Talks of the Swiss Health Economics Workshop 2013

1. Motivation
Empirical analyses
Discussion and Conclusion
Community-based health insurance in Rwanda:
An effective measure against child labour?
Renate Strobl
Department of Health Economics, University of Basel
13 September 2013
Swiss Health Economic Workshop, Lucerne
Renate Strobl CBHI in Rwanda: Effective against child labour?

2. Motivation
Empirical analyses
Discussion and Conclusion
Outline
1 Motivation
Children as insurance asset
Formal health insurance
2 Empirical analyses
Empirical strategy
Estimation results
Robustness check
3 Discussion and Conclusion
Discussion of results
Policy implications
Limitations and Outlook
Renate Strobl CBHI in Rwanda: Effective against child labour?

3. Motivation
Empirical analyses
Discussion and Conclusion
Children as insurance asset
Formal health insurance
Outline
1 Motivation
Children as insurance asset
Formal health insurance
2 Empirical analyses
Empirical strategy
Estimation results
Robustness check
3 Discussion and Conclusion
Discussion of results
Policy implications
Limitations and Outlook
Renate Strobl CBHI in Rwanda: Effective against child labour?

4. Motivation
Empirical analyses
Discussion and Conclusion
Children as insurance asset
Formal health insurance
Informal risk coping strategies
Options:
1 Drawing on savings
2 Selling assets
3 Borrowing from the extended family
4 Children as insurance asset:
School de-enrolment (→ economizing educational
expenditures)
Child labour (→ generating income; replacing family members
in household production)
Renate Strobl CBHI in Rwanda: Effective against child labour?

5. Motivation
Empirical analyses
Discussion and Conclusion
Children as insurance asset
Formal health insurance
Children as insurance asset
Ex post risk coping strategy:
Income shock ⇒ consumption smoothing
agricultural crop shocks (Beegle et al., 2006, Jakoby and
Skoufias, 1997)
parental health shocks (Bazen and Salmon, 2010, de Janvry et
al., 2006)
economic crisis (Thomas et al., 2004)
Ex ante risk coping strategy:
Income risk ⇒ precautionary savings
child time allocation is affected even if shocks do not realize
Fitzsimons (2007), Kazianga (2012)
Renate Strobl CBHI in Rwanda: Effective against child labour?

6. Motivation
Empirical analyses
Discussion and Conclusion
Children as insurance asset
Formal health insurance
Children as insurance asset
Ex post risk coping strategy:
Income shock ⇒ consumption smoothing
agricultural crop shocks (Beegle et al., 2006, Jakoby and
Skoufias, 1997)
parental health shocks (Bazen and Salmon, 2010, de Janvry et
al., 2006)
economic crisis (Thomas et al., 2004)
Ex ante risk coping strategy:
Income risk ⇒ precautionary savings
child time allocation is affected even if shocks do not realize
Fitzsimons (2007), Kazianga (2012)
Renate Strobl CBHI in Rwanda: Effective against child labour?

7. Motivation
Empirical analyses
Discussion and Conclusion
Children as insurance asset
Formal health insurance
Children as insurance asset
Significant long-term costs:
Child labour is associated with
worsened health (O’Donnell et al., 2005)
lower educational attainment (Beegle et al., 2008, Zabaleta,
2011)
lower cognitive achievements (Akabayashi & Psacharopoulos,
1999, Heady, 2003)
Withdrawals from school reduce probability to return to school
(de Janvry et al., 2006)
⇒ lower human capital accumulation
⇒ lower future earnings, productivity, well-being;
perpetuated poverty
Renate Strobl CBHI in Rwanda: Effective against child labour?

8. Motivation
Empirical analyses
Discussion and Conclusion
Children as insurance asset
Formal health insurance
Children as insurance asset
Significant long-term costs:
Child labour is associated with
worsened health (O’Donnell et al., 2005)
lower educational attainment (Beegle et al., 2008, Zabaleta,
2011)
lower cognitive achievements (Akabayashi & Psacharopoulos,
1999, Heady, 2003)
Withdrawals from school reduce probability to return to school
(de Janvry et al., 2006)
⇒ lower human capital accumulation
⇒ lower future earnings, productivity, well-being;
perpetuated poverty
Renate Strobl CBHI in Rwanda: Effective against child labour?

9. Motivation
Empirical analyses
Discussion and Conclusion
Children as insurance asset
Formal health insurance
Outline
1 Motivation
Children as insurance asset
Formal health insurance
2 Empirical analyses
Empirical strategy
Estimation results
Robustness check
3 Discussion and Conclusion
Discussion of results
Policy implications
Limitations and Outlook
Renate Strobl CBHI in Rwanda: Effective against child labour?

10. Motivation
Empirical analyses
Discussion and Conclusion
Children as insurance asset
Formal health insurance
Literature
Formal health insurance ⇒ Informal risk coping strategies:
Dekker and Wilms (2009):
insured households sell assets less frequently and borrow less
money to finance medical treatment (Uganda)
Wagstaff and Pradhan (2005):
insured households have higher educational expenditures
(Vietnam)
Guarcello et al. (2010):
children of insured households are less likely to work and more
likely to go to school (Guatemala)
Renate Strobl CBHI in Rwanda: Effective against child labour?

11. Motivation
Empirical analyses
Discussion and Conclusion
Children as insurance asset
Formal health insurance
Community-based health insurance in Rwanda
History:
1999: pilot test in 3 districts, provided by so-called Mutuelles
from 2003 on: progressively scaled up to a national system
population coverage rate: 7% (2003), 44% (2005), 73%
(2006), 91% (2010)
Affiliation conditions (time of survey):
enrolment at household level
annual premium: 2,500-11,500 RWF per household
(3.80-17.40 USD)
co-payments: 100-150 RWF (0.15-0.22 USD) per visit at
health center; 10% of hospital fee at district hospital
Benefit Packages:
Minimum Package: all services provided at local health center
Complementary Package: limited services provided at district
hospitals
Renate Strobl CBHI in Rwanda: Effective against child labour?

12. Motivation
Empirical analyses
Discussion and Conclusion
Children as insurance asset
Formal health insurance
Community-based health insurance in Rwanda
History:
1999: pilot test in 3 districts, provided by so-called Mutuelles
from 2003 on: progressively scaled up to a national system
population coverage rate: 7% (2003), 44% (2005), 73%
(2006), 91% (2010)
Affiliation conditions (time of survey):
enrolment at household level
annual premium: 2,500-11,500 RWF per household
(3.80-17.40 USD)
co-payments: 100-150 RWF (0.15-0.22 USD) per visit at
health center; 10% of hospital fee at district hospital
Benefit Packages:
Minimum Package: all services provided at local health center
Complementary Package: limited services provided at district
hospitals
Renate Strobl CBHI in Rwanda: Effective against child labour?

13. Motivation
Empirical analyses
Discussion and Conclusion
Children as insurance asset
Formal health insurance
Community-based health insurance in Rwanda
History:
1999: pilot test in 3 districts, provided by so-called Mutuelles
from 2003 on: progressively scaled up to a national system
population coverage rate: 7% (2003), 44% (2005), 73%
(2006), 91% (2010)
Affiliation conditions (time of survey):
enrolment at household level
annual premium: 2,500-11,500 RWF per household
(3.80-17.40 USD)
co-payments: 100-150 RWF (0.15-0.22 USD) per visit at
health center; 10% of hospital fee at district hospital
Benefit Packages:
Minimum Package: all services provided at local health center
Complementary Package: limited services provided at district
hospitals
Renate Strobl CBHI in Rwanda: Effective against child labour?

14. Motivation
Empirical analyses
Discussion and Conclusion
Empirical strategy
Estimation results
Robustness check
Outline
1 Motivation
Children as insurance asset
Formal health insurance
2 Empirical analyses
Empirical strategy
Estimation results
Robustness check
3 Discussion and Conclusion
Discussion of results
Policy implications
Limitations and Outlook
Renate Strobl CBHI in Rwanda: Effective against child labour?

15. Motivation
Empirical analyses
Discussion and Conclusion
Empirical strategy
Estimation results
Robustness check
Data
Data set:
Household Living Conditions Survey (EICV2) 2005/06
cross-sectional, nationally representative
socio-economic data of 6,900 households and 34,785
individuals
community-level data for 440 communities (only for rural part
of Rwanda)
Final sample:
restriction on rural regions of Rwanda
exclusion of households insured in health insurance schemes
other than Mutuelles (RAMA, MMI, private schemes)
households with children from 7-15 years
household head older than 15 years
⇒ 5,811 children living in 3,154 households
⇒ 43,4 % of households insured by Mutuelles
Renate Strobl CBHI in Rwanda: Effective against child labour?

