Cover Image
close this bookPrepayment Scheme for Provision of Healthcare for People Living with HIV/AIDS in Rwanda (UNAIDS - Best Practice Digest, 2000, 3 p.)
View the documentPrepayment scheme for provision of healthcare for people living with HIV/AIDS in Rwanda

Prepayment scheme for provision of healthcare for people living with HIV/AIDS in Rwanda

Summarised from an In Brief paper from PHR (Partnerships for Health Reform) on “ Prepayment scheme in Rwanda accepts sero-positive members”.

For further information, contact: Partnerships for Health Reform Project, Abt Associates Inc., 4800 Montgomery Lane, Suite 600, Bethesda, MD 20814. E-mail:

Nearly 11% of the Rwandan population is estimated to have HIV/AIDS, making it one of the most important health issues facing the country. HIV/AIDS is often excluded from insurance schemes, leaving low income sero-positive patients impoverished, financially ruined, and exposed to more health problems. Under the USAID-funded global PHR project, as part of a broader National Health Accounts, a survey of households was implemented to estimate sero-positive households’ utilisation and expenditures on healthcare in Rwanda. Alongside this study, an initiative to improve access to care through prepayment schemes was piloted in three health districts.


The study found that half of the sero-positive patients interviewed were widowed, that they use up to 10 times more basic healthcare services than the general population, and that HIV seriously impairs the ability of low-income households to meet basic needs. Less than 30% of households interviewed were able to meet the costs of healthcare exclusively from their own resources. Most had to borrow, or sell assets.

Prepayment schemes

The majority of Rwandans pay out-of-pocket user fees to receive health care. Paying these fees at the time when care is needed impedes access to care for the poor as well as for 90% of the Rwandan population who are subsistence farmers and have cash only on a seasonal basis. Prepayment schemes solve this problem.

The Rwandan Ministry of Health, in collaboration with the USAID-funded PHR Project, developed and implemented prepayment schemes in three Rwandan health districts. Since July 1999, almost 90,000 inhabitants in these districts became members of the schemes. Preliminary findings reveal members pay on a per capita level three times as much for healthcare as non-members. Members’ access to care has significantly increased to one visit per capita per year compared with non-members who still report 0.2 visit per capita per year.

The prepayment scheme of the health centre of Matyazo in the health district of Kabutare has decided to extend solidarity and prepayment scheme coverage to 50 sero-positive community members. The annual premium of FRw 2,500 (US$ 7.80) entitles a family of up to seven members to prepayment scheme membership for one year. Members benefit from all services and drugs on the essential drug list provided at the health centre, ambulance transport to the district hospital and a limited benefit package at the district hospital, which includes Caesarean section, overnight stay and physician consultation. These 50 members benefited from a church donation which paid for their one year membership premium at a higher price of FRw 2,000 per sero-positive member instead of FRw 530 for an individual that signs up in a group.

The health centre is aware of the financial risk taken in accepting sero-positive members. Although sero-positive members benefited from their membership premiums being subsidised at a higher price, which will increase the health centre’s monthly capitation revenue, the health centre will still need additional financial support from the government and donors to assure its financial stability.

It is too early to institutionalise risk-adjusted capitation payment and health re-insurance in a developing country like Rwanda. However, this pilot programme shows that positive measures can be created to support the health centres that do take the additional risks by accepting sero-positive members and hence ensure the access to care for these individuals.