Rwanda: Aid Efficiencies Lead to Health Improvements

Patrik Silborn, the Global Fund’s Head of Private Sector Engagement, External Relations Division, discusses Rwanda’s national response to its HIV/AIDS epidemic. Patrik was the former Fund Portfolio Manager for Rwanda.

Friends: Can you give us a brief overview of the HIV/AIDS epidemic in Rwanda?

Patrik: Rwanda was one of the first African countries to document an AIDS case in 1983.[1] The early response within the country was efficient and sustained until the civil war in the 1990s and the devastating genocide that followed. During this sad time, external donors had to leave the country.

In the aftermath of the war, the government of Rwanda worked to rebuild the country, making health a priority. In the years that followed, and in response to the national government’s commitment to addressing public health issues, external donors including the Global Fund to Fight AIDS, Tuberculosis and Malaria, the U.S. Government and the World Bank returned to the country, providing resources and supporting disease-specific programs.

With renewed resources in recent years, Rwanda has seen increases in the availability of services such as voluntary counseling and testing, prevention of mother to child transmission and antiretroviral treatment.[2] Through the efforts of the government and donors, the HIV/AIDS prevalence rate has remained stable in Rwanda, at about 3 percent, since 2005.

Friends: How has Rwanda managed to effectively sustain its progress against the HIV/AIDS epidemic?

Patrik: The driving force behind the HIV/AIDS response in Rwanda is strong, focused leadership. After the genocide, the government set a new course, focusing on development and health equity. This led to the creation of a “Vision 2020” strategy for equitable social and economic development. Vision 2020 aims to drive Rwanda toward middle-income status within the next six years and highlights health as a key pillar to achieving this goal.[3] Under Vision 2020, the government has stressed the importance of coordination and the use of health as a cross-sector approach to reducing poverty.

In the early 2000s, when external donors once again made health aid available for disease-specific programs in the country, Rwanda leveraged the funds to rebuild its health infrastructure and create a strong system of primary care, setting the stage for a sustainable response.

Another key aspect of the response is a focus on community health workers. Rwanda has made significant progress by training and using a foundation of community health workers to provide services to all of their citizens, even in the most remote of locations.[4] A well trained, skilled workforce is certainly another important aspect to a sustainable health system.

Friends: Earlier this year, it was announced that Rwanda will be piloting a National Strategy Financed Model (NSFM). Can you explain what this is?

Patrik: This is a grant agreement between the Global Fund and Rwanda that will be used to implement the country’s national strategic plan for HIV (2013-2018). The grant has been given as a block rather than disbursed as program-specific funds, which is a unique feature of this financing mechanism. This allows the government flexibility to spend funds on various programs within its National Strategic Plan.

Continued funding under the grant will be contingent on improved health impacts (e.g. mortality, morbidity, and other health outcomes) rather than inputs and outputs (e.g. the number of health products distributed).[5] Funding is based on progress as measured by six key indicators, specifically the percentage of:

  • Infants born to HIV-positive mothers who are infected by 18 months;
  • Adults and children known to be on treatment 12 months after starting antiretroviral treatment;
  • Adults and children currently receiving antiretroviral treatment;
  • Men having sex with men reporting use of condoms;
  • Female sex workers reporting condom use;
  • HIV/TB co-infected patients receiving both HIV and TB treatment.[6]

The results of these indicators will be verified, using rigorous data quality audit methodology, by local fund agents within the country.

This approach is designed to align with existing national systems and strategy, base future disbursements on outcome and impact indicators, and lessen administrative burden and cost. Under this model there is more flexibility as to how the Global Fund resources are used, allowing for savings to be placed back in the response.

A number of assurance mechanisms will enable the country to ensure the NSFM operates efficiently. These mechanisms are present at strategic, operational and financial levels:[7]

  • A Comprehensive National Strategic Plan (NSP) Operational Plan;
  • Office of the Auditor General audits the financial aspects;
  • Procurement and supply chain assessments;
  • Service availability and readiness assessment and procurement reviews.

Friends: How does the new grant management model align with Rwanda’s National Strategy to fight HIV?

Patrik:  This model is directly tied to the implementation of Rwanda’s national strategy, an important advantage. Through the use of the six key indicators, the grant management model emphasizes important, high impact interventions, allowing for focus in areas that are deemed important by the country. For example, in Rwanda, the key affected populations ― groups which are at a higher risk for the disease such as female sex workers and men who have sex with men ― are highlighted as priority groups within the national strategy. The NSFM helps to support this focus.

Friends: What do you think makes Rwanda a good pilot for this model?

Patrik: Rwanda is pioneering this model because of its proven success with national health programs. It has an excellent track record and has established a health care system that brings together partners under one national plan.

For example, one of the key pillars in the country’s health strategy is universal health coverage. The community-based health insurance program focuses on providing care to vulnerable populations and has more than halved out-of-pocket-health spending.[8] Plans under the insurance program fully cover many preventive measures and treatment for HIV, as well as other diseases, exemplifying efficient and effective stewardship of resources.

Friends: In your opinion, what does the future hold for Rwanda’s response to HIV/AIDS?

Patrik: Rwanda has demonstrated a steadfast commitment to health and a drive to continue making progress against not just HIV/AIDS, but also tuberculosis and malaria. The Rwandan Ministry of Health requires transparency and accountability of all of its aid partners. In fact, it has turned down the opportunity for external resources when donors are not willing to work with the national strategies, demonstrating the country’s focus on what it sees as the most effective approaches to fighting these diseases.

The country has already achieved a more than 50 percent reduction in HIV incidence rates since 2000, an example of its tremendous success in the fight against HIV/AIDS. If these trends continue, it will go well beyond the target of Millennium Development Goal (MDG) 6 to halt the infection by 2015 and reverse its spread. In fact, it is one of few countries in sub-Saharan Africa that is on track to meet most of the MDGs by 2015.[9] In short, I am optimistic about the direction in which Rwanda is headed.

This post was originally published in November 2014.


[2] Ibid.
[3] Farmer Paul E, Nutt Cameron T, Wagner Claire M, Sekabaraga Claude, Nuthulaganti Tej, Weigel Jonathan L et al. Reduced premature mortality in Rwanda: lessons from success BMJ 2013; 346:f65.
[4] Ibid.
[7] Summary – Rwanda: Results-Based Financing. Global Fund document. // also in: Rwanda Results-Based Financing (RBF) Model PPT. Jean Pierre Nyemazi, MD, MSc, MHCDS. Rwanda Biomedical Center. April 2014
[9] Farmer Paul E, Nutt Cameron T, Wagner Claire M, Sekabaraga Claude, Nuthulaganti Tej, Weigel Jonathan L et al. Reduced premature mortality in Rwanda: lessons from success BMJ 2013; 346:f65