Global Fund impact on building and strengthening a health system: The example of Rwanda
The Global Fund has recognized the importance of health systems in the response to the three pandemics since its inception, but building resilient and sustainable systems for health became a strategic pillar in the Global Fund’s 2017-2022 strategy "Investing to End Epidemics". The simultaneous release of evaluation and audit reports on Global Fund investments to build resilient and sustainable systems, by the Technical Review Panel and the Office of the Inspector General, presents an opportunity to examine how some countries have relied on the Global Fund and quickly seized the funding opportunity to strengthen their health systems’ response to the three pandemics. In this respect, looking at Rwanda's experience over the last twenty years offers several lessons, which have been widely documented in scientific literature. (Editor’s note: Because this is a literature review, we have included endnotes in the text.)
Positive developments in the Rwandan health system over 20 years
Following the genocide against the Tutsis in 1994, Rwanda implemented major reforms in the late 1990s and early 2000s to rebuild and strengthen its health system, particularly with a view to achieving the Millennium Development Goals (MDGs) and later the Sustainable Development Goals (SDGs). These first reforms included decentralizing health services, introducing performance-based financing and creating community-based health insurance (1). Then came the extension of the community health program in 2007, culminating in 2009, in having four community health workers trained in every village in the country. Between 2010 and 2015, these reforms enabled better coverage of the population, especially in rural areas, and improvements in the overall quality of services (2). They also produced positive, tangible results, especially in the area of HIV/AIDS (3): a decrease in AIDS-related deaths of around 80%, achievement of UNAIDS targets for universal prevention of mother-to-child transmission (PMTCT) and antiretroviral treatment coverage (4). At the same time, coverage by the national health insurance scheme exceeded 90% (5).
One factor that is regularly cited to explain this success is that of Rwandan governance and leadership which, beyond proactive health sector reforms, has led to a desire to align external aid to government policy. Therefore, support from external donors has enabled initiatives such as health insurance and results-based financing. The relationship between Rwanda and the Global Fund and the synergies created between Rwanda’s HIV program and its health sector provide a good illustration of this approach.
Decision to integrate Global Fund-supported programs into Rwandan health sector
Rwanda's relationship with the Global Fund was characterized early on by Rwanda's desire to integrate HIV, tuberculosis and malaria-specific interventions into efforts to strengthen primary health care, to provide people with equal access to health services and to strengthen the health system.
In 2002, however, an influx of funds targeted for the fight against HIV (from the World Bank, Global Fund, PEPFAR) initially resulted in a duplication of services, with different approaches being used and difficulties experienced in monitoring the activities being implemented. Some partners were also reporting the results of their activities directly to donors without going through national channels. This situation led to the need for better coordination, culminating in the establishment of a technical coordination team in 2005, led by the Ministry of Health and comprising technical partners and non-governmental organizations. In 2005 this team deployed an electronic reporting system called TRACnet, enabling monthly reporting on a set of health indicators through a centralized database to better monitor the different activities being implemented to respond to HIV (1).
With its new will to improve coordination of funding, Rwanda has found, in the Global Fund, a partner open to funding interventions that extend beyond the three pandemics. Rwanda's HIV program was quickly characterized by efforts to integrate not only HIV-related prevention and control but also related issues, such as tuberculosis, malnutrition, and systems strengthening (5).
At the decentralized level, vertical funds from the Global Fund and PEPFAR have been used to rehabilitate health infrastructure and to set up treatment platforms in rural areas that have gradually been used to strengthen primary health care. Despite some fears, integration of HIV services with primary health care has not led to a decline in the provision of primary-care services. A study on integrating HIV services into primary health care (6) even shows that this approach has had a catalytic effect and has led as much to an increase in the provision of reproductive health services as to greater use of care platforms overall.
Similarly, at the national level, the strengthened procurement and supply chain for ARVs was then used for other types of drugs. The information systems created to monitor HIV treatment have been adapted to monitor other treatments. Health workers in maternity wards were trained as part of PMTCT programs and delivered babies regardless of the mother’s HIV status (3).
Global Fund support to health insurance and results-based financing
The Global Fund's support to Rwanda's health system was also delivered more directly through a $34-million, five-year grant in 2006, to scale up the community-based health insurance system, which until then had been tested in three regions. Establishing health insurance is one of the key reforms of the Rwandan health sector. It is important to note that this grant was one of the first provided by the Global Fund for health system strengthening (alongside Laos and Malawi). The purpose of this grant was to strengthen financial access to health care by subsidizing health insurance for the poorest, in order to respond to the three diseases. This objective was achieved by the end of the grant - improved financial access led to increased use of health services, and as a result improved health among the population.
