Tayebwa Morris Health Issues Paper

8/2/2019 Tayebwa Morris Health Issues Paper

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Better access to healthcare in East Africa; Comparison of

Free Access to health care and Health insurance financing

systems.

Tayebwa Morris

Super visor Dr. Leon Beatus

Arcadia University



Center for East African Studies

Nyerere Center for Peace Research, East African

Community

Better access to healthcare in East Africa; Comparison of Free Access to health care and

Health insurance financing systems.

Key words: (Access to health care, Health financing)

Abstract

Introduction

Health care financing provides the resources and economic incentives for operating health

systems and is a key determinant of health system performance. The purpose of health

financing is to make funding available, as well as to set the right financial incentives for

providers, to ensure that all individuals have access to effective public health and personal

health care. Government spending on health from domestic sources is an important indicator of

a government's commitment to the health of its people, and is essential for the sustainability of

health programmes

This paper discusses the health care financing systems of Uganda and Rwanda, the two East

African countries that have adopted different systems.

Methods

Relevant literature and government documents were extensively reviewed with the aim of

assessing whether health care financing mechanisms of the two countries facilitated adequate

access of health services to the people.

Results and Discussion

Uganda's health sector remains significantly under-funded, mainly relying on private sources of

financing, especially out-of-pocket spending. At 9.6 % of total government expenditure, public

spending on health is far below the Abuja target of 15% that government of Uganda committed

to. Without compulsory health insurance and low coverage of private health insurance, Uganda

has limited pooling of resources. In other words even among public facilities the cost of care

remains a barrier to utilization of services.



Rwanda on the other hand made impressive progress in economic and social development since

the 1994 genocide due to the introduction of a mixed health care financing model, combining

decentralization and performance-based financing with community-based micro-insurance.

Conclusion

The health care financing system in Rwanda should be an inspiration to Uganda and other EastAfrican countries in their efforts to promote equitable health care and achieving universal health

care.

Introduction

There are many definitions of access to health services, with most researchers recognizing that

access is related to the timely use of services according to need.1 Facilitating access is concerned

with helping people to command appropriate health care resources in order to preserve or improve their health. Access is a complex concept and is evaluated by the evaluation of about

many aspects; availability, utilization, affordability, equity and then the sustainability of the

services.2 If services are available and there is an adequate supply of services, then the

opportunity to obtain health care exists, and a population may 'have access' to services. The

extent to which a population 'gains access' also depends on financial, organizational and social or

cultural barriers that limit the utilization of services.

Thus access measured in terms of utilization is dependent on the affordability, physical

accessibility and acceptability of services and not merely adequacy of supply. Services available

must be relevant and effective if the population is to 'gain access to satisfactory health outcomes'.

Equity of access may be measured in terms of the availability, utilization or outcomes of services

for all social groups in the population. These services should also be available for a considerable

time and therefore the sustainability of their adequate provision is vital.

The global health community has recognised that public spending on health in developing

countries is essential for meeting the Millennium Development Goals, reducing poverty, and

1Campbell, S.M. et al. 2000: Defining quality of care. Soc. Sci. Med. 11: 1611–1625.

2McIntyre D, Thiede M, Birch S 2009: Access as a policy-relevant concept in low- and middle-income countries. Health Econ Policy Law 2009, 4:179-193



fighting major diseases that kill, such as HIV/AIDS, tuberculosis, and malaria.3 In 2005, WHO

member states adopted a resolution encouraging countries to develop sustainable and

equitable health financing systems capable of achieving universal coverage4 African leaders

acknowledged in Abuja, Nigeria, in 2001, by pledging to devote 15% or more of their yearly

budgets to the health sector to fight HIV/AIDS and other infectious diseases5

Results from studies have suggested that a country's gross domestic product (GDP), government

size, and external health resources might affect government health financing.6-7 An increase in

domestic public financing of health in low-income countries is also suggested to be crucial for

the sustainability of health programmes8 Categories of health care financing sources include,

taxation, donor funds, social health insurance, private health insurance, other private

sources like NGOs own resources and out-of-pocket (OOP) expenditures.

