Rwanda's health system: some concerns

Numerous details in the Public Health paper by Dorothy Logie and colleagues (July 19 p 256) are not consistent with available evidence. Thus several aspects of donor coordination health insurance and performance-based approaches might require further investigation. Logie and colleagues state that "by 2007 government health spending had increased to 9·5% of total public expenditure." However the latest available data2 suggest that this figure decreased from its peak of 9·0% in 2003 to 6·5% in 2006. The "decline" in adult HIV prevalence up to 2005 is explained by the improved validity of the household survey in 2004-05 compared with former sentinel-site surveys. The improvements in other Millennium Development Goal indicators correspond to a return to the pre-genocide levels of 1990-92. It might be argued that extreme efforts will be necessary to maintain such progress. The Rwandan Mutuelle scheme has limited similarity to community-based health insurance: the management of the scheme is largely assured by civil servants under direct control of the Ministry of Health. It is thus more parastatal than autonomous or community-based. A flat-fee contribution to the scheme is compulsory for every Rwandan citizen and subsidies are only available for a minority of those in need. This approach causes substantial hardship for large population groups. Altogether the Mutuelle system corresponds more to an additional tax for health than to a proper insurance system yet it contributes only 5% to the national health expenditure (2006 data). The introduction of performance-based financing in Rwanda indeed went hand in hand with an increase in health-service use. But health staff receive financial incentives for doing www.thelancet.com Vol 372 November 15 2008 1729 activities that they are supposed to do anyhow according to their working contracts. The introduction of these schemes and a series of other factors led on average to the tripling of health-staff salaries in Rwanda within a few years. The question remains how far progress is attributable to performance contracts or to the salary increase itself. Health-sector performance in Rwanda is interesting impressive and characterised by the active role of the government. But the time is not ripe to promote these models on a large scale let alone beyond the borders of the "land of a thousand hills". (full-text)