Better access to healthcare in East Africa; Comparison of Free Access to health care and Health insurance financing systems.

Tayebwa Morris

Super visor Dr. Leon Beatus

Arcadia University

Center for East African Studies Nyerere Center for Peace Research, East African Community
Better access to healthcare in East Africa; Comparison of Free Access to health care and Health insurance financing systems. Key words: (Access to health care, Health financing) Abstract Introduction Health care financing provides the resources and economic incentives for operating health systems and is a key determinant of health system performance. The purpose of health financing is to make funding available, as well as to set the right financial incentives for providers, to ensure that all individuals have access to effective public health and personal health care. Government spending on health from domestic sources is an important indicator of a government's commitment to the health of its people, and is essential for the sustainability of health programmes This paper discusses the health care financing systems of Uganda and Rwanda, the two East African countries that have adopted different systems. Methods Relevant literature and government documents were extensively reviewed with the aim of assessing whether health care financing mechanisms of the two countries facilitated adequate access of health services to the people. Results and Discussion Uganda's health sector remains significantly under-funded, mainly relying on private sources of financing, especially out-of-pocket spending. At 9.6 % of total government expenditure, public spending on health is far below the Abuja target of 15% that government of Uganda committed to. Without compulsory health insurance and low coverage of private health insurance, Uganda has limited pooling of resources. In other words even among public facilities the cost of care remains a barrier to utilization of services.

Rwanda on the other hand made impressive progress in economic and social development since the 1994 genocide due to the introduction of a mixed health care financing model, combining decentralization and performance-based financing with community-based micro-insurance. Conclusion The health care financing system in Rwanda should be an inspiration to Uganda and other East African countries in their efforts to promote equitable health care and achieving universal health care. Introduction There are many definitions of access to health services, with most researchers recognizing that access is related to the timely use of services according to need.1 Facilitating access is concerned with helping people to command appropriate health care resources in order to preserve or improve their health. Access is a complex concept and is evaluated by the evaluation of about many aspects; availability, utilization, affordability, equity and then the sustainability of the services.2 If services are available and there is an adequate supply of services, then the opportunity to obtain health care exists, and a population may 'have access' to services. The extent to which a population 'gains access' also depends on financial, organizational and social or cultural barriers that limit the utilization of services. Thus access measured in terms of utilization is dependent on the affordability, physical accessibility and acceptability of services and not merely adequacy of supply. Services available must be relevant and effective if the population is to 'gain access to satisfactory health outcomes'. Equity of access may be measured in terms of the availability, utilization or outcomes of services for all social groups in the population. These services should also be available for a considerable time and therefore the sustainability of their adequate provision is vital. The global health community has recognised that public spending on health in developing countries is essential for meeting the Millennium Development Goals, reducing poverty, and
Campbell, S.M. et al. 2000: Defining quality of care. Soc. Sci. Med. 11: 1611 1625.
1

McIntyre D, Thiede M, Birch S 2009: Access as a policy-relevant concept in low- and middleincome countries. Health Econ Policy Law 2009, 4:179-193
2

fighting major diseases that kill, such as HIV/AIDS, tuberculosis, and malaria.3 In 2005, WHO member states adopted a resolution encouraging countries to develop sustainable and equitable health financing systems capable of achieving universal coverage4 African leaders acknowledged in Abuja, Nigeria, in 2001, by pledging to devote 15% or more of their yearly budgets to the health sector to fight HIV/AIDS and other infectious diseases5 Results from studies have suggested that a country's gross domestic product (GDP), government size, and external health resources might affect government health financing.6-7 An increase in domestic public financing of health in low-income countries is also suggested to be crucial for the sustainability of health programmes8 Categories of health care financing sources include, taxation, donor funds, social health insurance, private health insurance, other private sources like NGOs own resources and out-of-pocket (OOP) expenditures. This study aims at assessing the adequacy of health services in two of the East African countries ( Uganda and Rwanda) that have adopted different health care financing systems in order to determine the ideal system that can be adopted throughout the East African region. Background Health care resources in most East African countries come from either public or private sources. Private sources include households, private firms and not-for-profit organizations; the major
WHO 2001: WHO Commission on Macroeconomics and Health. Macroeconomics and health: investing in health for economic development. Geneva: World Health Organization, 2001. http://whqlibdoc.who.int/publications/2001/924154550x.pdf. (Accessed Nov 25, 2011).
3

