摘要：Objectives. We analyzed the likelihood of rural children (aged 6–24 months) being stunted according to whether they were enrolled in Mutuelles , a community-based health-financing program providing health insurance to rural populations and granting them access to health care, including nutrition services. Methods. We retrieved health facility data from the District Health System Strengthening Tool and calculated the percentage of rural health centers that provided nutrition-related services required by Mutuelles ’ minimum service package. We used data from the 2010 Rwanda Demographic and Health Survey and performed multilevel logistic analysis to control for clustering effects and sociodemographic characteristics. The final sample was 1061 children. Results. Among 384 rural health centers, more than 90% conducted nutrition-related campaigns and malnutrition screening for children. Regardless of poverty status, the risk of being stunted was significantly lower (odds ratio = 0.60; 95% credible interval = 0.41, 0.83) for Mutuelles enrollees. This finding was robust to various model specifications (adjusted for Mutuelles enrollment, poverty status, other variables) or estimation methods (fixed and random effects). Conclusions. This study provides evidence of the effectiveness of Mutuelles in improving child nutrition status and supported the hypothesis about the role of Mutuelles in expanding medical and nutritional care coverage for children. Undernutrition is a leading cause of child morbidity and mortality in low-income countries. 1 Lack of sustainable financial support is one of the major barriers to scaling up nutritional interventions in resource-poor settings. 2,3 Evidence suggests that the most effective nutritional interventions are those with regular financial support via integration into existing local health systems. 2–14 Community-based financing, an approach designed to address financial bottlenecks at both the demand and supply side of medical care, has been proposed to promote financial sustainability of nutrition (and other health-related) programs and equitable access to nutrition care. 2,3 With increasing global efforts invested in child nutrition, evidence of the effectiveness of the community-based financing approach in improving child nutrition status is urgently needed. Existing studies on community-based health-financing programs, which have mainly focused on their impact toward achieving universal health coverage in developing countries, have found a positive association between the programs and individual-level medical care utilization or household-level financial risk protection in countries such as Burkina Faso, China, Ethiopia, India, Laos, Malawi, Mexico, and Rwanda. 15–23 To our knowledge, little research has been conducted to investigate the role of community-based health financing in improving the nutritional status of children in resource-limited settings. We aimed to fill the knowledge gap through a case study in rural Rwanda. As an agricultural country in central and east Africa with a per capita gross domestic product of US $595,24 Rwanda has been making remarkable progress in reducing child mortality in the past decade: the mortality among children younger than 5 years in Rwanda has declined from 152 per 1000 live births in 2005 to 76 in 2010. 25 Child stunting, however, continues to be a public concern: about 44% of children younger than 5 years were stunted in 2010. 25 Stunted children in Rwanda are susceptible to infectious diseases such as diarrhea, malaria, and acute respiratory infections, 25 and stunting contributes to approximately 50% of morbidity and mortality among children younger than 5 years in Rwanda. 26 Stunting in Rwanda is found to be associated with food shortage and insecurity, repeated illnesses and poor health care, a lack of knowledge on feeding, and inadequate hygiene and sanitation. 25 The government of Rwanda has adopted a public health approach to improve child nutritional status. The public health sector in Rwanda provides the majority of health services to its population, especially in rural areas. In recent years, various nutrition interventions, from preventive to curative, were integrated into the local public health systems as a part of the minimum service package (MSP) covered by Mutuelles , a community-based health insurance program providing health insurance to populations in rural and informal economies (Panel A, available as a supplement to the online version of this article at http://www.ajph.org ). 27 The inclusion of nutrition-related services in the MSP of Mutuelles has sparked our research interest in understanding the relationship between Mutuelles enrollment and child nutritional status. The Mutuelles program has been found to be effective in promoting medical care utilization with financial risk protection among its enrollees. 19,28 A few studies have discussed the possible link between Mutuelles enrollment and health outcomes, but without supporting empirical evidence. 29,30 In this study, taking advantage of the 2010 Rwanda Demographic and Health Survey (RDHS 2010) and the 2010 District Health System Strengthening Tool (DHHST), we determined the availability of nutritional services in the MSP of Mutuelles across rural health centers in Rwanda and conducted the first empirical study at the individual level that quantifies the association between Mutuelles enrollment and the likelihood of being stunted for rural children.
