelle de Sante is supposed to pay 15% as direct out of pocket cash.

The health centers and hospitals are required to prescribe medicines which are on a national list of medicines which RSSB is able to pay for in a specific scheme. For example, a government employee on RAMA insurance has right to a lot more options of medicines compared to Mutuelle patients.

Dr Jean de Dieu Tuyishime, from a public hospital explained how it works. He said when a nurse or doctor prescribes a branded medicine and it is not among the list of medicines insured by RSSB, the hospital makes a loss.

He said: “Many Generics are significantly less effective and they work when administered in large quantities. For example, there is branded Ibuprofen, a painkiller, which a patient takes one or two tablets. For an equal dosage of Generic Ibuprofen, it requires a dosage of between 15 to 20 tablets for the medicine to work.”

As a result of prescribing medicines not on RSSB list, hospitals lead to district pharmacies paying more to the government medicines importer. Gasabo district pharmacy coordinator, told The Chronicles his network covering Gasabo alone has Rwf 400m debt, a very big debt to manage.

According district pharmacy coordinators who spoke to us, there is no district without huge debts accrued from over-prescription.

The central government also requires district pharmacies to operate as businesses, meaning they have to be able to pay their staff and restock themselves. As a consequence, when a district pharmacy buys medicine from the central government drugs importers, it sells it to patient at 20% more. For example, Paracetamol bought at Rwf 100, is sold to a patient at health center and district hospital at Rwf 120.

For RSSB to ensure health centers and hospitals don’t give treatments they are not allowed to prescribe, there is a person called a “Verificateur” or Verifier at every health center.

When a Mutuelle de Sante card holder arrives at a hospital, you have to get a form from the Verifier. It is this paper that you give to nurse at the health center. If a nurse orders for tests, you have to go back to the Verifier to check if that particular test is allowed under Mutuelle de Sante. And when diagnosis is complete, the nurse has to ensure they prescribe what they are sure is available in the in their small drug shop (small pharmacy) and on the list of medicine allowed under the insurance scheme.

The resulting effect here is that the RSSB Verifier adds another layer of offices a patient has to line up for. This office, at nearly every government health facility including health centers and hospitals, is the most crowded. Depending on the people in line, you could take half a day just at this office, even before you see the nurse or doctor to diagnose and prescribe medicines.

In addition to Verifiers at every health facility, RSSB also has a cumbersome process at the headquarters in Kigali under which it verifies every request for payment from a hospital. Richard Tushabe, RSSB director-general has recently hinted that the agency is paying a lot more money than planned.

At two press conference in less than 3 months, Tushabe said “criminal network” involving doctors, some hospitals and private pharmacies were leading to over-prescription, thereby requesting more money to be paid back to them.

Basically, the nurses from health centers and doctors at higher facilities know a particular medicine is not allowed, but they prescribe it anyway. Or, the patient is treated as many times as possible since the bill is sent to RSSB for refund.

“We are paying more for the same population yet there has not been any epidemic in the country,” he said.

RSSB has responded with a long process of verifying each invoice. It takes up to 8 months for RSSB to send the money for monthly invoices – all the while, leaving hospitals and district pharmacies struggling to stay open.

Dr Rutagengwa William, director of Nyamata ADEPR hospital in Bugesera district told us: “The last payment we received for Mutuelle de Santé was in March. Seven (7) months are about to elapse.”

No official at RSSB was available by press time to speak to The Chronicles over the delayed reimbursements to hospitals and district pharmacies.

Back to the Kagugu Health Center in Kigali, as the system stays unfavorable to Mutuelle de Santé subscribers like Mukamusoni Martha, she remains not cured. When we met her, it was the third time she was coming to this health center over the same illness that is easily treatable. Each of the previous times, the nurses changed the treatment but nothing works.

NOTE: This story has been slightly edited. In the previous version, it was not clearly indicated that at the health center there are only nurses and midwives who diagnose and prescribe medicines. There are no doctors at this sector level due to the limited number of doctors in the country. Instead, doctors are at district hospitals and national referral hospitals where patients from health centers are given transfers for farther intervention. This essentially means that nurses who are at health center level may not be able to treat more serious illness. However, as demonstrated by Kibagabaga hospital case, even the doctors, expected to have more skills and knowledge, are limited by shortages and other factors beyond their control.

EDITOR: Though the patients in this story all accepted to use their names, The Chronicles decided to keep their identities for privacy reasons. The names used are not those of the patients