HEALTH MONITOR - HEALTH FINANCING IN THE AFRICAN REGION SPECIAL ISSUE: Regional Office for Africa
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ISSUE 17 · JULY 2013 · A SERIAL PUBLICATION OF THE WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR AFRICA · ISSN 2077 6128
FINAL AHM 17.indd 1
THE AFRICAN
IN THE
REGION
HEALTH
AFRICAN
SPECIAL ISSUE:
FINANCING
HEALTH
MONITOR
REGIONAL OFFICE FOR
Africa
18/07/2013 08:48
REGIONAL OFFICE FOR Africa
Contents
The African Health Monitor Editorial: Health financing in Africa. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Issue 17 • July 2013 Luis Gomes Sambo
AFRO support for a policy dialogue to develop health financing systems
and move towards universal health coverage in Africa. . . . . . . . . . . . . . . . 2
HEALTH
AFRICAN
REGIONAL OFFICE FOR Africa
Laurent Musango, Riku Elovainio and Bokar Toure
MONITOR
Financial risk protection in the African Region. . . . . . . . . . . . . . . . . . . . . . . 4
Laurent Musango, Priyanka Saksena and Bokar Toure
THE
Strategies towards universal health coverage in Rwanda: Lessons
learned from extending coverage through mutual health organizations. 6
ISSN 2077 6128
. .
Laurent Musango, Andrew Makaka, Diane Muhongerwa, Ina R Kalisa and Riku Elovainio
·A SERIAL PUBLICATION OF THE WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR AFRICA
Is universal health coverage via a national health insurance scheme
financially feasible in Zanzibar?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Maximillian Mapunda, Juliet Nabyonga, Ole Doetinchem and Riku Elovainio
SPECIAL ISSUE:
HEALTH La Caisse Nationale d’Assurance Maladie et de Garantie Sociale
FINANCING
IN THE du Gabon : Un chemin vers la couverture universelle. . . . . . . . . . . . . . . . . 15
·JUNE 2013
AFRICAN Aboubacar Inoua et Laurent Musango
·
REGION
ISSUE 17
Exemption du paiement direct des soins d’urgences au Tchad
ISSUE 16 • KEY DETERMINANTS FOR HEALTH IN THE AFRICAN REGION 1
2007–2010 : Une étape vers la couverture sanitaire universelle. . . . . . . . . . 20
Seydou O Coulibaly et Hamadou Nouhou
Une approche novatrice pour progresser vers la couverture universelle
au Burundi : Intégration du financement basé sur la performance et
de la gratuité des soins. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
© WHO-AFRO, 2013 Laurent Musango, Olivier Basenya et Riku Elovainio
Articles may be reproduced for noncommercial purposes Long-term effects of the abolition of user fees in Uganda. . . . . . . . . . . . . . 30
by citing at least the authors’ names, title of article, year Juliet Nabyonga, Maximillan Mapunda, Laurent Musango and Frederick Mugisha
of issue and name of magazine (African Health Monitor,
World Health Organization Regional Office for Africa). Dépenses catastrophiques de santé et leur impact sur l’appauvrissement
For all other uses, permission for reproduction should be des ménages et l’utilisation des services de santé : Cas du Burkina Faso. . . 36
sought by sending an email request to the Editorial Office J Edouard O Doamba, Alexandre Ouedraogo et Priyanka Saksena
at AHM@afro.who.int. Rapport sur les dépenses catastrophiques et l’impact des paiements
directs sur l’appauvrissement des ménages : Cas de la Mauritanie. . . . . . . 41
The designations employed and the presentation of the
material in this publication do not imply the expression of Mohamed Mahmoud Ould Khatry, Taleb Ely Ould Taleb Ahmed et Kelly Aminata Sakho
any opinion whatsoever on the part of the World Health Rapport d’analyse sur les dépenses catastrophiques de santé et
Organization concerning the legal status of any country, leur impact sur l’appauvrissement et l’utilisation des services au
territory, city or area or of its authorities, or concerning the
Sénégal, 2005 et 2011.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
delimitation of its frontiers or boundaries. Dotted lines on
Magor Sow, Malick Diop, Arona Mbengue, Abou AW, Farba Lamine Sall, Abibou Cissé,
maps represent approximate border lines for which there Badou Sonko, Ousseynou Diop, Sokhna Gaye et Priyanka Saksena
may not yet be full agreement.
News and events. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
The mention of specific companies or of certain
manufacturers’ products does not imply that they Abstracts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
are endorsed or recommended by the World Health
Organization in preference to others of a similar nature
that are not mentioned. Errors and omissions excepted,
the names of proprietary products are distinguished by
initial capital letters. The African Health Monitor is a quarterly magazine of the World Health Organization Regional Office for Africa
(WHOAFRO). It is a multilingual publication with peer reviewed articles in English, French and Portuguese.
All reasonable precautions have been taken by the World
Health Organization to verify the information contained in The aim of the African Health Monitor is to promote and facilitate evidence-based policy and decisions to
this publication. However, the published material is being strengthen programmes for health promotion, protection and restoration in the African Region. In order to
distributed without warranty of any kind, either express achieve its aim, the Monitor publishes articles that monitor health situations across the region, discuss trends and
or implied. The responsibility for the interpretation and track progress toward the health-related Millennium Development Goals and other internationally agreed-upon
use of the material lies with the reader. In no event shall goals. It disseminates relevant and scientifically rigorous public health information and interventions carried out
the World Health Organization or its Regional Office for in the Member States with the cooperation of AFRO technical programmes.
Africa be liable for damages arising from its use.
Comments on published articles and suggestions for new papers are welcome. Prospective authors should follow
The contents of this publication do not necessarily reflect the Monitor style guidelines, which can be obtained by contacting the Editorial Office at AHM@afro.who.int or by
official WHO views. Some papers in this publication have using this intranet link http://intranet.afro.who.int/ guidelines/ahm.pdf
not passed through formal peer review.
