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Debriefing for the Study Tour of the Malian and
Senegalese Delegations to Rwanda
October 25-30, 2009
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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.
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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 tripsTwo groups were formed: Mali team Senegal team
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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.
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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.
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HEALTH INSURANCE
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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
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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
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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
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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
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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
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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
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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
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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
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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
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PERFORMANCE-BASED FINANCING
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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
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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
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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)
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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
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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
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Thank You
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