Geneva Health Forum Archive

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Community-health insurance in Rwanda: equity, quality and financial viability.

Author(s) Bonaventure Savadogo1, Joelle Shwarz2, Manfred Zahorka3, Florence Secula4.
Affiliation(s) Swiss Center for International Health, Swiss Tropical and Public Health Institution, Democratic Republic Congo, Switzerland, Swiss Center for International Health, Swiss Tropical and Public Health Institution, Basel, Switzerland, Swiss Center for International Health, Swiss Tropical and Public Health Institution, Basel, Switzerland, Swiss Center for International Health, Swiss Tropical and Public Health Institution, Basel,Switzerland, 5.
Country - ies of focus Rwanda
Relevant to the conference tracks Advocacy and Communication
Summary Rwanda has launched three prominent reforms in the field of health financing since 2000, which have shown significant results in increasing both the supply of and access to services. The fiscal decentralisation, the community-health insurance (mutuelles de santé), and the performance-based financing (PBF) have largely contributed to the fact that Rwanda is on good track in reaching the targeted health MDGs.
Funded by the Swiss Cooperation and Development Office since 2002, the Programme de Santa Publique – PSP (Public Health Programme) aims at strengthening the health system in two districts (Karongi and Rutsiro) in the Western Province.
What challenges does your project address and why is it of importance? In the context of Rwanda, one of the main challenges is to reconcile the necessity to mobilise resources to ensure the financial viability of health services with a context of wide-spread poverty.
In the two districts of intervention, the project supported the setting-up of pilot mutuelles by providing management training for the staff of the mutuelle sections (sections are located within each health facility) and the mutuelle directions (at district level). This was done  by providing tools, registrars and equipment and by monitoring the performances of sections and directions, as well as the financial flow between them and the health facilities.
Early on, the project sought to include the dimensions of equity within the scheme and this was enacted by financially supporting the administrative districts to set-up the identification process of indigent people, and in turn by subsidising adherence fees and co-payments to health services utilisation via the mutuelle sections. This reduced health access barriers for this group. However, as close to 1/4th of the population is identified as indigent, a sustainable equity mechanism in covering the costs of the scheme (and not by external subsidising) is yet to be found.
How have you addressed these challenges? Do you see a solution? Though previously scaled upon the basis of the socioeconomic status of households, the adherence fee has been fixed since 2007. This scheme does not allow a cross-subsidising of costs across the population. The PSP has supported a community solidarity mechanism for such cross-subsidising in each district. The Ikimana system is the grouping of 25 to 50 households into community associations where members motivate one another to pay their fees and assist members that are less well-off. This system has substantially raised the coverage of mutuelle in the two districts and shown that commitment and solidarity can be fostered amongst small groups who share a common reality. Policy dialogue has been conducted for the project about the gradual withdrawal of the subsidisation of indigent people in favour of other sources of funding, such as the Ikimana system. However, the taking-up of those groups by Ikimana has to be monitored in order to ensure that people are not left behind.Support of quality of care is challenging as because from the beginning the quality has always been relatively low due to the limited resources (financial, human and infrastructure) and the remoteness of some facilities. The concomitant reform introduced, Performance-based Financing (PBF), is expected to correct the negative effects of the utilisation increase by motiving the performance of the health staff in the facilities through incentives. However, most incentivised indicators of the PBF scheme are quantitative rather than qualitative. Ensuring a good quality of care is of primary importance to maintain the high adherence rate and the satisfaction of the insured. The PSP has supported the establishment of a monitoring system of quality of care (structure, process and results). It has also supported the conduct of client satisfaction surveys, which have shown fairly good levels of satisfaction. The project has also repeatedly conducted quality of care assessment in the intervention zone to evaluate the situation.
How do you know whether you have made a difference? The PSP cannot claim to have made a difference on its own. The programme aims at supporting national policies and strategies. It has been observed in the two districts of intervention that the mutuelle adherence uptake is observed to be parallel with a marked increase in the utilisation rate, as well as an increase in the proportion of the indigent people within the general population that benefit from a free adherence card. The implementation of the mutuelle has not followed an experimental design, therefore establishing causality in the positive developments is not possible.
The PSP supported Karongi district was declared a model district in 2010, and has received a visit from the central level Mutuelles Technical Working Group. Other districts have subsequently visited Karongi’s direction and sections, to learn from their organisation and experiences. The mutuelle sections in the two districts are well organised, equipped and coordinated (at the national level), and they manage to cover the costs for the primary level.
At the national level, studies have shown that catastrophic expenditures have declined for all groups of the population. The approach has revealed not to be pro-poor, but neither pro-rich (Lu et al, 2012). In 2010, the government introduced a new measure to induce an increase in the utilisation by the poorest sections of the population by reducing the co-payments for such groups.
Have you or the project mobilized others and if so, who, why and how? Firstly, the staff from the mutuelle sections and directions have been mobilised through the project. They have been trained, equipment and tools have been provided, and their performance has been monitored in order to provide tailored support. The support in their establishment as federations has also helped the coordination and organisation of their services in efficient ways. Ensuring the smooth functioning of mutuelle sections was a condition for the health facilities to remain financially viable.  The project is structured so that the health services can be reimbursed by the sections of the health facilities. Delays in reimbursing the costs, as seen at the level of hospitals, can jeopardise the capacities of the health facilities.
It is undeniable that the observed success of the mutuelles in Rwanda is linked to the national political context. The government has declared adherence to a mutuelle as mandatory, and strong political will, with support from donors,  has pooled the funds to ensure the establishment of the scheme and its financial viability in the first years. Setting performance targets for the local administration that included the increase in the adherence to mutuelles has also contributed to a very high coverage rate. Furthermore, Rwanda after 1994 has benefited from large external funding (in 2009, external funding represent 46% of the total health expenditures), which has facilitated the scheme's implementation.
When your donor funding runs out how will your idea continue to live? Most of the support in implementing the mutuelle scheme in the two districts has been enacted in a way that the districts have substantial control. Direct financial support has been phased out between 2002 and 2013, and today the fees for indigent people are partially covered by communities through the Ikimana system. The district mutuelles are financially supported at the central level, with funds from the government and it’s partners such as the Global Fund.
The remaining main challenge is quality assurance. Continuous support is needed to ensure that the district level supervises and monitors the quality of care in the facilities. Supervision and monitoring of the financial flows are needed from the central level down to the district (directions) and the facilities (sections) to ensure the scheme's viablity.
The challenge for the mutuelle scheme is financial sustainability.  Political instability in the region, mainly in neighbouring DRC where Rwanda plays a role, raises the concern of the international community and external funding may become fragile. Currently the financial viability of the system relies upon external funding, and if it diminished, financing the scheme at the secondary and tertiary levels could be at stake.

