Causes of insufficient cost recovery of the health care services provided to the members of the community-based health insurance in Rwanda: case of Kabusunzu Health Center from 2009 to 2010

Abstract

Our study is focused on the causes of insufficient cost recovering of medical care provided to adherents of community based health insurance (CBHI or MUSA) in Rwanda: case of Kabusunzu health center. Kabusunzu health center is one of the country‘s public health centers, located in Kigali city with a big number of adherents to CBHI. Existence of many unpaid invoices compromising the functioning and sustainability of CBHI. Indeed, until November 2011, the accounting situation notes a debt of more than 59.000.000 Frw due to Kabusunzu Health Center by the section of CBHI (mutuelle de santé). Our question is to know what are the major causes that hinder the cost recovery of health care provided by Kabusunzu health center to the members of CBHI? The objective of the study consist of identifying the causes of difficulties in cost recovering of medical care provided by the health centers (HC) to adherents of CBHI with the aim of proposing possible strategies to improve the functioning and sustainability of CBHI. To achieve this objective, we have conducted a qualitative study. Mainly three techniques have been used: i) individual interviews of 15 people having at least responsibilities in the functioning of CBHI, from HC to Ministry of Health (MoH) passing through primary entities, and those intermediaries including Non Government Organization (NGOs), ii) two focus group, one composed of 7 clients and another composed of 10 community health workers (CHW), iii) at last a documentary technique for taking in account the existing literature on this topic in our country as well in the world. The study has showed, from literature review that there has been many unpaid invoices compromising the functioning and sustainability of CBHI. Identified causes of difficulties encountered in cost recovering of medical care and services provided to the adherents CBHI are numerous. The more prominent and quoted is the poverty of the population to afford the cost of medical care, the abusive use of the card of health insurance including fraud, falsification and overuse of health services, low contribution of members, the ―Adverse selection‖ by the NGOs, the insufficient motivation of the staffs, the background of paternalism from the colonial period, the quantitative and qualitative insufficiency of staff's, the overcharging of medical services including tests of laboratory, favouritism and the long process in the transmission of the lists of the indigents. Among the proposed strategies and recommendations, it has been suggested the diversification of financing sources (e.g. contribution of enterprises producing tobacco, alcohol, gas stations, transportation companies etc.) to CBHI and the universal coverage of health insurance.