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Mutuelles to Improve Child Health

Demonstrating the Potential of Mutuelles to Improve Child Health

Unsafe or inadequate supplies of water, and poor hygiene and sanitation are major contributors to diarrheal disease in Rwanda. Only 40% of rural populations and 60% of urban populations have access to safe water sources, and a mere 2.5% of the population has access to piped water in their homes; 27% obtain drinking water from unsafe sources.

Community-based health insurance (CBHI or mutuelle de santé) is believed to be a potentially powerful, but untested, distribution and communications channel to promote and deliver preventative health products like Sûr’Eau, a point-of-use (POU) water disinfection product, to vulnerable populations.

Jointly with the Point-of-Service Water Disinfection and Zinc Treatment (POUZN) project, Health Systems 20/20 launched a pilot program in February, 2008 in Nyagatare District, followed in June 2008 in Rubavu district to promote and distribute the Sûr’Eau water product in Rwanda, capitalizing on well established CBHI organization channels and membership in the area. The CBHI enrollment rate in 2007 in the District of Nyagatare was 81% and in Rubavu the enrollment rate was 51%.

In Rukomo, one of 19 sectors in Nyagatare District and where the official project launch took place, frequent outbreaks of cholera have historically been linked to a lack of potable water. The last outbreak occurred just as the POUZN project (in collaboration with the Ministry of Health and Population Services International) was initiating the pilot phase of distribution and promotion of Sûr’Eau through CBHI channels.

The POUZN pilot program aims to:

• Reduce morbidity and mortality due to diarrheal disease in children under five.
• Increase the use of Sûr’Eau point-of-use safe water system (SWS), especially amongst rural and poor populations enrolled in mutuelles. This was achieved through provision of information on the importance of safe water and good hygiene practices for the prevention of diarrhea and the inclusion of Sûr’Eau at a discounted price in the mutuelle de santé system in three pilot districts.
• Contribute to the financial sustainability of mutuelle organizations by increasing membership (through Sûr’Eau promotional sales) and/or reducing mutuelle spending on diarrhea services.

The Sûr’Eau product, available in commercial markets and health centers for 300 RWF (US$0.54), was offered to CBHI members in Nyagatare district only at the discounted price of 200 RWF. At the pilot launch ceremony, each household that had reenrolled in their mutuelle received a free promotional bottle of Sûr’Eau. Newly trained CBHI committee members (who are also community health workers) in both Nyagatare and Rubavu districts promoted and sold Sûr’Eau to CBHI members.

In July 2009 the program was evaluated, comparing the two intervention districts with a third, control, district of Karongi. The pilot was associated with a 41 percentage point increase in ever use of Sûr’Eau. At endline, the proportion of households reporting ever use of Sûr’Eau reached 60% in the pilot districts, but remained at just over 11% in the control district.

The evaluation of the mutuelles de santé pilot project in 2010 revealed that the members of the organizations who received an interpersonal communication (IPC) on Sûr’Eau in the past six months were more likely to have ever used or currently be using Sûr’Eau. IPC, especially through mutuelles de santé, had consistent and significant effect on use. Exposure to IPC on Sûr’Eau (particularly from community health workers and mutuelle staff), and hearing about the product at community meetings and health centers was associated with a significant increase in use.