Memoire Online - The contribution of rwandan health insurance in economic development of rwanda

I, DUSABIMANA Athanase, hereby declare that to the best of my knowledge, this Dissertation entitled «The contribution of Rwandan health insurance in the economic development of Rwanda» is original and my inventive work and has not been presented in Umutara Polytechnic or any other university or institution of higher learning for the academic award. Where other beneficiaries' work has been used, references are appropriately given.

APPROVAL

This is to certify that the Dissertation entitled «The contribution of Rwandan health insurance in economic development of Rwanda» was done by DUSABIMANA Athanase under my supervision.

To Almighty God and His Son Jesus Christ, my Duagther, your sleep does not mean the absence. To my mother, my sisters, and my brothers your tireless support and prayers will always be remembered!! Friends and relatives whose courage, love and contribution were of great influence to the successful completion of my study.

ACKNOWLEDGEMENT

The memoire is in fact the final result of my loving and understanding beneficiaries and thus the production of which owes much to the assistance of many beneficiaries without whose efforts this work would not have seen the light of the day. However, due to limited space I cannot mention all, but nevertheless I appreciate their efforts in all respects.

Thanks to God our father and Jesus our savior for giving me energy, enthusiasm, health body, wisdom, which helps me during my studies.

This research is a result of joint effort from the beneficiaries who, in away or in another contributed to its completion. I register my sincere gratitude to them.

My heartfelt recognition goes to Mr. KABANDANA Ernest for his encouragement, correction, advice and motivation through my research work as my supervisor. I am great full to him for tireless contributions to my work.

My gratitude is extended to all my teachers and lectures, which taught and guide me from primary schools to the institutions of higher learning. For their devoted tutelage and guidance.

My recognition is also extended to the beneficiaries of Ruganda sector; authorities and beneficiaries of MHI, from whom the information used were given and their staff for the ideas and support offered.

My personal singular appreciation and love go to my parents; my father NKUMBUYE Leonidas, my mother MUKARWEMA Judith for sacrifice of choosing and permitting me to be away in the academic work.

Special credit goes to my Brothers and Sisters mostly the families of Mr. SIBOMANA J. Damascène and Mr. HITIMANA Marcel, Friends for their encouragement, financial, social, and moral and all material support you have given me throughout my life and academic pursuit.

Lastly but not least, to all of you out there who wished me good luck and success. May God reward you unsparingly!

LIST OF ABBREVITIONS

GTZ: Deutsche Gesellschaft fur Technische Zusammenarbeit (German International Development assistance program)

LIST OF TABLES

LIST OF APPENDICES

DEDICATION........................................................................................................................III

1.5.1.General objective.................................................................................3

1.5.2.Specific objectives...............................................................................3

2.2.1. Health insurance.................................................................................7

2.2.2. Economics......................................................................................10

2.2.3. Development...................................................................................11

3.4.1. Primary data ....................................................................................33

3.4.2. Secondary data ................................................................................33

3.8.1. Interview guide ................................................................................34

3.8.2. Observation.....................................................................................35

3.8.3. Documentation ................................................................................35

3.8.4. Questionnaire .................................................................................35

3.9.1. Data processing ...............................................................................35

3.9.1.1 Editing ........................................................................................36

3.9.1.2. Tabulation ....................................................................................36

3.9.2. Data analysis...................................................................................36

4.3. Analysis, Presentation, and Interpretation of data part two (Staffs) .........................51

ABSTRACT

This study is about the contribution of Mutual Health Insurance on the economic development in Ruganda sector as a case of study. The study was carried out in Ruganda sector and its objective are as follows: To Examine the functioning of Mutual health insurance scheme in Ruganda sector; to find out the impact of improved health status of the people on Economic development in Ruganda sector, to identify the challenges encountered by both mutual health officials and the beneficiaries of mutual health insurance in Ruganda sector. In order to arrive to the findings, the researcher used structured questionnaires and the interview guide to collect data.

The population of the study was comprised both beneficiaries of mutual health insurance and staffs at the sector and cell levels in Ruganda sector. These questionnaires were given to 30 respondents including fourteen questionnaires (14) which include six heads of households (6); six agents (6) of mutual health insurance and two patients (2) in health centre of Biguhu. Sixteen questionnaires (16) designed to the staffs at sector and cell levels and two nurses (2). A sample of 30 respondents was randomly selected.

Findings revealed that Mutual health insurance plays a big role in the economic development process of the beneficiaries in Ruganda sector through real costs of healthcare services costs minimization. Hence new ventures were to be born through good management of mutual health insurance contributions. At the end of the study, several suggestions were given to the officials and beneficiaries of this policy of MHI scheme and even suggestion for further research was proposed.

CHAPTER ONE: GENERAL INTRODUCTION

1.1 Introduction

This chapter is detailed with background of the study, problem statement, objectives of the study, purpose of the study, research questions, significance of the study, organization of the study and conceptual framework.

1.2 Background of the study

The concept of community health dates back in 1831-32 during the great revolution in sanitation when cholera broke up in England. Cholera caused panic and beneficiaries fled the cities and others had died during the medieval plagues. It is a salutary reminder to the rich that they could not be the privileged immunity that pestilence was something Shared by the poor and therefore could be combated communally through community health. In many African countries a considerable proportion of the population faces problems of financial access to essential healthcare services. This holds especially true for the informal sector and beneficiaries living in rural areas. (Barry1965:322)

Community health insurance schemes have existed in Rwanda; it was in the 1960s that community-based health insurance systems, like the association Muvandimwe de Kibungo (1966) and the association Umubano mu bantu de Butare (1975) started to be constituted. However, these community-based health insurance initiatives were further developed only since the reintroduction of the payment policy in 1996 and especially increase during the past five years. Membership rates of Community Based Health Insurance (CBHI) stood at 73% in 2006 and increased since then to reach 91% of coverage in 2010. (The World Health Report (2000). WHO, Geneva.)

Community health insurance schemes are normally local community initiatives based on concepts of solidarity and risk pooling and involve active participation of group members. They improve equity access to healthcare for the excluded high level of solidarity, trust and finally improve the ability to counter-risk, cover all healthcare cost. In order to enhance healthcare coverage and provide financial protection against impoverishment due to the costs of catastrophique illness, the Government of Rwanda has implemented several financing mechanisms; (The World Health Report (2000). WHO, Geneva.).

In addition to the Community Based Health Insurance Policy, the present policy has been elaborated to provide a comprehensive guiding framework for a National Health Insurance system in Rwanda. In 2010, the CBHI policy has been updated in order to be more adapted to the current challenges. The new policy was improving population's access to quality health services in a fair and equitable manner. The existing statutory social security system in Rwanda includes the Social Security Fund (pensions and occupational risks); and, for the health part, the RAMA and the MMI. (World Bank (2003), Washington, DC.).

The Ruganda sector has shown a strong interest in strengthening the structure and capacity of public institutions in providing social security through healthcare services. The sector is striving to achieve set targets for MDGs despite this being an uphill task considering that economic development level prevailing in the country is still low. In Ruganda this policy is in and most of them are the client. Financially, the health institutions can develop themselves and auto finance because the payment of the premium at the right time in a collective system, health institutions can procure enough materials and medicines in order to effectively continue serving the beneficiaries.

1.3. Statement of the problem

According to Hellman and Atim C (1999:143). An estimated 1.3 billion people worldwide lack access to effective, affordable healthcare, while millions of households worldwide every year face financial ruin as a direct result of large medical bills. To reduce such large medical bills there is a need to share the bills through community based health insurance. With the help of community based health insurance schemes, health costs are minimized and these costs would be invested in profitable ventures/investments to reduce poverty.

However; there is this policy of community based health insurance, in Rwanda, beneficiaries still facing the above problem of large medical bills. Hence poor or inappropriate healthcare service in Rwanda and in Ruganda sector in particular. Basing on the above problem, the researcher intended to examine, «The contribution of Rwandan health insurance (Mutuelle de santé) in Economic development of Rwanda.

1.4. Purpose of the study

This study aimed at examining the reciprocity between mutual health insurance scheme and its contribution towards the economic development of Rwanda.

1.5. Objectives of the study

1.5.1. General objective

The general objective of this study was to examine whether there is a contribution of Mutual health insurance scheme (Mutuelle de santé) to the Economic development.

1.5.2. Specific objectives

i. To find out the functioning of Mutual health insurance scheme in Ruganda sector;

ii. To find out if improved health status of the people has the impact on Economic development in Ruganda sector,

iii. To identify the challenges encountered by both mutual health officials and the beneficiaries of mutual health insurance in Ruganda sector.

1.6. The research questions

ii. What is the impact of improved health status of the citizens on the Economic development in Ruganda sector?

iii. What are the challenges encountered by both the officials and beneficiaries of Mutual health insurance in Ruganda sector?

1.7. Scope of the study

This research was carried out in Ruganda sector and covers a selected sample of households living in cells that made up Ruganda sector. Findings of this study were based on the analysis of the views of surveyed households in this sector. It involved a survey of households benefiting from Mutual health insurance from the period of 2010-2011.

1.8. Significance of the study

Firstly, this study complemented the various academic courses undertaken in the domain of Economics and Business Studies. Besides; this research enabled the researcher to get his Bachelor's Degree in Commerce and Applied Economics with specialization in Economics.

To Umutara Polytechnic and other Higher Learning Institutions in Rwanda, the results from this study constituted the secondary data as the literature review for future researchers on the same or related topics or field. This study expected to equip the researcher with appropriate and suitable skills and experience in conducting important future researches.

Research findings are expected to be helpful to the policy-makers in Rwanda in formulating policies in favor of rural development especially those aimed at reducing poverty and improving health status of the beneficiaries. The study intends to help the rural beneficiaries to know and understand the benefits of Mutual health insurance (Mutuelle de Santé) for easy and better health accessibility.

The government of Rwanda enlightened with the functioning and the contribution of Mutual Health Insurance schemes in general and Health status of the citizens in particular to the economic development of Rwanda. Therefore, the need to be more improved. Finally, this study also intends to highlight beneficiaries' perceptions on the current implementation of Mutual health insurance policy. This helped to make necessary adjustments of the health policies depending on the wishes of the beneficiaries.

1.9. Organization of the study

This study concerned about the contribution of Mutual Health Insurance on Economic development of Rwanda. It is thus organized in the following five chapters:

Chapter one tackled the introductory part showing the background of the study, statement of the problem, objectives of the study, research questions, and scope of the study, significance of the study and organization of the study.

Chapter two discusses the theoretical background under which the topic understudy lies; it also indicates the definition of various key concepts making up the topic.

Chapter three covers the methodology; it provides methods and techniques used in data collection, analysis and interpretation of findings.

Chapter four gives the findings of the study and the relevant interpretation, which is compatible to the stated objectives and hypothesis of the study.

Chapter five provides a summary of the findings, conclusions, recommendations and suggestions concerning potential areas for further research.

2.1. General introduction

This chapter is detailed with the review of the available literature related to the research under study. It addresses the conceptual understanding of research literature on CBHI in Rwanda and mutual health insurance in general, definition of key concepts, the requirements for economic development, community health insurance schemes in Rwanda, the interventions on the policy of health insurance, current problems of mutual health insurance schemes in Rwanda, global overview of Rwanda health insurance schemes, principal objectives of insurance schemes, organization and management of mutual health insurance schemes in Rwanda, HIWTP, challenges of health insurance schemes in Africa . The literature was gathered through various sources such as Books, journals, and Internet websites.

2.2. Definition of key concepts

Many studies have focused on the dilemma of poverty and indeed on strategies to alleviate it. Most developing countries including Rwanda have put poverty alleviation as their primary development plan. UNDP, as cited by Sobhan R. (2001:2) Showing the best provider of the best solutions to the problems hinder MHI indicates that, 69% of all developing countries have prepared explicit poverty plans or have incorporated poverty alleviation into their National plans. For Rwanda's case, rural development and agricultural transformation is the first priority for development and as such, the human development is also among the government's most priorities for development. (Sobhan R. and Carrin G; 2003:2).

Many authors have contributed much in the elaboration of the study variables of mutual health insurance and rural poverty reduction. Therefore, literature on these two study variables especially poverty is wide and inexhaustible and as such, limits have been set and the unexhausted part acts as an eye-opener for the completion of other researches in the same field. (Carrin G, 2003:11)

2.2.1. Health insurance

The function of insurance is to provide protection to individuals against financial loss. It does so by pooling the risks of each individual across an entire group of individuals who by paying to be covered. Thus, an insurer of a particular financial risk faced by an individual was offer to «cover» that risk in return for payment of a premium. This premium is determined by averaging the expected losses (during the time period covered) for the whole group of individuals buying the coverage, and adding a charge for the administrative and other expenses of the insurer (Jutting, J, 2003:132).

