I think I promised to post some more technical stuff than Zack, so I'd better deliver:

Shortly after I arrived, Elie and Consolate brought me up-to-speed on their efforts on Mutuelle (community insurance).  It’s one of my big projects here and it consists of three pieces:

1. An immediate effort to boost Mutuelle enrollment in the Shingiro catchment area for 2010
2. Develop a report for the District Mayor on common barriers to enrollment and recommendations to overcome those barriers.
3. Liaise with the Shingiro Mutuelle office as part of the broader effort to make Shingiro work well

Mutuelle enrollment costs RWF 1,000 per household member for each year.  The Mutuelle-subscription year corresponds to the calendar year.  To prevent people from only purchasing Mutuelle when they become sick, aka to prevent adverse selection, Mutuelle must be purchased before the year begins.  If families wait until the subscription year to purchase Mutuelle, they face a 30-day waiting period before their Mutuelle enrollment becomes active and can only purchase for the current year until June.  Mutuelle enrollment for the next year begins in August.  Thus, from now until the end of December is the important period for enrolling community members.  An additional measure against adverse selection, heads of household must purchase Mutuelle for every member of their households, not just those that are mostly likely to become sick.

Mutuelle enrollment is the key to creating access to the formal health system in Rwanda.  Indeed, looking at the data from 2008 in the Musanze district, there is a strong correlation between Mutuelle enrollment and health center use at the 11 health centers:

*I should note, in loyalty, fairness, and kudos to CCHIPs that “Mutuelle Enrollment vs. Target” and “New Cases Seen vs. Target” in Shingiro are both up considerably in 2009.  Both gains have no doubt been helped by CCHIPs'involvement.

While correlation does not prove causality there are a few points of reality that make the distinction moot.

1. Mutuelle is a great deal for its members.  The true cost of health care is far higher than the RWF 1,000 enrollment fee, which is ‘only’ about $2.  Mutuelle is subsidized by various NGOs and the government.  Thus, beyond the normal insurance functions of consumption smoothing, risk pooling and so on, Mutuelle gives preferential access to the health center vs out of pocket payers.
2. We do see enrollment creep up between January and June, as people recognize that they need Mutuelle after they get sick.  However, this just reinforces the argument for educating people about the cost-savings of using Mutuelle before they get sick.  Mutuelle creates access to health centers at an affordable price.
3. The great deal means that adverse selection is less of a problem, in the short run at least.  Very few families have a risk profile for illness that makes not purchasing Mutuelle a good bet.

Therefore, I suspect that the Mutuelle enrollment rate indicates the proportion of the population that

a. believes in the formal healthcare system vs traditional healers or doing nothing at all

and

b. is able to pay for coverage. 

Focusing on Mutuelle enrollment allows the health center to ‘bag’ wins and concentrate its ‘sales’ effort within a relatively small window of time.  We don’t have to expend significant resources all year round trying to convince people on the benefits of using the health center.  We know how many people will use the health center based on our enrollment figure, and we know the time period that we need to focus on to sell health center use for the whole next year.

A question one of my professors raised about the subsidization of Mutuelle is: ‘if you are already heavily subsidizing the system, why not just give free healthcare to everyone?  Why make people pay anything at all, if that will get them to use health services more often?’

There are a few reasons:

1. The poorest (“indigents” in local parlance) receive financial aid to cover the Mutuelle enrollment fee (though we are looking at the current system of identifying these people – it does not work very well).
2. Forcing people to pay for at least part of the cost of care helps prevent adverse incentives from forming (such as creating a sense of entitlement, etc).  It might also create good habits and general acceptance of health insurance as ‘just something you do’.
3. NGO pockets are deep, but not limitless.  In fact, we are currently doing analyses of what would happen to the Shingiro budget if various sources of income were delayed or ceased (my working hypothesis: if Mutuelle cut back on its reimbursements, the health centers would quickly become insolvent).
4. Most important is the recognition that the current system is developing alongside the Rwandan economy.  The goal is for most parts of the healthcare system to not fundamentally change when the system becomes self-sustaining.  It is important to sensitize (a favorite word of Rwandan technocrats) the population to the benefits of using the health centers, even if they cannot afford them currently.  Indeed, using the health centers now might help people be able to afford them in the future.  The hope is for the development of a virtuous cycle with better health standards driving income growth driving a greater ability and willingness to pay for health services.