WHO: Sustainable health financing, Universal coverage and social health insurance. Geneva 2005. (A58/33) 5 UN. African summit on HIV/AIDS, tuberculosis and other related infectious diseases: Abuja declaration on HIV/AIDS, tuberculosis, and other infectious diseases. New York: United Nations, 2001. http://www.un.org/ga/aids/pdf/abuja_declaration.pdf. (Accessed Nov 25, 2011).
4 6

Farag M, Nandakumar AK, Wallack SS, Gaumer G, Hodgkin D. Does funding from donors displace government spending for health in developing countries? Health Aff 2009; 28: 1045-1055. PubMed 7 Baldacci E, Clements B, Gupta S, Cui Q. Social spending, human capital, and growth in developing countries. World Dev 2008; 36: 1317-1341. PubMed 8 Heller PS. Understanding fiscal space. Washington DC: International Monetary Fund, 2005. https://www.imf.org/external/pubs/ft/pdp/2005/pdp04.pdf. (Accessed Nov 25, 2011).

sources of public funds are government and donors usually channeled through specific country budgets or through health projects. Questions concerning the mechanisms of financing health services and their affordability for the poor have been one of the most controversial topics concerning access to health services in East Africa. User fees, in particular, have been a contentious source of financing public services for these low-income country settings.9 There are now many studies in a wide variety of developing countries that have shown that the introduction of user fees or increases in prices can lead to decreased utilization.
[10][11]

and

that this effect can be larger for the poor. Sometimes the

reduction in service use has been associated with serious conditions. The abolition of user fees and the introduction of free access to health care in Uganda and community health insurance in Rwanda have been shown to increase use of curative, preventive, and promotive health services.
[12][13]

Methods A systematic review of studies on the two most common health financing systems in East Africa was conducted through an online search. Only peer-reviewed studies, i.e., those that were evaluated by a committee of experts in the field of study before being published were considered in order to guarantee content quality.A search of all peer-reviewed studies published between 1988 and 2011 on the abolition of user fees, the adoption of free access to health care in Uganda and community mutual insurance schemes in Rwanda. Results Health care funding in Uganda: Free access to health care. The Health Status
James, C.D. et al . 2006. To retain or remove user fees? Reflections on the current debate in low- and middle-income countries. Appl. Health Econ. Health Policy 3: 137153. 10 Yoder, R.A. 1989. Are people willing and able to pay for health services? Soc. Sci. Med. 1: 3542. 11 Collins, D. et al. 1996. The fall and rise of cost sharing in Kenya: the impact of phased implementation. Health Policy Plan. 1: 5263. 12 Burnham, G.M. et al. 2004. Discontinuation of cost sharing in Uganda. Bull. World Health Organization 3: 187195. 13 Nabyonga, J. et al. 2005. Abolition of cost-sharing is pro-poor: evidence from Uganda. Health Policy Plan. 2: 100108.
9

Uganda has a population of 30.7 million with an annual growth rate of 3.2%. With a population density of about 120 persons per km2, Uganda is one of the most densely populated countries in SubSaharan Africa. 88% of the population lives in rural areas. Uganda has made progress in improving the health of its citizens. the health sector investments in both the public and private sectors have yielded modest successes including reduction in Maternal Mortality Ratio (MMR) from 505 deaths per 100,000 live births in 2001 to 435 deaths per 100,000 live births in 2006, a decline in the Infant Mortality Rate (IMR) from 89 deaths per 1,000 live births in 2001 to 75 deaths per 1,000 live births in 2006 and an increase in the Life Expectancy at birth from 46.9 years in 2001 to 51 years in 2006. Despite these successes, health indicators are still poor and health systems weak. These and other challenges prevent attainment of key national and international targets. Health Financing Utilization Studies have shown that the abolition of user fees increased the demand of health services by more people.1415 Utilization of services (especially primary care visits and assisted deliveries) steadily rose, particularly among the poor. However, most health facilities got more numbers than they could accommodate. This led long waiting times, congestion, low time devoted to each patient and a lack of privacy, shortages of drugs and medicines, a deterioration of cleanliness in most health facilities and increase in workloads hence poor quality services exacerbated by the negative attitudes on the part of health care workers. This has slightly improved over the years and public-sector resources are insufficient therefore those who are able to pay have turned to private services. In Uganda utilization of private health care services is high but limited to those that can afford the high costs.
14