When applied to the area of healthcare, a similar logic applies for any one person, getting sick or injured can be an unpredictable and very costly event, but it was happen to relatively few beneficiaries during any particular time period. By «pooling» the risk of large healthcare costs over many beneficiaries, health insurance can make necessary healthcare relatively more affordable and thus more available to all «Pooling» health risks, however, does not need to be done through commercial insurance markets. Besides, there are relatively few opportunities to do so in developing countries where private markets for medical services are mostly small and underdeveloped (Jutting, J, 2003:132).

Instead, in these countries, the broader function of health insurance to provide protection against loss of good health has traditionally been performed by governments' organizing and financing a system for delivering medical care, when needed, for the whole population. Despite broad scale efforts and the best of intentions, governments of developing countries have not been able to cover all of their populations with the needed (acute, inpatient) services. Often these services that are available have been delivered inefficiently. Community based health insurance has been introduced in many countries as a potentially effective way to supplement or to complement government-sponsored healthcare. Efforts to promote the development of health insurance in developing countries may therefore be needed as a part of overall health reform efforts.(Jutting, J. 2000a),

2.2.1.1. Understanding Health Insurance Terms

According to Schneider and Diop (2001:43), the following terminologies help in providing an insight about health insurance. There is a need to understand mutual health which is a term applied to bringing together different efforts to reduce the severity of something.

Another term is co-payment which implies the mode of sharing medical costs, where you pay a flat fee every time you receive a medical service (for example, $5 for every visit to the doctor). The insurance organization pays the rest. Additionally, there are covered expenses which means that most insurance plans whether they are fee-for-service, health maintenance organization (HMOs), or preferred provider organization (PPOs), do not pay for all services. Some may not pay for prescription drugs. Others may not pay for mental healthcare. Covered services are those medical procedures the insurer agrees to pay for. (Schneider and Diop, 2001:43).

Maximum Out-of-Pocket; this involves the amount of money one is required to pay a year for deductibles and coinsurance. It is a stated dollar amount set by the insurance company, in addition to regular premiums.

Non-cancelable policy; this is a policy that guarantees you can receive insurance, as long as you pay the premium. It is also called a guaranteed renewable policy.

Premium; this is the amount you or your employer pays in exchange for insurance coverage.

Provider; this includes any person (doctor, nurse, dentist) or institution (hospital or clinic) that provides medical care.

Third-part payer; this means any payer for healthcare services other than you. This can be an insurance company or any well-wisher.

2.2.1.2. Relevant scheme models

Health insurance schemes are arrangements in which officials formally hold a fund that consists of payments by insured participants and use resultant resource pools to finance all parts of members' healthcare costs. In African countries that have schemes for the informal sector, most plans fall into the first three of the following four models, where the officials are members of an identifiable group whose contributions make up the pools, and are responsible for management activities such as determining benefits and contributions, the model is a mutual benefit society model. In a variant of these mutual and provider model, the officials are responsible for managing the insurance product and providing healthcare and are drawn from members of mutual society as well as a healthcare provider organization, (Arhin and Carrin G, 2003:43).

Such a model may be termed as mutual-provider partnership model and correlates in general to the concept of mutual-based insurance put forward to test the hypothesis of feasibility of insurance for households in the formal sector. (Arhin and Carrin G, 2003:43).

2.2.1.3. Micro insurance in Rwanda

Micro insurance: is voluntary group self-help scheme for social health insurance. The underpinning of micro insurance is that excluded populations have not covered under the existing health insurance schemes because of two concurrent forces. The first is that Insurers have done little to include these population segments. The second factor has been that excluded beneficiaries have forgone claiming access because of their disempowerment within society. (Dror and Jacquier 1999:78).

2.2.1.4. Experience of mutual health insurance in African countries

Similar to the whole insurance industry, private commercial health insurance is hardly developed in Africa. Nevertheless, private prepaid schemes are a significant source of total health financing in a couple of countries. Once again, the health insurance market is well established in South Africa, where 42.3% of all expenditure on healthcare gets channeled through a private health insurance intermediary. Relative to total health expenditure, PHI also plays a significant role in Namibia and Zimbabwe. However, the high share of PHI spending is not reflected in equally significant coverage rates; i.e., only 8% of the populations in Zimbabwe are estimated to have private health insurance (Campbell et al., 2000:2).

Increasing the access of African population to healthcare is one of the formidable challenges facing the global community. During the 1980s and 1990s, African governments with the endorsements of their international and bilateral donor partners, implemented health sector reforms intended to improve the efficiency of health systems and the quality of care. In many countries, these reforms included the introduction or the consolidation of cost recovery mechanisms, in particular out of pocket fees, paid at the time of illness (user fees), which had an intended effect on decreasing the poor's access to healthcare (J. M 1997:5).

As most functional health insurance schemes in Africa are associated with formal sector employment-requiring regular contributions compatible with formal sector earnings- the majority of individuals are not insured. Hellman, C. (1990:3) concludes that the formal sector schemes effectively cover members of the relatively small upper and middle classes. Uncertainty about the timing of illness, the unpredictability of healthcare costs during illness, and the low and irregular income of individuals mean that it is virtually impossible for households to make financial provision for illness related expenditures. (Hellman, C. 1990:3) Users contribute a major part of such expenditures. As consequence user fees have been and still are a major contributing factor to the high incidence of out-of-pocket payment by individuals and households at the time of illness. Furthermore, most households cannot obtain credit from formal banking system. (Hellman C.1990:3)

Thus user fees, in addition to having been largely unsuccessful in raising significant resources, have contributed significantly to increasing the exposure of poor households to financial risks associated with illness. Individuals are subject to illness-related financial risks correlated with healthcare prices and their disable incomes. As ratios of healthcare prices to incomes rise, households' probabilities of illness-related loss of wealth and assets increase. Consequently in many situations of low per capita incomes, ranking households into income groups is of little use for policy formulation aimed at providing universal access to effective healthcare. (Hellman, C.1990:3)

Rather, public provision of financial protection becomes a crucial element of strategies to reduce poverty for all households' poor communities such as those in rural areas and slums, irrespective of their incomes relative to others in those areas. Ernst & Young (2003) estimate PHI coverage to reach 18% among the total South African population. The government provides basic healthcare services to the poor and is committed to achieve universal coverage. (World Health Organization report 2003:54)

In almost all African countries, international donors remain a very important part of the healthcare system, especially in the Sub-Saharan region where countries often obtain more than 25% of total resources through these channels. Again, this number is notably greater for some countries (e.g., Mozambique with donor contributions accounting for 52% of total health expenditure) while others may not receive any international funding. (World Health Organization report 2003:54)

2.2.2. Economics

The primary textbook distinction is between microeconomics, which examines the behavior of basic elements in the economy, including individual markets and agents (such as consumers and firms, buyers and sellers), and macroeconomics, which addresses issues affecting an entire economy, including unemployment, inflation, economic growth, and monetary and fiscal policy. Other distinctions include: between positive economics (describing "what is") and normative economics (advocating "what ought to be"); between economic theory and applied economics; between mainstream economics and between rational and behavioral economics. (Bruce T; pradip tapadar, December 2005)

2.2.3. Development

Development has been defined by many scholars in different ways. Some argue that development involves growth of per capita income while others focus improving living conditions of the beneficiaries by reducing inequality of income distribution. According to Kocher (1973:4), development means the process of a general improvement in level of living together with:

The components of socio-economic well-being are the substance of development. Inevitably, there must be certain arbitrariness in choosing the components to include and their relative importance. A minimal, though not inclusive, set would consist of income, employment, education, health and nutrition and consumption including food, housing and such services as water supply, electricity, transportation police and fire protection. The above definition of development is very significant to rural areas as the author insists on decreasing inequality of income distribution to ensure the well being of the entire population. (Carrin G. 2003:63).

According to Todaro M. (1982:56), development should therefore be perceived as a multi- dimensional process involving the re-organization and re- orientation of entire economic and social system. In addition to improvements in income/output; it typically involves radical changes in institutional, social and administrative structures as well as in popular activities and sometimes even customs and beliefs. Demas (1965:24) asserts that development means a structural transformation of the economy so that:

i. The degree of dualism between the productivity of different regions is reduced.

iii. Subsistence production is limited and a national market is established for goods and services.

iv. The share of manufacturing and services in GDP is increased in response to the changing composition of demand.

v. The volume of inter-industry transactions increases mainly as a result of the growth of the manufacturing sector.

vi. The ratio of exports increases absolutely and composition of imports shift away from consumer to intermediate and capital goods, and

vii. The economy becomes not only more diverse but also more flexible and adoptable as a result of underlying political social and institutional changes.

From the above definition, it is seen that the author is concerned with transformation of economy in all sectors so as to improve the welfare of the beneficiaries. (Todaro 2000:18) concluded that «development» is both a physical reality and a state of mind in which society has through some combination of social, economic and institutional process, secured the means for obtaining a better life. Whatever the specific components of this better life, development in all societies must have at least the following objectives:

i. To increase the availability and widen the distribution of basic life-sustaining goods such as food, shelter, health and protection.

ii. To raise levels of living including in addition to higher incomes, the provision or more jobs, better education and greater attention to cultural and humanistic values, all of which was served not only to enhance material well-being but also to generate greater individual and national self-esteem.

iii. To expand the range of economic and social choice available to individuals and nations by freeing them from servitude and dependence, not only in relation to other beneficiaries and nation-states, but also to the forces of ignorance and human misery.

Todaro's emphasis is on obtaining a better life through providing basic life sustaining goods, which is in most cases, is lacking in rural areas. Some development economists argue that most of the development planners aim at attaining a high gross rate in the Gross National Product (GNP) regardless of the real goal of development, which is economic growth with justice. Economic growth is not an end in itself; it has a human, social and economic magnitude. This supports the view that development is a many-sided dynamic process, which should benefit the neediest segment of the local population. (M. Todaro 2000:18)

2.2.4. Economic development

Economic development: refers to social and technological. It implies a change in the way goods and services are produced, not merely an increase in production achieved using the old method of production on a wider scale Economic development refers to. It implies a change in the way goods and services are produced, not merely an increase in production achieved using the old methods of production on a wider scale. Economic development typically involves improvements in a variety of indicators such as literacy rates, life expectancy, and poverty rates. GDP does not take into account other aspects such as leisure time, environmental quality, freedom, or social justice; alternative measures of economic wellbeing have been proposed. (M. Todaro 2000:18)

A country's economic development is related to its human development, which encompasses, among other things, health and education. In other words Economic development is the increase in the standard of living in a nation's population with sustained growth from a simple, low-income economy to a modern, high-income economy also, if the local quality of life could be improved, economic development would be enhanced. Its scope includes the process and policies by which a nation improves the economic, political, and social well-being of its beneficiaries (M. Todaro; 2000:18).

Gonçalo L. Fonsesca at the New School for Social Research defines economic development as "the analysis of the economic development of nations." The University of Iowa's Center for International Finance and Development states that: `Economic development' is a term that economists, politicians, and others have used frequently in the 20th century. The concept, however, has been in existence in the West for centuries. Modernization, Westernization, and especially Industrialization are other terms beneficiaries have used when discussing economic development. Although no one is sure when the concept originated, most beneficiaries agree that development is closely bound up with the evolution of capitalism and the demise of feudalism" (Ibrahim, 1998:2).

In many developing countries however, the masses are complaining that development has not reached them, instead growth has been attended by high rates of unemployment and absolute and relative deprivation. This calls for putting the needs of the poor as a top priority, economic growth and efficiency should come late. However, viewing the above definitions as put forward by several writers, development is to be attained only if the low income are put into consideration by accessing them with the means of production and become the source of development other than being an obstacle to development (Ibrahim, 1998:2).

This was achieved through provision of income generating activities, creation of rural based industries and improved educational facilities and these in hand with the healthy body of the beneficiaries through the provision against various illnesses as well as disease. The study of economic development by social scientists encompasses theories of the causes of industrial-economic modernization, plus organizational and related aspects of enterprise development in modern societies (Ibrahim, 1998:2).

It embraces sociological research on business organization and enterprise development from a historical and comparative perspective; specific processes of the evolution (growth, modernization) of markets and management-employee relations; and culturally related cross-national similarities and differences in patterns of industrial organization in contemporary Western societies; (Ibrahim, 1998:2). Economy Development can also be considered as a static theory that documents the state of economy at a certain time. According to Schumpeter (2003) the changes in this equilibrium state to document in economic theory can only be caused by intervening factors coming from the outside.

The notion of development is complex and multidimensional. It suggests progress and improvement. Development occurs with: the reduction and elimination of poverty, inequality and unemployment within a growing economy. Such outcome is development because they mean improved quality of life for all. Development is a qualitative change, which entails changes in the structure of the economy, including innovation in institutions, behavior and technology. Development entails the enrichment of materials ,social well being ,which can be measured in the flow of money and goal over time , increases in a jurisdictions' quality and quantity of public goods and access to job, (Schumpeter 2003:103 )

i. Increases in the availability and improvements in the distribution of food, shelter, health, protection, ect.

ii. Improvements in `levels of living', including higher incomes, more jobs, better education, ect.

iii. Expansion in the range of economic and social choices available to individuals and nations.