Breast cancer screening for everyone.

Author(s) Patrick Brander1, Marius Besson2, Béatrice Arzel3
Affiliation(s) 1Service de médecine de premier recours, University Hospital Geneva, Geneva, Switzerland, 2Service de médecine de premier recours, University Hospital Geneva, Geneva, Switzerland, 3Fondation genevoise de dépistage du cancer du sein, Fondation genevoise de dépistage du cancer du sein, Geneva, Switzerland.
Country - ies of focus Switzerland
Relevant to the conference tracks Social Determinants and Human Rights
Summary As breast cancer is the most prevalent cancer in women, a screening program has been developed in the canton of Geneva since 1999. The University Hospital’s CAMSCO service (Consultation ambulatoire mobile de soins Communautaires) is devoted to people living in precarious conditions which includes mainly undocumented migrants and women working in the domestic’s fields, those without health insurance, and inclusive of those aged over 50 years old. Since 2006 a collaboration between the cantonal breast cancer screening program and the CAMSCO was developed allowing for these undocumented women to have access to information in their own language and also mammography screening. Since 2008 280 women have had mammography screening.
What challenges does your project address and why is it of importance? Access to health systems for undocumented migrants in Switzerland is difficult and differs greatly between cantons. Some swiss cantons have organized a system to allow these people to have access to primary care and preventive medicine. Breast cancer screening is recommended by international guidelines and should, as such, be offered to every women between 50 and 74 years old.
How have you addressed these challenges? Do you see a solution? A collaboration between the CAMSCO and the “Geneva Breast Screening program” has been developed since 2006, allowing the undocumented women between 50 and 74 years old and living in Geneva to be offered mammography screening. This program is financially supported by public funds and the mammography itself is paid 90% by patients’ insurance with a 10% (19.15.-swiss francs) contribution by the patient. The exception is disadvantaged women, for whom this amount is supported by screening program through private funds.
How do you know whether you have made a difference? Due to this collaboration 280 migrants women without health insurance had access to mammography screening. Their number has been about stable since 2010 averaging 65 for each year.
Have you or the project mobilized others and if so, who, why and how? The project has mobilized the Geneva hospital gynecology service as they do the mammography and assure that any anomaly is investigated and treated as needed. Medical doctors working in the Geneva hospital primary care service are also encouraged to plan mammography for their undocumented migrants as indicated
When your donor funding runs out how will your idea continue to live? Our collaboration may be funded by public funds, as it is already in part. Otherwise, it could only be funded by patients themselves, which is impossible.