J Nabyonga et al 2005; Abolition of cost-sharing is pro-poor: evidence from Uganda. Health Policy Plan 20: 10008. http://heapol.oxfordjournals.org/content/20/2/100.full.pdf accessed Nov 30 2011.
15

Xu K, Evans DB, Kadama P, et al.2006 Understanding the impact of the elimination of user fees: utilization and catastrophic health expenditures in Uganda. Soc Sci Med 2006; 62: 866 76. http://www.who.int/entity/health_financing/documents/socscimed_06 impact_user_fee_elimination.pdf

On the other hand, some studies show that some of the transitory problems related to the quality of services (particularly shortages of medicines), excessive workload for health care workers, and patients turning to paid services when the free services are overloaded are not related to the abolition of fees as such.16 Rather, they are due to inadequate implementation; that is when implementation is precipitous, the required resources poorly planned and not available and follow-up lacking. Affordability Payment of user fees by patients excludes vulnerable populations from access to health services and places them at risk of further impoverishment. This impedes both the efforts to alleviate poverty and the attainment of the Millennium Development Goals. Therefore the government of Uganda adopted free access to health care aimed at improving the relevance, effectiveness and access of services that people need. However despite services being free, patients continue to pay certain expenses and some costs (for example, transportation to health facilities) are not covered by the abolition policies. Some health care providers still charge unofficial payments. This is at most times too expensive for the poor for example most women are unable to pay for their deliveries; there is also the problem of unofficial sale of small supplies such as gloves to women giving birth. Thus, abolition does not solve all problems related to health care costs.

Sustainability In Uganda, households constitute a major source of health financing (49%) followed by donors (35%) and then government (15%). NGOs contribute less than 1%.17 After user fees were abolished in all government health facilities in March 2001, it led to the loss of revenue for health facilities that heavily depended on the fees as a significant source of funding. This loss
16
Janestic M. Twikirize , Constance O'Brien; 2011 Why Ugandan rural households are opting to pay community health insurance rather than use the free healthcare services http://onlinelibrary.wiley.com/doi/10.1111/j.1468-2397.2010.00771.x/full

17

WHO: World Health statistics. 2010.

then had to be compensated therefore Ugandan government had to mobilize supplementary funding to continue adequately facilitating its health budget. However the funding has proved to be inadequate for the level of activity in the health facilities and therefore most of them have to run a dual system. This is a system where there is a free wing for those who cannot afford the payment and a wing for those who can afford. Nearly all private sector facilities still charge user fees and there is evidence of patients paying under-the counter fees in even in public institutions.18

Availability In all public health facilities curative, preventive, rehabilitative and promotive health services are free, having abolished user fees in 2001. However, user fees in public facilities remain in private wings of public hospitals. 72% of the households in Uganda live within 5km from a health facility (public or Private Not For Profit),19 however utilization is limited due to poor infrastructure, lack of medicines and other health supplies, shortage of human resource in the public sector, low salaries, lack of accommodation at health facilities and other factors that further constrain access to quality service delivery.

Health care financing in Rwanda: Community health insurance The Health Status Rwanda is a landlocked country with an estimated population of 9.2 million living within an area of 26,338 km2 or 350 persons per km2. It is also among the most densely populated countries in Africa. The population growth rate is currently 2.6% and it is estimated that Rwanda will attain a population of16 million by 2020 if the population growth rate remains unchanged. It has however made impressive progress in economic and social development since the 1994 genocide when about 1 million people were massacred, 2 million became refugees, and much of
Uganda Bureau of Statistics, National Service Delivery Survey; Uganda Bureau of Statistics, Kampala - Uganda; 2005 19 Ministry of Health Uganda 2010: Health Sector Strategic and Investment plan Promoting Peoples Health to Enhance Socio-economic Development 2010/11 2014/15 http://www.health.go.ug/docs/HSSP_III_2010.pdf
18