FINAL AHM 17.indd 2 18/07/2013 08:48
Editorial
Health financing in Africa
Health is now recognized as a key aspect of human and The 11 articles published in this edition of the Monitor were all
economic development, and health financing as a major finalized during an intensive one-week workshop organized by
function of a health system, whose objectives are to make the Health Financing programme of the African Regional Office
funding available and ensure that all have access to effective of WHO. Gathering experiences from English- and French-
health services. speaking countries, this issue focuses on a combination of
evidence and reforms related to health financing and identifies
An examination of the health financing situation in Africa key areas for future policy development in the African Region.
reveals that countries will need to increase their investment
in health and remove financial barriers to accessing health The challenges that countries face when implementing
care through a number of innovative approaches, including reforms and actions are numerous and often relate to financial,
compulsory prepayment and risk pooling mechanisms. administrative and political aspects that fall beyond the health
Improving health financing in the Region will require several sector. The first article discusses AFRO’s support for an
actions: the development of comprehensive health financing inclusive policy dialogue towards universal health coverage
policies, plans and strategies; a move towards universal involving all key governmental and non-governmental actors,
health coverage (UHC); institutionalizing national health emphasizing the importance of creating a discussion space
accounts (NHA); and monitoring efficiency. It will also require between the ministries of health and ministries of finance in
strengthening financial management skills at all levels, as particular.
well as implementing the 2008 Paris Declaration on Aid
Effectiveness with all international partners and the 2012 There are three aspects to universal health coverage: access
Tunis Declaration on Value for Money, Sustainability and to all health services needed; efficient and effective quality
Accountability in the Health Sector. services; and the absence of financial hardship (or financial
risk protection) discussed in the second article – the use of
The African Regional Office of WHO has taken a number of health services should not come at the expense of other
steps to support Member States in their implementation of essential necessities.
these actions. Among others, it has developed a regional
health financing strategy and supported countries in their Five articles look at the implementation of specific national
development of health policies and strategies to move towards health financing interventions and reforms, with a particular
universal health coverage. It has also helped several countries focus on evaluation and highlighting lessons learned. These
compile and institutionalize their national health accounts, and include the review of the health insurance reform and
developed an action plan to support the implementation of extension of coverage through mutual health organizations
the Tunis Declaration. in Rwanda; the process of planning a health insurance to
contribute towards universal coverage by the Government
Recently, participants from the African Regional Office, the of Zanzibar (United Republic of Tanzania); the implantation
WHO Headquarters in Geneva, non-profit organizations and of mandatory health insurance through the National Health
representatives from ministries of health and finance in the Insurance and Social Security Fund of Gabon; the exemption
Region were involved in the development of several technical from direct payment for emergency care in Chad between
and policy-related analyses and reports focusing on key 2007 and 2010; and an innovative approach towards universal
aspects of health financing in the African Region. The results health care in Burundi that integrates free health care and
of this work are now available in this special issue of the performance-based financing. A further article reviews the
African Health Monitor. outcomes, over a ten-year period, of the removal of user fees
in the health sector in Uganda.
There are three aspects to universal health The last three articles highlight the relationship between out-
coverage: access to all health services of-pocket payments and catastrophic health expenditure and
needed; efficient and effective quality their impact on impoverishment and health services utilization
in Burkina Faso, Mauritania and Senegal.
services; and the absence of financial
hardship (or financial risk protection)
I trust that this special issue on health financing will be useful
discussed in the second article – the use to country and regional policy-makers as well as academics.
of health services should not come at the
expense of other essential necessities.
Luis Gomes Sambo, Regional Director
ISSUE 17 • SPECIAL ISSUE • HEALTH FINANCING IN THE AFRICAN REGION 1
FINAL AHM 17.indd 1 18/07/2013 08:48
AFRO support for
a policy dialogue to
develop health financing
systems and move
towards universal health
coverage in Africa
Laurent Musangoi, Riku Elovainioii and Bokar Tourei
Corresponding author: Laurent Musango, e-mail: musangol@afro.who.int
Creating a discussion Session of the Assembly of the African
space between the Union (AU) on 24 July 2010 in Kampala,
the ministries of health Uganda and the second on 28 March 2011
in Addis Ababa, Ethiopia as part of the
and the ministries of AU Conference of Ministers of Economy
finance to support and Finance. A third panel discussion
policy dialogue towards took place on 30 September 2011 during
universal health the 61st session of the WHO/AFRO
coverage Regional Committee in Yamoussoukro,
Côte d’Ivoire.
WHO/AFRO has been actively involved
in the organization of several cross- On 4–5 July 2012, WHO/AFRO, through
ministerial panel discussions gathering the Harmonization for Health in Africa
participants from ministries of health and (HHA) initiative together with WHO/
of finance and other high-level officials. EMRO, co-organized a conference in
The first took place during the 15th Tunis, Tunisia, which was attended by over
SUMMARY—Accelerating progress towards the
goal of universal health coverage (UHC) calls for
concrete actions to reinforce health systems and
health financing mechanisms. Challenges that
countries face when implementing these reforms
and actions are numerous – they relate to financial,
administrative and political aspects that often fall
outside the health sector. In order to overcome these
challenges and bottlenecks and to push the UHC
agenda forward on all the fronts, countries will need
to rely on policy dialogues that are inclusive of all the
key actors. Within this larger policy dialogue, which
integrates all the government (central ministries and
other institutions) and non-government actors, one
of the key elements is the relationship between the
Ministry of Health (MoH) and the Ministry of Finance
(MoF).
Voir page 54 pour le résumé en version française.
Ver a página 54 para o sumário em versão portuguese.
i Health Systems and Services Cluster, WHO, Regional Office for Africa, Brazzaville, Congo
2 AFRICAN HEALTH MONITOR • JULY 2013 ii Department of Health Systems Financing, WHO, Geneva, Switzerland
FINAL AHM 17.indd 2 18/07/2013 08:48
40 African health and finance ministers.
The conference concluded with the Tunis
Declaration, a “call for strengthened
policy dialogue towards UHC between
MoH and MoF, development partners,
parliamentarians and civil society”.2 The
conference also adopted a framework
document to support the country level
implementation of the Tunis Declaration
(on value for money, sustainability and
accountability in the health sector).