The goals of development include: a balanced, healthful diet; adequate medical care; environmental sanitation and disease control; lab our opportunities; sufficient educational opportunities; individual freedom of conscience and freedom from fear; decent housing; economic activities and harmony with the natural environment; and political processes promoting equality.

2.2.4.1 The requirements for economic development.

For a Country to be economically developed some requirements must be combined in a logical and a meaningful relationship. These requirements or core values are achieved through improved health status of the population and this would be possible through the following core values for economic development; An Indigenous Base, Structural Changes, Socio-Cultural Requirements, Administration, Capital Accumulation, Infrastructure, Suitable Investment Criterion, Development Of Human Resources, Control Of Population, Development Of The Export Sector, Institutions (Schumpeter 2003:103).

i) An Indigenous Base: The general requirements for development include the following: A major requirement for economic development is that the growth progress must have the domestic base within the under-developed economy.

The initiative in carrying out development by the indigenous beneficiaries must arise from within the country. Development cannot be implanted from outside. (Schneider et al. 2004:24).

ii) Structural Changes: Economic development requires that LDCs make the structural transition from being an agrarian economy to being manufacturing or industrial economy there should be a transition from a traditional agricultural society to a modern industrial economy involving a radical transformation of existing institution; social attitudes, and motivations. This change would lead to increasing employment opportunities; higher labor productivity and the stock of capital, exploitation of new resources and improvements in technology. (Schneider et al. 2004:24).

iii) Socio-Cultural Requirements: The socio-cultural attitudes of the beneficiaries should be changed if development is to take place .Social organizations like the extended families, religious dogmas and the rural life should be modified so that they may be more favorable to development .This is because education leads to enlightenment .It opens beneficiaries' minds to new methods and new techniques of production .It enables one to think rationally. (Schneider et al. 2004:24).

iv) Administration: To achieve economic development, there should be strong competent and incorrupt administrations. The government should be capable of maintaining internal law and order and defending the country against external aggression .Insecurity and political instability scare away investors both domestic and foreign so a good administration is needed to stimulate economic development and the resources should be properly allocated into productive projects. (Schneider et al. 2004:24).

vi) Capital Accumulation: Capital formation is a very important factor in the process of economic development .Savings should be increased and should be productively invested. There should be an efficient banking system to mobilize savings and channel them into productive projects so as to accumulate capital domestic resources need to be supplemented by external resources and development of the basic infrastructure is necessary for capital accumulation. (Schneider et al. 2004:24).

vii) Infrastructure: Industrialization cannot occur in a vacuum. Factories require electricity and natural gas. They need paved roads, reliable railroads and modern airport facilities to ship supplies in and finished products out.

Business also needs modern telecommunication systems to stay in contact in with customers and suppliers and it is difficult for businesses to develop and prosper in the absence of such communications infrastructure. (Schneider et al. 2004:24).

Viii) Suitable Investment Criterion: The pattern of investment should be properly determined in order to achieve development .Investment should be directed towards the most productive projects and promote greater external economies. (Schneider et al. 2004:24).

ix) Development of Human Resources: For economic development to be achieved there should be an increasing number of person who have the skills, education and experience which are critical for the economic the political development of a country. Human resources development is associated with investment in human resources. Universal primary education should be available to enable individuals to acquire the basic skills required in the labor market. (Schneider et al. 2004:24).

x) Control of Population: Family planning programme; marriage age law, economic incentives and disincentives, formal and informal education, are some of the methods for controlling population. (Schneider et al. 2004:24).

Xi) Development of the Export Sector: Foreign exchange can be obtained to import capital for setting up industries that can provide employment opportunities. (Schneider et al. 2004:24).

xii) Institutions: The most important institutional reform necessary to generate sustained growth in the lesser developed parts of our world is the institution of peace. The opportunity cost of war include the reduced investment and actual destruction of physical capital and human capital, the use of scarce resources to produce weapons of war instead of computers, schools, and hospitals, and the security of knowing that you are working for was there when you wake up tomorrow morning. (Schneider et al. 2004:24).

2.3. Community health insurance schemes in Rwanda

Community health in Rwanda embraces the concept of primary healthcare which is defined as an essential healthcare based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination. (WHO, Alma-Ata Declaration, 1978)

It forms an integral part both of the country's health system, of which it is the central function and main focus, and of the overall social and economic development of the community. It is the first level of contact for individuals, family members and the community with the national health system, bringing healthcare as close as possible to where beneficiaries live and work, and constitutes the first element of a continuing healthcare process (WHO, Alma-Ata Declaration, 1978). Rwanda has lived one of the most tragic moments of its history with the genocide of 1994, which resulted in nearly one million deaths and the destruction of the social fabric of the country.

Her recent history has been proved as one of tragedy and despair. The country has faced immense development challenges after the genocide of 1994. These include the challenges of providing adequate social services such as health services to the population given the prevailing circumstances. In this respect, the government of Rwanda introduced the community based insurance schemes to ease access to healthcare services especially for the rural poor. (WHO, Alma-Ata Declaration, 1978)

2.4. Current problems of mutual health insurance schemes in Rwanda

According to the Ministry of health (ROR2004:4), mutual health initiatives or schemes like any other forms of organizations are not immune to various hardships problems as mentioned below. First, mutual health insurance schemes are insufficiently designed and this often results in a difficult start of the health insurance scheme. In many cases, there is no in-depth consideration (e.g. through a feasibility study) of the interest which the target population has in the exogenous insurance concept, what it is willing or able to pay for the scheme and what services it expects. It is equally important to identify the specific disease burden of the target group. (WHO, Alma-Ata Declaration, 1978)

When the level of insurance premiums, co-payment and benefit package are defined, attention is not always paid to the financial sustainability of the health insurance scheme. A high level of claims for services (moral hazard), adverse selection of members and the problem of free riders have to be avoided. The second problem concerns insufficiency of information and participation of the target group as potential members lack a significant say in the shaping of the scheme, and they also lack sufficient information at then disposal on the functional principles of their health schemes. (WHO, Alma-Ata Declaration, 1978)

Thirdly, mutual health insurance schemes lack management. Many local health insurance schemes are run by a voluntary management team in order not to impose too high a financial burden on these relatively small initiatives through high administrative costs. This leads to the situation where those responsible have hardly any insurance expertise and at the same time pursue their own individual activities to earn a living. Many health insurance schemes thus lack any rigorous mechanisms of cost control and claims examination, or regular information services and marketing for member recruitment. (Schneider et al. 2004:24).

Another problem is low membership. Many health insurance initiatives suffer from very low membership numbers, which results amongst other things from the problems discussed above. As soon as disease cases with very high costs occur, this can mean the end of the health insurance scheme due to insufficiency of pooled resources. Starting in 2001, an adaptation phase drawing on lessons learned and recommendations from the pilot phase extended the number of CBHI schemes and increased enrolment rates in individual schemes. (Schneider et al. 2004:24).

Consequently, on July 2003, ninety-seven CBHI schemes, covering half a million Rwandans, where functional in the country and some scholars have regarded them as viable tools for sound financial investment to both an individual and to the society as a whole. The development of mutual health insurance schemes is currently in an extension phase: in 2004, two hundred and fourteen (214) CBHI schemes have been established around the country as result of the combined efforts of promotional activities of central authorities (Ministry of health an Ministry of local Affairs), provinces, districts, local health personnel, local opinion leader and non-government organizations. In mid-2004, national coverage of CBHI schemes was estimated at 1.7 million which is about 21% of the Rwandan population (Schneider et al. 2004:24).

According to the Ministry of health (ROR 2004:4), the establishment of mutual health insurance has been on the rise considering the first five years. In fact, the number of mutual health insurance schemes rose from six in 1998 to 76 in 2001 and 226 in November 2004. The geographical coverage of the mutual health insurance was also extended: whereby in 1999, these mutual health insurance schemes were mainly functional in the four former provinces of the country which are Butare, Byumba, Gitarama and Kibungo, they have since September 2004, been established in virtually all the former eleven provinces of the country, as well as in Kigali city and they covered 2,101,034, beneficiaries representing 27% of the population in Rwanda. (ROR 2004:4)

External assistance for healthcare continues to be significant revenue source in low-income countries such as Rwanda, where it financed about 27 percent of total healthcare, leaving an estimated 9 percent to the Rwandan government. Healthcare in Rwanda is relatively expensive compared to other goods. In 1997, the medical consumer price index (CPI) scored 30 percent above the general CPI in Rwanda. From 1997 to 1998, the general CPI increased by 37 percent and the medical component, already high, increased by 5 percent (Kalk et al. 2009).

Schneider et al. (2008:15), confirms that contributions to the CBHI scheme funds in Rwanda are on yearly basis. Members have the option to sign up as a family with up to seven members, which costs us $ 7.6 per family per year, payment of the yearly premium entitles covered family members to a benefit package which includes all preventive, curative, services, prenatal care, delivery care, laboratory exams, drugs on the MOH essential drug list, and ambulance transport the district hospital provided by the partner health centers. (ROR 2004:4)

2.5. Global overview of Rwanda health insurance schemes

Mutual insurance schemes can be broadly defined as systems based on voluntary engagement and the principles of solidarity and reciprocity, members usually have to meet certain obligations, e.g. payment of premiums, and are bound together by a common objective and a strong local affiliation. Many times, these schemes evolve out traditional systems or form as a response to the low coverage provided by formal systems». (Jutting, J, 2003:60).

However great difficulties in instituting private health insurance schemes in rural areas in Africa where most beneficiaries live have greatly diminished the rate of private financing of health services among beneficiaries. He went further to propose the synergy concept in healthcare provision and financing to show how various groups in society can make a contribution to the process of health development in coordinated fashion. The concept synergy or mutual reinforcement of various participants in the process of improving health status, required coordination of the type of health service to be produced and their co-production and co-financing. (Schneider P, Diop F & Bucyana S. 2000)

LUCAS et al. (1999), assert that while living is expensive, illness is more so thus sound financial investment should offer preventive and promotive health activities to an individual and to the society at large. A sound financial policy for public health service therefore must be taken into consideration not only for humanitarian and social gains but also some economic advantages should be delivered there from. Public health is one of the best forms of social and economic insurance, different studies which were undertaken by various scholars have demonstrated that without coercive powers of the state, and pressure groups, the sound of community health insurance would prove futile.

According to Aisworth (1995:25), "experience with the user charges in Zimbabwe, Uganda, Swaziland, Ghana, Egypt, Cameroon, Tanzania, Kenya, Nigeria, among others, show that political elements and grass root support are important tools in economic development due to their support in health cost minimization. Mutual health organization can further be defined as «a voluntary, non-profit insurance scheme, formed on the basis of an ethic of mutual aid, solidarity, and the collective pooling of health risk, in which the members participate effectively in its management and functioning» (Atim. C 1999:46).

In providing insurance models, the officials originate from the healthcare provider institutions (or from the ultimate provider organization such as the government or mission health administration) and manage both the insurance and the healthcare aspect of the scheme, similar to Health Maintenance Organizations (HMO), (Atim. C 1999:46)

2.6. Principal objectives of insurance schemes

One is to bring about an increase in the Government's financial distribution to the EPI by constantly presenting the case for the importance of the EPI in terms of general policy.

Secondly is to increase the contribution from other donors (bilateral and multilateral cooperation) with the aim of closing the gap between needs and acquired resources and to reduce dependence on those donors by a greater diversification of sources of funding by improving the financial situation of the health facilities. Thirdly is to improve the population's financial access to health services, this improved the health situation of the population. Fourth is to increase the sustainability of funding, last but not least is to increase the efficiency of the program so as to improve the cost-benefit ratio. (Atim. C 1999:46)

2.7. The interventions on the policy of health insurance

Five intervention orientations were strengthening the process of implantation, extension and monitoring of mutual health insurance in the country. The concern notably:

i. Establishment of a technical unit, in charge of the day-to-day management and monitoring of mutual health insurance.

ii. Strengthening of the legal and regulatory framework of mutual health insurance.

v. Strengthening of national and provincial capacities in the area of mutual benefit systems.

vi. Most of mutual health insurance in Rwanda uses a policy of family subscription; and even when the insurance premium is individual, the family must register all the members.

Concerning the insurance premium, there is vast disparity in the present operation of mutual health insurance. In fact, the premium per household members varies from 2000Rwf for those in category I (for this category, its premium is given by the government) 3000Rwf for those in category II and 7000Rwf those in category III and above. (PRS annual progress report 2003-2004:56). The patient's contribution towards the cost of medical treatment, or contribution of the mutual health member at the time of using health services, also varies between 200Frw and 250Frw per disease episode or between 10% and 25% of co-payment of the real cost of healthcare.