the country's health facilities were destroyed.20Rwanda is now well on the road to recovery, and living standards have returned to and even surpassed their pre-1994 levels. Corruption is decreasing infrastructure has improved, and access to education has greatly.21 The country's impressive economic growth rate (presently 6% per year) has helped to reduce poverty but income is unequally distributed with a distinct urban to rural divide. 37% of Rwandans (mostly rural) live in extreme poverty, unable to afford basic foods, and 569% live on less than the national poverty line.22 The country's health status can be shown by health indicators data obtained from the Demographic and Health Surveys (2005/2006),23 and Rwandan Ministry of Health (2008).24 Where Infant (less1 year) mortality is at 86/1000, Mortality in children less than 5 years is 152/1000 and Maternal mortality is 750/100 000 with 486% of births delivered with the assistance of qualified personnel. HIV prevalence is still high at 30% and Malaria leads to 400% of consultations in health facilities while 600% of HIV patients are diagnosed with tuberculosis. Contraceptive prevalence is 170% among married women and 60% of Rwandans live within 5 km of a health facility. Rwanda is among the countries with the highest immunization coverage in Africa. And even with an overall prevalence rate of 30% evidence suggests that the rate of HIV/AIDS is decreasing25 Health Financing: The Mutuelle de Sante, a Community-Based Insurance Scheme

20

Gatete Claver. Rwandan Ambassador to the UK.; Post-genocide reconstruction and Development in Rwanda. Address to the International Development Group of the Scottish Parliament. Edinburgh, Scotland, May 24, 2006. 21 World Bank. Governance matters 2007. Worldwide governance indicators. Chart for Rwanda available at http://info.worldbank.org/governance/wgi2007/sc_chart.asp. (accessed Dec 1, 2011). 22 United Nations Development Programme and Government of Rwanda. Turning Vision 2020 into reality. From recovery to sustainable human development. National Human Development Report. United Nations Development Programme and Government of Rwanda, 2007. 23 Demographic and Health Surveys. Rwanda Demographic and Health Survey 2005 Final report. Calverton: Demographic and Health Surveys, 2006. http://www.measuredhs.com/pubs/pub_details.cfm? ID=594&ctry_id=35&SrchTp=ctry&flag=sur. (Accessed Dec 1, 2011). 24 Rwandan Ministry of Health. Health indicators. http://www.moh.gov.rw/health_indicator.html. (accessed Dec 1, 2011) 25 UNAIDS. 2008 progress reports submitted by country. http://www.unaids.org/en/CountryResponses/Countries/rwanda.asp.

With the advent of peace, the government began working to restructure health care and to decentralize management to the most local levels in order to increase utilization rates and improve overall health. The government of Rwanda implemented user-fees in 1994 to supplement meager health center budgets. However, a survey in 2001 found that utilization of primary care had declined to just 23% of the population, and health outcomes were deteriorating, with HIV/AIDS and other infectious disease burdens on the rise. The decline in utilization and health indicators was attributed to high user-fees for primary, secondary and tertiary-level care. Hence the health financing schemethe Mutuelle de Sante was introduced in 1999 and by 2006 had increased coverage to include nearly all provinces and about 73% of the population. Previously Rwanda relied on out of pocket financing mostly through the payment of user fees by patients in order to access health services. Health care was completely funded by patients. However, most health centers did not have enough competent staff and equipment and 6080% of their costs were generated from user fees,26 which became such a crippling burden to the poor that they turned to traditional medicine as a result. The scheme is run as an autonomous organization, managed by its members, and helps people to share the risk of having to pay in full for treatment at village and at district levels. Boosted by funds from the central government to a cut-off point of $5000, shared between the district and rural health facilities, the scheme provides basic servicesie, family planning, antenatal care, consultations, normal and complicated deliveries, basic laboratory examinations, generic drugs, hospital treatment for malaria, and some tertiary care. In the event of a health disaster, a central reserve fund has been set up. The administrative costs represent 58% of the total revenue.27 Each member of the insurance scheme contributes 1000 Rwandan Francs ($2) per year and also pays a 10% fee for each illness episode. Decisions relating to the scheme are made through an elected village committee that decides who is too poor to pay. The cost of the insurance scheme for the nominated poor is subsidized by donors. Those with HIV/AIDS (and their families) who are in a PEPFAR programme are excused from paying contributions. Data from 2004 suggest

26

Oeters R, Habineza C, Peerenboom P. Performance based financing and changing the district health system: experience from Rwanda. Bull World Health Organ 2006; 84: 884-889. 27 Kalk A, Kagubare J, Musango L, et al. Paying for health in two Rwandan provinces: financial flows and flaws. Trop Med Int Health 2005; 10: 872-878.

that 10% of the population had their fees waived, 28although an estimate in 2005 suggested that 1530% of the poorest population need to have their fees waived. The community insurance scheme coverage is impressive and generates substantial risk sharing. The increase in use of district health facilities means that families should have improved health and a reduction in the burden of unexpected bills. Though much has been achieved by the Government of Rwanda since 1994, major challenges remain. This densely populated country struggles to feed its inhabitants and is situated in an area of continuing geopolitical instability, with all the associated economic and political uncertainty.

