The Government is set to start implementing the ‘Capitation Model’ for Community Based Health Insurance (CBHI)/Mutuelle de Sante. Capitation is a form of payment where health service providers receive a fixed amount of money upfront for each person that uses the CBHI. This is opposed to the “Fee-for-service payment,” under which health facilities get paid after rendering services to clients and sending invoices to the Rwanda Social Security Board (RSSB) to reimburse. The New Times understands that the Ministry of Health (MoH) and the RSSB will roll out the capitation system before the end of this year, exclusively in public health centres and posts for the start. As part of the implementation plan, a survey will be carried out in health centres and posts, to establish the number of people in their respective catchment, the average consultations, the price of medication, among other things. This information will be used by RSSB and MoH to calculate the amount of money to be allocated to each specific facility under the Capitation Model. The Primary Health Care providers will sign a capitation agreement that comprises a list of specific services that must be provided to their clients. Pros and cons of the system: The model has advantages and disadvantages, according to some health sector experts. Dr. Jean Nepo Utumatwishima, the Director General of Rwamagana Provincial Hospital, says the new system is a positive move for Rwanda, since the globe is moving towards capitation. He notes that it is coming in handy to help health facilities have a good availability of cash, so that they can deal with any needs. “For us, this is a good move because the health facilities will have access to cash to buy consumables, laboratory commodities and medication. They can even pay contractual staff in case they have them,” he said. “Before, we had to wait for many months for RSSB to conduct the verification (of invoices) in order to pay us,” he added. However, he cautioned that there is need for strong controls in its implementation so that it will not be misused to degrade the quantity and quality of health services. “If a particular health centre knows that it will get 6 million per month whether it receives patients or not, it may end up trying hard to receive very few patients in order to avoid spending the money allocated to it. Some facilities may even reduce the quantity of services they render to clients. For example, if a patient has to receive four laboratory tests, the facility may end up prescribing only two, just to avoid spending the money given to it under the capitation model,” he said. He suggested that for the new system to work, there is need for strong leadership in health facilities, reinforcement of financial accountability, effective planning and budgeting. “There should be good measures to safeguard the quality and quantity of services in this capitation model. This might require clinical audits to check if the clinical guidelines are being respected, if the medication is of good quality and whether the patients are not being sent away from one facility to another,” he said. “But in Rwanda, as you know, we have good accountability and leadership - citizen centred leadership. I think we are going to encourage citizens to demand good services at every health centre, and if something is getting wrong they should communicate it quickly,” he added. Alypio Nyandwi, a Public Health researcher, says the new system will reduce some malpractices in terms of poor accountability on the side of health care providers. “Some health care facilities might have been overcharging the CBHI scheme by prescribing services that were not necessary for patients. For example, a health centre can prescribe very many laboratory exams for a patient, just to make sure they will have more money coming to them from RSSB,” he said. Like Dr Utumatwishima, Nyandwi noted that the capitation mode “requires a lot of controls for it to be effective.”
