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Rwanda

Demonstrating the Potential of Mutuelles to Improve Child Health

Jointly with the Point-of-Service Water Disinfection and Zinc Treatment (POUZN) project, Health Systems 20/20 launched a pilot program February 13, 2008 in Nyagatare District to promote and distribute the Sûr’Eau water product in the Eastern Province of Rwanda, capitalizing on well established community-based health insurance (CBHI or mutuelle de santé) organization channels and membership in the area. The CBHI 2007 enrollment rate in the District of Nyagatare is 81%.

CBHI is believed to be a potentially powerful, but untested, distribution and communications channel to promote and deliver preventative health products like Sûr’Eau, a point-of-use (POU) water disinfection product, to vulnerable populations.

In Rukomo, one of 19 sectors in Nyagatare District and where the official project launch took place, frequent outbreaks of cholera have historically been linked to a lack of potable water. The last outbreak was reported exactly one year ago, as the POUZN project (in collaboration with the Ministry of Health and Population Services International) was initiating the pilot phase of distribution and promotion of Sûr’Eau through CBHI channels.

Unsafe or inadequate supplies of water, and poor hygiene and sanitation are major contributors to diarrheal disease in Rwanda. Only 40% of rural populations and 60% of urban populations have access to safe water sources, and a mere 2.5% of the population has access to piped water in their homes; 27% obtain drinking water from unsafe sources.

The POUZN pilot program aims to:


• Reduce morbidity and mortality due to diarrheal disease in children under five.
• Increase the use of Sûr’Eau point-of-use safe water system (SWS), especially amongst rural and poor populations enrolled in mutuelles. This was achieved through provision of information on the importance of safe water and good hygiene practices for the prevention of diarrhea and the inclusion of Sûr’Eau at a discounted price in the mutuelle de santé system in three pilot districts.
• Contribute to the financial sustainability of mutuelle organizations by increasing membership (through Sûr’Eau promotional sales) and/or reducing mutuelle spending on diarrhea services.

The Sûr’Eau product, available in commercial markets and health centers for 300 RWF (US$0.54), will be offered to CBHI members at the discounted price of 200 RWF. At the pilot launch ceremony, each household that had reenrolled in their mutuelle received a free promotional bottle of Sûr’Eau. Newly trained CBHI committee members in the Nyagatare District are busy promoting and selling Sûr’Eau to CBHI members. This project also includes Rubavu District in the Western province of Rwanda.

This demonstration will generate measurable results to be shared with POU water product suppliers, policymakers, and MHO leaders throughout Africa who might consider replicating the approach.

National Health Accounts

National Health Accounts are a key policy tool for the health sector in Rwanda. In the East and Southern Africa region, Rwanda has pioneered the application of NHA, particularly the subaccount work. Its experience in turn has been incorporated into many international guidelines on implementing subaccounts. Health Systems 20/20 will technically support the Government of Rwanda in its 2006 round of NHA that includes a general estimation along with Malaria and HIV/AIDS subaccounts. The subaccounts data will allow for examination of spending on these priority diseases after the advent of major funding mechanisms such as PEPFAR, Global Fund, and PMI grants.

Comparisons of the 2006 expenditures with baseline data generated by NHA prior to the influx of donor funds will enable Rwanda to answer policy questions such as: Are government funds increasing or decreasing for HIV/AIDS and Malaria following the advent of targeted donor funds? This would help monitor the Global Fund clause of additionality. Other questions that would be addressed are — what is the financial burden on PLWHAs to pay for health care in the environment of this targeted funding- has it lessened or increased? Has the financing of malaria preventive commodities improved since the 2003 estimation, where it was found that households pay for three-quarters of all bed nets?

Efforts are underway to assemble an official NHA governance structure or “constitution,” convene a “financing team” for health accounts that invites other sponsoring agencies (in addition to USAID), and also to involve more local partners to serve on the technical team such as the School of Public Health, the Institute of Statistics, private firms, and consultants. This will complement other Mission-funded bilateral work that is focused on the long-term institutionalization of health accounts, particularly once decentralization of the government is completed. The activity works to address the government’s desire to achieve greater evidence-based policymaking and transparency – not just from the public sector but also from other major health stakeholders, such as donors and NGOs.