This study aims at assessing the adequacy of health services in two of the East African

countries ( Uganda and Rwanda) that have adopted different health care financing systems

in order to determine the ideal system that can be adopted throughout the East African

region.

Background

Health care resources in most East African countries come from either public or private sources.

Private sources include households, private firms and not-for-profit organizations; the major

3WHO 2001: WHO Commission on Macroeconomics and Health. Macroeconomicsand health: investing in health for economic development. Geneva: World HealthOrganization, 2001. http://whqlibdoc.who.int/publications/2001/924154550x.pdf . (Accessed Nov 25,2011).

4 WHO: Sustainable health financing, Universal coverage and social health insurance.Geneva 2005. (A58/33)5 UN. African summit on HIV/AIDS, tuberculosis and other related infectiousdiseases: Abuja declaration on HIV/AIDS, tuberculosis, and other infectiousdiseases. New York: United Nations, 2001.http://www.un.org/ga/aids/pdf/abuja_declaration.pdf . (Accessed Nov 25, 2011).66

Farag M, Nandakumar AK, Wallack SS, Gaumer G, Hodgkin D. Does funding fromdonors displace government spending for health in developing countries? HealthAff 2009; 28: 1045-1055. PubMed7 Baldacci E, Clements B, Gupta S, Cui Q. Social spending, human capital, and growth in developing countries. World Dev 2008; 36: 1317-1341. PubMed8 Heller PS. Understanding fiscal space. Washington DC: International Monetary Fund, 2005. https://www.imf.org/external/pubs/ft/pdp/2005/pdp04.pdf . (AccessedNov 25, 2011).

http://whqlibdoc.who.int/publications/2001/924154550x.pdf

http://www.un.org/ga/aids/pdf/abuja_declaration.pdf

http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=Search&term=Health%20Aff%5BJour%5D+AND+28%5BVolume%5D+AND+1045%5Bpage%5D

http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=Search&term=World%20Dev%5BJour%5D+AND+36%5BVolume%5D+AND+1317%5Bpage%5D

https://www.imf.org/external/pubs/ft/pdp/2005/pdp04.pdf

http://whqlibdoc.who.int/publications/2001/924154550x.pdf




https://www.imf.org/external/pubs/ft/pdp/2005/pdp04.pdf



sources of public funds are government and donors usually channeled through specific country

budgets or through health projects.

Questions concerning the mechanisms of financing health services and their affordability for the

poor have been one of the most controversial topics concerning access to health services in East

Africa. User fees, in particular, have been a contentious source of financing public services for

these low-income country settings.9 There are now many studies in a wide variety of developing

countries that have shown that the introduction of user fees or increases in prices can lead to

decreased utilization. [10][11] and that this effect can be larger for the poor. Sometimes the

reduction in service use has been associated with serious conditions. The abolition of user fees

and the introduction of free access to health care in Uganda and community health insurance in

Rwanda have been shown to increase use of curative, preventive, and promotive health services.

[12][13]

Methods

A systematic review of studies on the two most common health financing systems in East Africa

was conducted through an online search. Only “peer-reviewed” studies, i.e., those that were

evaluated by a committee of experts in the field of study before being published were considered

in order to guarantee content quality.A search of all peer-reviewed studies published between

1988 and 2011 on the abolition of user fees, the adoption of free access to health care in Uganda

and community mutual insurance schemes in Rwanda.

Results

Health care funding in Uganda: Free access to health care.

The Health Status

9 James, C.D. et al . 2006. To retain or remove user fees? Reflections on thecurrent debate in low- and middle-income countries. Appl. Health Econ. HealthPolicy 3: 137–153.10 Yoder, R.A. 1989. Are people willing and able to pay for health services? Soc.Sci. Med. 1: 35–42.11 Collins, D. et al. 1996. The fall and rise of cost sharing in Kenya: the impact of

phased implementation. Health Policy Plan. 1: 52–63.12 Burnham, G.M. et al. 2004. Discontinuation of cost sharing in Uganda. Bull.World Health Organization 3: 187–195.13 Nabyonga, J. et al. 2005. Abolition of cost-sharing is pro-poor: evidence fromUganda. Health Policy Plan. 2: 100–108.