Finally, several African countries were
involved in the joint MoH-MoF meeting
on UHC co-organized by WHO and
the World Bank in Geneva from 18–19
February 2013.3
also a source of concern. The MoH- 2013 aimed at deepening reflection on
MoF discussions have revealed a large how to address the current challenges
Lessons learned consensus that moving towards UHC not and bottlenecks in the move towards
from the MoH-MoF only requires increased funding, but also UHC. This panel discussion will broaden
discussions efficient use of existing resources. the debate to ministries of planning,
ministries of social affairs and other key
The issues discussed at the different In general, the discussions have revealed actors. It will focus on the key issues for
cross-ministerial events represent the several points of convergence and policy dialogues:
key questions over which the policy divergence between MoH and MoF. 5 ● creating a common understanding of
articulation between MoH and MoF These two actors still have different the concept of UHC;
is particularly important. Both parties “natural instincts”, cultures, mandates ● sharing country experiences on UHC
have acknowledged that countries in the and objectives. This calls for increasing reforms; and
African continent suffer from low public national and international efforts to ● proposing recommendations on how
health spending which has resulted in low reinforce collaboration between these to drive the policy dialogue in countries
service coverage rates and in catastrophic two institutions within the larger policy towards effective UHC reforms. v
health expenditures.4 dialogue towards UHC.
The MoH-MoF discussions have shown References
1. WHO Regional Office for Africa. Health Harmonization for
that common understanding on what Moving forward Africa, report of the panel discussion on health financing
UHC is, and how to get there, is still developments, WHO, 2012.
lacking among these stakeholders and AFRO will continue to support the 2. www.hha-online.org/hso/conference
3. http://www.who.int/mediacentre/news/
that MoH (and other health sector actors) process of improving the policy dialogue statements/2013/uhc_20130219/en/index.html
need to further improve their arguments to orient African countries towards UHC. 4. WHO Regional Office for Africa. The State of Health
in dealing with MoF regarding the need Together with its HHA partners, AFRO Financing in the African Region. Discussion paper for the
interministerial conference “Achieving results and value
to increase investment in health in order will support implementation of the for money in health”, 2012.
to effectively move towards UHC. Tunis Declaration by organizing regional 5. Musango L et al. “Moving from ideas to action –
seminars aimed at MoH, MoF and other developing health financing systems towards universal
coverage in Africa”, BMC International Health & Human
While inadequate funds for health is seen key stakeholders. WHO/AFRO will also Rights, 12:30, 2012.
as a fundamental problem in the African organize a new panel discussion at the
Region, inefficient use of resources is 63rd Regional Committee in September
ISSUE 17 • SPECIAL ISSUE • HEALTH FINANCING IN THE AFRICAN REGION 3
FINAL AHM 17.indd 3 18/07/2013 08:48
Financial risk protection
in the African Region
Laurent Musangoi, Priyanka Saksenaii and Bokar Tourei
Corresponding author: Laurent Musango, e-mail: musangol@afro.who.int
T
here are two aspects to universal the expense of other essential necessities
health coverage: access to all the such as nutritious food or children’s
quality health services needed education.
and the absence of financial hardship.1
Monitoring access to health services has Comparable indicators of financial risk
been on the radar of health policy-makers protection, both from a time series as
for some time. Investment in multiple well as an international perspective, have
instruments, notably demographic and simplified the task for analysts.3 However,
health surveys, has made this useful the data necessary for this type of exercise
information regularly available to guide are still missing in many countries, or are
policy in many countries. However, there not collected regularly enough. In other
is still much to know about services other countries, the ministries of health still
than those for reproductive, maternal and have not fully committed to monitoring
child health and additional investment financial risk protection.
in routine information systems could be
very useful. Additionally, information on
the quality of care is also urgently needed. Catastrophic health
expenditure in the region
The other key aspect of universal health
coverage – the absence of financial The availability of evidence on financial
hardship associated with seeking care risk protection in the African Region is
– has also emerged as an important limited. To date, fewer than 20 countries
assessor of health systems performance have produced data on financial risk
since 2000.2 The absence of financial protection using the methodology
hardship, or financial risk protection, is developed by WHO. 4 Excluding the
the embodiment of the notion that the four countries with detailed reports
use of health services should not come at on catastrophic health expenditure
SUMMARY—The absence of financial hardship (as
well as the availability of quality health services)
is a necessary prerequisite for universal health
coverage. Information on this indicator is not widely
available in the African Region. However, with
support from WHO methodology some countries
are now producing reports on catastrophic health
expenditure. The findings are used to inform policy
development on such issues as user fees and the
expansion of prepayment and pooling mechanisms
designed to encourage UHC. This article looks at
studies from Burkina Faso, Mauritania, Senegal
and Uganda, which show a number of interesting
findings and also the positive impact of targeted
policies in improving financial risk protection.
Voir page 54 pour le résumé en version française.
Ver a página 54 para o sumário em versão portuguese.
i Regional Office for Africa, World Health Organization, Brazzaville, Congo
4 AFRICAN HEALTH MONITOR • JULY 2013 ii World Health Organization, Geneva, Switzerland
FINAL AHM 17.indd 4 18/07/2013 08:48
presented in this edition of the African that despite the existence of coverage poorest. Policies should thus envisage not
Health Monitor, the average catastrophic mechanisms for the poor, such as the only improved access to health services,
health expenditure in the remaining waiving of user fees, the burden from but also better financial protection for all.
countries with available data is around OOPs is most pronounced among the
3.0%, with a range extending from almost poor. In fact, in all four countries, it is the
0% to around 8%. However, this figure poor who are most at risk of catastrophic Ownership of the
still hides important disparities: the health expenditures. The study from evidence and the study
incidence among the poorest quintiles Uganda also found that the removal of process
in these countries was over 4.5%, user fees is not necessarily sufficient in
while it was less than 2% in the richest the short term to reduce the incidence Overall, these studies provide much
quintiles. Impoverishment due to out-of- of catastrophic health expenditure – food for thought for policy-makers. The
pocket (OOP) health expenditures was it needs to be accompanied by other ministries of health of the countries
around 1%.4 mechanisms in order to be translated into where the studies were conducted have
a reduced burden from OOPs. In some been involved and have provided guidance
While these figures may not seem large, of these studies, others factors – such from the very beginning, so as to align
if applied to the whole region, they as households with disabled members, the studies with their information needs.