Healthcare and services covered by mutual health insurance comprise all services and drugs provided at the health centre. The annual contribution and registration is done at section level (Health center). (PRS annual progress report 2003-2004:56). This rapid increase in the number of mutual health insurance, and beneficiaries testifies undoubtedly to the affirmation of a community dynamics in the search for solutions to the problems of financial accessibility to healthcare and protection against financial risks associated with diseases. The government has designed a scale-up program to expand the community health insurance schemes to all Provinces of the country over the coming years. (Development indicator, 2003:29)

A detailed proposal has been submitted to create a national co-ordination unit or an executive secretariat to oversee the policy implementation of the three-year national mutual support program (PRS annual progress report 2003-2004:56). As explained in the Rwanda Development indicator (2003:29), in order to improve its utilization, the quality of health service is improving through the quality insurance projects within the Ministry of health. Whilst ensuring that the population has adequate financial accessibility to healthcare services which are also improving through community associations for healthcare (Mutuelle de Santé). (Development indicator 2003:29)

2.8. Organization and management

At the village, cell and sector level there are health « mutuelles » committees in charge of the sensitization and mobilization. At the health centre level `Mutual Section' is in charge of reimbursing the cost care to the health centre (cost-based reimbursement). There is a committee in charge of the sensitization and mobilization. At the district level, a Mutual Institution is in charge of reimbursing the cost of care at the district hospital. There is a committee in charge of the sensitization and mobilization. (Atim. C 1999:46)

At national level, there is a technical support cell (CTAMS) and the Pooling Risk in charge of: The capacity building for « mutuelles » managers, the development of policy, strategies and legal frameworks, the payment of the cost of the package of referral hospital development of management modules and tools, monitoring and training, management of the data base & IT awareness. (Atim. C 1999:46)

2.9. Challenges of health insurance schemes in Africa

On the path to adequate healthcare, rural populations in developing countries face many obstacles, which often seem insurmountable. In many African countries a considerable proportion of the population faces problems of financial access to essential healthcare services. This holds especially true for the informal sector and beneficiaries living in rural areas. In order to enhance healthcare coverage and provide financial protection against impoverishment due to the costs of catastrophic illness, the Government of Rwanda has implemented several financing mechanisms. (Atim. C 1999:46)

Apart from social health insurance schemes covering employees in the formal public and private sectors, a community based health insurance was established to improve access and offer financial protection to the majority of the Rwandan population working in the formal economy. In addition to the Community Based Health Insurance Policy, the present policy has been elaborated to provide a comprehensive guiding framework for a National Health Insurance system in Rwanda. Significant breakthroughs have been made in recent years concerning the extension of social security in Rwanda. (Ministry of health report 2000:2)

Notably, the Government's decision to introduce compulsory health insurance for the entire population, accompanied by a policy of strong support to the development of mutual health organizations throughout the country. Building on existing examples of community-based initiatives, there has been a huge growth in the number of mutual health organizations (mutuelles de santé), which have been set up in each of the 30 health districts and are also present at the level of the health centre in the form of a smaller unit called section of mutual health; there are now more than 400 of these units. (Ministry of health report 2000:2)

Membership rates of Community Based Health Insurance (CBHI) stood at 73% in 2006 and increased since then to reach 91% of coverage in 2010. In 2010, the CBHI policy has been updated in order to be more adapted to the current challenges. The new policy improved population's access to quality health services in a fair and equitable manner. The existing statutory social security system in Rwanda includes the Social Security Fund (pensions and occupational risks); and, for the health part, the RAMA (Rwandaise d'Assurance Maladie) and the MMI (Military Medical Insurance).

The Rwandan Government shows a strong interest in strengthening the structure and capacity of public institutions in providing social security.

More recently, on December 2008, the Rwandan Ministry of Finance and Economic Planning released a project on "Rationalizing delivery of social security benefits services to be delivered less than one institution". (Ministry of health report 2000:2)

The project of the Government is to merge two main social security institutions, the Social Security Fund of Rwanda and "la Rwandaise d'Assurance Maladie" (RAMA) in a single Rwanda Social Security Board (RSSB). In 2009, the «Social Security Policy» has been prepared by the Ministry of Finance and Economic Planning. The new Rwanda's vision for social security is to reach the ideal situation of «Social security coverage for all» and having all the population covered with maximum benefits possible (retirement, professional risk benefits, sickness benefits, maternity, healthcare, etc.).

In order to achieve this, key actions have been identified such as the reinforcement of compulsory affiliation and/or development of incentives for voluntary membership in order to increase the coverage, awareness campaign for active participation of the population through community based-organizations. In 2011, the Ministry of Local Government has prepared a National Strategy on Social Protection. This strategy presents the social protection vision for the next 10 years. (Ministry of health report 2000:2).

The long term vision for Rwanda is to establish by 2020 a «social protection system that complements and contributes to economic growth». The mission is to ensure «that all poor and vulnerable beneficiaries are guaranteed a minimum income and access to core essential services that those who can work are provided with the means of escaping poverty, and that increasing numbers of beneficiaries are able to access risk-sharing mechanisms that protect them from crises and shocks.» Therefore, two main elements have been identified to establish the social protection system:

A social protection floor for the most vulnerable groups and an increased participation of the informal sector in the contributory social security system. Furthermore, after the war and genocide the Ministry of health (MOH) set its priorities on the reconstruction of health infrastructures and services and the decentralization of the health sector into districts.

From 1994 until 1996, most health centres and hospitals were supported by international organizations and provided some free healthcare services. But in 1996, the MOH introduced user fees in public and mission facilities.

When international organizations decreased their support, health facilities started to increase prices for their drugs and services in order to cover a large part of their recurrent cost for health centers and comparatively lower cost recovery rates over time, the MOH addressed new cost recovery strategies for healthcare services by launching prepayment schemes focused on improving equity in access to quality healthcare for the rural population, and setting incentives to healthcare providers to improve quality and efficiency in health service delivery (Schneider P, Diop F & Bucyana S. 2000).

In the Poverty Reduction Strategy annual progress report (2003-2004:56); it was shown that community health insurance were regarded by the government of Rwanda as the main mechanism of expanding financial protectionism against health risks. After successive pilots since 1998, the ministry of health has promoted the establishment of mutual's schemes. Community health insurance schemes are normally local community initiatives based on concepts of solidarity and risk pooling and involve active participation of group members. They improve equity access to healthcare for the excluded high level of solidarity, trust and finally improve the ability to counter-risk, cover all healthcare cost (Ministry of health report 2000:2).

Community health insurance schemes have existed in Rwanda; it was in the 1960s that community-based health insurance systems, like the association Muvandimwe de Kibungo (1966) and the association Umubano mu bantu de Butare (1975) started to be constituted. However, these community-based health insurance initiatives were further developed only since the reintroduction of the payment policy in 1996. The development of community-based health insurance initiatives in the form of modern mutual health insurance has been on the increase during the past five years. In fact, the number of mutual health insurance increased from six (6) in 1998 to 76 in 2001 and 226 in November 2004.

The geographical coverage of mutual health insurance was also extended: whereas initially in 1999, this mutual health insurance was mainly developed in the four provinces of the country, as well as in the city hall of Kigali. They cover about 2.101.034 beneficiaries, representing 27% of the population of Rwanda. It is not uncommon that the closest health center is several kilometers away, the infrastructure is inadequate and the staffs receive their rural patients not as clients, but as beggars.

The bill also has to be paid out of pocket, which in the context of rural Africa is extremely difficult, especially during the run-up to harvest time. (Pledge of the district 2011:58)

The viability of a MHI partly depends on outside determinants that can hardly be influenced by the scheme such as a country's legal and policy framework, but nevertheless, the design of the scheme and its running as well as community participation is important factor for sustainability (Atim, 1998; Criel, 1998). Schemes are generally limited to a specific region or community and thus only reach a small number of beneficiaries. Moreover, insurance packages are not comprehensive, but only offer supplementary coverage for certain medical treatments. Mutual health insurance generally operates on a non-or low-profit basis.(Social Science and Medicine 48, 881-886)

The problem known as «moral hazard» should be considered; as insurance lowers the price of care at the point of use and removes barriers to access, utilization of health facilities was increase (Manning et al. 1987)-surely a desirable effect given the current under-utilization of facilities in developing countries. But healthcare costs may grow far more rapidly than resources mobilized through premiums-an effect which can quickly jeopardize the scheme's financial viability. Furthermore, some provider-payment mechanisms like fee-for-service reimbursement give incentives for the provision of unnecessary and expensive treatment to insured patients (McGuire et al. 1989).

Again there is a challenge third, called adverse selection where the beneficiaries most likely to join a voluntary scheme are high-risk individuals such as the chronically ill, who anticipate a high need for care. Due to this self-selection, the claims made to the scheme were exceed its revenues by far if premiums are based on the average risks in the community. As a consequence, premiums would have to be raised and insured persons with a relatively lower risk than other members would drop out of the scheme, and would therefore again increase the healthcare cost per insurance member (Cholet and Lewis 1997)

2.10. Health insurance and willingness to pay (WTP)

Health insurance is a mechanism for spreading the risks of incurring healthcare costs over a group of individuals or households. This definition is not dependent on the nature of the administrative arrangements employed, but not the outcome of risk sharing and subsequent cross-subsidization of healthcare expenditure among the participants.

An arrangement designed to provide risk sharing for illness-related events, and which is accessible to households in the informal sector in low-income countries, is a health insurance scheme regardless of the orthodoxy of its operational modalities. In such arrangement, an insured individual acquires «a state-contingent income claim» before the state of the world is known and is entitled to resources, income, or both to address the event for which he or she is insured if the event is occurred. (Manning et. Al 1987).

2.11. The situation of mutual health insurance schemes in Rwanda

According to Mutual Health Insurance policy report in Rwanda (December 2004), it was in1960's that community based health insurance system, like the association Muvandimwe de Kibungo (1960) and the association Umubano mu bantu de Butare (1975) started to be constructed. However, these communities based health insurance initiatives were further developed only since the reintroduction of the payment policy in 1966. The development of community health insurance in the form of modern mutual health insurance has been on the increase during the first five years. (Social Science and Medicine 48, 881-886)

In fact, the number of mutual health insurance has increased to six (6) in 1998 to 76 in 2001 and 226 in November 2004. The geographical coverage of mutual health insurance was also extended: where as initially in 1999, these mutual health insurances were mainly developed in the four Provinces of the country as well as the City hall of Kigali. They cover about 2,101,034 beneficiaries, representing 27% of the population of Rwanda. This rapid increase in number of mutual health insurance, and beneficiaries testifies undoubtedly to the affirmation of community dynamics in the search for the solutions to the problems of financial accessibility to healthcare and `protection against financial risks associated with diseases. (Social Science and Medicine 48, 881-886)

Dr. Claude Sekabaraga, an official in charge of Planning in the Ministry of Health, has said 90 percent of Rwandans countrywide have joined health insurance. He was speaking at a three-day recent meeting at Serena Kivu Sun Hotel in Gisenyi recently. The meeting, that brought together various health officials in the country including those from the World Health Organization (WHO) and GTZ, was meant to evaluate the achievements and failures of the health insurance policy. While officially opening the meeting, Sekabaraga explained that 85 percent of Rwandans were enrolled in health insurance commonly referred to as Mutuelle de Santé, while five percent belong to other health insurances such as RAMA and MMI. (Poverty Reduction Strategy annual progress report 2003-2004:56)

He disclosed that the ministry is doing everything possible to have the remaining 10 percent that are not registered under any insurance schemes to join Mutuelle de Santé because it's the cheapest and operates in all government health centers countrywide. He hailed the contribution of the health insurance schemes in enhancing improved health. Sekabaraga noted that research indicates that in 2001 only 23 percent of Rwandans afforded medical care, while the remaining 77 percent used traditional means which increased adult death and infant mortality rates. «Today 200% of residents have full access to medical care; that is to say, they access medical care at least twice a year,» he explained.

He observed that health insurance schemes have greatly reduced infant mortality rates because mothers are able to access antenatal care during their pregnancy. Poverty Reduction Strategy annual progress report 2003-2004:56). According to Sekabaraga, the government has controlled malaria infection which is the leading cause of infants' death. «There has been a tremendous decrease in deaths caused by malaria these days due to the campaign against the disease. Expectant mothers are sleeping under mosquito nets while the few malaria patients have access to good medical care due to Mutuelle de Santé,» he said. Fred Rugumira, one of the participants and a health work said that health insurance has reduced conflicts hither caused by patients who were incapable of meeting medical bills. (Poverty Reduction Strategy annual progress report 2003-2004:56)

2.12. An overview of literature review

The entitled chapter is detailed with views from different authors related to the research under study. Mutual health insurance is an insurance policy which covers the future healthcare costs by providing the necessary healthcare relatively more affordable and thus more available to all «Pooling» health risks and these does not need to be done through commercial insurance markets. The function of insurance is to provide protection to individuals against financial loss. (Jutting, J, 2003:132). Economic development refers to social and technological changes. Economic development typically involves improvements in a variety of indicators such as literacy rates, life expectancy, and poverty rates.

A country's economic development is related to its human development, which encompasses, among other things, health and education (Ibrahim, 1998:2). This chapter also addresses the conceptual understanding of research literature on CBHI in Rwanda and mutual health insurance in general, definition of key concepts, the requirements for economic development, community health insurance schemes in Rwanda, the interventions on the policy of health insurance, current problems of mutual health insurance schemes in Rwanda, global overview of Rwanda health insurance schemes, principal objectives of insurance schemes, organization and management of mutual health insurance schemes in Rwanda, HIWTP, challenges of health insurance schemes in Africa .