Uganda has a population of 30.7 million with an annual growth rate of 3.2%. With a population

density of about 120 persons per km2, Uganda is one of the most densely populated countries in

Sub‐Saharan Africa. 88% of the population lives in rural areas.

Uganda has made progress in improving the health of its citizens. the health sector investments

in both the public and private sectors have yielded modest successes including reduction in

Maternal Mortality Ratio (MMR) from 505 deaths per 100,000 live births in 2001 to 435 deaths

per 100,000 live births in 2006, a decline in the Infant Mortality Rate (IMR) from 89 deaths per

1,000 live births in 2001 to 75 deaths per 1,000 live births in 2006 and an increase in the Life

Expectancy at birth from 46.9 years in 2001 to 51 years in 2006. Despite these successes, health

indicators are still poor and health systems weak. These and other challenges prevent attainment

of key national and international targets.

Health Financing

Utilization

Studies have shown that the abolition of user fees increased the demand of health services by

more people.1415 Utilization of services (especially primary care visits and assisted deliveries)

steadily rose, particularly among the poor.

However, most health facilities got more numbers than they could accommodate. This led long

waiting times, congestion, low time devoted to each patient and a lack of privacy, shortages of drugs and medicines, a deterioration of cleanliness in most health facilities and increase in

workloads hence poor quality services exacerbated by the negative attitudes on the part of health

care workers.

This has slightly improved over the years and public-sector resources are insufficient therefore

those who are able to pay have turned to private services. In Uganda utilization of private health

care services is high but limited to those that can afford the high costs.

14

J Nabyonga et al 2005; Abolition of cost-sharing is pro-poor: evidence from Uganda. HealthPolicy Plan 20: 100–08. http://heapol.oxfordjournals.org/content/20/2/100.full.pdf accessed Nov 30 2011.

15 Xu K, Evans DB, Kadama P, et al.2006 Understanding the impact of the elimination of user fees: utilization and catastrophic health expenditures in Uganda. Soc Sci Med 2006; 62: 866–76.http://www.who.int/entity/health_financing/documents/socscimed_06impact_user_fee_elimination.pdf

http://heapol.oxfordjournals.org/content/20/2/100.full.pdf

http://www.who.int/entity/health_financing/documents/socscimed_06%20impact_user_fee_elimination.pdf







On the other hand, some studies show that some of the transitory problems related to the quality

of services (particularly shortages of medicines), excessive workload for health care workers,

and patients turning to paid services when the free services are overloaded are not related to the

abolition of fees as such.16 Rather, they are due to inadequate implementation; that is when

implementation is precipitous, the required resources poorly planned and not available and

follow-up lacking.

Affordability

Payment of user fees by patients excludes vulnerable populations from access to health services

and places them at risk of further impoverishment. This impedes both the efforts to alleviate

poverty and the attainment of the Millennium Development Goals. Therefore the government of

Uganda adopted free access to health care aimed at improving the relevance, effectiveness and

access of services that people need.

However despite services being free, patients continue to pay certain expenses and some costs

(for example, transportation to health facilities) are not covered by the abolition policies. Some

health care providers still charge unofficial payments. This is at most times too expensive for the

poor for example most women are unable to pay for their deliveries; there is also the problem of

unofficial sale of small supplies such as gloves to women giving birth. Thus, abolition does not

solve all problems related to health care costs.

