By Supreetha Gubbala
KIGALI CITY–Since its drafting in 2001, the community-based health insurance plan known as mutuelles de santé, or more commonly as mutuelles, has been an extremely effective tool for medically insuring the majority of Rwandan citizens in an affordable way.
Currently over 85% of Rwandans partake in the program, the highest percentage in all of sub-saharan Africa. Neighboring countries such as Burundi are looking to Rwanda’s medical insurance miracle.
However, what many have looked past in praising the universal plan is truly what lies ahead for the remaining 15% that are uninsured and the effects of this upon the public healthcare system.
In February of this year former Health Minister, Dr. Richard Sezibera, announced along with many improvements to the programme, a minimum premium price increase.
Prior to this revision, those on the lowest tier of the program were paying a minimum of Rwf. 1000, with the extreme poor often being marginalized and unable to pay even this amount.
The few micro financing NGOs available to help this population could not significantly aid this population, especially with interest rates often as high as 15% on loans given.
Unfortunately, for the extreme poor, the situation just got worse, to be exact. With the minimum now standing at Rwf 3000. By raising this bar, more poor will be unable to join the plan in the upcoming years.
Although the ministry has outlined financial support programmes for this population there, lies the question of how many will be reached by the programmes, and ultimately what will happen to those who simply cannot meet this minimum.
Well more likely than not in Kigali, they will end up at the doors of CHUK, the University Teaching Hospital of Kigali.
CHUK is currently the largest public hospital in Kigali city, and therefore often end up caring for many who are not in the mutuelles program, and cannot provide the premium, simply out of Hippocratic Oath.
Unfortunately, the Hippocratic Oath does not exactly stock the shelves of CHUK.
Dr. Florence Umurangwa working in Ward 6 of CHUK is a post-graduate of surgery.“We don’t wait to see whether or not the patient has mutuelle de santé, because we care for them first,” she explained to Igihe.com”
“It is a bit difficult because some people who couldn’t afford to pay Rwf. 1000, and are now being asked to pay three times that amount. It is hard for the hospital to continue operating because so many people are being treated that do not pay for the new mutuelle de santé.”
“When we go to the stock and take medicine, yet the patient is not paying, it will be a big challenge to the hospital,” she concluded.
With the recent two month extension for those still not updated to the new mutuelles plan, this further means that the new and improved mutuelles services must be open to everyone.
Arthur Asiimwe Director General of Rwanda Health Communication Centre, and the communications officers for the Ministry, however was incredulous at the idea of any potential issues with the new plan.
“As far as the ministry is concerned there are no problems with the new plan, sustainability or supplies of medicine. If this exists, there must be some mismanagement in the hospital,” he told Igihe.com in an interview.
In regards to the population of people who will be left unable to pay, Asiimwe stated confidently that, “All those who are unable to pay for mutuelles will be paid for by the government through the national budget which ultimately comes from taxes.”
In fact, with the new plan Asiimwe deemed it impossible for someone not to be covered and also reassures that any doubts of financial stability of the plan as fruitless.
“In fact, the new plan improves the future sustainability and enrollment in the programme,” he told Igihe.com.
For those on the ground however, it seems the story still is playing out quite differently.
Although the CHUK Hospital Director Dr. Theobard Hatekamana feels the majority of the plan has been beneficial to patients, as well as for everyone in the health sector, he does assert that there are still further issues to be addressed on the health care delivery level to enable sustenance of healthcare to the entire population of Rwanda.
He told Igihe.com more specifically, “We have some issues with people who can’t pay 10% of fees, so the hospital loses this money. Since we cover Rwf. 100,000 for these kind of cases, and there is currently no mechanism for recovery of this money.”
Furthermore, patients hospitalized in Ward 2 of CHUK had mixed reactions toward the new price increase in the mutuelles plan.
Grace Murekatete a 22-year old with swollen limbs on her right side from the Mparanyondo sector has been sick for 16 months. She told Igihe.com, “I have been here in the hospital for only four months. But I have not yet improved. I don’t know what I will do if they increase the price to Rwf 3000 because I am alone here no one is looking after me.”
Despite Asiimwe’s confidence, it seems even those currently hospitalized are not aware that they will be covered by the government if they are unable to pay.
This viewpoint was further confirmed by other patients such as Francoise Yankurije of the Kimindu sectors who explained to Igihe.com, “It’s right, but the problem we are having is capacity. Which results from low income, and we don’t know whether we can manage to buy it [new medical insurance].”
As we leave, CHUK confused about the true effects of the new plan on the rural and poor populations surrounding Kigali city, the receptionist of CHUK alerts us to even larger emerging problem.
The poor that often abuse their health insurance, overusing consultations and supplies, and once again restraining the capacity of the public hospital.
At the end, where to lay the sympathy or blame in this situation remains ambiguous. However, it is clear that the ministry’s rose coloured glasses must be cleared of their fog to see the reality that is occurring on the ground.
As with all economically based plans, the mutuelles is heavily based upon well-calculated predictions. Due to the great praise the plan is currently receiving, it may be easy to forget that these numbers are still predictions and that many holes are still present.
The great overconfidence provided by Asiimwe, although reassuring, does not erase the fact that these issues still exist. In fact, it is probably much better for the Ministry to resolve issues faced by hospitals early on, so as not to face larger issues down the road.
Of course, they don’t have to take my word for it and they probably won’t. But at least, try taking a trip to Ward 2 of CHUK and seeing Grace and Francoise yourself. You may find out more than numbers can tell you.
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