Sharing the burden of sickness: mutual health insurance in Rwanda.

Mandatory participation in mutual health insurance schemes and public subsidies for the poor have led to considerable improvement in public health and health care in Rwanda, but even at US$ 2 a year, the price for some members of the population remains prohibitively high. Aimable Twahirwa reports from Kigali. [ILLUSTRATION OMITTED] Rwanda's Ministry of Health plans, to boost community participation in the financing of health-care services in the 1980s and 1990s, were hampered in the immediate aftermath of the war and genocide of 1994. But since those dark days, Rwandan authorities have engaged in an effort to strengthen communities' role in managing and co-financing health-care provision. One of the ways it has done this is through mutual health insurance schemes, known in Rwanda as mutuelles de sante or mutuelles. Mutuelles were reinitiated as pilot projects in Rwanda in 1999 and uptake accelerated sharply in 2004-2005 with the adoption of a national policy on mutuelles and a roll-out of the schemes with the financial and technical support of development partners. As of April this year, every Rwandan is obliged by law to have some form of health insurance. There are currently several health insurance programmes in Rwanda targeting specific groups of the population. However, the biggest in terms of membership is the mutuelles scheme, participation in which is organized on a per household basis, with an annual payment of 1000 Rwandan francs (US$ 2) per family member. [ILLUSTRATION OMITTED] For 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 comers 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 argues that mutualization has also led to a reduction in health-care costs, and the increased use of healthcare services. Taken together with other reforms such as the decentralization of health-care services, performance-based financing, quality insurance and improvements in quality control through supervision, Musango believes mutualization has made a significant contribution to the well-being of the population. But 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 it difficult to pay for the mutuelle, but the government is doing a lot to help," says Didi Bertrand Farmer, director of community health and social development with Partners in Health, a nongovernmental organization that is working in eastern Rwanda. …