Utilization Between 2000 and 2007, Rwanda improved financial access for the poor, increased utilization of health services and reduced out-of-pocket payments for health care. Poor groups utilization increased for all health services. Use of assisted deliveries, for example, increased from 12.1% to 42.7% among the poorest quintile; payments at the point of delivery were also reduced; and catastrophic expenditures declined.29 Most of these achievements were linked to innovative health financing policies, particularly the expansion of micro-insurance (mutuelles) and performance-based financing. The mutuelles program has been a notable success; perhaps because of its community-based, grassroots formation and its affordability, the plans have seen high rates of uptake. Out-of-pocket spending has decreased, and primary care utilization has increased as a result of the program, which has enjoyed continued and increasing support from the Rwandan government and involved aid organizations. Rwandans widespread participation in the mutual insurance schemes is unique in the region; according to Laurent Musango of the World Health Organization, Rwanda is the only country in sub-Saharan Africa in which 85% of the population participates in mutual insurance programmes for their health coverage.
28

Schmidt J-O, Mayindo J, Kalk A. Threshold for health insurance in Rwanda: who should pay how much? Trop Med Int Health 2006; 11: 1327-1333. 29 Claude Sekabaraga, Francois Diop, and Agnes Soucat: Can innovative health financing policies increase access to MDG-related services? Evidence from Rwanda Health Policy Plan. (2011)

Most remarkably, family planning intake has increased from 3.4% to 27.4%, a result never previously observed elsewhere.30Utilization of preventive care such as antenatal care (ANC) and immunization are steadily on an increase among the poor. In 2005, 19% of children under 5 suffering from fever and cough used public health services, compared with 8% in 2000, while 3% made use of private health services in 2005 as compared to 6% in 2000.31 Traditional healers, who were the leading source of health care in 2000 when they accounted for 11% of consultations, were the least consulted by 2005, at 7%. This increase in utilization by children under 5 has taken place for all socio-economic groups. Among children from the poorest quintile, the rate of utilization of modern services in the case of fever and cough more than doubled from 7% to 18%.

Availability Since 2005, geographical access to health facilities has been improved after the construction and rehabilitation of 3 new district hospitals and 14 new health centers. Transport capacity has increased as 71 ambulances (2.5 per district) and 570 motorcycles have been distributed to health facilities.32 Nevertheless, unmet need remains considerable. Distance is a significant negative predictor for the utilization of many services, for example assisted deliveries. Rwandans distance from their nearest providers, a function of the countrys acute provider shortage, is a further barrier to care that mutuelles cannot solve.

Affordability Improvement of the accessibility and affordability of health services and the quality of care are key goals of the Health Sector Strategic Plan for 200509. 33 However the yearly fee of $2 per person in the population is still expensive for the rural poor, and insufficient to fund
May JF, Kamurase A: Demographic growth and development prospects in Rwanda: implications for the World Bank. Washington, DC: The World Bank; 2009. 31 Source: Demographic and Health Surveys (DHS) 2000 and 2005. Ministry of Health Rwanda 32 District Health System Strengthening Report, 2008. 33 Government of Rwanda. Health sector strategic plan 20052009. Ministry of Health (MINISANTE), Kigali, Rwanda
30

comprehensive basic care,34which necessitates substantial extra central funding and donor contributions. According to WHOs Laurent Musango, former director of the School of Public Health at the National University of Rwanda, the growth of the mutual health insurance system has been a great success from the point of view of the affordability of the programme, and the fact that all corners are covered: Rwanda is the only country in sub-Saharan Africa in which 85% of the population participates in mutual insurance programmes for their health coverage, he says, adding that coverage is afforded to, the rich as well as the poor, the young as well the old, the urban as well as the rural population. Musango further argues that mutualization has also led to a reduction in health-care costs, and the increased use of health-care services. However there have been suggestions that people are being pressured into participating in a scheme they can ill-afford. In the poorest regions of Rwanda there are people who are finding it difficult to pay for the mutuelle and currently there is no system of subsidies or premiumwaiving for these individuals.

