“Before, if we got sick and didn’t have any financial resources we used to have to sell our livestock or our land. Now, once we pay our contributions to the mutuelle we receive a membership card that we show to the health center, and we are treated without any constraints.”

For many residents of Bungwe, Rwanda, family planning and reproductive health care has improved through participation in a community prepayment health insurance scheme, or mutuelle. By pooling their resources, all mutuelle members receive services at their designated health center. Encouraged by Rwanda’s Ministry of Health, mutuelles are designed to enhance the performance of primary health care providers while reversing the low usage of services, especially family planning and reproductive health care, a trend due in large part to widespread poverty.

The PRIME II Project has been assisting the Ministry of Health since 2000 to strengthen and sustain 62 mutuelles in the health districts of Bugesera, Byumba, Kabgayi and Kabutare, home to approximately 15% of Rwanda’s population. Administered by community representatives in collaboration with local health care providers, mutuelles become increasingly sound as financial risk is spread over a larger and larger membership. Using the Performance Improvement approach to identify and overcome barriers to increasing membership and improving services, PRIME has designed and facilitated campaigns to involve local officials and community leaders as partners in mobilizing community members to join mutuelles. The mutuelles foster dialogue between communities and service providers on the quality of services, allowing communities to hold providers accountable for the services they offer. In turn, the mutuelles offer a reliable revenue stream for participating health centers, creating an important incentive for providers to deliver quality care.

To make it easier for community members who lack financial resources to join mutuelles, PRIME helped facilitate short-term microcredit loans from rural banks in Bungwe and some of the other participating communities. In addition, PRIME assisted in revamping the organizational structure of the mutuelles and conducting training workshops on administrative and financial management for 216 people involved in daily management. PRIME’s work with the mutuelles complements its other activities in Rwanda, including the development of national reproductive health policy and service guidelines.

The advocacy, partnering and sensitization campaigns initiated by the Ministry of Health and PRIME II are resulting in encouraging gains for participating mutuelles, including significant growth in membership, increased contributions to health center revenues and improved quality and use of services. As of September 2002, membership in the Bungwe mutuelle had increased 124% in just two years. With 16,020 members, the Bungwe mutuelle includes 43% of its target population. Overall, mutuelle membership in the PRIME project districts has increased by 63% from initial levels. These mutuelles have contributed to stronger financial capacity at their partner health facilities, with some mutuelles now generating up to 75% of the total revenue for their health center.

Most importantly, data show that mutuelle members access family planning and reproductive health services more often than non-members who must pay for services on a case by case basis. The mean yearly health consultation rate for Bungwe mutuelle members is 1.3 visits, as compared to a rate of 0.3 for non-members. “People are coming more often for preventive care, which decreases further disease complications,” says Sister Yvette Vincent, director of the Bungwe Health Center. “The mutuelles unify the population, creating an assembly that promises a better quality of life.”

The PRIME II Project works around the world to strengthen the performance of primary care providers as they strive to improve family planning and reproductive health services in their communities.

PRIME Voices #15, Rwanda: Mutuelles Increase Access to Improved Services, 12/11/02