Global Fund funding also contributed to the roll out of the results-based financing system at the community and hospital levels, another major feature of the Rwandan health system. Implementation of results-based financing in Rwanda demonstrates the government’s political will. There are many publications on the subject, but they are divided on the role that this funding mechanism has played as a strategic tool to reform the health system and respond appropriately to the needs of communities and patients. However, it is clear that the system has improved the availability of health care providers (including community health workers ) and operations within some health facilities, even if a clear link cannot be made with structural and overall health system improvements (11). In addition, the HIV program has particularly benefited from the implementation of results-based financing through Global Fund support to the system, as the selected indicators fit with the HIV care continuum (number of new adults and infants on ARVs, number of HIV-positive pregnant women on antiretroviral therapy, number of HIV-positive patients receiving a CD4-count test in line with national guidelines) (1). Since 2014, Rwanda has been the only major Global Fund portfolio that has been subject to a results-based financing model (called National Strategy Financing).
Management of external aid grants and domestic budgets
Rwanda’s strong political will and donors’ willingness to coordinate have also been reflected in the way in which external assistance is mobilized. As of 2010, 58.4% of foreign aid to Rwanda went through the national system. For HIV, in 2011, coordination mechanisms were integrated with other disease programs into a project implementation unit of the Rwanda Biomedical Center (RBC) in order to facilitate program integration. Since then, Global Fund funding has been managed by the Ministry of Health in its role as Principal Recipient, and the Rwanda Biomedical Center as a sub-recipient and lead implementing partner. All health sector funding from external development assistance (Global Fund; World Bank; Gavi, the Vaccine Alliance; bilateral cooperation) now goes through this single project implementation unit.
In addition to centralizing funding management, Rwanda's success in using external aid is intrinsically linked to mobilizing complementary national resources. The increase in external aid has not had a crowding-out effect on government investments and has been positively linked to the provision of maternal and child health, and infectious-disease services in rural health centers. Since 2016-2017, the government has allocated 16.5% of its budget to health (in line with the 2001 Abuja Declaration, in which African Union member states pledged to dedicate 15% of their national budget to health) and the country has also met its counterpart financing obligations in accordance with Global Fund policy (13).
Global Fund financing to Rwanda for the 2017-2019 cycle
Since 2003, the Global Fund has invested approximately $1.4 billion in Rwanda. $210 million is currently committed through active grants. Despite a continued reduction in Global Fund funding (down 30% for the last cycle), Rwanda continues to deliver the expected (targeted) results within its grants. This is probably linked to the country's unique funding model, which is funding the national strategy. Under this model, the country consolidates and allocates all public funding and grants from the Global Fund to national strategic plans to combat the three diseases in Rwanda (13). According to an independent evaluation by Euro Health Group, this approach to funding the national strategy has improved grant effectiveness, and has produced both good results and cost-effectiveness. It is an essential component of program sustainability in the country. Given the success of this model, there are plans to test it in other countries that meet the criteria necessary for its implementation.
Is Rwanda a replicable example?
Improvements in Rwanda’s health system are linked, in part, to several internal factors. One such factor is the decentralization of health services to increase health coverage, which has most likely benefited from the fact that Rwanda is a small country with a population that speaks the same language (1). Several qualitative studies have also found that processes and mechanisms for promoting accountability at different levels of the health pyramid (an important factor for a system based on results-based financing) have relied on traditional Rwandan culture, with its central values of being an "integrated and inclusive society" (8). In addition, there are certainly many other reasons behind the positive dynamics of the Rwandan health system, even if the existence of community health workers and health insurance are regularly cited among the factors that have contributed most to improving health outcomes (2).
Still, it is possible to draw from the Rwandan example a sense of the will to coordinate the various external resources going to programs to strengthen the health system as a whole, made possible by strong leadership (1). This has allowed for gradual integration of various donor-funded initiatives, including the Global Fund, into national funding channels and the transfer of responsibility, backed up by national resources committed for capacity building, which is fundamental to the long-term sustainability of health system improvements (8). Integration has not been detrimental to pandemics control programs, but has had a catalytic effect, which has improved results in the HIV, tuberculosis and malaria responses, in particular (1).
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7. Kalk A, Natalie Groos, Jean-Claude Karasi, Elisabeth Girrbach. Health systems strengthening through insurance subsidies: the GFATM experience in Rwanda. Tropical Medicine & International Health. 1 Jan 2010;15(1):94‑7.
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9. Ireland M, Paul E, Dujardin B. Can performance-based financing be used to reform health systems in developing countries? Bull World Health Organ. 1 Sept 2011;89(9):695‑8.
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13. Bureau de l’Inspecteur Général, Rapport de suivi d’audit des subventions du Fonds mondial au Rwanda [Internet]. [cited 25 June 2019]. Available at: https://www.theglobalfund.org/media/8383/oig_gf-oig-19-004_report_fr.pdf?u=636917016550000000
14. C. Baran, A. Sulcas. Rwanda’s pioneering National Strategy Financing model improved Global Fund grant performance, says external report | Aidspan [Internet]. [cited1 Jul 2019]. Available at: http://www.aidspan.org/gfo_article/rwanda%E2%80%99s-pioneering-national-strategy-financing-model-improved-global-fund-grant-0