Sustainability

In Uganda, households constitute a major source of health financing (49%) followed by

donors (35%) and then government (15%). NGOs contribute less than 1%.17 After user fees

were abolished in all government health facilities in March 2001, it led to the loss of revenue

for health facilities that heavily depended on the fees as a significant source of funding. This loss

16Janestic M. Twikirize , Constance O'Brien; 2011 Why Ugandan rural households are opting

to pay community health insurance rather than use the free healthcare services http://onlinelibrary.wiley.com/doi/10.1111/j.1468-2397.2010.00771.x/full

17 WHO: World Health statistics. 2010.

http://onlinelibrary.wiley.com/doi/10.1111/j.1468-2397.2010.00771.x/full








then had to be compensated therefore Ugandan government had to mobilize supplementary

funding to continue adequately facilitating its health budget. However the funding has proved to

be inadequate for the level of activity in the health facilities and therefore most of them have to

run a dual system. This is a system where there is a free wing for those who cannot afford

the payment and a wing for those who can afford. Nearly all private sector facilities still

charge user fees and there is evidence of patients paying under-the counter fees in even in

public institutions.18

Availability

In all public health facilities curative, preventive, rehabilitative and promotive health services are

free, having abolished user fees in 2001. However, user fees in public facilities remain in private

wings of public hospitals. 72% of the households in Uganda live within 5km from a healthfacility (public or Private Not For Profit),19 however utilization is limited due to poor

infrastructure, lack of medicines and other health supplies, shortage of human resource in the

public sector, low salaries, lack of accommodation at health facilities and other factors that

further constrain access to quality service delivery.

Health care financing in Rwanda: Community health insurance

The Health Status

Rwanda is a landlocked country with an estimated population of 9.2 million living within an area

of 26,338 km2 or 350 persons per km2. It is also among the most densely populated countries in

Africa. The population growth rate is currently 2.6% and it is estimated that Rwanda will attain a

population of16 million by 2020 if the population growth rate remains unchanged.

It has however made impressive progress in economic and social development since the 1994

genocide when about 1 million people were massacred, 2 million became refugees, and much of

18 Uganda Bureau of Statistics, National Service Delivery Survey; Uganda Bureau of Statistics, Kampala - Uganda; 2005

19Ministry of Health Uganda 2010: Health Sector Strategic and Investment plan Promoting

People’s Health to Enhance Socio-economic Development 2010/11 – 2014/15http://www.health.go.ug/docs/HSSP_III_2010.pdf

http://www.health.go.ug/docs/HSSP_III_2010.pdf




the country's health facilities were destroyed.20Rwanda is now well on the road to recovery, and

living standards have returned to and even surpassed their pre-1994 levels. Corruption is

decreasing infrastructure has improved, and access to education has greatly.21

The country's impressive economic growth rate (presently 6% per year) has helped to reduce

poverty but income is unequally distributed with a distinct urban to rural divide. 37% of

Rwandans (mostly rural) live in extreme poverty, unable to afford basic foods, and 56·9% live on

less than the national poverty line.22

The country's health status can be shown by health indicators data obtained from the

Demographic and Health Surveys (2005/2006),23 and Rwandan Ministry of Health (2008).24

Where Infant (less1 year) mortality is at 86/1000, Mortality in children less than 5 years is

152/1000 and Maternal mortality is 750/100 000 with 48·6% of births delivered with the

assistance of qualified personnel. HIV prevalence is still high at 3·0% and Malaria leads to40·0% of consultations in health facilities while 60·0% of HIV patients are diagnosed with

tuberculosis. Contraceptive prevalence is 17·0% among married women and 60% of Rwandans

live within 5 km of a health facility.

Rwanda is among the countries with the highest immunization coverage in Africa. And even

with an overall prevalence rate of 3·0% evidence suggests that the rate of HIV/AIDS is

decreasing25

Health Financing: The Mutuelle de Sante, a Community-Based Insurance Scheme

20 Gatete Claver. Rwandan Ambassador to the UK.; Post-genocide reconstruction and Development in Rwanda.Address to the International Development Group of the Scottish Parliament. Edinburgh, Scotland, May 24, 2006.21 World Bank. Governance matters 2007. Worldwide governance indicators. Chart for Rwanda available at