Through this information gathered from different author's works, the researcher clearly understood the research objectives and research questions and this understanding helped me to set up the questionnaire which is helpful to answer the research questions and to meet the specific objectives of the study. For instance reading through Lucas et al` s work, he asserted that while living is expensive, illness is more so thus sound financial investment should offer preventive and promotive health activities to an individual and to the society at large.( Lucas et al. 1999:76). From the writer's point of view of sound financial policy for public healthcare, therefore must be taken into consideration not only for humanitarian and social gains but also some economic advantages should be delivered there from.

Public health is one of the best forms of social and economic insurance, different studies which were undertaken by various scholars have demonstrated that without coercive powers of the state, and pressure groups, the sound of community health insurance would prove futile. (PRS annual progress report 2003-2004:56).

From the information gathered above from other authors' views related with this research topic entitled «The contribution of rwandan health insurance in the economic development of rwanda» the researcher come with a very clear understanding on this research topic. Most of suggestions from this secondary data, it was shown that the writers emphasized on the reduction of healthcare costs through risk pooling and shared among healthy beneficiaries and those fallen sick whom are not able to pay their healthcare bills. However this cannot guarantee a hundred percent of these costs and beneficiaries still claiming that healthcare services are high since the policy does not cover all health services costs.

Therefore, the investment in new venture and good management of these MHI contributions should raise the geographical coverage where the beneficiaries of this policy are always saying that there are some services that are not offered to them under pretext that collected contributions are not enough to cover all healthcare costs. This investment will be used generating the income which can be used to support beneficiaries' annual contributions. Hence one day health insurance contributions should be kept at the minimum even cancelled because of these investments which are profitable and make more money for the beneficiaries' gains.

Mutual health insurance's service packages increases and covers all healthcare costs whenever the person falls sick. This improves beneficiaries' behavior on this policy in relation with their contributions. The successful implementation of this policy is justified by the let go at each and every health centre or hospital without a barrier of limited contribution because the invested proportions of MHI contributions support their contributions.

CHAPTER THREE: RESEARCH METHODOLOGY

3.1. Introduction

This chapter presents, explains and justifies the methodology used in order to fulfill the objectives of the study. Methodology is a set of methods and principles that are used when studying a particular kind of work or subject (contemporary English Dictionary 1995: 927). The researcher used simple random sampling method to collect data. This chapter gives reasons why data was collected, from where data was collected, and how data was collected and analyzed. The chapter provides methods adopted during the study and explains the research design, analytical framework, and sources of data, data collection instruments, and sampling techniques.

3.2. Research design

According to Churchill (1976) research design is a plan for a study used as a guide in collecting and analyzing the data. Also the design of a research is the combination of methods you have chosen for empirical part of your study ( Bakkabulindi, 2004). It is worth noting that the choice of a research design is contingent upon choice of research approach whereby a research is either quantitative or qualitative. The researcher combined both quantitative and qualitative research design in carrying out this study.

This research has one hypothesis and tested in the final stage of this research and state that «improved health situation through Rwandan Health Insurance (Mutuelle de Santé) scheme can lead to economic development resulting from increased production and savings»

3.3. Areas of the study

In carrying out this study the researcher opted to select among heads of households, staff of a health center and authorities of cells of Ruganda sector, because of financial and time constraints which are the main barriers that limit this research to be taken on the whole members benefiting from commonly held health insurance in Ruganda sector.

3.4. Sources of data collection

In conducting this research, the researcher used the information from primary and secondary data sources.

3.4.1. Primary data

This research was relying considerably on primary data that was collected from 30 respondents selected among the six cells which made up Ruganda sector with a simple sampling method. This together with field observation was provided primary data.

3.4.2. Secondary data

In the scope of this research a literature review of the existing data in book, reports, journals, newspapers and articles on the topics and objectives of this research was used. The researcher used the already existing relevant information to the subject matter. Various published texts were consulted. The researcher was also used progress and evaluation reports/both annual and quarterly and other unpublished documents got from ministry of health, health centre, ministry of economic planning and Ruganda sector's offices.

3.5. Analytitical frame work

This study aimed at analyzing the contribution of Rwandan health insurance (Mutuelle de Santé) in economic development of Rwanda, with a case study of Ruganda sector. The research generally aimed at examining the contribution of Rwandan health insurance (Mutuelle de Santé) in economic development particularly in Ruganda sector. The link between Rwandan health Insurance (Mutuelle de Santé) and economic development is such that Rwandan health insurance helps to minimize health costs as well as enabling households to save some income, which they can use for other economic development activities.

Subscription to Rwanda Health Insurance (Mutuelle de Santé) also eases access to healthcare services and timely medical treatment. This leads to improved health status, which in turn enables beneficiaries to participate actively in productive and other income generating activities hence leading to economic development. This research generally aims at following these links between Rwanda health insurance and economic development.

3.6. Study population

Peter ODERA (2006) defined population as all members or elements, be it human beings, animals, trees, objects, events, etc of a well defined group. That is, Population means all the elements in a well-defined set of values. The population of this study was all beneficiaries, Rwandans and Foreigners, who benefit from the service provided by Community Based Health Insurance (CBHI) in Ruganda sector.

The target population was households living in Ruganda sector, out of which a sample of 30 made up with household heads, staffs and nurses were met depending on the pre-set questions. These were chosen purposely because they are the principal planners, managers of their respective families and are knowledgeable about health situations in the household. The researcher was to take the sample depending on the number of beneficiaries of Community Based Health Insurance (CBHI). Since the population is large, it is not be easy to reach all of them due to the financial and time constraints; a sample was therefore drawn as shown below.

3.7. Sample selection and sample size

The researcher selected a sample of 30 respondents and questionnaires were given to 30 respondents including Fourteen respondents which includes six heads of households (6), Six agents (6) of mutual health insurance and Two patients (2) in health centre of Biguhu; the second part of questionnaire is made up with Sixteen questionnaires (16) designed to the staffs at sector and cell levels and Two nurses. However due to high costs in terms of time and finance, the researcher decided to survey only a sample of 30 respondents.

3.8. Data collection instruments

To Examine the functioning of Mutual health insurance scheme in Ruganda sector; to find out the impact of improved health status on Economic development in Ruganda sector, to identify the challenges encountered by both beneficiaries of mutual health insurance and the staffs in Ruganda sector. Data for this study was collected through the combination of interview guide, observation, documentation, and questionnaire.

3.8.1. Interview guide

According to Richard and Williams (1990), an interview is a data collection method whose main purpose is to obtain necessary information. An interview may lead to the emergence of new ideas which would otherwise not be revealed using questionnaires. The information from households was gathered using the interview guide. The interview guide contains both closed ended and open- ended questions. Opened-ended questions were kept to minimum so as to keep the respondents focus on the major aspects of the research. The interview guide enabled the researcher to conduct face to face interviews with respondents. This was advantageous for two major reasons. First it helped the researcher to get information even from illiterate households.

Secondly, it enabled the researcher to explain well the questions to Rwandan health beneficiaries before they provide answers; this was increased clarity and reliability of data gathered.

3.8.2. Observation

While conducting face to face interviews with respondents, the researcher also used the observation technique to get relevant information. This helped the researcher to clarify certain types of information such as living standards, health status to mention but a few.

3.8.3. Documentation

Secondary data was collected from published books, journals, newspapers reports and academic writing from different libraries, electronic documents from the internet, and personnel records. All of these were accessed to add on the primary data from the field. The researcher used various published texts to obtain secondary data that seemed relevant to the study. However, some unpublished documents such as those provided by officials of Ruganda sector were also used.

3.8.4. Questionnaire

Questionnaire was the main tool of data collection. Completed questionnaires were received from 30 respondents of CBHI. This technique helped to collect primary data through a survey based on self-administered structured questionnaires with both open-ended and close-ended questions. They were administered to mainly two categories of respondents to include; staffs at cells and sector levels and beneficiaries of CBHI.

3.9. Data processing and data analysis

3.9.1. Data Processing

According to Marut, Bisht, (2000), data processing refers to the transformation of respondents `views into meaningful form and classifying responses into categories.

Under this study, data processing and analysis involved preparing the data which was gathered into useful meaning, clear and understandable information. Hence, in order to achieve this process, editing, tabulation and analysis of data was required so as to enable the researcher draw the objective conclusion in relation to the problem under investigation. Both quantitative and qualitative techniques were used to process and analyze the collected data. We have to note that data which was collected was analyzed and interpreted in reference to the established objectives. Then, the results were presented in the form of tables and texts.

3.9.1.1 Editing

During data editing, errors that occurred during the stress and strain of collecting data from the respondents was detected and eliminated. After data was collected, the exercise of inspection and editing followed in order to remove inconsistency in the responses and making necessary collections of partial or vague answers. This was done mainly as an attempt to insure that information provided by the respondent was complete and relevant.

3.9.1.2 Tabulation

Tabulation dialed with putting data into some kind of statistical tablets showing the number of responses in particular. In other words, it can be defined as the process of putting data into some sort of statistical tablets with percentages used to express data into a ratio format. The collected data was analyzed along the objectives of the study.

3.9.2 Data analysis

Content analysis was used to give a description of the state of affairs as it exists at present, what happened or is happening, and then discover the causes and relationships in order to come up with some useful conclusions and recommendations.

3.10. Limitations and delimitations of the study

The first limitation is that most rural household heads are illiterates and this is why the researcher used both the questionnaire and the interview guide. This required making long instances looking for respondents especially during meetings and in fact spending much time explaining questions to them. Lastly, the researcher selected only 30 respondents from the six cells of Ruganda sector. It would have been much better if this number was increased to make it more representative, but doing this would have required extra resources in term of finance that were unavailable to the researcher's disposal.

But, the researcher considered this sample size to be representative as respondents was randomly selected using the systematic random sampling technique. As a matter of fact, all rural households share a common life style, depending on health aspects, which make the sample size quite representative.

4.1. Introduction

This chapter presents research findings, analysis of data collected and interpretation of the primary data collected from the field (case of study) and draws a conclusion in tabular forms with percentage interpreted by giving suitable comments. According to Craven and Woodruff (1986) data interpretation is «the process of drawing conclusion from data analysis». This chapter presents the findings of the study in order to achieve the objectives of the study. Questionnaires were given to 30 respondents including Fourteen respondents which includes six heads of households (6), Six agents (6) of mutual health insurance and Two patients (2) in health centre of Biguhu; the second part of questionnaire is made up with Sixteen questionnaires (16) designed to the staffs at sector and cell levels and Two nurses.

4.2. Analysis, Presentation and Interpretation of data part one (Beneficiaries)

4.2.1. Distribution of age

Age groups	Number of respondents	Percentage (%)
Between 18-30	2	14
Between 30-42	3	21
Between 42-54	4	30
Between 54-66	3	21
Above 66	2	14
Total	14	100

According to this table, the age group between «42-54» is the most dominant since it scores 30% of the respondents; this implies that the information given by this group is significant and this group can contribute big to the understanding of mutual health.

The group of 30-42 and that of 54-66 follow and represents 21%, the following groups are that of 18-30 and that of above 66 each represents 14% of the whole respondents. The highest three first groups are made up of the majority of the population which can be involved in decision-making and these include the members from different groups such as heads of households, agents of mutual health insurance and these groups are more knowledgeable and able to provide information because there are the ones who contribute mutual health insurance's contribution for them and their families. They also participate in all government projections which covers also mutual health insurance policy.

4.2.2. Distribution of sex

Table 2: Distribution of sex

Gender	Number of respondents	Percentage (%)
Male	8	57
Female	6	43
Total	14	100

From the table above shows that the study addressed to female and male gender, the males was 8 which is equivalent to 57% of the selected sample of beneficiaries while females were 6 equivalent to 43% which shows that gender balance is prevailed in different levels where decisions are made and actively this number can influence decisions made in the sector and most of these females are health concelors, this implies that female gender plays a big role in health insurance sensitization among the poeple.

4.2.3. Distribution of marital status

Table 3: Distribution of marital status

Marital status	Number of respondents	Percentage (%)
Single	4	29
Married	8	57
Widow/widower	2	14
Total	14	100

The table above shows that the respondents in this study were classified into three categories; single, married and widow (er). The married presents a frequency of 8 which covers 57% of 14 respondents. This implies that the information given is significance since the married beneficiaries are the most part to face the problem of these costs of healthcare within their families. From this table single population were 4 which represent 29% this part is made up in the most number of health councilors and the patients. This population is contributing a big to this policy of MHI by sensitization and by paying for their member's families' insurance fees. At least 14% of the respondents are widowers and this is mainly linked with the genocide of 1994.

