The impact of reducing financial barriers on utilisation of a primary health care facility in Rwanda

Abstract

This study investigates the impact of subsidising community-based health insurance (mutuelle) enrolment, removing point-of-service co-payments, and improving service delivery on health facility utilisation rates in Mayange, a sector of rural Rwanda of approximately 25,000 people divided among five ‘imidugudu’ or small villages. While comprehensive service upgrades were introduced in the Mayange Health Centre between April 2006 and February 2007, utilisation rates remained similar to comparison sites. Between February 2007 and April 2007, subsidies for mutuelle enrolment established virtually 100% coverage. Immediately after co-payments were eliminated in February 2007, patient visits levelled at a rate triple the previous value. Regression analyses using data from Mayange and two comparison sites indicate that removing financial barriers resulted in about 0.6 additional annual visits for curative care per capita.

Although based on a single local pilot, these findings suggest that in order to achieve improved health outcomes, key short-term objectives include improved service delivery and reduced financial barriers. Based on this pilot, higher utilisation rates may be affected if broader swaths of the population are enrolled in mutuelle and co-payments are eliminated. Health leaders in Rwanda should consider further studies to determine if the impact of eliminating co-payments and increasing subsidies for mutuelle enrolment as seen in Mayange holds at greater levels of scale. Broader studies to better elucidate the impact of enrolment subsidies and co-payment subsidies on utilisation, health outcomes, and costs would also provide policy insights.

Keywords:

• user fees
• community-based health insurance
• Rwanda
• mutuelle
• Mayange

Notes

1. These data were synthesised in Schneider and Hansen (2007) who found that members of the micro-insurance scheme visited health centres at an average annualised rate of 1.3 versus 0.2 of non-members. More recent data from the Interim DHS 2007 indicate that mutuelle increases treatment rates for children with diarrhoea, fever and respiratory problems by 30%–60% (Appendix 1).

2. Nurses have been ranked based on the years of training: A0 (bachelors degree), A1 (Registered Nurse with 4 years professional training) and A2 (high school training).

3. No drugs besides those on the government's formulary list were stocked.

4. The project wealth ranking found dozens of families uncovered by government subsidies who clearly should have qualified for free mutuelle. In the years since, government has made improvements to its evaluation system to better identify the neediest.

5. During this period, the other health centres did not make any substantial upgrades nor receive new support from the millennium villages project nor from the GoR.