imply that more than 25 million Africans those with female heads, those living in All the actors involved in the studies
face catastrophic health expenditures, rural areas or with members who were also benefitted from the involvement
while over 8 million are impoverished hospitalized – were also found to be of the WHO, which provided extensive
due to OOP health expenditures. These more at risk of facing catastrophic health knowledge transfer and technical
numbers become even more daunting expenditure. In the three West African assistance to build national capacity
when we consider how many people, countries, the incidence of catastrophic for these studies. Additionally, these
particularly poor people, must have health expenditure ranged from 1.43% studies gained greatly from the fruitful
forgone the use of health services due to 4.11% among all households, while collaboration between analysts at national
to financial barriers to access. Indeed, impoverishment was between 1.52% statistical offices and the policy-makers
the situation of vulnerable populations and 1.78%. and specialists in the ministries of health.
is particularly worrying, as highlighted in This process has led to full ownership of
the four studies on catastrophic health The three West African studies also the results at the country level, as well
expenditures in this issue. indicate that medication accounts for as a commitment to use information on
the biggest share of OOPs, which is financial risk protection in guiding and
But this information on financial risk something that is often not adequately evaluating policy.
protection has been used constructively in appreciated by policy-makers. At the
many countries. The state of financial risk same time, hospitalizations also create Indeed, all countries in the African Region
protection has influenced a wide range financial problems for households. More should aim to monitor and evaluate
of policies on issues such as user fees, positively, these studies support the financial risk protection in their own
availability and cost of pharmaceutical beneficial effect of certain policies. For settings, with a view towards achieving
products and, of course, the expansion example, evidence from Burkina Faso universal health coverage. The WHO
of prepayment and pooling mechanisms and, to a certain extent, Senegal suggests continues to strive to support countries
aimed towards achieving universal health that households with children under five in this through customized knowledge
coverage. Indeed, without up-to-date are better protected from catastrophic transfer and other follow-up activities, as
information on financial risk protection, health expenditure, which could be linked was done for these four countries. To this
the need for and impact of these and other to policies targeted towards providing free end, WHO is planning to organize another
health systems policies is not evident. care for children in these countries. workshop on household survey analysis
In the end, even with good intentions, for monitoring financial risk protection.
the only way to be sure about being on Finally, these studies also highlight More information can be obtained on
the path to universal health coverage that, in addition to being most at risk this and other related activities from the
is through investing in monitoring and of catastrophic health payments, the WHO’s Regional Office for Africa. v
evaluation, including in this important poorest households – who often live in
domain of financial risk protection. rural areas – also use health services the
least. In addition to the financial barriers, References
1. World Health Organization. The world health report 2010
geographic and other types of barriers – health systems financing: the path to universal health
Evidence from Burkina could also explain this effect. Indeed, the coverage, WHO, Geneva, 2010.
Faso, Mauritania, study from Mauritania found that the 2. Murray CJL and Evans DB (eds). Health systems
performance assessment: debates, methods and empiricism,
Senegal and Uganda burden from transportation expenditures WHO, Geneva, 2003.
could be significant. Removal of these 3. Xu Ke et al. “Household catastrophic health expenditure: a
The four studies on catastrophic health barriers would increase the use of multi-country analysis”, The Lancet, 362, 2003, 111–7.
4. Xu Ke et al. Exploring the thresholds of health expenditure
expenditures presented in this issue of the health services, but may also increase for protection against financial risk, World health report
African Health Monitor highlight this key the incidence of catastrophic health (2010), background paper 19, WHO, Geneva, 2010.
point. The study from Mauritania found expenditures, particularly among the
ISSUE 17 • SPECIAL ISSUE • HEALTH FINANCING IN THE AFRICAN REGION 5
FINAL AHM 17.indd 5 18/07/2013 08:48
Strategies towards
universal health
coverage in Rwanda:
Lessons learned from
extending coverage
through mutual health
organizations
Laurent Musango,i Andrew Makaka,ii Diane Muhongerwa,iii Ina R. Kalisaiv and
Riku Elovainiov
Corresponding author: Laurent Musango, e-mail: musangol@afro.who.int
R
wanda, situated in central Africa, been the subject of particular attention
experienced war and genocide at both regional and international
in 1994. These tragic events level. Several articles have presented
contributed to the deterioration of MHO schemes as innovative financing
infrastructure and services, including mechanisms, focusing specifically on
in the health system. As soon as the household fund collection, risk pooling
war ended, Rwanda undertook its and purchase of services from providers.2
reconstruction and many initiatives and Recent studies have presented the
innovations were initiated, some of which results achieved, in terms of population
have resulted in positive outcomes. The coverage, improved access and avoidance
health insurance system is one such of catastrophic health expenditure.3,4,5
example of satisfactory performance.1
While it is true that the introduction of
The health system has undergone MHOs in Rwanda is a recent experience
several reforms, leading to the current that is still facing many challenges –
high level of coverage, notably through notably in terms of financing and
mutual health organizations. In an initial risk pooling – its overall performance
SUMMARY—Rwanda has undertaken several
first phase, between 1999 and 2001, a is generally deemed positive.6 In fact,
health sector reforms over the last two decades.
MHO pilot project was implemented substantial progress has been made
One of particular interest is the health insurance
in three districts. This was followed by towards the attainment of the main
reform and extension of coverage through mutual
a second phase that saw the extension targets of universal health coverage –
health organizations (MHOs). This strategy and
of these initiatives between 2002 and reduction of financial barriers for better
its implementation is analysed in this article with
2005 to other districts either by political access to health services and cutting of
a view to highlighting good practices or lessons
and administrative authorities, health catastrophic health expenditure.
learned, based on experience on the ground and
providers or high-profile personalities.
on existing literature, that could be used in other
This resulted in a third phase, starting This article proposes to review a number
countries. This report shows that it is possible to
in 2006 and still on going, which of the “lessons learned” with a view to
achieve health insurance coverage in countries such
witnessed a broad-based review on how identifying the specific strategies adopted
as Rwanda where the informal sector is as large as
to take advantage of a MHO approach by the Government of Rwanda to achieve
90% of its total population. Ten good practices were
to expanding the health insurance system such performance. It presents ten strategies
identified as lessons learned and these are deemed
nationwide with the aim of providing that can be of relevance in other countries
to be key factors in moving towards universal health
universal health coverage. or contexts. The section on discussions
coverage in Rwanda and should be supported and
is aimed at better understanding the
reinforced in order to sustain the improvements in
Rwanda’s approach to extend health “strategies”, and focusing attention on
health care access.
insurance coverage through MHOs has the validation of good practices.
