Page 263 - GHES-3-3

Global Health Economics and
Sustainability
Sustainability of Rwanda’s UHC: 2011–2021 and vision 2050

3.2. Identification of the challenges and its solutions 22.63 billion granted in FY 2020/2021, (iv) preserving
during the implementation of CBHI system (Specific existing financial resources instead of requesting additional
Objective 2) funds, (v) reforming the purchasing and claims payment
policy from FFS PPM to FASP PPM, (vi) implementing
The assessment of the 2011/2012 – 2020/2021 income
statements revealed gaps and deficiencies in the a Diagnosis-Related Groups (DRG)-based billing system,
implementation of the 2010 CBHI policy and the FFS PPM. (vii) integrating clinical and community performance-
based financing into routine CHFP management, (viii)
3.2.1. Institutional capacity-building gaps of the CBHI utilizing Health Management Information System (HMIS)-
system (2010 CBHI policy Objective 1) reported data for billing, (ix) improving access to HMIS
for CBHI staffs, (x) fostering a culture of cost control, and
Deficits in management, financial, and actuarial risk (xi) automating the billing system to facilitate financial
analysis skills hindered the achievement of this goal.
management and strengthen financial sustainability.
The recommended solutions for objective 1
include (i) providing institutional support through 3.2.3. Equitable quality health-care access for all
technical assistance and capacity-building services and (2010 CBHI policy Objective 3)
(ii) integrating relevant budget lines into the CBHI Regarding equitable health-care access, the goal of
expenditure component. providing equal domestic health-care access for all CBHI
beneficiaries (approximately 94% of the population)
3.2.2. Financial sustainability gaps of the CBHI system has largely been met. However, challenges remain with
(2010 CBHI policy Objective 2)
specialized care access.
The 2010 CBHI policy highlights incomplete legal revenue Suggested solutions to promote equitable quality
mobilization and recovery. A shortfall of RWF 62.13 billion health care and universal access include: (i) improving
was identified, including RWF 25.43 billion from 1% of the AGR of community health workers from a negative
domestic resources (FY 2022/2023) and RWF 36.70 billion growth rate of −5% to 206%, (ii) reducing fraud at health
from 13% of the Ministry of Health (MOH) budget. In posts and providing performance-based incentives for
addition, over-billing of health services led to an overpayment community health workers, (iii) opening new health
of RWF 39.25 billion, exacerbated by inefficiencies in the centers that meet new-generation facility standards and
FFS PPM, causing cost escalation. This resulted in a total strengthening existing ones, (iv) formalizing specialist
gap of RWF 101.38 billion, which represented 131.95% of outreach nationwide – especially in district hospitals,
the CBHI total expenditure in 2020/2021. If the two basic (v) expanding provincial hospitals from four to eight,
policies are effectively implemented, CBHI could achieve increasing their clinical capacity by raising AGR from 10%
self-sufficiency, enhance operational efficiency, and offer to 40%, and (vi) increasing contracted private specialty
specialized care to all, as outlined in HRV 2050. health establishments to improve access. The AGR of the
The study also identified other deficiencies on the related budget line increases from 10% to 20%.
CBHI demand side, including: (i) replacing the 13% MOH
budget with indigent enrolment subsidies, (ii) CBHI’s 3.2.4. Protection against financial hardship (2010
2020 – 2023 strategic budget, which included excessive CBHI Policy Objective 4)
common expenses of RWF 5,595,598,987 (omitted from While the goal of protecting against financial hardship has
the FY 2020/2021 revised budget), (iii) RWF 500 million largely been met, issues remain with specialized care access
incorrectly budgeted for returns on investment alongside and the 10% co-payment. According to Nyandekwe et al.
investment expenses, (iv) the “interest on current accounts” (2014), only 2.17% of the 94% CBHI target population can
budget line was removed in FY 2020/2021, (v) excessive afford the co-payment for specialized treatments, such as
time was spent on claims verification and reconciliation, kidney transplants, costing RWF 2.0 – 2.5 million. Without
(vi) an AGR of 48 – 50% in staff costs was observed, and abolishing the co-payment, 91.83% of the CBHI members
(vii) the lack of a cost-control culture led to ongoing will be excluded.
financial distress. Suggested solutions to protect against financial hardship
Suggested solutions to address CBHI’s implementation include: abolishing co-payments at all public health-care
gaps in financial sustainability include: (i) granting facilities and implementing free health care at the point
administrative and financial autonomy to CBHIs, (ii) of service, with CBHI reimbursing the co-payment to
establishing technical assistance and capacity-building P/A health-care providers through a third-party payment
services, (iii) effectively managing the additional RWF mechanism. Failure to abolish the co-payment may result

Volume 3 Issue 3 (2025) 255 https://doi.org/10.36922/ghes.5842