The policy of instituting Mutuelle de santé was put in place in December 2004, and later accompanied by the 2007 law enforcing the scheme whose objective was to assist grassroots communities and districts to establish health insurance systems that protect households against financial risks associated with diseases.

By 2010, subscription stood at average of 91 per cent as reports from the Ministry of Health indicate. The scheme was a huge success and an attraction to dozens of foreign officials who came to study how they could replicate similar health insurance policy in their countries. But Edwin Musoni writes that, along the way, some mistakes were made leading to a probe that has seen arrests as government tries to revamp the fund.

The recent arrests of local government officials in connection with irregularities alleged in Mutuelle de Sante have raised public concerns with many calling for total overhaul of the management of the highly successful community-based health insurance scheme.

The scheme, which has seen even the poorest Rwandan access medical services, has been described as a key vehicle for achieving the country’s development agenda, by ensuring a healthy population.

Dozens of delegations from several countries have been to Rwanda to see how this unique policy has worked.

However, some local leaders, for different reasons, mismanaged the scheme, which denied some subscribers access to the medical services they had paid for.

The complaints would later lead to an audit which started from the Western Province in December, last year, and is due to end this month.

The probe, by a team from different state organs, is looking into why Mutuelle subscriptions have lately gone down and also ascertaining the exact reasons behind the public complaints.

As the investigations took shape, gross malpractices and abuse of the scheme were discovered, with some leaders having inflated figures to attain their set targets or even embezzle the funds.

The probe has seen the arrest of several local leaders implicated in financial impropriety and mismanagement of the scheme.

Rusizi mayor Oscar Nzeyimana and four others at the district were arrested in connection with counterfeiting documents related to Mutuelle de Santé.

The quartet is accused of acting on orders of Nzeyimana to inflate mutuelle subscribers’ figures from 69 to 77.5 per cent to get good score in the evaluation of performance contracts, Imihigo.

Similar investigation also led to the resignations and subsequent arrests of the mayors of Karongi and Nyamasheke, Bernard Kayumba and Jean Baptiste Habyarimana, respectively.

Kayumba has since been released on bail as investigations continue.Routine check

Although the Ministry of Health maintains that the investigation is a routine exercise, sources who are part of the team conducting the audit say the purpose is to clean up Mutuelle de Santé house that is marred with a lot of abuse and mismanagement.

"We want to know the extent of the problem, so far we have discovered a number of malpractices where some leaders were ordering Mutuelle staff to inflate the figures in their own interests,” said another source close to the investigations.

The source added: "We have so far mapped areas where we suspect grave concerns and this investigation runs up to the end of February; by then we will know how big this problem is. When we happen to roll out this investigation countrywide, I am very sure most people will have to face the wrath of law, there has been gross abuse of the scheme and we can’t take it any longer.”

However, officials at the Ministry of Health have downplayed the concerns, saying that there is no cause for alarm.

In an e-mail Nathan Mugume, the head of the communication division at Rwanda Biomedical Centre, sent to The New Times, he pointed out that systems and measures are in place to curb any mismanagement.

"Even the current cases were discovered because of the current systems and control measures in place, more stringent control measures and mechanisms continue to be installed and implemented, therefore this will not affect functioning and sustainability of Mutuelle de Santé,” he said.

One of the key concerns has been the decrease in the Mutuelle de Santé rate of adherence.

Recent reports indicate that, an estimated 73 per cent of Rwandans subscribed to the scheme 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.

Although there have been suggestions that the decline is due to a recent review of contributions that resulted to increasing the amount paid in each category of the beneficiaries as stipulated in Ubudehe social stratification, the ministry says the decrease is rather due to public attitude towards the scheme.

"The decrease in subscription is mainly attributed to attitudes and perception of the population towards health insurance, there is need for increased sensitisation, this is being done in partnership with the Ministry of Local Government, the sensitisation trend is shifting from awareness to the benefits,” added Mugume.

When government initiated the Mutuelle policy back in 2000, local leaders were tasked with ensuring that members of the public subscribe to it and pay their annual premiums on time.

Since the initiative is meant to improve the welfare of the people, leaders had to report, annually through the performance evaluation (Imihigo), how their constituencies’ subscription stands.

Evolving into fully fledged scheme

By December 2004, the policy of Mutuelle de Santé was put in place and later accompanied by the 2007 law enforcing the scheme whose objective was to assist grassroots communities and districts to establish health insurance systems that protect households against financial risks associated with diseases.

By 2010, subscription stood at the average of 91 per cent as reports from the Ministry of Health indicate.

However, the revenues collected proved that there was a mismatch in the numbers and money.