16. Motivation
Empirical analyses
Discussion and Conclusion
Empirical strategy
Estimation results
Robustness check
Two outcome variables
1 Hours worked:
children age 7 - 15 (minimum working age in Rwanda: 16
years)
total hours worked in the last 7 days (employment and
household chores)
2 Education Gap:
Education Gap =
max{0, Expected Education −Actual Education}
with Expected Education =
0 if age 7
age−7 if 8 age 15
captures any delays (e.g. due to late entry, class repetitions) as
well as premature drop-outs
Renate Strobl CBHI in Rwanda: Effective against child labour?

17. Motivation
Empirical analyses
Discussion and Conclusion
Empirical strategy
Estimation results
Robustness check
Hours worked
Figure 1: Average weekly hours worked, by gender and health insurance status
Renate Strobl CBHI in Rwanda: Effective against child labour?

18. Motivation
Empirical analyses
Discussion and Conclusion
Empirical strategy
Estimation results
Robustness check
Education Gap
Figure 2: Average Education Gap, by gender and health insurance status
Renate Strobl CBHI in Rwanda: Effective against child labour?

19. Motivation
Empirical analyses
Discussion and Conclusion
Empirical strategy
Estimation results
Robustness check
Estimation equation
Estimation Equation:
Hijk = β0l +β1Xijk +β2Mutuelleijk +ηl +εijk
Hijk : Hours worked or Education Gap
Mutuelleijk : Mutuelle enrolment (dummy)
Xijk : Child, household, community characteristics
ηl : District dummies
⇒ Problem: possible endogeneity of Mutuelle enrolment
Renate Strobl CBHI in Rwanda: Effective against child labour?

20. Motivation
Empirical analyses
Discussion and Conclusion
Empirical strategy
Estimation results
Robustness check
Estimation equation
Estimation Equation:
Hijk = β0l +β1Xijk +β2Mutuelleijk +ηl +εijk
Hijk : Hours worked or Education Gap
Mutuelleijk : Mutuelle enrolment (dummy)
Xijk : Child, household, community characteristics
ηl : District dummies
⇒ Problem: possible endogeneity of Mutuelle enrolment
Renate Strobl CBHI in Rwanda: Effective against child labour?

21. Motivation
Empirical analyses
Discussion and Conclusion
Empirical strategy
Estimation results
Robustness check
Test of endogeneity
Two instrumental variables (IV)
1 Community Mutuelle enrolment rate = Ei −Di
Ni −1
Ei = Number of enrolled households in community
Di = Dummy if household is enrolled
Ni = Total number of households in community
2 Satisfaction of household with quality of services provided at
district hospital (dummy)
Test on relevance and overidentifying restrictions
⇒ IV validated
Test of endogeneity
⇒ Mutuelle enrolment can be treated as exogenous
⇒ Simple count data regression models
Renate Strobl CBHI in Rwanda: Effective against child labour?

22. Motivation
Empirical analyses
Discussion and Conclusion
Empirical strategy
Estimation results
Robustness check
Test of endogeneity
Two instrumental variables (IV)
1 Community Mutuelle enrolment rate = Ei −Di
Ni −1
Ei = Number of enrolled households in community
Di = Dummy if household is enrolled
Ni = Total number of households in community
2 Satisfaction of household with quality of services provided at
district hospital (dummy)
Test on relevance and overidentifying restrictions
⇒ IV validated
Test of endogeneity
⇒ Mutuelle enrolment can be treated as exogenous
⇒ Simple count data regression models
Renate Strobl CBHI in Rwanda: Effective against child labour?

23. Motivation
Empirical analyses
Discussion and Conclusion
Empirical strategy
Estimation results
Robustness check
Test of endogeneity
Two instrumental variables (IV)
1 Community Mutuelle enrolment rate = Ei −Di
Ni −1
Ei = Number of enrolled households in community
Di = Dummy if household is enrolled
Ni = Total number of households in community
2 Satisfaction of household with quality of services provided at
district hospital (dummy)
Test on relevance and overidentifying restrictions
⇒ IV validated
Test of endogeneity
⇒ Mutuelle enrolment can be treated as exogenous
⇒ Simple count data regression models
Renate Strobl CBHI in Rwanda: Effective against child labour?