Despite these qualifications, it is clear that Mutuelle is not an ideal system for paying for care.  However, it’s hard to imagine an ideal system, given the willingness to pay for most people is lower than the cost of providing healthcare.  But we’re not here to create an ideal system.  We are working at a local level; we are not trying to redesign the Rwandan healthcare system or how the government should ask its citizens to pay for that system.  We are trying to help the health center staff maximize the quality and usage of the health center in a way that is implementable, replicable, and can be easily monitored.  Mutuelle is vital to this effort.

Sometimes you have to take the slow boat to China or Mudende.  Patience is not really part of a 23 year old’s repertoire of emotional or mental paces.  Slothfulness, sometimes, but patience not so much.  A recent Mutuelle outreach trip to Mudende tempered my ambitions and fantasies somewhat, but also gave me hope for the long term potential of CCHPS and Rwanda.

On Tuesday morning, we hoped to lead a Mutuelle (community health insurance) information session at Mudende.  We drove the 20 minutes to Shingiro, picked up representatives of Mutuelle and several Shingiro nurses. 

At this point I realized that the two pots of coffee and two liters of water I had consumed earlier would be catching up to me at some point during the course of the morning.  Thinking nothing of making assumptions like: “oh, they’ll have a toilet at Mudende” I decided to wait.

We then drove the half hour up the winding, rocky, bumpy road to Mudende.  The road is narrow and at times seems to shoot straight up the side of the hills.  Elie remarked that the road was newly resurfaced, which is good because it’s hard to imagine driving on a less passable road.

I sat up front with Elie, and asked him about the people and plants as we drove.  We passed fields of beans, potatoes, gooseberry, maize, eucalyptus, and bamboo.  Elie explained that the altitude prevents the cultivation of coffee and that avocados grown here are much smaller than those grown in the south.  The sun was bright and I waved to the constant stream of children who would run to the side of the road as the Land Cruiser rumbled by.  It was a nice drive except for all the bumps in the road (and we’re talking softball to volleyball sized rocks here).

Mudende sits on what seems to be a peninsular hill jutting out into the openness of the falling hillside.  As we made the final turn down the hill peninsula, we came upon a young shepherd and his flock of about a half dozen sheep.  The shepherd stood on one side of the hill and his sheep on the other and as we drove past the sheep got out in front of the truck.  They began running away from the Land Cruiser and down the path and we nearly herded them to Mudende.  It was only a quarter mile and the shepherd ran behind us, yelling at us, the sheep, or whoever would listen.  The sheep finally turned up into a field just before we entered Mudende.

As we arrived, I was in for my first “Muzungu Celebrity Experience”.  Literally dozens of children began shouting “Muzungu!  Muraho Muzungu!” and variations on that theme as they began chasing the Land Cruiser.  We pulled up next to the community offices and we all got out.  I didn’t know quite what to do, so I smiled and waved to the children.  Soon, a police officer chased them away in a hilarious flock of giggles and yelling.

As is common in Rwanda, and I would guess most places with poor roads, communication, and little automobile ownership, everyone was late.  We settled in to wait for the community to arrive so that we could begin our presentation.  Unfortunately, as the only Muzungu in the group, this meant a lot of standing around and laughing along at jokes that I didn’t understand. 

After a few minutes, I asked Rene if he could ask someone where a toilet was.  He came back a minute later reporting that the nearest toilet was at the school we passed on our way in.  The school was only a quarter mile away, but it also lay in the treacherous territory of the Lollipop Guild.  I didn’t need 100 Rwandan school children watching me pee – talk about stage fright.

We waited some more as Elie went to find out why there were no locals present for the meeting.  I took this opportunity to take in the view.  The town overlooks a large valley, stretching out into the haze.  Rwanda is a beautiful country, all green and brown.  And yet the beauty of the landscape clashes forcefully with the poverty of its rural population.  From a distance, the tin roofed huts and the smoke rising from cooking fires and slash-and-burn agriculture present a beautiful image.  Rustic.  For an American, it stirs within the myths of our American frontier.  But when you approach one of the tin-roofed hut s and you are greeted by a small child with the big belly that signifies not over-indulgence but such malnurouishment that his body is too weak to keep his organs tight below his chest cavity, well, the myths disappear.  Reality sinks in.  The need is immediate, but the obstacles are many and, at times, desperately frustrating.