4.2.4. Distribution of level of education

Level of education	Number of respondents	Percentage (%)
Illiterate	1	7
Primary	9	64
O'Level	4	29
Secondary	0	0
High institution	0	0
Total	14	100

According to the table above, the total of 93% of the whole respondents know to read and to write while the analphetism is at 7%. 9 respondents which represent 64% hold primary certificates, 4 respondents which represent 29% of the whole respondents have attended O'Level studies. The implication of this is that, since the majority (9) among the respondents at least hold primary certificate while 4 hold O'Level certificate, this assure that the respondents are knowledgeable about concerned study and information given were more significance. This is a group of beneficiaries with lots of knowledge about government's policies and who have much capacity on understanding and conceptualization at the cell level. At least 7% of the whole respondents do not know how to read and to write, this situation is associated with the historical background of education in Rwanda which was not good and efficacy.

4.2.5. The general understanding of respondents about mutual health insurance

From the information given by respondents, they all have a general idea that mutual health insurance is a government policy through which the beneficiaries in different classes or levels share healthcare costs. The contribution is annually given and this period dated from July for every year. The beneficiaries are classified into three classes.

The first class is made up with the poor beneficiaries who cannot get MHI contribution themselves and the government care for this category of beneficiaries. The two other classes; the second and the third, they contribute themselves and their contributions are 3000Rwf and 7000Rwf respectively per member of the family per year. For those in first class the government contributes 2000Rwf for each person per year.

4.2.6. Distribution of source of information on MHI

Table 5: Distribution of source of information on MHI

Information source	Number of respondent	Percentage (%)
Local authorities	9	64
Radio	2	14
Neighbors	3	21
Total	14	100

From the table above, the information from the respondents shown that 9 respondents which represent 64% of 14 respondents asked their source of information is local authorities, 2 respondents which represent 14% their source of information to know MHI is through radio while 3 respondents knew MHI through their neighbours. High frequency or percentages of local authorities as the source of information shows its contribution on this policy of MHI and their interaction with the beneficiaries.

4.2.7. The motivator of beneficiaries to join MHI

Motivator	Number of respondents	Percentage (%)
Government authorities	10	71
Neighbor	4	29
NGOs	0	0
Total	14	100

According to the information given in the table above it is not as far as different from that given in the previous table. Also this table shows that government authorities act as a big motivator of the beneficiaries to join MHI and this is shown by their big proportion in number (10 respondents) and percentage 71% as scores. This shows that government authorities play a big role in motivating beneficiaries to join these mutual health insurances.

4.2.8: Number of children in family

Number of child	Number of respondents	Percentage (%)
None	2	14
One	1	7
Two	1	7
Three	3	21
Four	2	14
Five	4	29
Above Five	1	8
Total	14	100

From the table above, the information from respondents shows that two third of families in Ruganda sector, each family has at least 3 children while 36% of families have at least 5 children. The big number of children in one family increases the number of mutual health insurance family members which results in increased family's healthcare contribution then raising the claims that mutual health costs are high.

4.2.9. Contributions/Premium

Table 8: Contributions/Premium

Contribution/Premium (Rwf)	Number of respondents	Percentage (%)
2000	0	0
3000	14	100
7000	0	0
Total	14	100

As pointed out in point 4.2.5, there three categories or classes under which health insurance contributions are given. From the table above all respondents are under the second class which contributes 3000 Rwf each member in the family. They are made up of big number of heads of households and agents of mutual health insurance. However, the two classes (1^st and 2^nd) are presented in this sector, but as shown in the table above occupies a big proportion of mutual health insurance beneficiaries. There is no third class contributor in Ruganda sector.

4.2.10. Perception on the value of amount contributed

Table 9: Perception on the value of amount contributed

Rate/Value	Number of respondents	Percentage (%)
Very high	0	0
High	4	29
Medium	9	64
Low	1	7
Total	14	100

As indicated in the table above, most (64%) of the respondents argued that amount contributed by the beneficiaries of mutual health insurance is not very high nor low but it is medium, while 29% argued that this contribution is high. The good management of these contributions could lead to the investment of surplus on these contributions in new ventures. Hence this could lead to a situation by which the beneficiaries were no longer making contribution for their healthcare services.

4.2.11. Respondents point of view on health services offered to them

Nature of responses	Number of respondents	Percentages
Happy	6	43
Not happy	8	57
Total	14	100

From the table above 8 respondents or 57% show that they are not with the service offered to them by mutual health insurance while 6 respondents or 43% among the respondents show that they are happy with the services offered to them.

4.2.12. Reasons of unsatisfied beneficiaries of MHI

From the table 10, 57% of the respondents were not happy with the services offered to them because of the following reasons:

i. Low coverage or package of services offered by mutual health insurance and some drugs are not included by this insurance type;

iii. General image of customer care through which the healthcare services are delivered is not good, results in unsatisfied beneficiaries;

iv. Low numbers of nurses at health centre and this increase the number of patients on queuing system which brought about disorders in health service delivery.

All the reasons which are given above explain the idea behind the unsatisfied clients of this insurance scheme in Ruganda sector. If the above problems are to be mitigated so that this insurance policy should answer their customers' claims, this might contribute effectively and efficiently to the economic development processes of the beneficiaries in Ruganda sector.«We are trying to work with all organs within the sector to empower this policy of MHI to meet its objectives in effective and efficiently ways, though there are some issues which require a long time for its to be adjusted and these include mainly the problem of a big or excess number of patients per nurse». Executive secretary of the sector said.

4.2.13. Respondent's health before and after joining MHI

According to the respondents' different views they all argued that before this policy of mutual health insurance exists their health was not good. Even though there is a claim that this policy not satisfying beneficiaries' needs but with this policy there a considerable improvement in health status of the beneficiaries. There might be many factors linked with this health improvement such as deaths, maternal and infant mortality rate were decreased, family costs on illnesses were highly reduced and family income were increased.

The level of saving was also improved, a considerable level of understanding improvement was met because of this policy of MHI, and the misunderstanding among the beneficiaries brought about conflicts rose that some used to kill others is not in place. Before mutual health insurance come in existence and beneficiaries joining it they were suffering all the above problems. After the analysis and observation that I made I can confirm with no doubt that mutual health insurance played a big role in economic development processes because beneficiaries get more income than before this insurance was created.

4.2.14. Respondents about collaboration with mutual health insurance

Collaboration	Number of respondents	Percentage (%)
Very good	3	22
Good	9	64
Poor	2	14
Very poor	0	0
Total	14	100

From the table above, 9 respondents which represent 64% of the whole shows that the collaboration between beneficiaries and mutual health insurance provider was good, 3 respondents which represent 22%, shows that the collaboration with MHI provider was very good, while 2 respondents which represent 14% claim that their collaboration with this institution was poor and the point of very poor collaboration was selected by any respondent. The general implication from the information given above is that the collaboration was generally good since at least 86% of the whole respondents argued that their collaboration with health institution provider was good.

4.2.15. Specific problems that beneficiaries of mutual health insurance face

i. Non-covering of health service costs due to low level of risk sharing between sick beneficiaries and health beneficiaries.

ii. Poor quality of health services provided by some health centre to the beneficiaries.

iv. Inadequate management capacities of some mutual health insurance contributions by mutual health committees.

v. Over-utilization of the services by beneficiaries who solicit healthcare services.

vi. Premiums are fixed, not according to the real costs of healthcare, but the contributing capacity of the beneficiaries.

vii. Some among beneficiaries suffer the wrong stage or class and do not contribute accordingly.

From the above problems that beneficiaries of MHI face for it to be resolved three parties should be involved. These parties are the government, NGOs and the general public. The government intervenes in providing different facilities and policies formulation to empower this domain of health. Such policies could be the perfection of risk sharing policy/mechanism among sick beneficiaries and healthy beneficiaries; improving healthcare services through for example the provision of workshop of concerned staffs to resolve the current problems, encouraging a good management of MHI's contribution comparing to the real costs of healthcare services with the contributing capacity of the beneficiaries.

The understanding of beneficiaries on MHI scheme should be also prevailed. For instance the beneficiaries should be warned and informed about the relationship between how big or small number of family member and the costs of healthcare bills which is the sum contributed for the whole family let it be small or big.

4.2.16. Solutions to problems that beneficiaries of mutual health insurance face

Solutions have been proposed after it was noticed that there are problems that beneficiaries from mutual health insurance policy are facing for them to get better health services. For instance:

i. The investment in new ventures of a share of mutual health's contribution for purposes of making profits for supporting beneficiaries' contributions in future time.

ii. More health centres have to be built in order to avoid overpopulation in one health centre and long distance walked by the beneficiaries of mutual health insurance.

iii. Some beneficiaries' mindset about mutual health insurance should be changed for the beneficiaries profiting from effective risks sharing among those who are suck and those who are healthy.

iv. Beneficiaries' contribution capacity should be raised through community works given to those who cannot easily get the contribution per year.

v. The management of these mutual health contributions should be efficacy and timely controlled to avoid its losses as well as the misuses.

vi. The role of partners in support for mutual health is to be pointed in creating initiatives on coverage of vulnerable groups, for them to get mutual health insurance.

As stressed by Dr. Sekabaraga and quoted in chapter two (page 27-28) an official in charge of planning in the MOH, 90% of Rwandans' countrywide have joined health insurance. If the above solutions were to be effectively implemented, all Rwandans who do not have the access to any other health insurance such as RAMA and MMI could be motivated to join this MHI schemes because it is the cheapest compared to others and operates in all government health centres countrywide like Ruganda sector.

4.2.17. Problems that hinder Mutual Health Insurance

Problems	Number of respondents	Percentage (%)
Lack of contribution fees	3	21
Insufficient infrastructure	5	36
Few health centers	4	29
Beneficiaries' low income	2	14
Total	14	100

From the table above, 36% or 5 respondents shown that insufficient infrastructure was the most problem that hinders mutual health insurance, few health centres was pointed as MHI barrier by 4 respondents and this represents 29% of the whole respondents, 3 respondents show that lack of contribution fees was the one among the problem that hinder MHI, while 2 respondents which represent 14% argued that beneficiaries' low income problem hinders MHI.

4.3.1. Distribution of age

Age group	Frequency	Percentage (%)
Between 18-30	4	25
Between30-42	8	50
Between 42-54	2	12.5
Between 54-66	2	12.5
Above 66	0	0
Total	16	100

From the table above, a half (50%) of the whole respondents are in the age group of 30-42, 25% of the whole respondents are in group age of 18-30, while the other 25% respondents are in group age of 42-54 and 54-66 each includes 12.5% of the whole respondents' respectively. The big number of respondents is youth. Hence they can mentally and physically contribute to the economic development stages because these are majority staffs in the sector. They are the ones to sensitize and mobilise the beneficiaries on the governments' different initiatives.

4.3.2. Distribution of sex

Gender	Frequency	Percentage (%)
Male	10	62.5
Female	6	37.5
Total	16	100

From the table above, it is shown that the study addressed to female and male gender, the males were 10 which is equivalent to 62.5%% of the selected sample of workers while females were 6 equivalent to 37.5% which shows that gender balance is prevailed in different levels where decisions are made and actively this number can influence decisions made in the sector, this implies that female gender plays a big role in health insurance sensitization among the poeple.

4.3.3. Workers' distribution according to marital status

Table 15: Workers' distribution according to marital status

Marital status	Number of respondents	Percentage (%)
Single	9	56
Married	7	44
Widow/widower	0	0
Total	16	100

The table above shows that the respondents in this study were classified into three categories; single, married and widow (er). The single presents a frequency of 9 which covers 56% of 16 respondents. This implies that the information given by this group is significance since these include a big number of staffs which live with beneficiaries almost every day explaining to them governments' policies. They include a big number of executive secretary and social affairs of the cells. From this table married population were 7 which represent 44%. This part is made up in the most number of staff at the sector level and the nurses. This population is contributing a big to this policy of MHI by sensitization to pay insurance fees.

4.3.4. Workers' distribution according to the level of education

Level of education	Number of respondents	Percentage (%)
O'Level	0	0
Secondary	13	81
A1 Level	1	6
High institution	2	13
Total	16	100

According to the table above, the total of 81% of the whole respondents hold secondary certificates and are all cells' staff and one nurse. 2 respondents which represent 13% are the bachelor's degree holder, while 1 respondent which represent 6% of the whole respondents has an advanced certificate of high institution (A1 Level). The implication of this is that, the respondents are knowledgeable about concerned study and information given was highly significance to this study. This is a group of beneficiaries with lots of knowledge about government's policies and who have much capacity on understanding and conceptualization. This group of respondents act as the decision-maker, decision implementers and follow up as well as evaluate these decisions to ensure whether these are successfully implemented.

4.3.5. Distribution of staffs respectively with the post held in the sector

Table 17: Distribution of staffs respectively with the post held in the sector

Post	Number of respondents	Percentage (%)
Exec. Sec. of the sector	1	6
Exec. Sec. of the cell	6	37.5
Social affair of the sector	1	6
Social affair of the cell	6	37.5
Nurse	2	13
Total	16	100

According to the table above, 12 respondents which represent 75% of the whole respondents are social affairs and executive secretaries of the cell. They are the most popular administrative body which is acting as decision-makers, implementers and supervisors of these decisions. The other 4 respondents which include the executive secretary of the sector, the social affair of the sector and two nurses represent 25% of the whole respondents. These officials play a big role in mutual health insurance development process which results in its contribution on economic development process. From the information given in the table above, it is shown that the authorities in different levels contribute a big to the improvement of this policy of mutual health insurance, hence contributing to the economic development in Ruganda sector.