Health Insurance for Rural Population – the Re-Organisation of Community Health Funds in Tanzania.

Author(s) Manfred Stoermer1, Manoris Meshack2, Ralf Radermacher3, Fiona Chilunda4, Yann Gelister5
Affiliation(s) 1Swiss Centre for International Health, Swiss Tropical and Public Health Institute, Basel, Switzerland, 2Health Promotion and System Strengthening Project, Swiss Tropical and Public Health Institute, Dodoma, Tanzania, 3Micro Insurance Academy, Micro Insurance Academy, Bonn, Germany, 4Health Promotion and System Strengthening Project, Swiss Tropical and Public Health Institute, Dodoma,Tanzania, 5Micro Insurance Academy, Micro Insurance Academy, Bonn, Germany.
Country - ies of focus Tanzania
Relevant to the conference tracks Advocacy and Communication
Summary Community Health Funds (CHF) in Tanzania face problems in design, enrolment, servicing, and sustainability. Since 2011 the Swiss Government funded “Health Promotion and System Strengthening Project”, HPSS, has undertaken a re-design of the CHF in the 7 districts of Dodoma Region. The “CHF Iliyoboreshwa” (improved CHF) displays a purchaser-provider split, a strong Insurance Management Information System (IMIS), active enrolment at village level, portability of membership, and cross-district reimbursement. After one year of operation (August 2013), the “new CHF” has enrolled 408,000 persons, equivalent to 20% of the population, which is well above the national average of 7.9% of the previous CHF system.
What challenges does your project address and why is it of importance? Community Health Funds (CHF) in Tanzania aims at building a risk pooling mechanism for rural populations and informal sector communities. Implementing the “Health Promotion and System Strengthening” (HPSS) project, the Swiss Tropical and Public Health Institute (Swiss TPH) and their partner organisation Micro Insurance Academy (MIA) carried out an analysis which revealed structural problems with respect to design, enrolment, servicing, and sustainability. On request of the Ministry of Health and Social Welfare (MoHSW) the Swiss Agency for Development and Cooperation (SDC) supports the development of structural changes for CHF within the HPSS project.
CHF design problems arise from the a lack of separation between purchaser and provider roles, the CHF being operated by the District Medical Office. CHF coordinators work part-time, and benefit packages are inappropriate. The lack of a data management system results in data being not readily available for monitoring purposes, re-enrolment, or claiming of “matching funds”. Passive enrolment at health facilities is a weak enrolment mechanism. Problems of servicing include the missing linkage between provision of health care and reimbursement. Funds are spent at a district level regardless of the services provided by health facilities.
How have you addressed these challenges? Do you see a solution? The HPSS project has systematically addressed the problems identified by developing a re-organised Community Health Fund, the “CHF Iliyoboreshwa” (“Improved CHF). This model is being implemented in the 7 district and municipal councils of Dodoma Region since 2012.
The core of the re-design is the new Insurance Management Information System (IMIS) which provides the Community Health Funds with a comprehensive solution for data management, including membership enrolment through mobile phone technology, contribution management, claims processing and payment, as well as member feedback collection.
The IT system allows online and offline operation. Each family member is now getting their own CHF card, when it used to be one card per family, and this individual card allows easier access to health services. One of the major problems up to now has been the limitation of access to only one health facility in the home place of members. With the new system this limitation is overcome. The new CHF card can be used in any public health facility across the districts of Dodoma Region, including hospitals. Each health facility attached to the CHF network received a smart phone which is readily available in Tanzania and is able to connect to the data base to instantly download member photos from the IT system for easy identification of the member.
The same mobile phones are also used to enrol people into the CHF by taking their photo and uploading them to the IMIS database. This also works in rural areas with limited internet access through backup provisions for offline data management. Enrolment Officers are now placed at the community level to enrol members in a quick and easy procedure using the CHF phone. The new system also allows health facilities a fast and simple processing of the claims they submit after treating CHF patients. This is expected to strengthen the financial capacities of the health services. The new CHF system, once further tested and proven to be effective in Dodoma Region, is designed in a way that it can easily be rolled out nationwide, with the central server already being in place. The investment into developing the CHF Iliyoboreshwa is therefore hoped to benefit not only Dodoma Region, but the whole population of Tanzania.
How do you know whether you have made a difference? The re-organized CHF is a scheme operated fully by the Local Government Authorities themselves. The CHF offices are in place, and all cadres involved in the system have been trained. More than 600 Enrolment Officers have been identified by the communities and are enrolling CHF members against a moderate commission.
At the end of August 2013, after barely one year of operation, the “CHF Iliyoboreshwa” (together with remaining “old members” of the previous system”) had enrolled 68,027 households out of 347,265 households in Dodoma Region. Approximately 400,000 persons are now covered with health insurance, out of a population of 2,000,000. After not even a year of operation, the new health insurance system already reaches a coverage of approximately 20%, far above the national average of 7.9% with the “previous” CHF system, with some districts standing out with as much as 33%. This is a remarkable success already, and enrolment figures are still increasing.
Further, the members of the re-organized CHF now have access to each of the 250 health facilities being presently associated to the CHF network. Access to hospital level health care has become possible for the CHF members, even outside their home district. Cross-district reimbursement of claims directly to health facilities has been introduced, and for the first time health facilities start seeing tangible benefits for treating CHF members.
Have you or the project mobilized others and if so, who, why and how? The development of the reformed CHF “CHF Iliyoboreshwa” has been undertaken in close coordination and cooperation with the Government of Tanzania both at national as well as at regional and district / municipal level, and important stakeholders have been involved. The development of the “Insurance Management Information System” (IMIS), for instance, has been accompanied by a technical advisory group composed of the MoHSW, the Prime Minister's Office, Regional Administration and Local Government (PMO-RALG), and the National Health Insurance Fund (NHIF). The project activities are governed by a Regional Advisory Board chaired by the Regional Administrative Secretary (RAS), with the highest level representation of the district and municipal councils. The reforms are very actively pursued by the district and municipal councils responsible for the CHF structures, while the HPSS project limits itself to the provision of technical advice and expertise.
When your donor funding runs out how will your idea continue to live? The health insurance structures developed with support of the HPSS project are fully integrated in the structures of the Local Government Authorities. A “CHF Board” answerable to the district / municipal council oversees the operations of the CHF Iliyoboreshwa. The CHF office is staffed by personnel fully paid by the district / municipal council. The central CHF server will shortly be transferred to the premises of the Prime Minister's Office, Regional Administration and Local Government (PMO-RALG), who will take charge of operating the IT system on behalf of the district / municipal councils, as they do with other software (e.g. accounting software EPICOR). The central server is technically fully prepared to add on any further district and municipality in Tanzania depending on the decisions of the government. A decision on possible roll-out of the CHF Iliyoboreshwa is presently being discussed in the Ministry of Health and Social Welfare and in the “Interministerial Steering Committee” for the preparation of the new health financing strategy.