http://info.worldbank.org/governance/wgi2007/sc_chart.asp. (accessed Dec 1, 2011).22 United Nations Development Programme and Government of Rwanda. Turning Vision 2020into reality. From recovery to sustainable human development.National HumanDevelopment Report. United Nations Development Programme and Government of Rwanda,2007.23 Demographic and Health Surveys. Rwanda Demographic and Health Survey 2005— Final report. Calverton: Demographic and Health Surveys, 2006.http://www.measuredhs.com/pubs/pub_details.cfm?ID=594&ctry_id=35&SrchTp=ctry&flag=sur. (Accessed Dec 1, 2011).24 Rwandan Ministry of Health. Health indicators.http://www.moh.gov.rw/health_indicator.html. (accessed Dec 1, 2011)25 UNAIDS. 2008 progress reports submitted by country.http://www.unaids.org/en/CountryResponses/Countries/rwanda.asp.

http://info.worldbank.org/governance/wgi2007/sc_chart.asp



http://www.measuredhs.com/pubs/pub_details.cfm?ID=594&ctry_id=35&SrchTp=ctry&flag=sur


http://www.moh.gov.rw/health_indicator.html

http://www.unaids.org/en/CountryResponses/Countries/rwanda.asp









With the advent of peace, the government began working to restructure health care and to

decentralize management to the most local levels in order to increase utilization rates and

improve overall health.

The government of Rwanda implemented user-fees in 1994 to supplement meager health center

budgets. However, a survey in 2001 found that utilization of primary care had declined to just

23% of the population, and health outcomes were deteriorating, with HIV/AIDS and other

infectious disease burdens on the rise. The decline in utilization and health indicators was

attributed to high user-fees for primary, secondary and tertiary-level care.

Hence the health financing scheme—the Mutuelle de Sante was introduced in 1999 and by 2006

had increased coverage to include nearly all provinces and about 73% of the population.

Previously Rwanda relied on out of pocket financing mostly through the payment of user fees by

patients in order to access health services. Health care was completely funded by patients.

However, most health centers did not have enough competent staff and equipment and 60—80%

of their costs were generated from user fees,26 which became such a crippling burden to the poor

that they turned to traditional medicine as a result.

The scheme is run as an autonomous organization, managed by its members, and helps people to

share the risk of having to pay in full for treatment at village and at district levels. Boosted by

funds from the central government to a cut-off point of $5000, shared between the district and

rural health facilities, the scheme provides basic services—ie, family planning, antenatal care,

consultations, normal and complicated deliveries, basic laboratory examinations, generic drugs,

hospital treatment for malaria, and some tertiary care. In the event of a health disaster, a central

reserve fund has been set up. The administrative costs represent 5—8% of the total revenue. 27

Each member of the insurance scheme contributes 1000 Rwandan Francs ($2) per year and also

pays a 10% fee for each illness episode. Decisions relating to the scheme are made through an

elected village committee that decides who is too poor to pay. The cost of the insurance scheme

for the nominated poor is subsidized by donors. Those with HIV/AIDS (and their families) whoare in a PEPFAR programme are excused from paying contributions. Data from 2004 suggest

26 Oeters R, Habineza C, Peerenboom P. Performance based financing and changing the district health system:

experience from Rwanda. Bull World Health Organ 2006; 84: 884-889.27 Kalk A, Kagubare J, Musango L, et al. Paying for health in two Rwandan provinces: financial flows and

flaws. Trop Med Int Health 2005; 10: 872-878.



that 10% of the population had their fees waived, 28although an estimate in 2005 suggested that

15—30% of the poorest population need to have their fees waived.

The community insurance scheme coverage is impressive and generates substantial risk sharing.

The increase in use of district health facilities means that families should have improved health

and a reduction in the burden of unexpected bills.

Though much has been achieved by the Government of Rwanda since 1994, major challenges

remain. This densely populated country struggles to feed its inhabitants and is situated in an area

of continuing geopolitical instability, with all the associated economic and political uncertainty.