4.3.6. The contribution of mutual health insurance towards economic development.

The economic development goes hand in hand with an improved health of the beneficiaries through mutual health insurance and the following are the points that justified this contribution:

i. Mutual health insurance contributes in finding ways to keep healthcare costs down by negotiating reduced tariffs and fixed fees per day of hospitalization.

iii. The MHI contributes to the extension of social protection to the rural and informal sectors.

iv. It helps to poorest of the poor, do not have gainful occupations and cannot work and afford the financial contributions through government intervention.

v. It provides the opportunities for all members to access healthcare which results in reduced mortality rates which hinders the economic development.

vi. It provides equitable and equal access to quality healthcare for children and women who mostly suffer from different illnesses and this promotes the economic status of households.

The points outlined here above imply that MHI contributes a big to the economic development processes. If each point is to be analyzed at the own, it is shown that this policy of MHI contributes significantly to the economic development by reducing expenses which are incurred on healthcare costs, efficiency allocation of health centres, providing to the poor healthcare services and equitable access to quality healthcare for children and women because these are most vulnerable exposed to different illnesses such as Malaria. Through a successful MHI, the economy gained healthy HR and the excess to real costs on healthcare services can be invested in new ventures to generate or make more income. Hence these reserves are used to promote the economic development of the beneficiaries.

4.3.7. The indicators of economic development brought about by MHI.

In Ruganda sector, there are some indicators of economic development which result from mutual health insurance policy implementation. These indicators are:

ii. Above 70 percent or 23 respondents of the beneficiaries have opened the accounts in BPR and umurenge SACCO as financial institutions and do save,

iv. Infrastructure development, such as health centres, schools, water sanitation and cooperatives.

From the points above which indicate MHI's contribution on the economic development, tangible and physical evidences are shown while moving around the sector, though few beneficiaries still against with this policy of CBHI (sects like «Abagorozi» which born from 7^thDay Adventists and «Temoins de Jehovah».

4.3.8. Health expenditure of the beneficiaries before and after joining MHI

Health expenditure of the beneficiaries in Ruganda sector before this policy of mutual health insurance was very high. The beneficiaries were usually fallen sick and stay at their home because of the lacking and insufficient of financial means for them to go to the health centre for their healthcare. They normally used to cure themselves using traditional methods. They also used to the witchcraft/traditional doctors when they fallen sick. This practice works as a source of conflicts among the beneficiaries and the resources of the beneficiaries were spent buying wrong medicines or drugs. The costs of healthcare were very high while health services were very low.

With the introduction of MHI and after its sensitization among the beneficiaries in Ruganda sector, these join mutual health insurance. From the time, health expenditure of the beneficiaries were low compared to the bills of health costs before beneficiaries joining the MHI because of costs risk sharing nature of CBHI. With MHI beneficiaries' behavior were changed. The beneficiaries' health expenditures were reduced at a big proportion and these costs were used by households for other purposes. However, still the beneficiaries claim that these costs were somehow high; there is a big change or gap between the situations before and after the beneficiaries joining these MHI schemes.

4.3.9. Distribution of respondents about willingness to pay (WTP)

Table 18: Distribution of respondents about willingness to pay (WTP)

Nature of response	Number of respondents	Percentage (%)
Yes	11	69
No	5	31
Total	16	100

According to the table above, 11 respondents or 69% argued that the beneficiaries are willingly to pay their premiums, while 5 respondents or 31% are not willingly to pay. This big percentage or numbers of those who are willingly to pay, justify the success of this government policy. At the other hand this percentage of those who pay but not willingly, local authorities and their neighbors contribute a big to sensitize them to pay their contributions. At this issue of paying mutual health insurance contribution, through community works, jobs are mostly given to those who do not have the was to pay and their due contributions were taken as the advance before being paid.

4.3.10. Problems hinder MHI from contributing a hundred percent on economic development processes.

Table 19: Problems hinder MHI to contribute a hundred percent on economic development

Problems	Number of respondents	Percentage (%)
Lack of contribution fees	3	19
Poor health services	3	19
Limited services provided by MHI	5	31
Few health centres	2	12.5
Lack or inappropriate infrastructure	0	0
Low contribution in % / person /year	0	0
High contribution	2	12.5
MHI verse other health insurances	1	6
Total	16	100

According to the table above, 5 respondents or 31% argued that low coverage/package of services provided by MHI was a big problem that hinders MHI to contribute a hundred percent on economic development. This is because some beneficiaries pay this contribution while continue to pay in other health institutions for health services at high costs when they are supposed to pay only between 200Rwf and 250Rwf on each visit at health centre.

Lack of contribution fees and poor health services come at the second with 19% each, while high contribution and few health centres range at the fourth place with 12.5% scores respectively, then MHI compared to other health insurance ranges at last position with 6% scores. These problems can have its source either from beneficiaries when the family members are of a big numbers as shown in the table 7.

4.3.11. Where best solutions to the problems hinder MHI can be gotten.

The best answer providers	Number of respondents	Percentage (%)
Government	8	50
Mutual health as insurance institution	5	31
Other organization	3	19
Total	16	100

From the table above, 8 respondents which represent 50% of the whole number of respondents was satisfied that the government should be the good provider of the best solution to the problems that hinder mutual health insurance from performing as it expected. Five respondents which represent 31% of the whole sample were arguing that MHI as institution of health service provider is the good provider of the best solutions to the problems hinders mutual health insurance from performing as pretended or expected. The 3 respondents which represent 19% of the whole number of respondents argued that other organizations should be the providers of the best solutions to the problems hinder MHI for it not performing as it was expected.

A big number of respondents on the idea that government should be the provider of the best solutions imply that the government as the policy maker should renew this policy for effective contribution to the beneficiaries' economic improved status and hence mutual health insurance contribute to the economic development in Ruganda sector.

CHAPTER FIVE: SUMMARY OF FINDINGS, CONCLUSION, RECOMMENDATIONS AND SUGGESTION FOR FURTHER RESEARCH

5.1. INTRODUCTION

This chapter includes summary of the major findings, conclusion, recommendations and suggestion for further research. Findings have shown that the majority of respondents are in the range of the age between «30-42» with the total of 11 respondents which represent 35.5% of the whole respondents. The majority of the respondents are of male gender and are 18 beneficiaries who represent 60% of the whole respondents while the majority respondents are married and these represent 50.5% of the whole number of respondents. The big number of respondents knows to read and to write and represent 93% of the whole respondents and the majority hold at least secondary certificates while they are majority cells and sector level. The government was suggested as the provider of the best solutions to the problems MHI.

5.2. SUMMARY OF THE MAJOR FINDINGS.

Findings have shown that 35.5% of respondents are in age range of 30-42 and they are the majority. 21% lie in range of 42-54, while 19.5% lie in the range of 18-30 and 17% of respondents are in range of 54-66, only 7% of respondents are in the range of 66 and above. The findings shown that the majority of respondents are males while the female gender were minority; 60% were males and 40% were females. Also findings have shown that 50.5% of respondents are married and they are the majority. 42.5% were single while only 7% of respondents are widows and widowers.

From the findings, the majority of respondents have Secondary level education and are represented by 40.5%, Primary level is 32%, and O'Level is 14.5%, Bachelor's degree is 9.5% of the respondents while the illiterates' beneficiaries are 3.5% of the respondents. The major's source of information on MHI are local authorities and are 64% of the respondents, Neighbors are source of information of 21% of respondents while 14% of respondents their source of information are Radios. The major motivator of beneficiaries to join MHI is the government authorities and this is represented 71%of the whole respondents. Findings have also shown that 72% of respondents each family has at least 3 and above children, while 14% of respondents have at least one child and only 14% have no child that's because they are single. Findings have shown that all respondents contribute 3000Rwf in mutual health insurance.

With the observation that I made, among the beneficiaries there is a vulnerable group poor whose contribution is 2000Rwf and since are poor, the government contributes for them. Some beneficiaries such as Teachers, Nurses, Soldiers, Policemen and Authorities are in others health insurances such as RAMA and MMI. Findings have shown that the majority of respondents' perception on the value of amount contributed in mutual health insurance is medium and this represented 64% of the total respondents, while 29% of respondents were argued that MHI premium are high, then only 7% of respondents were satisfied that these premium are low.

Only 43%of the whole respondents are happy with the health services offered by MHI, while 57% of the respondents which are the majority are not happy with the services offered by MHI, this is because of low package of health services provided by this insurance. 86% of respondents argued that their collaboration with mutual health insurance is at least good, while 14% are claiming that their collaboration with health services provider through this policy of CBHI was poor. Nevertheless, there some are specific problems that beneficiaries of mutual health insurance face.

These problems are; Non-covering of health service costs due to low level of risk sharing between sick beneficiaries and health beneficiaries, Poor quality of health services, Benevolent nature of membership of mutual health insurance, Inadequate management capacities of some mutual health insurance contributions by mutual health committees, Over-utilization of the services by beneficiaries who solicit healthcare services, Premiums are fixed, not according to the real costs of healthcare, but the contributing capacity of the beneficiaries, Some among beneficiaries suffer the wrong stage or class and do not contribute accordingly.

From the study some solutions to problems that beneficiaries of mutual health insurance face have been proposed for them to get better health services. For instance: The investment in new ventures of a share of mutual health's contribution for purposes of making profits for supporting beneficiaries' contributions in future time, more health centres have to be built in order to avoid overpopulation in one health centre and long distance walked by the beneficiaries of mutual health insurance. Some beneficiaries' mindset about mutual health insurance should be changed for the beneficiaries profiting from effective risks sharing among those who are suck and those who are healthy.

Beneficiaries' contribution capacity should be raised through community works given to those who cannot easily get the contribution per year, the management of these mutual health contributions should be efficacy and timely controlled to avoid its losses as well as the misuses, the role of partners in support for mutual health is to be pointed in creating initiatives on coverage of vulnerable groups, for them to get mutual health insurance. The study shown that there is a contribution of mutual health insurance towards economic development as shown in the following points:

Mutual health insurance contributes in finding ways to keep healthcare costs down by negotiating reduced tariffs and fixed fees per day of hospitalization, it contributes to the health sector's allocation efficiency, MHI contributes to the extension of social protection to the rural and informal sectors, it helps to poorest of the poor, do not have gainful occupations and cannot work and afford the financial contributions through government intervention, it provides the opportunities for all members to access healthcare which results in reduced mortality rates which hinders the economic development. It provides equitable and equal access to quality healthcare for children and women who mostly suffer from different illnesses and this promotes the economic status of households.

In Ruganda sector, there are some indicators of economic development which result from mutual health insurance policy implementation. These indicators are: Reduced illnesses and mortality rate among the beneficiaries, above 70 percent of the beneficiaries have opened the accounts in BPR and umurenge SACCO as financial institutions and do save, the outlook and behaviour of the beneficiaries are also improved, infrastructure development, such as centres, schools, water sanitation and cooperatives, income is increased because of increased economic activities. About 69% of the whole respondents argued that the beneficiaries willingly pay their premiums, while 5 respondents or 31% are not willing to pay.

Health insurance policy is hindered by some problems and these are: Lack of contribution fees, Poor health services, and Limited services provided by MHI, Few health centres, High contribution, and MHI verse other health insurances. For the above problems which hinder MHI, 47% of the respondents argued that the government is the good provider of the best solutions, 29% of the respondents shown that MHI institution could be the good provider of the best solutions, while 24% of the respondents claimed that the implication of NGOs should contribute a good solution.

64% of the respondents on perception of the amount contributed argued that the premium is medium. 57% of respondent on whether are they happy or not, argue that they are not happy with services package offered by MHI, while 64 argued that its collaboration with MHI institution was good.

5.3. CONCLUSION

The development of Rwanda's first Health Financing Policy marks an important step in the evolution of the health sector. The present policy for developing mutual health insurance was elaborated by the Government of Rwanda with a view to centralizing the potential and especially meeting the increasing social demand for the extension of mutual health insurance. Hence the functioning of MHI in Ruganda sector was shown significance vis-a-vis to beneficiaries and the staffs along the sector. In fact, establishing mutual health insurance across the country was to ensure that the population of Rwanda, particularly those in rural communities such as those of Ruganda sector and the informal sector have equitable access to quality healthcare services. Mutual health insurance is therefore intended to complete existing social and private health systems.

Basing on findings of this study, it is shown that improved health status of the beneficiaries has a significant effect on the economic development processes in Ruganda sector. The policy offers an instrument to build and manage partnerships for community health. It is crucial that the coordination and monitoring of the implementation of this policy at the sector, health centre and community levels be effective. In light of the above facts this study has examined the contribution of Rwandan health insurance on the economic development of the beneficiaries in Ruganda sector. Although mutual health insurance has the contribution on improvement of healthcare services and economic development in Ruganda sector through decrease in real costs of healthcare services.

