Rwanda’s mutuelle health insurance scheme has been consistently held up as an example of how community health insurance can be scaled up to achieve large scale improvements in access and health outcomes. However, the role of the mutuelle scheme in achieving recent health improvements in Rwanda has often been exaggerated without consideration of other important factors (including a five-fold increase in health spending).
This post takes an in-depth look at the mutuelle scheme, raising critical questions about its impact on access to health care and the extent to which mutuelles are really financially sustainable. It shows that while insurance premiums and co-payments are less prohibitive than traditional point-of-service charges, they continue to pose a financial barrier for many Rwandans. International commentators should be careful not to disproportionately underscore the mutuelle’s role in improving health outcomes and oversell community health insurance as a health financing panacea.
User fees for healthcare in poor countries have been an issue of intense controversy since their adoption in the 1980s. In recent years, fees have drawn criticism for the inequitable barrier they create for the poor and the lack of improvement in service delivery that they were expected to produce.
As an alternative, community health insurance programs that shift fees from the point-of-service to prepayments have received increasing attention in Sub-Saharan Africa. In addition to alleviating financial barriers at the time of illness, community insurance programs have also been touted as a ‘sustainable’ approach to health financing.
In practice, however, few countries employing community insurance schemes have achieved meaningful coverage with most having fewer than 10% of the population enrolled. Government-led programs in Ghana and Rwanda are frequently cited exceptions with Rwanda’s mutuelle reaching 91% coverage in 2010 (although a recent report has challenged the claimed impact of Ghana’s health insurance scheme). In light of Rwanda’s dramatic improvement in health indicators, the mutuelle is often offered as an impetus for introducing insurance to other countries in the region.
However, the mutuelle deserves closer scrutiny before being promoted as a model for health financing. While Rwanda’s insurance program has surely improved access compared to traditional point-of-service charges, it is not clear how much of Rwanda’s success can actually be attributed to the mutuelle. Insurance coverage improved from 7% in 2003 to 91% in 2010. Over the same period, utilization of health services jumped from 0.31 outpatient visits per capita to 0.95. Health indicators made an unprecedented improvement during this time with under-five mortality dropping by half from 15.2% in 2005 to 7.6% in 2010.[6,7] This is a staggering reduction in just five years and puts Rwanda almost on par with far wealthier countries like India and South Africa.
The correlation between mutuelle coverage and improvements in utilization and indicators, however, is confounded by massive concurrent increases in health spending. In 2002, Rwanda spent just 10 USD per capita on health; by 2010, this increased almost five times to 48 USD per capita.[9,10] Much of this growing investment in health comes from donors who contributed 53% of Rwanda’s health budget in 2006, up from 33% in 2002.[11,12] And mutuelle has had very little to do with this expanding resource envelope; it accounted for only 5% of all health spending in 2006 (and now probably closer to 3%).[13,14] Moreover, at least 20% of mutuelle funds, in fact, come from donor and government subsidies.
In a recently published study based on a small pilot in 2007, several colleagues and I examined utilization patterns at a health facility in rural Rwanda. Service delivery at the facility was aggressively upgraded with increased staffing, reinforced drug supplies, new equipment, and improved management. Despite these enhancements, utilization rates remained unchanged compared to neighboring sites that received no upgrades. After mutuelle enrollment was subsidized to achieve full coverage and associated point-of-service co-payments removed, utilization skyrocketed, literally tripling overnight and eventually leveling to a sustained rate of 1.2 to 1.6 visits per capita up from a baseline of 0.65. Statistical analysis showed that the removal of financial barriers was responsible for an increase of 0.6 visits per capita, or a doubling of utilization.
So what does this tell us?
First, premiums and co-payments, while less harmful than traditional point-of-service fees, remain a financial barrier without whose removal true universal access to healthcare cannot be achieved. Even with rising incomes, Rwanda’s mutuelle has not achieved universal coverage and, even at high coverage, access remains constricted by co-payments charged at the point-of-care.
Second, even with high enrollment, mutuelle generates minimal financing. In order to increase the funds collected, Rwanda is now introducing higher premiums. While robust economic growth in recent years may enable some to pay more, others may be priced out of the system. In addition, administering the insurance program requires considerable overhead costs and diverts donor and government funds that could perhaps be more efficiently injected directly into the health system. Further, the need for heavy subsidies to garner sufficient coverage begs the question of how much more ‘sustainable’ – one of the reasons made for the adoption of insurance in the first place – these programs actually are.
Third, Rwanda has made unparalleled progress in health by doing what its leadership has felt best for the country and its people. Despite the limitations of the mutuelle strategy, the country’s collective policies have helped it achieve historic gains. However, some international commentators disproportionately underscore the mutuelle’s role in these achievements and oversell community insurance as a financing panacea for others to adopt solely on its basis. It is important for all aspects of Rwanda’s success to be acknowledged and studied for broader adaptation and, in particular, its increasing and strategic investments in health, strong economic performance, uniquely effective public administration, and popular buy-in to government initiatives. Indeed, these other factors are part of the reason why the mutuelle as a program has been as successful as it has.
Rwanda’s leadership should be lauded for their impressive accomplishments. Policymakers in countries looking to follow in their footsteps need to take the Rwanda model as a whole and look at the mutuelle program more critically to understand its relative merits and many limitations rather than simply buying the hype.
Ranu S. Dhillon M.D. is a Health Advisor with The Earth Institute, Columbia University and a Clinical Fellow in the Division of Global Health Equity at Brigham and Women’s Hospital/Harvard Medical School
 Walsh C and Jones N. 2009. Maternal and Child Health: The Social Protection Dividend. UNICEF.
 Ministry of Health (MOH), Republic of Rwanda. 2010. Annual Report July 2009 – June 2010. Kigali: MOH.
 Diop, F., Leighton, C., and Butera, D. 2007. Health financing task force discussion paper: policy crossroads for mutuelles and health financing in Rwanda. Washington, DC: Health Financing Task Force.
 MOH 2010 op.cit.
 MOH 2010 op.cit.
 National Institute of Statistics of Rwanda (NISR). 2006. Rwanda demographic and health survey 2005. Calverton, Maryland, USA: NISR and ORC Macro.
 National Institute of Statistics of Rwanda (NISR). 2011. Rwanda demographic and health survey 2010: Preliminary Report. Kigali, Rwanda: NISR and ICF Macro.
 World Bank, 2011. Data: Mortality rate, under-5 (per 1,000) [online]. Accessed 9 September 2011.
 Ministry of Health (MOH), Republic of Rwanda, 2008. National health accounts Rwanda 2006 with HIV/AIDS, malaria, and reproductive health subaccounts. Kigali: MOH.
 World Health Organization (WHO), 2011. National health accounts: country health information [online]. Accessed 9 September 2011.
 MOH 2008 op.cit.
 The most recent National Health Accounts is for 2006. A more recent figure is not available. However, using budget information in the MOH Annual Report and WHO estimates for recent health spending, this percentage is likely consistent with current trends.
 MOH 2008 op.cit.
 The 3% figure was calculated based on World Bank estimates for population in 2009, mutuelle coverage of 91%, and WHO estimates for health spending in 2010.
 MOH 2008 op.cit.