Voir page 54 pour le résumé en version française.
i Regional Office for Africa, WHO, Brazzaville, Congo
Ver a página 54 para o sumário em versão portuguese. ii Ministry of Health, Kigali, Rwanda
iii Health Systems and Innovation Cluster, WHO, Rwanda office
iv School of Public Health, Rwanda
6 AFRICAN HEALTH MONITOR • JULY 2013 v Health Systems and Services Cluster, WHO, Geneva, Switzerland
FINAL AHM 17.indd 6 18/07/2013 08:48
Methodology In a bid to determine the social category itself defined the various categories
of each household at the village level of rich/poor among its members
A desk review of the studies and reports for deciding on the MOH contribution and identified criteria for allocating
cited above was undertaken, in parallel exemptions and subsidizations, community members to the various
to discussions with the government discussions were carried out within categories. The number of categories
authorities and other stakeholders to communities on the notion of poverty, its identified and their characteristics are
review the MOH approach and its role causes and consequences. The community described in Table 1.
and function within the overall health
financing system. To strengthen the
analysis, the strategies that were identified Table 1. Household classification criteria for identifying destitute people using
were matched with available literature the ubudehe approach
and compared with the good practices
Population group Characteristics
identified by other experts involved in
other policy processes. Such comparisons Abatindi nyakuja This group of people own no property, live from begging and the assistance
(people living in of other people and consider that death would be a relief.
enabled us to determine to what extent abject poverty)
the choices and operational processes These people are homeless and lack food, access to food is not easy but they
Abatindi
adopted in Rwanda were allied to possibly are able to work for other people in order to survive. They are poorly clothed
(very poor people) and own no land or livestock.
more generic practices in other parts of
the world. Efforts were also made to verify These people depend on food deficient in nutrients, own a small plot of land,
Abakene have low production and cannot afford to send their children to secondary
to what extent the strategies adopted (poor people) school.
in Rwanda are referred to in scientific These people own a small plot of land, some livestock, a bicycle and produce
Abakene bifashije
literature on health insurance extension an average quantity of food; their children can attend secondary school and
(less poor people) they face fewer difficulties accessing health care.
through MHOs implemented in other
Abakungu – jumba This group of people own large areas of land, can afford a balanced diet
low or middle-income countries. This (rich people because and live in decent homes. They employ other people, own livestock and their
dual comparison prompted reflections they have food) children can easily attend university.
on the external validity of lessons learned Abakire This group comprises people who have a bank account, can access bank
in Rwanda. (rich people because loans, own a beautiful house, a car, livestock, fertile lands, sufficient food and
they have money) have permanent employees.
Source: Ministry of Public Administration and Social Protection, “Ubudehe” programme, Kigali, Rwanda.
Results – the ten best
practices identified
1. Selection and management
of destitute people
A strategy namely ubudehe (collective
work) was devised to select and manage
destitute people in order to determine
MHO contribution subsidizations and
exemptions. This approach is based on
traditional values aimed at rallying the
people around a collective and shared
effort, with a view to improving their
social conditions. In the past, the
population living in the same smallest
village level unit used to organize
themselves to work in farms and build
houses for poor people. Building on this
practice was recognized and encouraged
by some of the country’s development
partners. Under the new organization,
the community identifies destitute people
itself and determines the assistance they
need. The participation of government
and development partners involves
sending aid to such organized population
groups that have identified their own
needs, within the overall context of
poverty alleviation.
ISSUE 17 • SPECIAL ISSUE • HEALTH FINANCING IN THE AFRICAN REGION 7
FINAL AHM 17.indd 7 18/07/2013 08:48
2. Resource mobilization Any foreigner entering the country or leader, a training officer, a research
mechanisms for the granting territory of Rwanda shall also be bound officer, a planning officer, a monitoring
of microcredit to facilitate to health insurance within a time limit and evaluation officer, an accountant
MHO subscription not exceeding 15 (fifteen days)”. The and a stocks manager.
Microcredits are granted to beneficiaries application of this law, however, depends b) At the district level, there is a board
without any obligation of guarantee; only on ministerial orders that are still being of directors and a manager. The
the moral guarantee of the administrative prepared. board is composed of seven people,
authority is required by banques populaires.7 and board members are elected for a
Credits are granted annually, either 4. Decentralization and term of three years, renewable once.
to individuals, households, groups separation of functions The manager is a permanent officer
or associations. They are repaid over In the context of decentralization, district in charge of the daily management
a 12-month period at an interest mayors sign performance contracts with and monitoring of health insurance
rate of 4%. It should be noted that the Presidency of the Republic. These activities in the district.
the negotiations which led to these contracts relate to four main elements: c) At the branch level, there is a
arrangements took place between the ● good governance; management board composed of five
Government and the banques populaires ● justice; people, notably: the chairperson, the
which cover the entire national territory. ● economic development; and vice-chairperson, the secretary and
This method is aimed at helping the ● promotion of the well-being of the two advisors, each from a sector. They
population pay their MHO contribution population. are elected for a term of two years,
in a single instalment. Information renewable once.
obtained from the banks show that 96% For each element, the performance d) Finally, at the level of villages
of debtors repay their debt regularly, indicators to be assessed at the end of and communities, there are MHO
without any delay. Another option every year are defined. Performance committees in charge of sensitizing
would be to combine health insurance indicators relating to MHOs are the community. Their staffing depends
credits with loans for income-generating among the main indicators regarding on the size of the community; on
activities in communities organized the promotion of well-being of the average, one person is responsible
within cooperatives. This enables population. Consequently, mayors are for 100 to 150 households. Figure 1
people not only to borrow, work and encouraged to sensitize communities on shows MHO management bodies at
repay collectively, but also reduces the the importance of MHOs in order to the various levels.