24. Motivation
Empirical analyses
Discussion and Conclusion
Empirical strategy
Estimation results
Robustness check
Outline
1 Motivation
Children as insurance asset
Formal health insurance
2 Empirical analyses
Empirical strategy
Estimation results
Robustness check
3 Discussion and Conclusion
Discussion of results
Policy implications
Limitations and Outlook
Renate Strobl CBHI in Rwanda: Effective against child labour?

25. Motivation
Empirical analyses
Discussion and Conclusion
Empirical strategy
Estimation results
Robustness check
Estimation results: Mutuelle effect
Table 1: Count data regression estimates: Average marginal effect of Mutuelle enrolment
Hours worked Education Gap
(ZINB) (Poisson)
n AME (SE) AME (SE)
All 5,811 -1.058** (0.475) -0.120*** (0.035)
Boys 2,880 -1.491*** (0.573) -0.085* (0.049)
Girls 2,931 -0.311 (0.616) -0.168*** (0.045)
Standard errors corrected for clustering at the community level;
*p < 0.10, **p < 0.05, ***p < 0.01;
Control variables: child: sex, age, number of older children in household; household:
sex, age, education of head, household size, land owned in acres, distance to primary
and secondary school; community: proportion of households with landownings less 2
acres, dummies indicating presence of health center, primary school, market, public
telephone.
Renate Strobl CBHI in Rwanda: Effective against child labour?

26. Motivation
Empirical analyses
Discussion and Conclusion
Empirical strategy
Estimation results
Robustness check
Outline
1 Motivation
Children as insurance asset
Formal health insurance
2 Empirical analyses
Empirical strategy
Estimation results
Robustness check
3 Discussion and Conclusion
Discussion of results
Policy implications
Limitations and Outlook
Renate Strobl CBHI in Rwanda: Effective against child labour?

27. Motivation
Empirical analyses
Discussion and Conclusion
Empirical strategy
Estimation results
Robustness check
Propensity score matching
Table 2: Propensity score matching: Average treatment effect of Mutuelle enrolment
Hours worked per child Education Gap per child
n ATT (SE) Γ ATT (SE) Γ
Radius 3,263 -1.216** (0.437) 1.4 -0.148** (0.059) 1.2
Kernel 3,263 -1.751** (0.673) 1.0 -0.107 (0.070) -
Standard errors attained by bootstrapping (50 replications);
*p < 0.10, **p < 0.05, ***p < 0.01;
Caliper width for radius matching: 0.01; bandwidth for Kernel matching: 0.06;
Γ: Sensitivity parameter of Rosenbaum bounds sensitivity analysis;
Covariates: sex, age and education of the head, dummy indicating chronical health problems
of household members, household size, number of children under 7, number of children in age
7-15, land owned in acres, dummy indicating if the household is houseowner, dummies for
consumption quintiles, distance to the nearest health center, district dummies.
Renate Strobl CBHI in Rwanda: Effective against child labour?

28. Motivation
Empirical analyses
Discussion and Conclusion
Discussion of results
Policy implications
Limitations and Outlook
Outline
1 Motivation
Children as insurance asset
Formal health insurance
2 Empirical analyses
Empirical strategy
Estimation results
Robustness check
3 Discussion and Conclusion
Discussion of results
Policy implications
Limitations and Outlook
Renate Strobl CBHI in Rwanda: Effective against child labour?

29. Motivation
Empirical analyses
Discussion and Conclusion
Discussion of results
Policy implications
Limitations and Outlook
Discussion of results
Substantial impact of mutual health insurance on schooling
outcomes:
remarkably, as Mutuelles cover only a part of total economic
cost of illness:
do not compensate for lost earnings
co-payments have to be effected
compared to decrease of child working time of 1 hour per week:
suggests that impact on schooling not only via time-liberating
effect
Renate Strobl CBHI in Rwanda: Effective against child labour?