Among the main factors hampering beneficiaries' enrolment in CHI in the developing world, there are the problems with the affordability of premiums, the trust in the integrity and competence of the managers, the attractiveness of the benefit package and the quality of care that is offered by the providers. In many instances, risk pooling remains limited because of the small size of the CHI member population and going to scale remains a huge challenge. In that respect, it is appropriate to further explore the feasibility of creating CHI federations in which funds get pooled.

Also the packages of services given to their members are not effectively given because of increase of services and number of beneficiaries. The CHI thus still has a long way to go if it wants to strongly contribute to health system performance. As is shown, CHI, under certain circumstances, can well be an attractive strategy to improve beneficiaries' access to healthcare. Therefore the major to improve this policy must be taken by the ministry of health and other partners in health sector.

5.4. RECOMMENDATIONS

Basing on the findings of this study carried out in Ruganda sector on the contribution of rwandan health insurance in the economic development of rwanda especially in Ruganda sector, the following are the recommendations given to the officials and the beneficiaries of mutual health insurance in Ruganda sector:

Invest in new ventures of a share of mutual health contributions should be prevailed for purposes of making profits for supporting beneficiaries' contributions in future time in promoting its economic development.

More health centres should be built with equal capacity of delivering health services in order to avoid overpopulation in one health centre and long distance walked by the beneficiaries of mutual health insurance as shown by the researcher in findings of this research.

The grassroots leaders and the entire community should be trained to change some beneficiaries' mindset about mutual health insurance policy, for the beneficiaries profiting from effective risks sharing among those who are suck and those who are healthy because, it has been remarked by the researcher that some beneficiaries pay the annual contribution forcibly.

Beneficiaries' contributions capacity should be raised through community works given to those who cannot easily get the annual contribution or/and sensitize them on paying for themselves before any kind of aid is given to them.

Some mutual health insurance staff should be sensitized on improving healthcare services given to the beneficiaries and control the management of these mutual health contributions to avoid its losses as well as misuses which are persistently observed.

The role of partners in health sector should be encouraged in supporting mutual health in creating initiatives on coverage of vulnerable groups, for them to get basic healthcare costs.

The beneficiaries should be sensitised on the role of contributing on time because when they use to contribute at late time, medical services could be also late and poor and this results in unsatisfaction. Hence, creates the conflicts among MHI beneficiaries and the executive community of the government policy which includes that of MHI scheme.

The beneficiaries should be aware of their problems concerning healthcare services they are given by mutual health insurance service provider,

Those who don't want to contribute claiming that they don't fall sick should change their behavior because MHI is collective rather than individuals separately.

The beneficiaries should raise their saving habit for them to enhance future scarce of liquidity money to be used in different transactions including contribution of mutual health insurance which is one among the problems that hinder mutual health insurance.

5.5. SUGGESTION FOR FURTHER RESEARCH

The study that was intended to examining the contribution of mutual health insurance on the economic development of the beneficiaries in Ruganda sector had not covered the whole population. This research cannot claim to be as exhaustive as many readers may expect it to be. This was due resources constraints. In the future, some closely related studies can be conducted. The following are some of them:

a. The impact of commonly based health insurance on the economic development compared with some beneficiaries' beliefs towards health insurance,

b. The relationship between economic development and mutual health insurance scheme,

d. The contribution of reduction of the real costs of health services on the economy.

Moreover, the future research should focus on the standardization of mutual health insurance schemes for these to contribute effectively on the economic development of the beneficiaries.

Barry M. (1963) You Need to Be A Little Crazy: The Truth about Starting and Growing Your Business» Third edition; Wadsworth publishing company Belmont, California.

Jutting J (2001) The Impact of Health Insurance on the Access to Healthcare and Financial Protection in Rural Developing Countries, Fourth Edition, Washington, DC.

Michael Todaro and Stephen Smith (2001) Economic Development, Tenth Edition, New York.

Atim C (1999) Social movements and health insurance: a critical evaluation of voluntary, non-profit insurance schemes with case studies from Ghana and Cameroon. Social Science and Medicine 48, 881-886.

Carrin G (2003) Community-Based Health Insurance Schemes in Developing Countries: Facts, Problems and Perspectives.

Discussion Paper no.1. World Health Organization, Department Health System Financing, Expenditure and Resource Allocation (FER), Geneva.

Carrin, G. 1987. «Community Financing of Drugs in Sub-Saharan Africa.» International Journal of Health Planning and Management 2: 125-45.

Criel B (1998) District-Based Health Insurance in Sub-Saharan Africa. Tropical Medicine and International Health volume 10 no 8 pp 799-811 august 2005

Davies P & Carrin G (2001) Risk-pooling: necessary but not sufficient. Bulletin of the World Health Organization 79, 587.

G. Carrin et al. Community-based health insurance in developing countries 810 2005 Blackwell Publishing Ltd in Gujarat, India. Bulletin of the World Health Organization 80,613-621.

Perrot J & Adams O (2000) Applying the Contractual Approach to Health Service Delivery in Developing Countries. Discussion article. WHO, Department of the Organisation of Health Services Delivery, Geneva.

Schneider P, Diop F & Bucyana S (2000) Development and Implementation of Prepayment Schemes in Rwanda. Partners for Health Reform Technical article no. 45.

Toonen, Jurrien. 1995. «Community Financing for Healthcare: A Case Study from Bolivia.» Amsterdam: Royal Tropical Institute.

WHO (2000) Health Systems: Improving Performance. The World Health Report 2000. WHO, Geneva.

World Bank (2003) The World Development Report 2004. Making Services Work for Poor Beneficiaries. World Bank, Washington, DC.

APPENDICES

Ndi Dusabimana Athanase, umunyeshuri muri Kaminuza y'Umutara Polytechnic mu ishami ry'Ubucuruzi n'ubukungu, nkaba nitegura kurangiza bityo nkaba ndimo gukora ubushakashatsi ku»Uruhare rw'ubwisungane mu kwivuza mu iterambere ry'ubukungu».

Ndifuza ko mwamfasha mumpa amakuru, mukanyuzuriza urutonde rw'ibibazo nk'uko biteguwe. Ndabizeza ko amakuru mutanga azakoreshwa neza mu bijyanye n'ubu bushakashatsi kandi afatwe nk'ibanga.

I am Dusabimana Athanase student in Umutara Polytechnic in the Faculty of Commerce and applied Economics, Economics option. I am carrying out a research entitled «The contribution of Rwandan Health Insurance (Mutuelle de santé) in the Economic Development of Rwanda». This study is to be presented in partial fulfilment for the award of bachelor's degree in Commerce and your input dear Respondent is important in the completion of the study. I assure you total confidentiality of information given; it is only for academic purposes.

i. Sector/Umurenge........................................................................

ii. Cell/Akagari..............................................................................

2. What do you understand by Rwanda Health Insurance (Mutuelle de santé)/Wumva ute ubwishingizi mu kwivuza?.......................................................................................................................................................................................................................................................................................................

3. How did you know about Rwanda Health Insurance/Wamenye ute ubwishingizi mu kwivuza?

4. Who motivated you to join Rwanda Health Insurance (Mutuelle de santé)/Ninde wagushishikarije kujya m'ubwishingizi mukwivuza?

If the answer is No, give reasons/Niba igisubizo ari Oya, tanga impamvu ..............................................................................................................................................................................................................................

7. How much money (Premium) are you charged in Rwanda Health Insurance/Mwishyura amafaranga angahe mubwishingizi m'ukwivuza?

8. How do you value the amount charged by Rwanda Health Insurance (Mutuelle de santé) /Ese ubona ute amafaranga yakwa mubwishingizi m'ukwivuza?

9. If you are a member of (Mutuelle de santé), are you happy with the services offered/Niba uri umunyamuryango wa (Mutuelle de santé),waba wishimira serivisi itangwa?

...........................................................................................................................................................................................................................

10. How do you compare your health before and after joining Rwanda Health Insurance/Ese ugereranya ute ubuzima bwawe mbere na nyuma yo kujya m'ubwishingizi mu kwivuza?

11. Compare your health expenditure before and after joining Rwanda Health Insurance/Gereranya ku mikoreshereze y'amafaranga yo kwivuza mbere na nyuma yo kujya m' ubwishingizi mu kwivuza.

a. Before/Mbere................................................................................................................................................................................................................................................................................................................................................................................................................

b. After/Nyuma.....................................................................................................................................................................................................................................................................................................................................................................................................................

12. How do you find your collaboration with Rwanda Health Insurance/Ubona ute ubufatanye bwawe n'ubwishingizi mu kwivuza?

13. As member of Rwanda Health Insurance, what specific problems do you meet/Nkumunyamuryango w' ubwishingizi mu kwivuza, ni ibihe bibazo uhura nabyo?

i. ...................................................................................... ............................

ii. ...................................................................................................................................

iii. ...................................................................................................................................

iv. ....................................................................................................................

i. Sector/Umurenge........................................................................

ii. Cell/Akagari..............................................................................

3. Do you find Rwanda Health Insurance acting as a tool towards economic development?

If yes, how?....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

4. Has Mutual health insurance contributed to any economic development in Ruganda sector?

i. .......................................................................................................................................................................................................................................................................

ii. ..............................................................................................................................................................................................................................................................................

iii. ........................................................................................................................................................................................................................................................................

iv. ..............................................................................................................................................................................................................................................................................

v. ..........................................................................................................................................

....................................................................................................................................

5. What are indicators of economic development that are brought about by mutual health insurance in Ruganda sector?

6. Compare the Heath expenditure of the beneficiaries in Ruganda sector before and after joining Rwanda Health Insurance system?

a. Before......................................................................................................................................................................................................................................................................................................................................................................................................

b. After........................................................................................................................................................................................................................................................................................................................................................................................................................................

8. a) Do you think Mutual health insurance contribute a hundred percent to the economic development in Ruganda sector?

b) If no what do you think are the problems which hinder mutual health insurance from contributing effectively to the economic development in Ruganda sector?

9. From whom do you think you can get the best solution to those problems if exist?

The contribution of rwandan health insurance in economic development of rwanda

DECLARATION

APPROVAL

ACKNOWLEDGEMENT

LIST OF ABBREVITIONS

LIST OF TABLES

LIST OF APPENDICES

TABLE OF CONTENTS

ABSTRACT

CHAPTER ONE: GENERAL INTRODUCTION

1.1 Introduction

1.2 Background of the study

1.3. Statement of the problem

1.4. Purpose of the study

1.5. Objectives of the study

1.5.1. General objective

1.5.2. Specific objectives

1.6. The research questions

1.7. Scope of the study

1.8. Significance of the study

1.9. Organization of the study

2.1. General introduction

2.2. Definition of key concepts

2.2.1. Health insurance

2.2.1.1. Understanding Health Insurance Terms

2.2.1.2. Relevant scheme models

2.2.1.3. Micro insurance in Rwanda

2.2.1.4. Experience of mutual health insurance in African countries

2.2.2. Economics

2.2.3. Development

2.2.4. Economic development

2.2.4.1 The requirements for economic development.

2.3. Community health insurance schemes in Rwanda

2.4. Current problems of mutual health insurance schemes in Rwanda

2.5. Global overview of Rwanda health insurance schemes

2.6. Principal objectives of insurance schemes

2.7. The interventions on the policy of health insurance

2.8. Organization and management

2.9. Challenges of health insurance schemes in Africa

2.10. Health insurance and willingness to pay (WTP)

2.11. The situation of mutual health insurance schemes in Rwanda

2.12. An overview of literature review

CHAPTER THREE: RESEARCH METHODOLOGY

3.1. Introduction

3.2. Research design

3.3. Areas of the study

3.4. Sources of data collection

3.4.1. Primary data

3.4.2. Secondary data

3.5. Analytitical frame work

3.6. Study population

3.7. Sample selection and sample size

3.8. Data collection instruments

3.8.1. Interview guide

3.8.2. Observation

3.8.3. Documentation

3.8.4. Questionnaire

3.9. Data processing and data analysis

3.9.1. Data Processing

3.9.1.1 Editing

3.9.1.2 Tabulation

3.9.2 Data analysis

3.10. Limitations and delimitations of the study

4.1. Introduction

4.2. Analysis, Presentation and Interpretation of data part one (Beneficiaries)

4.2.1. Distribution of age

4.2.2. Distribution of sex

Table 2: Distribution of sex

4.2.3. Distribution of marital status

Table 3: Distribution of marital status

4.2.4. Distribution of level of education

4.2.5. The general understanding of respondents about mutual health insurance

4.2.6. Distribution of source of information on MHI

Table 5: Distribution of source of information on MHI

4.2.7. The motivator of beneficiaries to join MHI

4.2.8: Number of children in family

4.2.9. Contributions/Premium

Table 8: Contributions/Premium

4.2.10. Perception on the value of amount contributed

Table 9: Perception on the value of amount contributed