Elie returned and reported that no one had canvassed to spread the word about the meeting.  We would need to reschedule.  However, before we could reschedule we needed to wait for another member of the Mutuelle team to arrive. 

I squirmed as we waited some more.  Elie is a gregarious guy, so he kept everyone entertained.  All the Kinyarwanda speakers anyway. 

I began to circle the cell office.  I noticed, excitedly, that on the back of the building seemed to be several latrines.  I tried each door down the line.  Locked.  Locked.  Locked.

I returned to the group talking and asked Rene about a toilet.  He pointed to a man coming out of a small group of trees.  “You can probably do that.”  I considered it, but Rwanda is very densly populated, especially around the cell office.  No, best not be the foreigner that comes in and pees on the country.

I returned to the group again, and noted that there was not a large group of residents waiting, but there were 15-20 elderly people waiting.  I asked Elie about them.  He said that they were not here for our Mutuelle presentation, and wanted to meet with cell officials to discuss other matters.  Fair enough, I thought, but they look bored, we were certainly bored, why not talk to each other about Mutuelle anyway?  I asked Elie.  Politics.  We didn’t want to step on any toes by appearing to take these people’s attention.  I understood, and was grateful for the informed local perspective.  But, still, frustrating.

Waiting...

Rene tries the tardy Mutuelle official’s phone, with no response...

Waiting…

She arrives!  We can go!  But first, the team decides we should look at the Twa resettlement project located next to the cell office.  The Twa, sometimes referred to as a pygmy group (though they seemed normal height to me) are the smallest of Rwanda’s 3 “ethnic” groups.

We went and surveyed the Twa settlement.  A broken door and they need a latrine.  So did I.  I died a little inside as my bladder nearly ruptured.

After 2 hours of sitting around, we finally left.

On the way back, we passed through the small town of Gwanda Riushya.  Hikers park their vehicles here before they climb the nearby Virunga range volcanoes.  With the Mutuelle meeting date for the next week set, we decided to inform the locals.  We parked the Land Cruiser, and a group began to grow, curious at what we were doing/would say.  Rene smiled, “this is grass roots organizing.”  Note to self: Grassroots organizing is easier when your presence draws a crowd. Rene and Elie said a few words and we were off again.

Now began the serious descent to Shingiro.  I was smushed in the back of the Land Cruiser with 8 other people.  The back of the Land Cruiser has narrow benches on either wall, facing each other.  Maximum capacity, Zack has told me, is however many can squeeze in.  So I guess I should have been happy that there were only 8 people in the back.  As my legs fell asleep, this probably wouldn’t have been consolation.  I am still learning things about the best place to sit in the Land Cruiser.  On the way up to Mudende, I sat shotgun, which is the best spot.  On the way down I discovered a basic rule of thumb for sitting on the benches in the back of the Land Cruiser: when you are mostly going uphill, sit near the front.  When you are going mostly downhill, sit near the back.  The key is to ride on top of everyone else, and not be ridden.  Unfortunately, as we descended toward Shingiro, I was in the front of the back, with 3 people uphill of me.  Ugh.  At this point, the combination of altitude and my desperate need to relieve myself was inducing some serious claustrophobia.  Rene sat in front, happily snapping pictures with my camera.  We slowed down several times for him to get better shots of Shingiro from above.  My bladder screamed: Ahhhhhhh!

Finally, in a ride that seemed like an hour instead of twenty minutes, we rolled back into Shingiro.  I ran into the new Global Fund building, and found the restroom.  How do you spell relief?

I met up with Monique who was taking notes on a community health worker (CHW) training session.  After our utter lack of turnout at Mudende, I was reminded that with trained CHWs and a system for deploying them, such a problem should never occur again.  After a seemingly wasted morning at Mudende, I have the personal experience to know the value of such a system.

While I came away from the morning with my grand ambitions somewhat tempered, I took from the experience a perspective which will allow me to actually have an impact.  The wild dreams and fantasies are gone, mostly.  I know more of the reality of Rwanda – its poverty, its frustrations, but also the enormity of good that can be accomplished.