30. Motivation
Empirical analyses
Discussion and Conclusion
Discussion of results
Policy implications
Limitations and Outlook
Discussion of results
Substantial impact of mutual health insurance on schooling
outcomes:
remarkably, as Mutuelles cover only a part of total economic
cost of illness:
do not compensate for lost earnings
co-payments have to be effected
compared to decrease of child working time of 1 hour per week:
suggests that impact on schooling not only via time-liberating
effect
Renate Strobl CBHI in Rwanda: Effective against child labour?

31. Motivation
Empirical analyses
Discussion and Conclusion
Discussion of results
Policy implications
Limitations and Outlook
Possible impact channels
Formal health insurance ⇒ Child labour and schooling:
1 Mutuelles protect Rwandan households efficiently against
high OOP payments (Lu et al., 2012, Saksena et al. 2011,
Shimeles, 2010)
ex ante: reduced need to build up a buffer stock
ex post: facilitated consumption smoothing
2 Mutuelle members use modern health care more likely
(Lu et al., 2012, Saksena et al. 2011, Shimeles, 2010)
faster recovery / better overall health status
less income losses and treatment costs
less time absent in school, better learning performance
Renate Strobl CBHI in Rwanda: Effective against child labour?

32. Motivation
Empirical analyses
Discussion and Conclusion
Discussion of results
Policy implications
Limitations and Outlook
Possible impact channels
Formal health insurance ⇒ Child labour and schooling:
1 Mutuelles protect Rwandan households efficiently against
high OOP payments (Lu et al., 2012, Saksena et al. 2011,
Shimeles, 2010)
ex ante: reduced need to build up a buffer stock
ex post: facilitated consumption smoothing
2 Mutuelle members use modern health care more likely
(Lu et al., 2012, Saksena et al. 2011, Shimeles, 2010)
faster recovery / better overall health status
less income losses and treatment costs
less time absent in school, better learning performance
Renate Strobl CBHI in Rwanda: Effective against child labour?

33. Motivation
Empirical analyses
Discussion and Conclusion
Discussion of results
Policy implications
Limitations and Outlook
Outline
1 Motivation
Children as insurance asset
Formal health insurance
2 Empirical analyses
Empirical strategy
Estimation results
Robustness check
3 Discussion and Conclusion
Discussion of results
Policy implications
Limitations and Outlook
Renate Strobl CBHI in Rwanda: Effective against child labour?

34. Motivation
Empirical analyses
Discussion and Conclusion
Discussion of results
Policy implications
Limitations and Outlook
Policy implications
Formal health insurance:
Indirect benefits so far unrecognized:
crowding out of inefficient risk coping strategies (child labour
and school de-enrolment)
higher human capital accumulation
should be taken into account in cost-efficiency analyses of such
policy interventions
Useful and necessary complement to explicit child labour
countermeasures (bans, compulsory schooling):
eliminating child labour without undermining household’s
ability to cope with risk
Renate Strobl CBHI in Rwanda: Effective against child labour?

35. Motivation
Empirical analyses
Discussion and Conclusion
Discussion of results
Policy implications
Limitations and Outlook
Policy implications
Formal health insurance:
Indirect benefits so far unrecognized:
crowding out of inefficient risk coping strategies (child labour
and school de-enrolment)
higher human capital accumulation
should be taken into account in cost-efficiency analyses of such
policy interventions
Useful and necessary complement to explicit child labour
countermeasures (bans, compulsory schooling):
eliminating child labour without undermining household’s
ability to cope with risk
Renate Strobl CBHI in Rwanda: Effective against child labour?

36. Motivation
Empirical analyses
Discussion and Conclusion
Discussion of results
Policy implications
Limitations and Outlook
Outline
1 Motivation
Children as insurance asset
Formal health insurance
2 Empirical analyses
Empirical strategy
Estimation results
Robustness check
3 Discussion and Conclusion
Discussion of results
Policy implications
Limitations and Outlook
Renate Strobl CBHI in Rwanda: Effective against child labour?

37. Motivation
Empirical analyses
Discussion and Conclusion
Discussion of results
Policy implications
Limitations and Outlook
Limitations and Outlook
Cross-sectional data set:
Unobserved heterogeneity and biasing effect on estimates
cannot be definitely ruled out
however, solid evidence on robustness of results by using two
different evaluation methods
Impossible to disentangle impact channels of health
insurance (ex post, ex ante, health-related effects)
might be important to choose optimal policy intervention
(e.g. if ex post consumption smoothing is main driver of results
→ could also be reached with provision of credits)
Renate Strobl CBHI in Rwanda: Effective against child labour?

