| Community Based Health Insurance (CBHI) was implemented in 1999, to improve health care utilization, particularly for the rural and poor population, and also as an alternative to user fees for health care financing in Rwanda.; Using health facility data, this retrospective longitudinal study assesses the impact of the community based health insurance scheme on utilization of health services and on financial sustainability. Data on health services utilization and cost recovery was collected from all health centers and CBHI schemes in pilot and control health districts from 1998 to 2002, including the period before the introduction of CBHI.; Our findings show that the CBHI significantly improved utilization of health services by increasing visits of members four-fold to 1.74 visits per member and per year, while the non member utilization remained unchanged at 0.4 visits over the same period. Results from multivariate regression models indicate that an increase of one percentage point in CBHI enrollment was associated with a reduction in visits by 0.026 points.; The majority of health mutuelles was not able to cover operating costs from the revenues collected from members. Only 25% of health mutuelles managed to be financially self-sufficient; some of these were even able to generate a substantial and sustainable amount of money for health centers. The study found that in general a minimum membership of 30% of enrollment was required for CBHI to be financially sustainable. Government and donors should play an active role in financially supporting CBHI, especially at their early stage of development, when they are financially and administratively most vulnerable. Good risk management and community participation remain key elements for the success of CBHI in Rwanda. The study provides recommendations for the improvement of performance of CBHI, intended to help policy makers scale it up across the country. |
