Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA.
PLoS One. 2012;7(6):e39282. doi: 10.1371/journal.pone.0039282. Epub 2012 Jun 18.
Mutuelles is a community-based health insurance program, established since 1999 by the Government of Rwanda as a key component of the national health strategy on providing universal health care. The objective of the study was to evaluate the impact of Mutuelles on achieving universal coverage of medical services and financial risk protection in its first eight years of implementation.
We conducted a quantitative impact evaluation of Mutuelles between 2000 and 2008 using nationally-representative surveys. At the national and provincial levels, we traced the evolution of Mutuelles coverage and its impact on child and maternal care coverage from 2000 to 2008, as well as household catastrophic health payments from 2000 to 2006. At the individual level, we investigated the impact of Mutuelles' coverage on enrollees' medical care utilization using logistic regression. We focused on three target populations: the general population, under-five children, and women with delivery. At the household level, we used logistic regression to study the relationship between Mutuelles coverage and the probability of incurring catastrophic health spending. The main limitation was that due to insufficient data, we are not able to study the impact of Mutuelles on health outcomes, such as child and maternal mortalities, directly. The findings show that Mutuelles improved medical care utilization and protected households from catastrophic health spending. Among Mutuelles enrollees, those in the poorest expenditure quintile had a significantly lower rate of utilization and higher rate of catastrophic health spending. The findings are robust to various estimation methods and datasets.
Rwanda's experience suggests that community-based health insurance schemes can be effective tools for achieving universal health coverage even in the poorest settings. We suggest a future study on how eliminating Mutuelles copayments for the poorest will improve their healthcare utilization, lower their catastrophic health spending, and affect the finances of health care providers.
Mutuelle 是一种社区为基础的健康保险计划，自 1999 年由卢旺达政府设立，作为提供全民医疗保健的国家卫生战略的一个关键组成部分。本研究的目的是评估在实施的头八年中，Mutuelle 对实现医疗服务普及和财务风险保护的影响。
我们使用全国代表性调查对 2000 年至 2008 年期间的 Mutuelle 进行了定量影响评估。在国家和省级层面，我们跟踪了 Mutuelle 覆盖范围的演变及其对儿童和孕产妇保健覆盖范围的影响，从 2000 年到 2008 年，以及家庭灾难性卫生支出，从 2000 年到 2006 年。在个人层面，我们使用逻辑回归调查了 Mutuelle 覆盖范围对参保者医疗服务利用的影响。我们关注了三个目标人群：一般人群、五岁以下儿童和分娩妇女。在家庭层面，我们使用逻辑回归研究了 Mutuelle 覆盖范围与发生灾难性卫生支出的概率之间的关系。主要限制是，由于数据不足，我们无法直接研究 Mutuelle 对儿童和孕产妇死亡率等健康结果的影响。研究结果表明，Mutuelle 提高了医疗服务利用率并保护家庭免受灾难性卫生支出的影响。在 Mutuelle 参保者中，最贫困支出五分位数的利用率明显较低，灾难性卫生支出的发生率较高。研究结果在各种估计方法和数据集上都是稳健的。
卢旺达的经验表明，社区为基础的健康保险计划可以成为在最贫困环境中实现全民健康覆盖的有效工具。我们建议未来研究如何取消最贫困群体的 Mutuelle 共付额，以提高他们的医疗保健利用率，降低灾难性卫生支出，并影响医疗保健提供者的财务状况。
