NR 553 Week 8 Comparative Country Report Example

Comparative Country Report: How Malawi and Rwanda Pay for Primary Care for Rural Households, One Function Asked of Both Countries, Section by Section on Money, Authority and Risk

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College of Nursing, Chamberlain University

NR 553: Global Health

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Month Day, Year

Comparative Country Report: How Malawi and Rwanda Pay for Primary Care for Rural Households, One Function Asked of Both Countries, Section by Section on Money, Authority and Risk

The Function

This report examines one function in two countries: how a rural household pays for primary care, meaning a visit to a health center for a child's fever, antenatal care or a chronic condition. Malawi and Rwanda are both low-income, largely rural, densely populated countries in east and southern Africa with histories of heavy donor dependence. They have taken different routes to paying for primary care. Malawi provides public services free at the point of use, financed by taxes and donors. Rwanda built a national system of community-based health insurance, known as Mutuelles, in which households pay annual premiums and small copayments. The same three questions are asked of both: who holds the money, who decides, and who absorbs the loss when the arrangement fails.

Who Holds the Money

Malawi. The money for public primary care sits in the government health budget and donor funds. The Ministry of Health and district health offices hold it and spend it on staff, medicines and facilities. The household pays nothing at a government health center but may pay out of pocket at a faith-based facility, a private clinic or a drug shop, and always pays for transport.

Rwanda. The money for primary care is split. Households pay annual premiums into Mutuelles, pooled at district and national levels, supplemented by government and donor contributions, including premium subsidies for the poorest households. Health centers are paid partly by the insurance scheme for services provided. Households also pay a small copayment at the point of care. Lu and colleagues found that Mutuelles expanded coverage substantially in its first eight years, increased use of medical care and protected households from catastrophic health spending (Lu et al., 2012).

Who Decides

Malawi. The Ministry of Health decides what services are free through its essential health package, and districts decide how to allocate staff and supplies. Donors influence decisions through earmarked funding. Households decide only whether to go to a free public facility or pay elsewhere.

Rwanda. The government sets premium levels, stratified by household socioeconomic category so that poorer households pay less or nothing, and sets the benefit package. Enrollment has been strongly promoted by local authorities. Health centers are accountable for performance through a performance-based financing system in which part of their income depends on meeting targets.

Who Absorbs the Loss

Malawi. When the arrangement fails, for example when medicines are out of stock, the household absorbs the loss: it buys the medicine privately, travels to another facility or goes without. When donor funding falls, services funded by that donor shrink, and households again absorb the gap. Staff vacancies, worsened by migration, add a further failure mode (Record & Mohiddin, 2006). There is no insurance pool to cushion the household.

Rwanda. When the arrangement fails, the loss is partly absorbed by the pool and partly by households. A household that cannot afford its premium may be uninsured and face full fees; Lu and colleagues found that among enrollees, those in the poorest quintile still had lower use of care and higher rates of catastrophic spending than wealthier enrollees (Lu et al., 2012). Premium stratification and subsidies were introduced to reduce that risk.

Similar Results, Different Routes

Both countries have made substantial progress on some primary care outcomes over two decades, including large falls in child mortality, though Rwanda's gains have been particularly rapid. The two routes reach some similar results by opposite means. Malawi removes price at the point of use but relies on a thin, donor-dependent budget, so the household's risk shows up as stock-outs and travel. Rwanda introduces a small price and a premium, but pools money, links payment to performance and gives households a claim on services, so the household's risk shows up as the premium. Neither route removes the need for external funding.

The comparison also shows what each system does to accountability. In Malawi, accountability runs from district to ministry to donors. In Rwanda, households pay premiums and local officials are measured on enrollment, which creates accountability to households as well, though critics have noted that enrollment was promoted with strong administrative pressure.

What Each Could Borrow

Malawi could borrow Rwanda's performance-linked payments to health centers, which do not require introducing premiums and could be funded from existing budgets and pooled donor money. It could also borrow the discipline of publishing coverage and financial protection data regularly. Rwanda could borrow Malawi's commitment to no charges at the point of use for the poorest, extending full premium and copayment exemptions where the poorest still face barriers. Development assistance for health remains a large source of financing in both countries (Dieleman et al., 2016), so both depend on donor decisions they do not control.

Limits of the Comparison

This comparison looks at one function, paying for primary care, and says little about the rest of each system, such as hospital care, the workforce or medicine supply, which may explain differences in outcomes as much as financing does. Rwanda's rapid gains also coincided with strong central government, extensive community health worker programs and substantial donor support, so they cannot be attributed to Mutuelles alone. Malawi's slower progress on some measures reflects, among other things, a larger population, different geography and repeated economic shocks.

The comparison also relies on published evaluations that cover particular periods. Both systems have changed since those studies. A report intended for policy should update the figures on coverage, out-of-pocket spending and catastrophic spending before drawing conclusions for current decisions.

Conclusion

Asking the same three questions of both countries shows that the choice between free public services and community insurance is less about ideology than about where money sits, who decides and who absorbs the loss when things go wrong. In Malawi, the household absorbs the loss through stock-outs and private purchases; in Rwanda, through premiums and residual fees for the poorest. A reform in either country should be judged by whether it moves that loss away from the households least able to bear it.

Both countries show that the question of who pays at the point of care cannot be separated from who funds the system as a whole, and that the poorest households remain the test of any arrangement.

References

Dieleman, J. L., Schneider, M. T., Haakenstad, A., Singh, L., Sadat, N., Birger, M., Reynolds, A., Templin, T., Hamavid, H., Chapin, A., & Murray, C. J. L. (2016). Development assistance for health: Past trends, associations, and the future of international financial flows for health. The Lancet, 387(10037), 2536-2544. https://doi.org/10.1016/S0140-6736(16)30168-4

Lu, C., Chin, B., Lewandowski, J. L., Basinga, P., Hirschhorn, L. R., Hill, K., Murray, M., & Binagwaho, A. (2012). Towards universal health coverage: An evaluation of Rwanda Mutuelles in its first eight years. PLoS ONE, 7(6), Article e39282. https://doi.org/10.1371/journal.pone.0039282

Record, R., & Mohiddin, A. (2006). An economic perspective on Malawi's medical "brain drain". Globalization and Health, 2, Article 12. https://doi.org/10.1186/1744-8603-2-12