insolvency risks related to credits granted satisfy these indicators.
only for health insurance. 6. Upgrading of services
The recent decentralization process provided to MHO subscribers
3. Establishment of a legal in Rwanda divided the country into During the pilot phase, the health services
framework for the operation 30 districts. As MHOs are developed provided to MHO subscribers were
of health insurance in according to districts, there are 30 MHOs limited to minimal services proposed
Rwanda in the country at the health centre level, by health centres and complementary
The various health insurance schemes, there is a MHO branch in each health services offered by district hospitals.
including MHOs, in Rwanda were centre and at a lower level, that is, at the During the second phase, the system
governed by several legal instruments: level of cells and communities (imidugudu), was similar, although complementary
firstly, the decree of 15 April 1958 committees are set up to sensitize people ser vices could var y between the
relating to “mutual organizations” which on the need to subscribe to MHOs. MHOs, and the contribution amounts
remained in force until 2006. Later, were not the same. MHO subscribers
from 2006 to April 2008, a ministerial 5. Development of human complained about the gaps in coverage
order set out the provisions of the law resources and establishment in comparison with the existing health
that was tabled before parliament for of management bodies insurance schemes for formal sector
enactment, relating to the coordination Several committees have been established workers and civil servants (RAMA and
of MHO expansion activities. Finally, at different levels: MMI). Those covered by these schemes
Law No. 62/2007 of 30 September 2007 a) The MHO Technical Support Unit could access care in district and referral
setting up compulsory health insurance (CTAMS), set up at the Ministry of hospitals. With the advent of risk
in Rwanda was enacted in April 2008 Health, provides support for the pooling between the district MHOs
and published in the Official Gazette of development of MHOs, facilitates during the third phase (see next section
the Republic of Rwanda. This law sets experience sharing between districts on resource mobilization), community
out provisions relating to the creation, and improves policies and strategies. or district MHO subscribers could
organization, operation and management The unit is also responsible for also access care in district and referral
of health MHOs within the strategy g athering MHO-related data, hospitals. This enabled the mobilization
of extending health insurance coverage operational research, as well as training of additional resources for MHOs and
in Rwanda. It stipulates in Section 33 and dissemination of good practices. is greatly appreciated by subscribers, as
that: “Any person residing in Rwanda CTAMS has a staff of nine people, well as being an incentive to subscribe to
shall be bound to health insurance. including a coordinator, a project a MHO since subscribers are entitled to
8 AFRICAN HEALTH MONITOR • JULY 2013
FINAL AHM 17.indd 8 18/07/2013 08:48Figure 1. MHO management bodies and their composition at various levels of the health pyramid
Management level Structure Management Composition
bodies
1. Coordinator
2. Project leader
MHO technical 3. Training officer
National Support unit support unit 4. Research officer
5. Planning officer
6. Monitoring and evluation officer
Management 1. District representative
committee 2. Two branch representatives
District Union 3. Representatives of associations
4. Representatives of faith groups
Administrator 5. Representatives of health structures
Management
committee 1. Chairperson
Branch 2. Vice-chairperson
3. Secretary
Administrator
Health centre
MHO initiatives Staffing depends on the size of the
Village/cell committee community (1 person for 100 to 150
households)
the same services as those in the formal MHO contributions of destitute people. cooperation (GIZ), Belgian cooperation
sector, except private health providers Table 2 presents the contributions of the (CTB), International Labour Organization
and pharmacies. Government and the Global Fund to (ILOSTEP), Dutch cooperation, Swiss
MHO strengthening. cooperation, the European Union, World
7. Mobilization of additional Bank, WHO and UNICEF. Such financial
financial resources to support Negotiations between the Government support enabled broadening of the scope
MHO initiatives of Rwanda and its partners extended of coverage to include services at referral
Several sources of financing are directed to include other development partners, hospitals.
towards MHO support, in particular, e.g. US cooperation (USAID), German
member contributions that account for
a large share of resources, government
support and partner assistance. The Table 2. Contribution of the Government of Rwanda to health insurance
Government of Rwanda allocates a strengthening through the Global Fund and under the state budget
budget to MHO strengthening. The
funds are used for the operation of Contributions (US$8)
MHOs and district level inter-branch 2008 2009 2010
pools. The Government also negotiated Subsidization of health insurance contributions of destitute 714 250 646 024 5 202 400
with partners to secure their financial people (basic and complementary services)
contribution to the MHO mechanism. Subsidization of health insurance contributions of “poor 937 166 1 098 278 6 094 316
people” (for complementary services)
The Global Fund, in the context of the
2005 Round 5, granted the Government Subsidization of health insurance contributions for orphans 74 359 69 244 545 741
(basic and complementary services)
of Rwanda US$ 34 million over a five-
Subsidization of health insurance contributions for PLWHIV 121 677 125 784 971 912
year period to subsidize the coverage (basic and complementary services)
of complementary services in district Total 1 847 452 1 939 330 12 814 368
hospitals and the MHO subscription
Government contribution (US$) under the state budget
of people living with HIV (PLWHIV).