Sustainability Rwanda benefits from a high level of foreign aid. By 2002, the government was spending 86% of its revenue on health, which constituted about a third of Rwanda's spending on health; the remainder came from international donors or from the population in the form of direct payments for care. By 2007, government health spending had increased to 95% of total public expenditure.
35

African Development Bank. Aid, debt relief and development in Africa. African Development Report 2006. Oxford: Oxford University Press, 2006. 35 United Nations Development Programme and Government of Rwanda. Turning Vision 2020 into reality. From recovery to sustainable human development. National Human Development Report. United Nations Development Programme and Government of Rwanda, 2007.
34

More than half the health sector funding comes from a proliferation of donors or nongovernment organizations.36 Very short donor timescales lead to continual renegotiation because 55% of donor projects end within 1 year. The timing of aid delivery is often unreliable, whereas other factors, such as inflation or exchange rate variations, can grossly distort the final payout. Long-term health plans are therefore difficult to make.

Conclusion Although Uganda's decentralization has been praised, it has introduced major obstacles to service provision. This is because most of the funds distributed to districts have been earmarked by donors and the Ministry of Health for specific uses. As a result specific local priorities are often not addressed. Decentralization has actually widened disparities in the nature and quality of health services. Due to the consistent provision of poor quality services in public health facilities there has been a growth of private clinics which have further promoted socioeconomic inequality within Uganda and the poor, who make up the majority of the population, have become worse off. Fixed funding of hospitals by the government has not made it possible to increase staffing or provide the extra drugs and equipment needed to treat the growing population. Technical inefficiency among health facilities is so high. Healthcare outputs are more expensive than they used to be. Thus the reforms have not increased efficiency. Nor have they reduced reliance on external support. Currently, over 50% of Uganda's health sector spending still comes from external aid. Uganda should adopt a universal health and welfare framework, which they must increasingly finance from internal sources. The Ugandan health sector has shown considerable desire to have Community Health Insurance (CHI) as an elaborate health sector financing mechanism in Uganda though it still faces low enrolment only limited to the private not for profit sub-sector, mainly church-related rural hospitals. It therefore has a lot to learn from Rwanda.
United Nations Development Programme and Government of Rwanda. Turning Vision 2020 into reality. From recovery to sustainable human development. National Human Development Report. United Nations Development Programme and Government of Rwanda, 2007.
36

An important lesson learned from the Rwanda experience is that in introducing pro-poor financing policies there is need to develop a mixed health care financing model, combining decentralization and performance-based financing with a strategy to pool private spending through the building of grassroots, community-based micro-insurance. This paper shows that the route chosen by Rwanda yields promising results which could be emulated by other low-income countries especially in East Africa in search of models to reduce financial barriers to health care. Taken together with other reforms such as quality insurance and improvements in quality control through supervision and additional of contributions from other insurance schemes and the government, community health insurance is highly successful. However Rwanda should ultimately reduce its dependency on aid. The Rwandan government needs to increase health spending from the present level of 95% of national budget to the 2001 Abuja target (agreed by African governments) of 15% of national budgets for health, and to align development to target the most vulnerable in society. Sustainability and the necessary evolution of the institutional support for the health financing approach of Rwanda should be considered. Mutuelles certainly provide a way towards more sustained domestic funding and are an efficient way to pool private out-of-pocket spending. But there is a need for the government with the help of donorsto subsidize the enrolment of the poorest and to ensure the regulation of the package benefits as well as the provider payments mechanisms in order to ensure equitable access to quality services. All in all, Health care financing in Rwanda should be in many ways an inspiration to Uganda and other East African countries in their efforts in achieving universal health care. Bibliography African Development Bank. Aid, debt relief and development in Africa. African Development Report 2006. Oxford: Oxford University Press, 2006. Baldacci E, Clements B, Gupta S, Cui Q. Social spending, human capital, and growth in developing countries. World Dev 2008; 36: 1317-1341. PubMed Burnham, G.M. et al. 2004. Discontinuation of cost sharing in Uganda. Bull. World Health Organization 3: 187195.

