R. Koch1, T. Nkurunziza2, H. L. Irasubiza2, M. Shrime1, B. Hedt-Gauthier2,3, F. Kateera2 1Harvard School Of Medicine,Program In Global Surgery And Social Change,Boston, MA, USA 2Partners in Health/Inshuti Mu Buzima,Kigali, Rwanda 3Harvard School Of Medicine,Global Health And Social Medicine,Boston, MA, USA
Introduction: To ensure universal health coverage (UHC), essential surgical care must be affordable. In Rwanda, more than 90% of citizens have community-based health insurance (Mutuelle de Sante). For all but the poorest citizens who are fully covered, insured members are responsible for a 10% co-pay as out of pocket (OOP) payment at time of service. However, 59.5% of the population is already below the international poverty line meaning that even this amount along with associated care-seeking costs have a significant impact on a family’s financial health. The aim of this study was to describe OOP payments for cesarean sections in the context of Mutuelle de Sante and determine if having insurance reduces catastrophic health expenditure in rural Rwanda.
Methods: This study is nested in a larger study of women undergoing cesarean section at a rural district hospital in the Eastern Province of Rwanda. All eligible women between March and June 2018 were surveyed at time of discharge. Data included demographics, household income and routine monthly expenditures and direct and indirect spending related to the cesarean delivery hospitalization. Catastrophic health expenditure (CHE) can be defined as >10% estimated total yearly expenses or >40% annual non-food expenses.
Results: Of 346 women, 339 (98.0%) met the World Bank definition of extreme poverty (income <$1.90/person/day). 339 (98.0%) reported having health insurance; the majority (93.2%, n=316) have Mutelle de Sante. The median OOP expenditure for a direct medical costs related to a cesarean section was $26.29 (IQR 21.20-29.48). 30 (8.7%) patients had unpaid balances at time of discharge. The average cost including transportation to the hospital was $34.35 (IQR 26.99-40.93). 168 patients (48.6%) had to borrow money and 43 (12.4%) had to sell possessions to pay for the hospitalization. The direct medical costs alone were a CHE, defined as >10% estimated total yearly expenses, for 22 patients (6.3%). However, this increased to 33 (9.5%) when including direct non-medical costs such as transportation and food and 94 (27.0%) when including indirect expenses such as lost wages. Using 40% of non-food expenses to define CHE, up to 51.5% of patients experienced CHE when including other direct and indirect costs.
Conclusion: Despite universal health insurance, essential surgery still impoverishes households in rural Rwanda, the majority of whom already lie below the poverty line. Although insurance offers some protection against catastrophic expenditure from the cost of healthcare alone, when adding in the cost of non-medical expenses, cesarean section is still too often a catastrophic financial event. Further innovation in financial risk protection is needed in order to provide equitable UHC.