Utilization

Between 2000 and 2007, Rwanda improved financial access for the poor, increased utilization of

health services and reduced out-of-pocket payments for health care. Poor groups’ utilization

increased for all health services. Use of assisted deliveries, for example, increased from 12.1% to

42.7% among the poorest quintile; payments at the point of delivery were also reduced; and

catastrophic expenditures declined.29 Most of these achievements were linked to innovative

health financing policies, particularly the expansion of micro-insurance (‘mutuelles’) and

performance-based financing.

The mutuelles program has been a notable success; perhaps because of its community-based,

grassroots formation and its affordability, the plans have seen high rates of uptake. Out-of-pocket

spending has decreased, and primary care utilization has increased as a result of the program,

which has enjoyed continued and increasing support from the Rwandan government and

involved aid organizations. Rwandans’ widespread participation in the mutual insurance schemes

is unique in the region; according to Laurent Musango of the World Health Organization,

“Rwanda is the only country in sub-Saharan Africa in which 85% of the population participates

in mutual insurance programmes for their health coverage.”

28 Schmidt J-O, Mayindo J, Kalk A. Threshold for health insurance in Rwanda: who should pay how much?

Trop Med Int Health 2006; 11: 1327-1333.

29Claude Sekabaraga, Francois Diop, and Agnes Soucat: Can innovative health financing

policies increase access to MDG-related services? Evidence from Rwanda Health Policy Plan.(2011)



Most remarkably, family planning intake has increased from 3.4% to 27.4%, a result never

previously observed elsewhere.30Utilization of preventive care such as antenatal care (ANC) and

immunization are steadily on an increase among the poor. In 2005, 19% of children under 5

suffering from fever and cough used public health services, compared with 8% in 2000, while

3% made use of private health services in 2005 as compared to 6% in 2000. 31 Traditional healers,

who were the leading source of health care in 2000 when they accounted for 11% of

consultations, were the least consulted by 2005, at 7%. This increase in utilization by children

under 5 has taken place for all socio-economic groups. Among children from the poorest

quintile, the rate of utilization of modern services in the case of fever and cough more than

doubled from 7% to 18%.

Availability

Since 2005, geographical access to health facilities has been improved after the construction and

rehabilitation of 3 new district hospitals and 14 new health centers. Transport capacity has

increased as 71 ambulances (2.5 per district) and 570 motorcycles have been distributed to health

facilities.32 Nevertheless, unmet need remains considerable.

Distance is a significant negative predictor for the utilization of many services, for example

assisted deliveries.” Rwandans’ distance from their nearest providers, a function of the country’s

acute provider shortage, is a further barrier to care that mutuelles cannot solve.

Affordability

Improvement of the accessibility and affordability of health services and the quality of care are

key goals of the Health Sector Strategic Plan for 2005—09.33 However the yearly fee of $2 per

person in the population is still expensive for the rural poor, and insufficient to fund

30 May JF, Kamurase A: Demographic growth and development prospects in Rwanda:implications for the World Bank. Washington, DC: The World Bank; 2009.31 Source: Demographic and Health Surveys (DHS) 2000 and 2005. Ministry of HealthRwanda32 District Health System Strengthening Report, 2008.33 Government of Rwanda. Health sector strategic plan 2005—2009. Ministry of Health(MINISANTE), Kigali, Rwanda



comprehensive basic care,34which necessitates substantial extra central funding and donor

contributions.

According to WHO’s Laurent Musango, former director of the School of Public Health at the

National University of Rwanda, the growth of the mutual health insurance system has been a

great success from the point of view of the affordability of the programme, and the fact that all

corners are covered: “Rwanda is the only country in sub-Saharan Africa in which 85% of the

population participates in mutual insurance programmes for their health coverage,” he says,

adding that coverage is afforded to, “the rich as well as the poor, the young as well the old, the

urban as well as the rural population”. Musango further argues that mutualization has also led to

a reduction in health-care costs, and the increased use of health-care services.

However there have been suggestions that people are being pressured into participating in a

scheme they can ill-afford. “In the poorest regions of Rwanda there are people who are finding itdifficult to pay for the mutuelle and currently there is no system of subsidies or premium-

waiving for these individuals.

Sustainability

Rwanda benefits from a high level of foreign aid. By 2002, the government was spending 8·6%

of its revenue on health, which constituted about a third of Rwanda's spending on health; the

remainder came from international donors or from the population in the form of direct payments

for care. By 2007, government health spending had increased to 9·5% of total public expenditure.

35

34 African Development Bank . Aid, debt relief and development in Africa. AfricanDevelopment Report 2006. Oxford: Oxford University Press, 2006.35 United Nations Development Programme and Government of Rwanda. Turning Vision 2020into reality. From recovery to sustainable human development. National HumanDevelopment Report. United Nations Development Programme and Government of Rwanda,2007.



More than half the health sector funding comes from a proliferation of donors or non-

government organizations.36 Very short donor timescales lead to continual renegotiation because

55% of donor projects end within 1 year. The timing of aid delivery is often unreliable, whereas

other factors, such as inflation or exchange rate variations, can grossly distort the final payout.

Long-term health plans are therefore difficult to make.

Conclusion

Although Uganda's decentralization has been praised, it has introduced major obstacles to service

provision. This is because most of the funds distributed to districts have been earmarked by

donors and the Ministry of Health for specific uses. As a result specific local priorities are often

not addressed. Decentralization has actually widened disparities in the nature and quality of

health services.

Due to the consistent provision of poor quality services in public health facilities there has been a

growth of private clinics which have further promoted socioeconomic inequality within Uganda

and the poor, who make up the majority of the population, have become worse off.

Fixed funding of hospitals by the government has not made it possible to increase staffing or

provide the extra drugs and equipment needed to treat the growing population.

Technical inefficiency among health facilities is so high. Healthcare outputs are more expensive

than they used to be. Thus the reforms have not increased efficiency. Nor have they reduced

reliance on external support. Currently, over 50% of Uganda's health sector spending still comes

from external aid. Uganda should adopt a universal health and welfare framework, which they

must increasingly finance from internal sources.

The Ugandan health sector has shown considerable desire to have Community Health Insurance

(CHI) as an elaborate health sector financing mechanism in Uganda though it still faces lowenrolment only limited to the private not for profit sub-sector, mainly church-related rural

hospitals. It therefore has a lot to learn from Rwanda.

36 United Nations Development Programme and Government of Rwanda. Turning Vision 2020into reality. From recovery to sustainable human development. National HumanDevelopment Report. United Nations Development Programme and Government of Rwanda,2007.



An important lesson learned from the Rwanda experience is that in introducing pro-poor

financing policies there is need to develop a mixed health care financing model, combining

decentralization and performance-based financing with a strategy to pool private spending

through the building of grassroots, community-based micro-insurance.

This paper shows that the route chosen by Rwanda yields promising results which could be

emulated by other low-income countries especially in East Africa in search of models to reduce

financial barriers to health care. Taken together with other reforms such as quality insurance and

improvements in quality control through supervision and additional of contributions from other

insurance schemes and the government, community health insurance is highly successful.

However Rwanda should ultimately reduce its dependency on aid. The Rwandan government

needs to increase health spending from the present level of 9·5% of national budget to the 2001

Abuja target (agreed by African governments) of 15% of national budgets for health, and to align

development to target the most vulnerable in society. Sustainability and the necessary evolution

of the institutional support for the health financing approach of Rwanda should be considered.

‘Mutuelles’ certainly provide a way towards more sustained domestic funding and are an

efficient way to pool private out-of-pocket spending. But there is a need for the government—

with the help of donors—to subsidize the enrolment of the poorest and to ensure the regulation of

the package benefits as well as the provider payments mechanisms in order to ensure equitable

access to quality services.

All in all, Health care financing in Rwanda should be in many ways an inspiration to Uganda and

other East African countries in their efforts in achieving universal health care.

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Documents

Tayebwa Morris Health Issues Paper