Debriefing for the Study Tour of the Malian and Senegalese Delegations to Rwanda

1. Debriefing for the Study Tour of the Malian and Senegalese Delegations to Rwanda October 25-30, 2009

2. Mission Objectives • Inquire about Rwanda’s experience with the following reforms: • Resource allocation systems, with special emphasis on performance-based financing; • Pooling risk in the health sector for community-based health insurance; • The organization and operation of health mutuelles; • Systems to identify and provide care for the indigent.

3. The Mission (1) Central level meetings • Director of Planning, • Community Based Health Insurance Support Unit (CTAMS) and Contractual Approach Support Unit (CAAC), • RAMA (Rwanda Health Insurance Scheme) and World Bank Field trips Two groups were formed: • Mali team • Senegal team

4. The Mission (2) • Mali Team • Gicumbi District: • District hospital and district mutuelle, • Bungwe section mutuelle, • Bungwe Health Center. • Muhanga District: • Kabgayi Hospital, district mutuelle, • Gitarama section mutuelle, • Gitarama Health Center.

5. The Mission (3) • Senegal Team • Gakenke District: • District hospital and district mutuelle, • Nemba section mutuelle, • Nemba Health Center. • Rwamagana District: • District hospital and district mutuelle, • Rwamagana section mutuelle, • Rwamagana Health Center.

6. HEALTH INSURANCE

7. Principal Findings (1) • A strong commitment to the President’s health insurance reforms by the political/ administrative authorities down to the decentralized level • The pivotal role of the district mayor • Strong provider involvement in promoting mutuelles • Incorporate mutuelle system performance into the performance contracts the President of the Republic signs with the mayors

8. Principal Findings (2) • Good coverage of Rwanda’s population (>90%) by combining health insurance systems: RAMA, military medical insurance (MMI), private insurance, insurance for school and university students, community-based health mutuelles • An attractive package of services that is consistent with the way the provision of care is organized (PMA and PCA) • Implement a coordination and monitoring system at every level

9. Principal Findings (3) • Establish structured management bodies and tools at the decentralized level • Decentralize the management system by setting up local decision-making centers • Involve RAMA in providing technical and financial support to the health mutuelles • Employee status for mutuelle managers

10. Principal Findings (4) • A citizen control system exists • RAMA is helping to improve coverage in dispensaries • The system enjoys good financial health under RAMA management • Formality is lacking in the relations between some mutuelles and the health facilities • RAMA is not providing care for retirees

11. Principal Findings (5) • RAMA territorial coverage is insufficient • The community-based mutuelle management system is not computerized • The financial balance of some mutuelles is tenuous

12. Lessons Learned (1) • Community health mutuelles are an appropriate approach to achieve universal health coverage • An ongoing commitment of the political-administrative authorities at all levels is required to make the system sustainable • Incorporating the mutuelle performance indicators into monitoring will ensure that their operations are properly monitored

13. Lessons Learned (2) • The existence of a complete package of service benefits contributes significantly to the people’s acceptance of mutuelles • Technical and financial support from the partners should be harmonized and made consistent with the national policy to be effective. • The organization of grass-roots mutuelle infrastructures around the health facilities strengthens beneficiary loyalty

14. Lessons Learned (3) • Solvency is key to ensuring access to services at every level of the pyramid • Combined public and private funding contributes to a more rapid expansion of health insurance coverage

15. Lessons Learned (4) • The effectiveness of the health insurance system depends on the existence of sufficient managerial capacities • Signing performance contracts and implementing them is an incentive measure

16. PERFORMANCE-BASED FINANCING

17. Principal Findings (1) • A minimum benefits package (PMA) is available at the health center level and a comprehensive benefits package (PCA) is available at the district hospital level • The activities targeted by PBF are the health sector priorities • PBF primarily finances personnel motivation • PBF also assists in funding FOSA (health structure) operations

18. Principal Findings (2) • The large number of skilled healthcare workers in the FOSAs and their ability to function are important outcomes of PBF • The monitoring/evaluation system has been implemented and is operational from the central level down to the FOSAs • The individual evaluation system implemented at the FOSA level has not yet been implemented at all levels • Individual evaluation is more complex for hospital personnel

19. Principal Findings (3) • The State is the principal donor and partner contributions are gradually on the decline • The same priorities are applied to all districts without taking their specific features into account • There is a real risk that PBF is neglecting the activities that are not targeted (not compensated)

20. Lessons Learned (1) • The decentralization of skilled healthcare worker positions at the district level fosters good healthcare worker coverage in rural areas • Implementing incentives is an effective way of encouraging workers to remain in rural areas • Having the State provide all the financing promotes the sustainability of PBF

21. Lessons Learned (2) • Financing community-based health through PBF is an effective strategy to improve performance, especially in the areas of Reproductive Health/Family Planning, acute respiratory infections and controlling diarrhea • Both quantitative and qualitative evaluation of services is an incentive for healthcare workers to place greater emphasis on the quality of services • PBF must continue to be dynamic and develop capacities to adjust to changes in priorities

22. 22 Thank You