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.

When the National Hospital Insurance Fund (NHIF) was transformed from a department of the Ministry of Health to a State Corporation, the management of the organization switched to become an all-inclusive board composed of the Permanent Secretary in the Ministry of Health (MOH), Central Organisation of Trade Unions, Directorate of Personnel Management, Kenya National Union of Teachers, Director of Medical Services, Federation of Kenya Employers, Association Kenya Insurers, Christian Health Association of Kenya, Kenya Medical Association and an additional, rotating member of civil society. In all, 2/3 of the board comes from outside of the ranks of the government itself. The NHIF board makes the primary decisions regarding management of NHIF. The Board suggests an annual budget which is then voted on by the National Assembly. The NHIF has decentralized its operations to 31 local branches and 82 service points across the country. These branches are responsible for claims processing and quality assurance, enrollment and collection of premiums (especially from informal sector employees and other ‘voluntary’ enrollees), and marketing of the program. The branches also implement quality programs alongside contracted providers, and execute most of the monitoring and evaluation programs within the NHIF.

Since its separation from the MOH, the NHIF is no longer held directly accountable by the MOH. Several new mechanisms for ensuring accountability have been instituted, however. These include the Board’s Audit and Integrity Subcommittee, the Auditor General of the Kenyan Government (which files annual reports to the Parliament on the performance of each government agency, including the NHIF), the NHIF’s Efficiency Monitoring Unit (which handles complaints and performs periodic audits of the operations of the agency) and finally the NHIF Ombudsman (which receives and mediates complaints).

Source: National Hospital Insurance Fund The Kenyan health system is administered from the top down by the Ministry of Health (MOH), which was broken into two Ministries after the post-election turmoil of 2007: the Ministry of Medical Services, and the Ministry of Public Health and Sanitation. Kenya has a Sector Wide Approach (SWAp) to coordinate and support the health care system, which incorporates health partners on all levels. The role of the central government is to formulate policy, set priorities, budget and allocate resources, and regulate service provision through a decentralized framework. Provinces, districts and local community areas are increasingly responsible for implementation and day to day management of the health system.

Implementing partners and development partners aid the MOH in implementing health plans by providing services such as funding, specialized care, research, training or health insurance. The majority of them are parastatals who receive a portion of their annual funds from the Government of Kenya and have to raise the other part themselves through cost sharing or other sources, such as the National Hospital Insurance Fund, the Kenyatta National Hospital, and Kenya Medical Research Institute, though they can also be private organizations.

Aarogyasri is managed by the Aarogyasri Healthcare Trust, a body that is responsible for overseeing the entire insurance program, including certain administrative functions such as setting benefits packages and pricing, managing contracts with insurer(s) and in-network providers, approving claims and monitoring of the scheme.

The administrative structure of Aarogyasri is comprised of four main organizations:

• Aarogyasri Healthcare Trust: The Trust is responsible for oversight of the entire insurance program as well as some important administrative functions such as setting benefits and pricing, managing contracts with insurer(s) and in-network providers, approving claims, and monitoring.
• Insurer: The insurer is selected based on a competitive bidding process to bear risk and manage all back-end insurance administration, including claims processing, reimbursements to providers, oversight of hospitals. The Insurer is also responsible for holding health camps in villages to screen, diagnose, treat, and make beneficiaries aware of any health problems they might have; health camps are also used to enroll eligible beneficiaries.
• Network hospitals: Network hospitals provide care to Aarogyasri beneficiaries.
• Aarogya Mithras: Aarogya Mithras are patient advocates and assist Aarogyasri beneficiaries to navigate through the system and ensure beneficiaries receive quality care. Aarogya Mithras are also responsible for community outreach.

The table below summarizes the roles and responsibilities of all of the organizations involved in operationalizing Aarogyasri: