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Utilization and
Expenditures on
Outpatient Health
Care by HIV Positive
Individuals in Rwanda
PHR Rwanda - Abt Associates Inc.
IAEN and AIDS Conference Durban
July 2000
Partnerships
for Health
Reform
Abt Associates Inc.
In collaboration with:
 Development Associates, Inc.
 Harvard School of Public Health
 Howard University International Affairs Center
 University Research Co., LLC
Background: NHA and HIV in
Rwanda


PHR, Rwandan National Health Accounts
Team, UNAIDS, PNLS, and MOH collaborating
to examine the sources of uses of funding for
HIV services in Rwanda using the NHA
framework
National Health Accounts will clearly illustrate:
 Who
(Private, Public, Donors) pays for what?
 How much do they pay?
Why National Health Accounts?





Effective method for compiling descriptive statistics of
a nation’s health economy.
Represents the flow of funds throughout the system.
Can assist policy-makers in setting health care policy
priorities.
Can assist governments in assessing the performance of
their health sectors.
Can assist governments in identifying areas of inequity
in the distribution of care.
NHA Data Collection

Data on sources and uses of HIV funds is
collected through surveys from all levels of the
health system including:
 Donors
 Hospitals
 Pharmaceutical
Companies
 Ministry of Health
 NGOs
 Households*
Household Survey: Snapshot of
Out-of -Pocket Expenditures



PHR with NHA team, UNAIDS, and MOH
developed a survey to investigate the use of
and expenditures on outpatient and inpatient
health by HIV positive individuals in Rwanda
Findings on expenditures will contribute to
understanding of out-of -pocket expenditures
on health, and
contribute to existing limited body of literature
looking at the impact of HIV on households
Outpatient Survey: Methodology

350 HIV positive individuals were identified in
four facilities
1
Hospital
 1 Health Center
 1 AIDS Association
 1 meeting and testing facility

Interviews were conducted by social assistants
who had a relationship with the patient
Data Limitations for the Study

Sample size
 350
total
 293 were women



Many facilities do not test, nor inform patients
of their HIV status in Rwanda, which limits the
sample size
Issue of self-selection: all patients knew their
status
Findings are not representative of the universe
of HIV positive individuals in Rwanda as most
were identified from non-routine testing
Rwanda: Background



7.8 million people in 1998
Per Capita GDP in 1997: $242
Service Sector:
 economically
most productive with 7% of the
population produces 43% of GDP

70% of population lives below the poverty line
Rwanda NHA 1998 Results
Health
Spending
Public
Per capita
Exp. on
Health
$1.30
Health
Distribution
Exp. as % of Sources
of GDP
0.5%
12%
Private
$2.70
1.1%
25%
Donors
$6.80
2.7%
63%
HIV/AIDS in Rwanda




Estimated that 11% of the adult population is
sero-positive
Highest prevalence in service sector population
(19%)
Testing takes place in few facilities and often
status is not revealed to those tested
Government of Rwanda has a clearly
articulated multi-sectoral approach to
combating the HIV epidemic
Socio-demographics of surveyed individuals:
mainly women, widowed, without education,
living in urban areas
100%
80%
92%
85%
69%
60%
50%
43%
40%
41%
5+ Y HIV
<=PRIM EDU
AGE 26-35
URB
WIDO
0%
FEM
20%
HH 2+HIV
26%
NHA Finding: Households affected
by HIV/AIDS suffer economically

The following percentage of people indicated
that they were “with difficulty” and “unable to
meet” the following basic needs:
 food
(73%)
 housing (57%)
 education (86%)
 clothing (82%)

Average Number of Work days lost in the past
two weeks: : 4.8
NHA Finding: Sero-positive
patients seek care more often

Annual per capita utilization rates
 0.29
visits per general population
 10.9 visits per sero-positive individual

Highest service use rates among sero-positive
patients who are:
 urban,
 married,
 in
highest expenditure quintiles
NHA Finding: Sero-positive
individuals have higher per capita
spending
$200
$180
$160
$140
$120
$100
$80
$60
$40
$20
$0
$182
$63
$2.7
TOT POP
HIV+
SAMPLE
HIV+
MARRIED
SAMPLE
Per Capita Health
Spending
How are health expenditures
financed?



66% receive assistance from church and family
18% borrow from family/friends
Sero-positive low-income individuals did not
perceive to have received donor and
government assistance
Conclusions for Sample Group

Sero-positive individuals who are poor
 need
care almost 10x more often than the general
population
 have higher health care costs than the general
population
 need assistance to pay out-of-pocket fees
 receive help from family, friends and church
Recommendations

Prevention:
 Strengthen
efforts to prevent HIV/AIDS
 Provide extensive public information - IEC
 Broader, more extensive and routine testing for HIV

Improve access and equity for the poor with
HIV
 increase
government financing targeted to lowerincome groups
 donor financed prepayment for poor households
with access to health centers and district hospital
 international efforts lower the costs of AIDS
treatments
Recommendations

Further Research
 effectiveness
of alternative approaches to improve
access and equity for the poor with HIV/AIDS
Partnerships for Health Reform is implemented by
Abt Associates Inc. under contract
No. HRN-C-95-00024 with the
U.S. Agency for International Development (USAID)
Partnerships
for Health
Reform