Campbell, S.M. et al. 2000: Defining quality of care. Soc. Sci. Med. 11: 16111625. Claude Sekabaraga, Francois Diop, and Agnes Soucat: Can innovative health financing policies increase access to MDG-related services? Evidence from Rwanda Health Policy Plan. (2011) Collins, D. et al. 1996. The fall and rise of cost sharing in Kenya: the impact of phased implementation. Health Policy Plan. 1: 5263. Demographic and Health Surveys (DHS) 2000 and 2005. Ministry of Health Rwanda Demographic and Health Surveys. Rwanda Demographic and Health Survey 2005 Final report. Calverton: Demographic and Health Surveys, 2006. http://www.measuredhs.com/pubs/pub_details.cfm? ID=594&ctry_id=35&SrchTp=ctry&flag=sur. (Accessed Dec 1, 2011). District Health System Strengthening Report, 2008. Farag M, Nandakumar AK, Wallack SS, Gaumer G, Hodgkin D. Does funding from donors displace government spending for health in developing countries? Health Aff 2009; 28: 10451055. PubMed Government of Rwanda. Health sector strategic plan 20052009. Ministry of Health (MINISANTE), Kigali, Rwanda Heller PS. Understanding fiscal space. Washington DC: International Monetary Fund, 2005. J Nabyonga et al 2005; Abolition of cost-sharing is pro-poor: evidence from Uganda. Health Policy Plan 20: 10008. http://heapol.oxfordjournals.org/content/20/2/100.full.pdf accessed Nov 30 2011. James, C.D. et al . 2006. To retain or remove user fees? Reflections on the current debate in low- and middle-income countries. Appl. Health Econ. Health Policy 3: 137153. Janestic M. Twikirize , Constance O'Brien; 2011 Why Ugandan rural households are opting to pay community health insurance rather than use the free healthcare services http://onlinelibrary.wiley.com/doi/10.1111/j.1468-2397.2010.00771.x/full Kalk A, Kagubare J, Musango L, et al. Paying for health in two Rwandan provinces: financial flows and flaws. Trop Med Int Health 2005; 10: 872-878. May JF, Kamurase A: Demographic growth and development prospects in Rwanda: implications for the World Bank. Washington, DC: The World Bank; 2009. McIntyre D, Thiede M, Birch S 2009: Access as a policy-relevant concept in low- and middleincome countries. Health Econ Policy Law 2009, 4:179-193

Ministry of Health Uganda 2010: Health Sector Strategic and Investment plan Promoting Peoples Health to Enhance Socio-economic Development 2010/11 2014/15 http://www.health.go.ug/docs/HSSP_III_2010.pdf Oeters R, Habineza C, Peerenboom P. Performance based financing and changing the district health system: experience from Rwanda. Bull World Health Organ 2006; 84: 884-889. Rwandan Ministry of Health. Health indicators. http://www.moh.gov.rw/health_indicator.html. (accessed Dec 1, 2011) Schmidt J-O, Mayindo J, Kalk A. Threshold for health insurance in Rwanda: who should pay how much? Trop Med Int Health 2006; 11: 1327-1333. Uganda Bureau of Statistics, National Service Delivery Survey; Uganda Bureau of Statistics, Kampala - Uganda; 2005 UN. African summit on HIV/AIDS, tuberculosis and other related infectious diseases: Abuja declaration on HIV/AIDS, tuberculosis, and other infectious diseases. New York: United Nations, 2001. http://www.un.org/ga/aids/pdf/abuja_declaration.pdf. (Accessed Nov 25, 2011). UNAIDS. 2008 progress reports submitted by country. http://www.unaids.org/en/CountryResponses/Countries/rwanda.asp. United Nations Development Programme and Government of Rwanda. Turning Vision 2020 into reality. From recovery to sustainable human development. National Human Development Report. United Nations Development Programme and Government of Rwanda, 2007. WHO 2001: WHO Commission on Macroeconomics and Health. Macroeconomics and health: investing in health for economic development. Geneva: World Health Organization, 2001. WHO: Sustainable health financing, Universal coverage and social health insurance. Geneva 2005. (A58/33) WHO: World Health statistics. 2010. World Bank. Governance matters 2007. Worldwide governance indicators. Chart for Rwanda available at http://info.worldbank.org/governance/wgi2007/sc_chart.asp. (accessed Dec 1, 2011). Xu K, Evans DB, Kadama P, et al.2006 Understanding the impact of the elimination of user fees: utilization and catastrophic health expenditures in Uganda. Soc Sci Med 2006; 62: 86676. Yoder, R.A. 1989. Are people willing and able to pay for health services? Soc. Sci. Med. 1: 35 42.