38. Motivation
Empirical analyses
Discussion and Conclusion
Discussion of results
Policy implications
Limitations and Outlook
Limitations and Outlook
Cross-sectional data set:
Unobserved heterogeneity and biasing effect on estimates
cannot be definitely ruled out
however, solid evidence on robustness of results by using two
different evaluation methods
Impossible to disentangle impact channels of health
insurance (ex post, ex ante, health-related effects)
might be important to choose optimal policy intervention
(e.g. if ex post consumption smoothing is main driver of results
→ could also be reached with provision of credits)
Renate Strobl CBHI in Rwanda: Effective against child labour?

39. Motivation
Empirical analyses
Discussion and Conclusion
Discussion of results
Policy implications
Limitations and Outlook
Thank you very much for your attention!
Renate Strobl CBHI in Rwanda: Effective against child labour?

40. Appendix References
References I
Akabayashi, H., Psacharopoulos, G. (1999). The trade-off
between child labour and human capital formation: A
Tanzanian case study. The Journal of Development Studies,
35(5), 120-140.
Beegle, K., Dehejia, R., Gatti, R. (2006). Child labor and
agricultural shocks. Journal of Development Economics, 81,
80-96.
Beegle, K., Dehejia, R., Gatti, R., Krutikova, S. (2008). The
consequences of child labor: Evidence from longitudinal data in
rural Tanzania. Policy Research Working Paper No. 4677.
Washington, DC.: World Bank.
Renate Strobl CBHI in Rwanda: Effective against child labour?

41. Appendix References
References II
de Janvry, A., Financ, F., Sadoulet, E., Vakis, R. (2006). Can
conditional cash transfer programs serve as safety nets in
keeping children at school and from working when exposed to
shocks? Journal of Development Economics, 79, 349-373.
Dekker, M., Wilms, A. (2009). Health insurance and other
risk-coping strategies in Uganda: The case of Microcare
Insurance Ltd. World Development, 38(3), 369-378.
Fitzsimons, E. (2007). The effects of risk on education in
Indonesia. Economic Development and Cultural Change, 56(1),
1-25.
Renate Strobl CBHI in Rwanda: Effective against child labour?

42. Appendix References
References III
Guarcello, L., Mealli, F., Rosati, F.C. (2010). Household
vulnerability and child labor: The effect of shocks, credit
rationing, and insurance. Journal of Population Economics, 23,
169-198.
Heady, C. (2003). The effect of child labor on learning
achievements. World Development, 31(2), 385-398.
Jacoby, H.G., Skoufias, E. (1997). Risk, financial markets and
human capital in a developing country. Review of Economic
Studies, 64, 311-335.
Kazianga, H. (2012). Income risk and household schooling
decisions in Burkina Faso. World Development, 40(8),
1647-1662.
Renate Strobl CBHI in Rwanda: Effective against child labour?

43. Appendix References
References IV
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), e39282.
O’Donnell, O., Rosati, F.C., van Doorslaer, E. (2005). Health
effects of child work: Evidence from rural Vietnam. Journal of
Population Economics, 18, 437-467.
Saksena, P., Antunes, F.A., Xu, K.Musango, L., Carrin, G.
(2011). Mutual health insurance in Rwanda: Evidence on
access to care and financial risk protection. Health Policy, 99,
203-209.
Renate Strobl CBHI in Rwanda: Effective against child labour?

44. Appendix References
References V
Shimeles, A. (2010). Community based health insurance
schemes in Africa: The case of Rwanda. African Development
Bank Group Working Paper Series. Working Paper No. 120.
Tunis: African Development Bank.
Wagstaff, A., Pradhan, M. (2005). Health insurance impacts
on health and nonmedical consumption in a developing country.
World Bank Policy Research Working Paper 3563. Washington,
DC.: World Bank.
Zabaleta, M.B. (2011). The impact of child labor on schooling
outcomes in Nicaragua. Economics of Education Review, 30,
1527-1539.
Renate Strobl CBHI in Rwanda: Effective against child labour?