Total financial flows for health care 4 048 169 7 409 543 11 193 705
Such funds are also used to subsidize
ISSUE 17 • SPECIAL ISSUE • HEALTH FINANCING IN THE AFRICAN REGION 9
FINAL AHM 17.indd 9 18/07/2013 08:488. Raising community universal health coverage. It has already be reinforced and sustained in order to
awareness on the importance been mentioned that the Presidency of consolidate the system. Support from
of MHO coverage the Republic signs contracts with district development partners for subsidizing the
Political and administrative authorities mayors with a view to meeting certain contributions of destitute people and
use various channels to raise awareness: indicators. PLWHIV remains significant. Hence,
popular gatherings, church services, the Government should continue to
community labour, etc. Officials from Within the framework of performance mobilize both domestic and external
the MHO management bodies use contracts signed between the Presidency resources for strengthening these
the opportunity offered by these mass of the Republic and districts, an annual subsidization mechanisms. Combining
gatherings to transmit messages regarding evaluation is conducted to ensure the further innovation in the contribution
MHOs. effectiveness of the performance categories according to capacity to
indicator relating to social well-being (see pay of households and consolidating
CTAMS has produced a number of point 4 on decentralization and separation the subsidization policies could lead
brochures on MHOs and has sent them of functions). Mayors who fail to comply to resource mobilization in line with
to district MHO offices for dissemination. with the performance commitments Rwanda’s economic development and
Sensitization messages are aired on undertaken with the Presidency of the growth in the long run. External support
national radio and bi-weekly television Republic are expected to resign. The will also be indispensable to accompany
programmes, even where the number practice of performance assessment thus the process in the foreseeable future.
of viewers is limited – only 3.9% of the encourages political and administrative
population owns a television.9 authorities to undertake commitments Lastly, it is incontrovertible that research
that they have a duty to honour, for the is a useful instrument that needs
Finally, in the context of sensitization benefit of the population, at risk of losing strengthening in order to improve
efforts, it should be noted that each year their position. universal health coverage and the
the Ministry of Health organizes a health mechanisms to achieve it, and to enable
insurance day during which it awards political leaders to defend their policy
prizes to the best MHOs. Conclusions and decisions on the basis of reliable facts. v
recommendations
9. Synergy between MHOs
and other health system The support from the Government References
1. Musango L. Organisation et mise en place des mutuelles
processes with a view to of Rwanda to the MHO approach de santé : Défi au développement de l’Assurance Maladie
improving health care quality deserves particular attention. The high au Rwanda, Université Libre de Bruxelles/Ecole de Santé
and political leadership level of government involvement that Publique, thèse de doctorant, Bruxelles, 2005.
2. Schneider P et al. Pilot testing prepayment for health
Other health system mechanisms, characterized the establishment of the services in Rwanda: Results and recommendations for policy
including performance-based financing MHO schemes enabled the population directions and implementation, Partnerships for Health
(PBF) and quality assurance (QA), have to understand the importance of pooling Reform, Technical Report no. 66, Bethesda, 2001.
3. Kayonga C. Towards Universal Health Coverage in Rwanda,
developed in Rwanda and synergies risk and created public support of the Briefing Summary Notes, Brookings Global Economy and
between the various approaches could MHO approach. Today, the population Development, 2007.
facilitate their institutionalization. For adheres strongly to the MHO system but 4. De Rebecca Donauer, Elsa Kleinschmager, Faustin
Murangwa et Florence Touly. Rwanda : une assurance-
instance, the increase of service utilization in the years ahead, there will be a need to maladie pour tous, ARTE GEIE, France 2011.
due to MHOs will also have a positive strengthen ownership by the population 5. Priyanka Saksena et al. “Mutual health insurance in
impact on the quantitative indicators used in order to sustain MHOs in Rwanda. Rwanda: Evidence on access to care and financial risk
protection”, Health Policy 99, 2011, 203–209.
in the context of PBF and thus leads to 6. Idem 5.
increased funding flows to health facilities Performance of health facilities is not 7. The Rwandan Government, with support from Swiss
that operate under a PBF contract with due to a single strategy but rather to technical cooperation, developed a network of banques
populaires throughout the national territory. Farmers can
the Government. a combination of different strategies, deposit their money and the bank requires no minimum
including: MHO, PBF and AQ. amount for opening an account. This bank also grants
Regarding quality assurance, the strategy credits to its members at an interest rate of 4%, contrary
to commercial banks where the interest rate is between
facilitates continuing supervision and It is also worth noting that households 12% and 18%.
technical audit which, additionally, is constitute a major direct source of MHO 8. The institutions in charge of the Global Fund contributions
useful for the management of MHOs financing. Financial viability therefore are: CTAMS and Imbuto Fondation (for orphans and
PLWHIV).
and PBF. depends on the capacity and will of 9. Ministry of Finance and Planning, 2002.
households to pay to these mechanisms.
10. Political leadership and Consequently, contribution costs should
involvement of political and remain affordable and the various
administrative authorities in mechanisms enabling the population to
extending coverage through mobilize funds strengthened. In fact, new
MHOs mechanisms, such as the classification
The Government of Rwanda is involved of populations in income categories,
at the highest level in the promotion of depending on their capacity to pay, should
10 AFRICAN HEALTH MONITOR • JULY 2013
FINAL AHM 17.indd 10 18/07/2013 08:48Is universal health
coverage via a national
health insurance
scheme financially
feasible in Zanzibar?
Maximillian Mapunda, Juliet Nabyonga, Ole Doetinchem and Riku Elovainio
Corresponding author: Maximillian Mapunda, e-mail: mapundam@tz.afro.who.int
Z
anzibar is a state within the United of a potential health insurance scheme
Republic of Tanzania. The Ministry in Zanzibar.
of Health (MoH) in Zanzibar
collaborated with the President’s Office
of Public Service and Good Governance Methodology
(PoPSGG), the President’s Office of
Finance, Economy and Development The financial sustainability assessment
Planning (PoFEDP), the Zanzibar Social of the proposed scheme made use of
Security Fund (ZSSF), the Zanzibar macroeconomic, health and demographic
Insurance Corporation (ZIC) and the data. The key data required for the
Office of Chief Government Statistician macroeconomic input were GDP and its
(OCGS) from June 2011 to September growth rate, a measure of inflation, interest
2012 to undertake a feasibility study on rates, national account data as well as public
the introduction of a health insurance finances, i.e. general government revenues
scheme as an option to finance health and expenditures by different categories.