Patients on the Move

Author(s): M. M. Kingma1
Affiliation(s): 1International Council of Nurses, Geneva, Switzerland
Key messages:

1 – Globalisation is affecting the health sector - expanding the health services provider market as well as the health professional labour market.
2 – Health tourism tends to introduce or facilitate the growth of the private sector health industry. This may result in intranational tensions and competing vested interests.
3 – Health tourism needs to be monitored and evaluated in terms of population access to care, service stan- dards, and local labour conditions.

Summary (max 100 words):

The international migration of health professionals has increasingly been on the political agenda, especially in the context of widespread shortages of employed care providers. Globalisation is a reality and recognised characteristic of today’s world. Health systems are faced with the challenge of increasing demands on their services and a relative decrease in funding. Privatisation in the health sector is increasing, including in areas known as health tourism – patients seeking care outside their country of residence. Health facilities are being established providing medical and surgical interventions, as well as health promotion services (e.g. massage, relaxation therapy) essentially for foreign patients. While recognised as an income generating initiative in many cases, the introduction of health tourism may distort the public/private mix within the national economy, increase the intranational “migration” of health professionals from the public to the private sector, influence educational and practice standards, challenge professional regulatory bodies, place new demands on health insurance systems and create wide disparities among the pay and working conditions on offer locally. Health tourism may also help retain health professionals by providing better employment and professional development opportunities, improve working conditions, advance health care, harmonize standards of service delivery, and disseminate evidence-based practice.

Conclusion (max 400 words):

Health tourism is on the increase and predicted to be a growth industry in the years to come. Its introduction influences aspects far beyond health care, including the national economy, education, regulation, access to and quality of public sector services, insurance companies’ sustainability, the tourist industry and people’s expectations. Health tourism needs to be monitored and evaluated as a social phenomenon as well as studied in terms of impact on the accessibility and quality of care, patient outcomes, labour market and health personnel behaviours.

