A Service of Leibniz-Informationszentrum econstor Wirtschaft Leibniz Information Centre Make Your Publications Visible. zbw for Economics Binagwaho, Agnes; Hartwig, Renate; Ingeri, Denyse; Makaka, Andrew Working Paper Mutual health insurance and its contribution to improving child health in Rwanda Passauer Diskussionspapiere - Volkswirtschaftliche Reihe, No. V-66-12 Provided in Cooperation with: University of Passau, Faculty of Business and Economics Suggested Citation: Binagwaho, Agnes; Hartwig, Renate; Ingeri, Denyse; Makaka, Andrew (2012) : Mutual health insurance and its contribution to improving child health in Rwanda, Passauer Diskussionspapiere - Volkswirtschaftliche Reihe, No. V-66-12, Universität Passau, Wirtschaftswissenschaftliche Fakultät, Passau This Version is available at: http://hdl.handle.net/10419/66213 Standard-Nutzungsbedingungen: Terms of use: Die Dokumente auf EconStor dürfen zu eigenen wissenschaftlichen Documents in EconStor may be saved and copied for your Zwecken und zum Privatgebrauch gespeichert und kopiert werden. personal and scholarly purposes. 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V-66-12 Volkswirtschaftliche Reihe ISSN 1435-3520 PASSAUER DISKUSSIONSPAPIERE Herausgeber: Die Gruppe der volkswirtschaftlichen Professoren der Wirtschaftswissenschaftlichen Fakultät der Universität Passau 94030 Passau Mutual Health Insurance and its Contribution to Improving Child Health in Rwanda l Agnes Binagwaho, Renate Hartwig, Denyse Ingeri, and Andrew Makaka Diskussionsbeitrag Nr. V-66-12 Volkswirtschaftliche Reihe ISSN 1435-3520 Adresse des Autors/der Autoren: Renate Hartwig Wirtschaftswissenschaftliche Fakultät Universität Passau 94030 Passau Telefon: (0851) 509 3314 Telefax: E-Mail: [email protected] Für den Inhalt der Passauer Diskussionspapiere ist der jeweilige Autor verantwortlich. Es wird gebeten, sich mit Anregungen und Kritik direkt an den Autor zu wenden. Mutual Health Insurance and its Contribution to Improving Child Health in Rwanda Agnes Binagwaho Ministry of Health of Rwanda Renate Hartwig* International Institute of Social Studies, Erasmus University Rotterdam Paris School of Economics University of Passau Denyse Ingeri Health Financing Unit, Ministry of Health of Rwanda Andrew Makaka Health Financing Unit, Ministry of Health of Rwanda October 2012 Abstract ─ Rwanda is among the few countries in Sub-Saharan Africa and the developing approaching universal health insurance coverage. To date, over 90 per cent of the population are enrolled in the Mutuelles de Santé - a system that started off from a number of stand-alone community based health insurance schemes and gradually evolved into a unified social health insurance plan. The country has also made remarkable progress in ameliorating child health, particularly since 2005, which coincides with the year when the Mutuelles de Santé was standardised and raises the question to what extent the insurance scheme did contribute to the observed improvements. In order to address this issue we conduct a quantitative impact evaluation using nationally representative micro-data from the 2005 and 2010 Rwandan Demographic and Health Surveys (RDHSs) and also consider potential channels from which improvements could originate. Our results suggest the following: The Mutuelles de Santé improves access to preventative and curative health services. Insured households are more sensitive to health issues, in the sense that they are more inclined to use bed nets and ensure safe drinking water. Despite a weak effect on health outcomes overall, the insurance scheme seems to have contributed to improvements in stunting and mortality, at the critical ages (before the age of two). Key words ─ Health Insurance, Child Health, Mutuelles de Santé, Rwanda JEL codes ─ I11, I38, J13 *Corresponding author: Renate Hartwig, International Institute of Social Studies, Erasmus University Rotterdam, Kortenaerkade 12, 2518 AX The Hague, The Netherlands, Phone: +31(0)70-4260 652, Email: [email protected]. We thank Michael Grimm and Robert Sparrow for very helpful comments and suggestions on earlier versions of this paper. We are equally grateful for the comments received at the 4th International Conference on Development Economics in Bordeaux and the 2012 PEGNet Conference in Dakar. The financial support through the AMID programme is gratefully acknowledged. Any errors or omissions are solely the responsibility of the authors. 1 Introduction A growing strand in the empirical literature argues that early childhood experiences are determinant for future physical and cognitive development. Periods of prolonged under nutrition or illness, for example, have been found to lead to an unrecoverable reduction in height or lower educational achievements (see e.g. Behrman and Rosenzweig, 2004; Case et al., 2005; Alderman et al., 2006; Heckman, 2006; Oreoupolous et al., 2008; Currie, 2009; Maluccio et al., 2009; Alderman, 2010; Almond and Currie, 2010; Schultz, 2010). Some studies even go as far and argue that shocks in early childhood then influence earnings capabilities (see e.g. Hoddinot et al., 2008). The period that is considered as being crucial for later development and well-being in most of these studies are the years from birth up until two (some argue up until three) years of age. In light of the potential negative long-term consequences and the provisions of the Millennium Development Goals (MDGs), policy makers in low income countries are increasingly trying to mitigate child ill-health through targeted interventions including vaccination campaigns, supplementary feeding or cash transfer programmes. In addition to these concentrated efforts, in recent years there has also been a global push to expand health insurance coverage in low-income settings (see e.g. WHO, 2005) which is ultimately also intended to improve population health. Hence, if health insurance is also assumed to improve the health status of the population, the question arises how much it actually should, or rather could contribute. Coming back to the issue of child health, the before mentioned question becomes even more interesting when contrasting the potential outcomes of health insurance to the more targeted interventions. Whereby the different measures should not necessarily be seen as directly competing options but rather be evaluated from an overall cost-effectiveness perspective. Concentrating on the health insurance question for now, there is, so far, still very little empirical evidence on the contribution of insurance coverage towards the amelioration of child health and the limited, robust evidence that is there actually draws a rather mixed picture particularly when it comes to measuring improvements in the child’s health status. Thus, the question of how much health insurance could contribute to improving child health still remains an open one. Reviewing the existing literature on the topic, it becomes evident that the results obtained are very much dependent on the context and the design of the insurance scheme which makes cross-country comparisons rather difficult. Nevertheless, generally it can be said that more often than not, does the success of any health insurance system hinge on the accessibility to 2 good quality health care and the level of trust vested in the system.1 In light of the importance of context, this paper presents yet another case study and investigates the question to what extent health insurance contributes to the amelioration of child health in the case of Rwanda. Rwanda, which is a small landlocked country in central eastern Africa, provides an interesting case to study for three reasons. First, it is among the few countries in Sub-Saharan Africa and the developing world that managed to reach almost universal health insurance coverage. To date, over 90 per cent of the population are enrolled in the Mutuelles de Santé (hereafter also referred to as Mutuelles) - a system that started off from a number of stand- alone community based health insurance schemes and over time evolved into a standardised social health insurance plan. Second, of its current population of an estimated 11 million, a substantial share, namely 17.5 per cent is below 5 years of age (NISR, 2009), which is also considered the generation that will be key to reap the benefits of a demographic dividend. Third, the country has made significant progress in improving child health particularly since 2005,2 which coincides with the year when the Mutuelles scheme was standardized; raising the question to what extend the insurance system did manage to contribute to this.