The Rwanda Social Security Board (RSSB) has commissioned a study to investigate falling subscriptions for Mutuelle de Santé, The New Times has learnt.

Mutuelle de Santé, which is the country’s Community-Based Health Insurance system (CBHI) covering the majority of Rwandans, including those in poor rural areas, has been marred by decreasing subscriptions and accumulation of debts.

Earlier last week the RSSB, which took over the scheme’s management from the Ministry of Health invited interested experts to apply for a tender to conduct the study.

For close to two months starting next month, consultants will be assigned to investigate "root causes” of the insurance scheme’s falling subscriptions and suggest "clear strategies” in order to ensure its sustainability, RSSB said in a call for applications from qualified bidders to conduct the study.

"The main objective of the study is to assess CBHI’s current challenges and their root causes, and then provide strategies to ensure CBHI’s sustainability within the bigger picture of the health financing,” RSSB said this month in an official request for proposals to conduct the research.

An estimated 73 per cent of Rwandans subscribed to Mutuelle de Santé for their health insurance in the last fiscal year 2013/14, down from 80.7 per cent and 90.7 per cent in the financial years 2012/13 and 2011/12, respectively.

The social security board said that ways to make the health scheme sustainable after it had been marred with challenges remains at the centre of interest even if it has registered many success stories.

Among the issues, researchers will be expected to assess whether the scheme’s current contribution mechanism based on Ubudehe poverty or wealth categorisation is appropriate, identify root causes for non-adherence to the scheme by some Rwandans, and evaluate the scheme’s sensitisation system, and evaluate member’s level of satisfaction.

They will also design strategies and make recommendations to ensure the health scheme’s financial sustainability and institutional and organisational arrangements.

Though Mutuelle de Santé is known for having helped many Rwandans to access health care, a recent dip in subscriptions to the scheme and its accumulating debts to healthcare providers have been causing for concern.

While there is compelling evidence of the positive impact of the CBHI, the main challenge that is on top now is the question about its sustainability, according to RSSB.

A review of the health scheme conducted by the Senate last year indicated that the government had accumulated over Rwf2.3 billion in arrears owed to district hospitals and over Rwf400 million to national referral hospitals and health centres.

A big debt owed to district hospitals has been cleared with the government promising to clear the balance this financial year.

But arrears point to an indication of disconnect in the scheme’s administration.

"Carrying arrears was a sign that the scheme wasn’t self-sufficient. Those managing the Fund have to ensure that no more arrears are carried,” says Senator Gallican Niyongana, the vice-president of the Senate’s Committee on Social Affairs, which conducted the senatorial review of the scheme.

Because it maintains a decentralised financial management—whereby every section of Mutuelle de Santé at different health centres in districts across the country has its own bank accounts and signatories—the scheme’s coordination at the national level has remained challenging, officials say.

The RSSB says that "currently, CBHI is characterised by lack of clear records which has been a hindrance of report consolidation”.

There has been decreasing levels of the population’s subscriptions to the community health insurance scheme, falling below the 2007 levels – of 75 per cent – to 73 per cent- which forced cabinet in late April to order an inquiry into issues affecting the scheme.

"It remains unclear why subscription to Mutuelle de Santé has dropped and that’s why a study needs to be done,” said an official in the Health Financing Unit of the Ministry of Health, a section that was in charge of monitoring the health scheme.

The source was uncomfortable being quoted officially because the scheme is now technically under RSSB.

He said that dropping subscription rates could be the result of the fact that local officials were warned not to use aggressive measures to get people into the scheme since 2011, unlike when it was first rolled out.

The official also said statistical errors could have been made in previous figures about the scheme’s coverage rate.

"There are a lot of speculations on what could be the reasons for the decrease,” he said in an interview last week.

However, Dr Alvera Mukabaramba, the Minister of State for Community Development and Social Affairs, said  the increase of the average annual Mutuelle since 2012, from Rwf 1000  to Rwf 3000, may have dragged down subscriptions as some Rwandans may have found the charges too high or are still pondering on whether to pay that much or not.

"Some people, especially those with large families, say that they can’t afford getting the money. You may find one household having to pay up to Rwf 30,000 in case they have ten people in the family; which is a lot of money for poor households even if they are sometimes the ones with more people,” she said.

Justus Kangwage, the Mayor of Rulindo District and Chairperson of the Rwanda Association of Local Government Authorities (RALGA), echoed Mukabaramba’s views, saying the increase could have affected the subscriptions.

But the mayor says efforts to educate the people about the benefits of paying more money in Mutuelle fee are being scaled up countrywide.

"It’s all about people’s mindset. Changes are naturally difficult for people to accept but some have already understood that the new premium will help improve the healthcare services they receive and have created measures to save money for mutuelle. It will require new energy and new strategies before everyone can understand why the Mutuelle fee was increased and we are working on it,” Kangwage said in an interview.

Dr William Namanya, the Director of Kibungo Hospital, said if the the decreasing trend is not checked it could affect drug stocks.

"There has been much sensitisation about the importance of the health insurance. But, the number of people registered is so far very low…we risk running short of drugs because people don’t pay for what they take. When restocking of medicine fails, we shall only be doing examination and send patients to buy prescribed medicine outside,” he said.

"It is a sad reality that the attitude of the people towards Mutuelle de Santé is an issue. A new approach to raise awareness about the importance of health insurance in communities should be devised.”

Robert Mbonima, a resident of Kirehe District said increasing the premium has been the main issue.

"In rural communities you find a family of nine to 14 people…it is difficult for these peasants to pay the required amount for every house member. So, this, coupled with people’s failure to understand the importance of health insurance, has been the problem.”

Innocent Mbonimpaye, executive secretary of Muhororo cell in Karongi District, says the change in charges was a challenge when it started but the situation has gone back to normal.

"It was an issue when the new Mutuelle fee was introduced and numbers dropped a bit but for now people have adapted to the changes. More and more people can now see the positive impact of the changes in Mutuelle fee,” he said.

Additional reporting by Stephen Rwembeho