care in Zanzibar. The financial feasibility Most of these data were obtained from
SUMMARY—The Government of Zanzibar is in
assessment consisted of calculating and the Office of the Chief Government
the process of planning a health insurance scheme
projecting revenues and expenditures Statistician Zanzibar (OCGSZ), using its
expected to contribute towards the aim of universal
of the scheme from 2013 to 2021. March 2012 statistical report.1
health coverage (UHC). The scheme is expected to
Quantitative data from government
be implemented either as part of or in collaboration
and other sources and qualitative data Other documents consulted were the
with the Zanzibar Social Security Fund (ZSSF). The
from discussions with health financing OCGSZ household budget survey
Zanzibar Social Security Fund Act, 1998, specifies
stakeholders were gathered. 2009/10, for the household consumption
that ZSSF is to pay medical benefits to its members
data and the World Economic Outlook
and the health insurance is one way of fulfilling
The team selected to lead the Database of the International Monetary
this legal requirement. Current coverage of ZSSF
implementation of the health insurance Fund for the US dollar inflation estimates
includes formal sector employees only – both public
scheme in Zanzibar was led jointly by the as of April 2012.
and private, however, for UHC the access to health
directors of the MoH and the PoPSGG
services and financial protection of the entire
and included representatives from each The health care data needed for the study
population must be considered. A study to assess
collaborating institution. It also included a centred on variables that can explain what
the financial feasibility of national health insurance
consultant recruited to conduct a training drives the cost of covering health care
(NHI) in Zanzibar was undertaken using the SimIns
workshop on SimIns – a health insurance services by a health insurance scheme.
(health insurance simulation software) tool in July
simulation that allows the financial Information on public and private
2012. This article reports on that assessment. There
forecasting and evaluation of the financial expenditures was also used, although the
is strong indication that health insurance in Zanzibar
feasibility of health insurance. estimate for total private expenditure on
is financially feasible in the medium term leaving
health had to be estimated in the absence
policy-makers with some room for designing the
The purpose of the study was to provide a of concrete data. For the preliminary
technical aspects of a health insurance within the
solid foundation upon which policy-makers scenarios the group used the approximate
financial parameters, i.e. population and costs,
could make an informed and evidence- ratio of public to private expenditure
leaving the other dimension on health services
based decision on the establishment of on health from the Tanzanian mainland2
access to be considered separately.
a health insurance scheme in Zanzibar as and applied it to the total government
an element of health financing reform for expenditure on health as taken from
Voir page 54 pour le résumé en version française. UHC in Zanzibar. Moreover, the findings the public expenditure review reports,
Ver a página 54 para o sumário em versão portuguese. of this study can be used to design features thereby making the working assumption
ISSUE 17 • SPECIAL ISSUE • HEALTH FINANCING IN THE AFRICAN REGION 11
FINAL AHM 17.indd 11 18/07/2013 08:48patient is assumed to pay twice that of
an outpatient in user fees.
Most of the population data were
obtained from the OCGSZ economic
survey, whereas the workforce data
predominantly came from ZSSF/
POFEDD/POPSG annual reports and
database. The data sets were analysed
using the SimIns tool, which helps analyse
the basic financial mechanisms of health
insurance. Its principal use is in financial
projections for social health insurance.
that the ratio of total private expenditure MoH budgets, the team assumed that Results
on health to total public expenditure on maintenance costs and 40% of drugs and
health in Zanzibar is the same as that on supplies would represent the government- Four SimIns scenarios for health
the Tanzanian mainland. funded share of the cost. insurance in Zanzibar have emerged on
the basis of the data inputs described
Health care services were categorized For secondary and tertiary health care in the previous section, each varying
by types of facilities and by in- and services, data from the Medium-Term in terms of population coverage and
outpatient services. For each category Expenditure Framework (MTEF)5 was payment into health insurance.
utilization rates were calculated using used to estimate average costs. For this,
full head counts of patients from every the MTEF expenditure was added by Scenario 1 models a simple policy of
facility, as provided by the MoH Health health care facility type (which did not mandatory enrolment of all working in
Management Infor mation System include human resources either) and the formal sector of the economy into
(HMIS).3 cost-sharing revenue, before receiving the health insurance, while excluding
the limitation of budget figures from the rest of the population. This scenario
Data estimating the average cost per the MoF. To estimate the government- translates into a population coverage
health service came from two principal funded share of this cost, the sum was level of 16.4%. The contribution rate
sources: the 2007 review of the essential compared with MTEF following the entered into the model corresponds to
health care package (EHCP review) 4 budgetary figures provided by MoF. Non- 3% of gross wages. As a result, the first
for primary-level care (PHCUs); and food inflation data from OCGSZ were scenario has only a modest impact on the
the MOH medium-term expenditure used to standardize figures using 2011 as overall structure of health expenditure in
framework for secondary and tertiary the base year. Zanzibar, which currently registers only
health care. It is important to note that around 5% of total health expenditure.
it was decided not to include the cost of As the MTEF data do not distinguish In other words, the insurance as such
personnel in the calculation of average between outpatient (OP) and inpatient would have little impact on the way health
cost per health service, as the current (IP) services, a working assumption services are financed for the population
policy of having basic salaries paid of the two as IP/OP cost ratio was as a whole, but would improve access to
directly by the government is expected applied to the total sums, to be able to services for the formal sector.
to continue and thus does not affect the artificially split the cost into these health
health insurance bottom line. care categories. Thus, the preliminary In terms of financial feasibility, the
scenarios assume that admissions are, projection shows a probable large
The EHCP review provided costs for on average, twice as costly as outpatient surplus for the health insurance under the
PHCUs by input type. To estimate the cases. The same assumption was applied configurations of Scenario 1. As detailed
part of the cost that is funded from to cost-sharing data, i.e. an admitted in Table 1 the insurance is estimated to
Table 1. Scenario 1: Health insurance revenue and expenditure (in TZS millions, constant prices)
Scenario 1 2013 2014 2015 2016 2017 2018 2019 2020 2021
Revenue from contributions 6 203 6 116 6 030 5 945 5 862 5 779 5 698 5 618 5 539
Revenue from interest on reserves 10 20 29 38 46 54 61 68
Expenditure on health care services 1 861 1 919 1 978 2 039 2 103 2 168 2 235 2 304 2 376
Expenditure on administration and reserves 279 288 297 306 315 325 335 346 356
Balance of the fund (deficit [-] / surplus [+]) 4 063 3 920 3 775 3 629 3 481 3 332 3 181 3 029 2 875
Surplus as a percentage of total revenue 66% 64% 62% 61% 59% 57% 55% 53% 51%
12 AFRICAN HEALTH MONITOR • JULY 2013
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