At the same time, the Auditor-General’s office conducted a value for money audit into Mutuelle de Sante that revealed that there was a 56 per cent deficit in Mutuelle funding despite cases of embezzlement and mismanagement.

Although the insufficient funding had already been realised and the policy was being reviewed, the value for money audit objected to the proposal to have Mutuelle contributions raised by almost 600 per cent.

A new policy proposed increment on premiums in order to facilitate financial sustainability of Mutuelle and, eventually, the premiums were revised upwards, but took into context the economic status of households.

In the determination of the new policy, the Ministry of Health was forecasting an accumulated reserve of Rwf 23.9 billion by 2014.

Asked if the projection was achieved, Mugume said: "On savings, yes, we have managed to make savings but we have put back the savings into the pool to cater for some districts that have failed to meet the total funds pooled mainly due to cases where some districts experience low subscription rates.”

A source who has been following the developments, speaking on condition of anonymity for fear of jeopardising matters still under investigation, told The New Times that despite the change in policy which is likely have led to the decline in the percentage, local leaders who were obliged to report about the performance of the scheme ‘doctored’ the percentages as they were competing to retain good ranking in Imihigo.

"An example of inflated figures is in Karongi District where reported membership rate as of October 31, 2011 was 99 per cent, while the amount paid was Rwf328,690,124 out of the overall expected Rwf713,325,000 by mid December 2011, membership rate was 102 per cent,” said the source.

Reacting to the development, the spokesperson of the Rwanda Civil Society Platform, Edouard Munyamaliza, said government should embark on advocacy to improve the quality of services delivered to Mutuelle beneficiaries.

"Mismanagement and doctoring of figures result into poor quality of services which consequently make the public unhappy. If Mutuelle de Santé is managed well, the health of the people would be good which would reflect on the development of the country,” said Munyamaliza.

He proposed that if government is seeing failures then there is need to consider an overhaul reform of the system, saying "maybe we may see significant changes.”

As investigations continue, plans are in advanced stages to transfer Mutuelle de Sante from the Ministry of Health to Rwanda Social Security Board, a move that is aimed at boosting its management.

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Timeline to mayor arrests

January 8. Two mayors of Nyamasheke and Karong districts, Jean Baptiste Habyarimana and Bernard Kayumba, respectively, resign citing personal reasons.

January 9. Kayumba is arrested in connection with misuse of Mutuelle de Santé funds.

January 19. Kayumba granted bail, three other co-accused; Philipe Turatsinze, Innocent Gashema and Samuel Muvunyi denied bail.

January 12. Jean Baptiste Habyarimana arrested over alleged ‘forgery’ and possible embezzlement of public funds, particularly money meant for Mutuelle de Sante.

Police spokesperson Celestin Twahirwa confirms to The New Times that "We are holding him over a possible misuse of public funds and forging official documents.”

January 6. Rusizi mayor Oscar Nzeyimana arrested. Police spokesperson Celestin Twahirwa says arrested linked to "forging documents related to his work.”

January 17. Mayor Nzeyimana denied bail to together with his co-accused including his former deputy for social affairs Basile Bayihiki, the director of health, Emmanuel Ndamuzeye, Juliette Muhawenimana, in-charge of community mobilisation and Nzayituriki Theoneste, head of Mutuelle at Gihundwe Hospital.

Prosecution alleged the officials, acting on orders from Nzeyimana, inflated Mutuelle subscribers’ figures from 69 to 77.5 per cent to get better score in Imihigo.

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What is the way forward for the cherished ‘mutuelle de sante’?

The 2013 National Leadership Retreat directed that medical insurance scheme, Mutuelle de Sante, be moved from Health ministry to Rwanda Social Security Board (RSSB). Explaining the decision during a subsequent media briefing, Cabinet ministers said the move was aimed at improving the fund’s financial accountability.

Membership to the scheme is voluntary and payment of premiums is based on one’s economic status, with government paying for the most vulnerable of society.

Premiums were supposed to be collected by local authorities and paid to hospitals through the Ministry of Health. But this was not always the case, as evidenced by the mismanagement that have seen the arrest of some local government officials.

The Retreat instructed the Health ministry and RSSB to fast-track the handover process Speaking at a post-retreat briefing last year, then Local Government minister James Musoni said the decision was taken in light of past mismanagement of the scheme and to ensure transparency.

He said the idea of moving the scheme to the pensions body was first mooted way back in 2011 following the merger of then social security fund of Rwanda and Rama to form present-day RSSB. Rama is an insurance scheme for mainly the working class.

The Minister for Health, Dr Agnes Binagwaho, admitted that her ministry lacked capacity to manage the Mutuelle premiums, explaining that the latest changes were designed to improve health financing.

editorial@newtimes.co.rw