Health Financing Options for Himachal Pradesh: Agenda for Health Policy Reforms

Author(s): R. N. Batta1
Affiliation(s): 1Special Secretary Planning, Government of Himachal Pradesh, Shimla, India
Keywords: Health policy; health financing; social health insurance

Health services in Himachal Pradesh are largely in the public domain with government being the key provider of health services. Even though the state has excellent record in terms of some health indicators, there are serious concerns of access, equity, and quality of service. In the absence of health insurance, people living below the poverty line meet their healthcare needs through direct out-of-pocket expenditure. Things are much worse in remote and hilly regions where neither government nor private facilities are available. Where accessibility is not a constraint, the primary health centres are generally found to be dysfunctional or providers of low quality services.


This paper aims at (a) evaluating the current health policy regime and finding out its effectiveness to handle healthcare issues (b) finding out alternate health financing options and their relevance for Himachal Pradesh (c) the current gaps in human resource availability and the possible public private partnership options to meet the gaps. Primary data on use of health facilities at selected rural and urban health centres is collected from the records maintained at the health centres. For information on position of Himachal Pradesh with regard to selected health indicators, report of the National Family Health Survey (NFH3) 2005-06 is used. The availability of resources at the Primary Health Centre (PHC) level is examined by conducting interviews of the health functionaries at urban centres and remote localities. A thorough review of literature on health studies in the state and other parts of the country, the experience of various states in India on alternate options of health financing, and examination of possible public private partnership options helped in firming up recommendations for policy changes.


Major findings of the study are: (1) There is a serious problem of public under funding of healthcare. As a result, even though health services are supposed to be available free, people have to pay for purchase of medicine and diagnostic services. There are concerns in terms of equity of access. With tertiary healthcare consuming 70% of resources and being used mostly by rich people, civil servants and the formal sector workers; poor are deprived of even the primary healthcare services. (2) While all positions in urban health centres are filled up, more than 50% of health centres in rural areas are without doctors and technicians. Besides, there is a serious problem of mismatch of health professionals and diagnostic hardware. While 42% centres have hardware facilities without technicians, 30% centres have technicians without diagnostic facilities. Even urban centres have problems in meeting recurring expenses making the availability of services erratic. (3) Attempts to mobilize funds through the introduction of user charges though showed initial good results, however, in the absence of adequate participatory arrangement in management of funds, absence of transparency in expenditure and inability to tap the willingness to pay, resulted in withdrawal of the policy. (4) Health policy has no provision to attract private investment in the healthcare and health education. The policy of offering free tertiary care services even to the rich and those having capacity to pay presents a strong disincentive for the private investors. Policy of providing unlimited payments for OPD and inpatient services to the civil servants in public and private hospitals has created serious problems of moral hazard.

Lessons learned:

Since health services cannot survive and deliver efficiently unless appropriate cost recovery mechanisms are in place, health policy has to aim at developing suitable environment that enables cost recovery while simultaneously protecting the poor through tax funded social health insurance. Such a policy could promote public private participation in health provision thus filling the gap due to shortage of government resources.

Creation of Mutual Health Insurance in Madagascar: Providing Access to Healthcare in Marginalized Com- munities

Author(s): A. E. Sturm1, R. R. R. Ramanankavana*1, C. C. R. Rakatomanga1
Affiliation(s): 1International Association of Charities, Louvain la Neuve, Belgium

Madagascar, mutual health insurance system, single mothers, solidarity, participation, responsibility, self-help, prevention, health education.


In spite of some limited progress, Madagascar is one of the poorest countries and especially single mothers and their children do not participate in the economic growth. When left alone or becoming widow, due to cultural tradition, they have to give back their properties to the former husband’s family, making them homeless. Lacking pensions, maintenance or income support, single mothers and their children must then live in the streets and are depending of begging or informal and irregular work. Consequently, due to malnutrition, insane housing and frequent birth giving, their health is bad. As in Madagascar no health insurance system exists, single mothers and their children cannot be treated. To improve this terrible situation, Irak’I MD Vincent de Paul created a Mutual Health Insurance for single mothers and their children in the town of Manakara. Irak’I MD Vincent de Paul was founded by five volunteer women in 1988 to improve living conditions of single mothers and children living in poverty, to whom they offered training, birth registration, micro credits, community housing programmes, healthcare, schooling and school kitchen.


