The contribution of micro-health insurance to equity and sustainability in Rwanda

Doctoral thesis English OPEN
Schneider, Pia Helene

Many countries are looking to health insurance to improve \ud access \ud to \ud medical care \ud for low- \ud income groups and to raise additional revenues \ud for \ud a \ud depleted \ud health \ud sector. \ud In Rwanda, \ud concerns about a sharp drop in demand for medical services \ud after the \ud re-introduction \ud of user \ud fees in 1996, motivated the government to design \ud and pilot-test \ud micro-health \ud insurance \ud (MHI) \ud in three districts. This thesis compares the performance \ud of the \ud current \ud Rwandan MHI \ud with the \ud user fee system and against principles of egalitarian equity \ud and sustainability. \ud It \ud draws from \ud the economic and social literature related \ud to \ud health insurance, \ud equity \ud and \ud sustainability; and \ud uses cross-sectional routine and survey data collected \ud on \ud insured \ud and uninsured population \ud groups from health centres, MHI, households, patients \ud and \ud focus \ud groups \ud during the \ud Rwandan \ud pilot phase (7/1998-6/2000). It aims to contribute to the \ud research on equity \ud and sustainability \ud in health financing and utilisation by evaluating and \ud comparing the implications \ud of \ud MHI \ud and \ud of user fees for households and on the health sector. \ud The \ud analysis comprises three \ud main \ud components. First, it examines the demand for \ud health insurance in \ud a \ud binary \ud choice \ud model. \ud Second, following egalitarian equity principles \ud and the \ud minimum \ud standard \ud approach, \ud it \ud evaluates the impact of utilisation and financing of \ud health \ud care \ud on the financial \ud situation of \ud insured and uninsured households. Third, it \ud uses \ud an \ud econometric \ud cost \ud function that \ud allows \ud identification of payer-specific outputs to analyse \ud and \ud compare the \ud cost \ud and efficiency \ud implications of MHI with capitation payment versus \ud user \ud fees in health \ud centres, \ud in \ud order to \ud test the hypothesis that providers adjust the treatment intensity to the \ud expected \ud payment \ud mechanisms. Based on findings, a MHI insurance design is derived to \ud scale \ud up risk-pooling \ud and improve equity and sustainability in the \ud district \ud health \ud system.
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