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The report was commissioned by Norwegian People's Aid (NPA) with funds from NORAD. The evaluation looks into NPA's support to health services in Gisenyi district of Rwanda. The focus of the evaluation is on Mutuelle, a community based health insurance scheme. The evaluation has a number of recommendations for reforming the Mutuelle, which may contribute to financial sustainability. A necessary condition for sustainability is a high membership rate, which in turn depends on the payment scheme as well as the quality of the health services. We recommend that the premiums must be transferred automatically to the health centre and the district hospital. This will ensure financial sustainability for the Mutuelle and the risk is transferred to the health district that can more easily bear the risk. In addition, small co-payments must be applied to avoid excessive use of the health services. We also suggest a second voluntary contract, where the prepayment is higher than in the present contract, and the co-payment is smaller. Finally, we suggest that NPA, or other agencies, pays the prepayment for the very poor.

Magnus Hatlebakk

Senior Researcher; Coordinator: Poverty Dynamics