Our programme gives single mothers and their children access to healthcare, provides information on prevention and raises their sense of self-reliability according to the Millennium Development Goals. To reach this aim, professionals train AIC volunteers which then offer for the first time a regular training in their townships for health, hygiene, prevention of AIDS and abortion, family planning and breastfeeding. For the youth, they additionally offer a new programme: education for life and pre-school children are educated in hygiene and prevention of infections. Following the training, all mothers are invited to become members of the Mutual Health insurance by paying a small fee. Members and their children are then registered and their health status and need is recorded. In case of illness they can address the AIC social centre for free medicaments and ask for free medical care from a doctor or a midwife, both AIC volunteers. The Mutual Health Insurance also provides hospital care. The AIC, founder of the Mutual Health insurance, offers to the members housing and professional training programmes, and provides access to micro credits. The AIC organizes also vaccination and anti-malaria programmes, distribution of vitamin A and participates in governmental health campaigns. The Insurance is financed by the fees of its members, by a micro credit, donations from a Belgian NGO and twinning with AIC France.


Given an affordable healthcare system, the members can now seek medical care, thus achieving an improved and sustained health status including vaccination. Consequently, this programme allows the members to follow professional or school activities more regularly. Next to the improvement of the health status, this programme generates solidarity and confidence among the members. The requirement to pay the fees regularly even in the absence of sickness is a new idea to them and makes the members responsible not only for themselves and their children but also for the community. Given the new perspective for a better life, the members actively participate in the acquisition and training of new members.

Lessons learned:

This programme converts the ideas of the first social insurance systems in Europe to societies in developing countries and helps to provide access of poor and marginalized humans to a basic healthcare. The active participation of the poor and their feeling of solidarity, mutual responsibility and confidence are crucial for the functioning of the mutual health insurance system in a very poor society still suffering from the consequences of a war. Once being established, the final aim of the project will be to transmit the mutual health insurance system to other developing countries and thus spread the idea of solidarity and mutuality.

Can Micro Health Insurance Raise the Health Status of Its Participants?

Author(s): S. A. Hamid*1, J. Roberts1, P. Mosley1
Affiliation(s): 1Economics, University of Sheffield, UK
Keywords: Micro-credit, micro health insurance, health awareness, health status

A Micro Health Insurance (MHI) scheme, a risk pooling and card based prepaid insurance mechanism, was added as a complement to micro-credit programmes by some Micro Finance Institutions (MFIs) in Bangladesh in the late 1990s and early 2000s in order to protect their clients from health risk. Under MHI scheme, some organizations (Grameen Bank, BRAC) provide both preventive and curative care. To date there is little evidence whether MHI raises health awareness or health status of the micro-credit members.


This paper examines the impact of MHI on health awareness and health status of micro-credit members in the rural areas in Bangladesh.


The paper is based on primary data collected from three areas of Grameen Bank: (I) where MHI has been operated for at least five years, (II) where MHI has been placed recently, (III) where MHI has not yet been placed, but will be placed soon; and two areas of the Society for Social Services (SSS): (i) an area with MHI and (ii) an area with no MHI. Two villages were randomly selected from each area and then two micro-credit centres were randomly selected from each village. Finally, all the current female micro-credit members (micro-entrepreneurs) of the selected loan centres were surveyed using a set of structured questionnaires. A total of 329 female micro-entrepreneurs were interviewed from Grameen Bank areas (136, 85 and 108 from area I, II, and III respectively) and 136 from SSS (70 and 66 from area I and II respectively). The overall response rate was 74%. Health awareness was measured on the basis of knowledge about some general health issues (i.e., treatment of diarrhoea, signs of pneumonia, and sources of vitamin A). An index was constructed to measure the health awareness score of the micro-entrepreneurs giving the same weight to each of the three questions and the same weight for each of the answers to each question. Health status was measured based on (i) self-reported health on a 5-point scale (excellent, good, fair, poor, and very poor) asking how good your health was compared to people of your own age; and (ii) activities of daily livings (ADLs). Appropriate regression techniques (including the detection of and controlling for endogeneity) were applied to analyse health status and health awareness using a broad set of conditioning variables and focusing on the role MHI. The mean difference in health awareness score between area I and area II, and area I and area III was positive and significant in Grameen Bank. Between area II and area III it was found positive, but not significant. The regression results for the Grameen Bank confirm that MHI had a significant positive impact on health awareness as well as health status. In the case of SSS MHI had positive, but insignificant impact on health awareness and health status on the micro-entrepreneurs.

Lessons learned:

MHI scheme of Grameen Bank has the significant influence on raising the health awareness and health status of the micro-entrepreneurs.

