Joint Learning Network for Universal Health Coverage

The health system is organized on a 3-tier pyramid system composed of central, district, and sector levels. The central government is managed by the Ministry of Health (MOH) and is responsible for the stewardship of the Mutuelles program, focusing on policy development, capacity building, monitoring and evaluation of operational programs, and resource mobilization. The central level monitors and coordinates technical and logistic support and training at the district and sector levels. The central level is also in charge of the payment to national tertiary care hospitals.

The district level is composed of about 5 sectors, with roughly 250,000-500,000 people each (Rwanda has 30 districts in total), and at least one hospital and secondary care facility. A board of directors governs the district Mutuelle and a permanent salaried agent conduct audits and overviews. At the district level, the Mutuelle Fund manages member premium subsidies and disburses funds to the appropriate district and sector level facilities based on need and service utilization. Districts guide and facilitate the administrative, logistical, technical, and political supervision, training, and management of the sector level Mutuelles. The district level is also responsible for contractual relations with the district hospital, hospital reimbursement, and quality-of-care supervision at the district hospital levels.

The sector-level includes roughly 50,000 people, with at least one health center for primary care. Each sector has a Mutuelle that is managed by community elected officials. At the sector level, Mutuelles are owned and privately managed by their members. Sector level Mutuelle organizations adopt a Constitution and By-laws, through which they define the organizational structure, roles and functions of management, and election of organizational leaders. These leaders then determine benefit packages, annual premiums and periodicity of the subscriptions, establish conventions on care and health services, service providers and reimbursement. In addition, these sector-level Mutuelles are responsible for recruitment of members and membership collections, as well as monitoring and evaluation of local health and reimbursing health centers.

In 2009 the government created the Rwanda Social Security Board which merges Rwanda Health Insurance Scheme (RAMA) and Military Medical Insurance (MMI) with the Society Security Fund with the objective of improving performance and decision-making.

The National Health Insurance Scheme (NHIS) is the body responsible for regulation of the system and the different health insurance schemes. The Governing Board of the National Health Insurance Scheme is the National Health Insurance Council (NHIC). NHIC works to regulate the scheme (including setting standards, determining contribution rates, providing technical support, etc), license HMOs and providers, train health care providers, and manage the National Health Insurance Fund (NHIF).

HMOS are licensed by the NHIS to facilitate the provision of healthcare benefits to contributors under the Formal Sector Social health Insurance Program; to interface between eligible contributors, including voluntary contributors and the healthcare providers, ensure member registration, public education about the schemes, collect premiums from members and employers, contract with providers, process claims, and pay claims directly to providers.

The informal sector scheme under the NHIS is managed by a Board of Trustees composed of the Chairman, Secretary, Treasurer and four others. A clerk is appointed to carry out clerical and accounting duties. The Board of Trustees has executive power and is responsible for collecting contributions from participants, paying providers for services rendered, and operating a bank account with an NHIS accredited Bank.

The Nigerian system is organized as a federation and divided into three tiers: federal, state, and local. The federal government sets overall policy direction and standards, implements national immunization programs, and oversees federally funded tertiary health facilities. The states undertake policy making and regulation as well as financial responsibility for the personnel, operating costs, and capital investment of the tertiary, secondary, and primary care facilities. The 774 local government associations (LGAs) are responsible for primary health care delivery, under the guidance and supervision of federal and state departments of primary health care. LGAs tend to exert the least influence in this system, and frequently suffer from insufficient funding.