The Interrelationship between Community Health Insurance and Quality of Care

Author(s): W. Soors*1, A. Boré2, O. Ouattara2, P. Ndiaye1, B. Criel1
Affiliation(s): 1Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium, 2Union Technique de la Mutualité malienne, Bamako, Mali
Keywords: Community health insurance, primary care services, quality of care, empowerment, Sub-Saharan Africa

Perceived quality of care is key to service utilisation and to community health insurance (CHI) enrolment. In Mali, both service utilisation and CHI enrolment are typically low. Whereas the possible positive effects of CHI on service utilisation are well documented, little is known on whether and how CHI might also influence quality of care.


To bridge the knowledge gap on the interrelationship between CHI and quality of care, ITM and UTM engaged in a comprehensive effort to investigate the effects of CHI on quality of care at first-line level in Mali, West Africa. The study addresses these effects through a series of case studies in urban and rural healthcare facilities where a functioning CHI scheme is present. For this purpose, ITM developed a conceptual framework, which distinguishes between favourable and adverse quality-related possible effects of CHI at both supply and demand side of healthcare. A team of sociologists and public health experts collected data during two weeks per site. Tools and methods involved comprise exit interviews and focus group discussions (with healthcare users, both CHI members and non-members), in-depth interviews (with healthcare users as well as other actors), document analysis and archival research (including analysis of pre-existing meeting records and case-mix and prescription analysis from routine data), discourse analysis and observational research (including ethnographic data collection and systematised observation of clinical consultations) and triangulation (corresponding to the complementary sources, methods and researchers). Analysis is in full process. This presentation focuses on findings and preliminary lessons from two rural case studies (Cinzana and Nongon), centred on the opinions voiced by healthcare users as a proxy for perceived quality.


In both Cinzana and Nongon, users express their dissatisfaction with waiting times, opening hours and staff attitude. CHI members have the most outspoken opinion. Demand for change in staff attitude is the most frequent topic found in the records of CHI-provider exchanges. Document analysis so far identifies changes in relational aspects of care, but no influence of CHI beyond giving voice to discontents. Users in Cinzana and Nongon have a different opinion on biomedical aspects of quality. In Cinzana, most users are satisfied with provider skills and drug prescription, but dissatisfied with drug procurement. In Nongon, users disagree on provider skills and drug prescription, but are highly satisfied with drug procurement. CHI members and non-members have no different opinion. The perception of biomedical aspects by significant parts of the communities differs strikingly from the perception of the same by public health experts. A CHI-channelled demand for change in biomedical aspects of care is not documented. None of the CHI schemes has a medical adviser at hand. Analysis so far does not identify changes in biomedical aspects of care, related to CHI as such. In Cinzana, users see CHI as lever to quality improvement, even if restricted to change in staff attitude. In Nongon, users see CHI as lever to quality improvement, gender balance and social cohesion, even in adverse economic times.

Lessons learned: The cases of Cinzana and Nongon suggest a positive but limited influence of CHI on the relational aspects of quality of care. In the given context, the lever function of CHI seems at least as related to the development of social capital as to the pooling of monetary capital. Lack of informed users might possibly explain the discrepancy between the users’ and the researchers’ perception of biomedical aspects of quality of care. A CHI support and capacity gap – as illustrated by the absence of a medical adviser – might possibly explain the lack of influence of CHI on biomedical aspects of quality of care. The latter hypotheses need further analysis.

Health Insurance in Western Uganda

Author(s): P. R. M. Mommers1
Affiliation(s): 1Sector Health and Wellbeing, Cordaid, The Hague, The Netherlands
Keywords: Health insurance, Western Uganda

In Uganda Cordaid, a Dutch development organisation, is working on different health issues in order to improve the access to healthcare for the population. One of the methods is through health insurance. In Uganda a lot of Health Insurance schemes which are mostly hospital or community based, are operational. Till 2001 they were supported by other international organisations but because of the government’s decision to stop the user fees in the public sector, subsidies were brought to a halt which caused an immense decrease in membership numbers. The Private not for Profit Sector still relies on user fees (30% of total income) and the Health Insurance schemes continued to function but financial sustainability was a big problem as were under-utilization and high out of pocket expenditure.


Cordaid has been involved with Community Health Insurance in Western Uganda since 2000 through small financial support. In order to improve the health situation for the population, Cordaid is currently working with 4 hospital based schemes on improving scheme design (e.g. addressing adverse selection, provider payment, premiums, information),linkage of hospital schemes to lower level units, involvement at regional and national level. The specific objectives are: (1) Improving access to healthcare; (2) Inclusion of poor and vulnerable groups; (3) Protection against catastrophic Out of Pocket Expenditure; (4) Empower demand side of the health system; (5) Integration of first and second line healthcare (strengthen referral system); (6) Stable income source for health providers; (7) Capacity building of staff members. Cordaid’s approach is through gathering data to measure results and for decision making on improved design, training components, (financial) purchaser-provider split, gradual inclusion of lower level units and subsidies which gradual decrease from 70% in 2007 to 35% in 2010.


In the first year of implementation, through training, facilitated by the Institute of Tropical Medicine in Antwerp, a new scheme design has been elaborated. To succeed in this, a baseline survey (CHI schemes, hospitals, community representatives, household survey) has been performed together with the Uganda Martyrs’ University and ITM. The data have been used not only to decide on the package content but also the height of the premiums, all in concordance with the community. One year after the programme started, a significant increase in membership numbers has been signalled. Also all hospitals have included a lower level health unit to increase the coverage area and have split the financial dependence between purchaser (scheme) and provider (hospital). The inclusion of the poorest will be subject for 2008.

Lessons learned: Training and surveys take a lot of time, so implementation of new designs can not be done in 3 months.

Use of Private Sector and Out-of-Pocket Payment for Antibiotics In Spite of a Policy Granting Formal Access to Free Healthcare and Drugs for Children in a Poor Area of Peru

Author(s): C. Kristiansson*1, M. Petzold2, H. Rodriguez3, E. Gotuzzo4, L. Pacheco5, A. Bartoloni6, A. Bechini7, M. Larsson1, G. Tomson1
Affiliation(s): 1HCAR, Div. International Health, Karolinska Institute, Stockholm, 2Nordiska Högskolan för folkhälsovetenskap, Göteborg, Sweden, 3Health Directorate of Loreto, Iquitos, 4Inst. Med. Trop. A. von Humboldt, Universidad Peruana Cayetano Heredia, Lima, 5Health Directorate of San Martin, Tarapoto, Peru, 6UFDID, 7Dept. Public Health, University of Florence, Italy

Health policy, access to health, household survey, state health insurance, antibiotic use, health seeking behaviour, health financing


The Peruvian state insurance Seguro Integral de Salud (SIS) was created in 2001 to improve access to health. One of its strategies was to provide healthcare and medicaments free of charge for all children up to 15 years of age in provinces where poverty exceeded 60%. As shown in the framework of this study (Project ANTRES; EC-INCO DEV) a high percentage of caregivers in the Amazonian area consulted public sector health facilities for their sick children in the year 2002. However, the health seeking behaviour during the subsequent years, after some years of SIS implementation, has not previously been assessed. Little is known in general about health policy implementations and effects of health insurance on health seeking and drug use.


The objective of the study was to follow health seeking behaviour and antibiotic utilization over time in the urban Amazonian community of Moyobamba, San Martin, between the years 2002, with SIS recently introduced, and 2005, after some years of SIS implementation. Cross-sectional surveys using household interviews were carried out in 2002 and 2005. For each survey 800 children aged 6-72 months were sampled through a modified cluster sampling approach and their caregivers were interviewed on healthcare seeking strategies (public/private sectors; formal/informal providers), and medication in their children in relation to reported symptoms.


In 2002 and 2005, 32% and 43% respectively of caregivers sought help when their children were sick. In 2002 a high percentage of these (87%) had consulted a public sector health professional, but in 2005 the percentage had decreased significantly (65%; p<0.05), and significantly (p<0.05) more caregivers had consulted pharmacy staff (7% year 2002; 23% year 2005). In 2002 the majority (82%) of caregivers that consulted public sector health facilities exclusively sought help at these facilities without attempting self care. In 2005 the number of caregivers that exclusively sought help decreased significantly (p<0.05) to 37% and the majority tried to treat their children at home before seeking help. The percentage of children that received antibiotics free of charge after consulting a health professional decreased significantly (p<0.05) from year 2002 (82%) to year 2005 (55%).

Lessons learned:

The change in health seeking behaviour from prompt public health facility consultations to increased self care in combination with increased consultations at pharmacies and out of pocket payment for antibiotics could be due to problems both with the content of the SIS policy and with its implementation. The increase in the number of children caregivers paying for antibiotics in 2005 as compared to 2002 indicate that the SIS did not succeeded in providing medicines free of charge. The SIS policy revisions presently taking place in Peru should consider the importance of continuously monitoring the implementation of SIS, as barriers to healthcare remain although there is now formal access to free healthcare.