Rwanda and the Global Fund on 10 February announced the piloting of a new results-based financing approach with the material reprogramming of Phase 2 of an HIV grant (RWN-H-MOH). The RBF model is designed to streamline and encourage flexibility and eliminate bottlenecks in the financing of programs for countries with stronger capacities.
Rwanda’s selection as the pilot for the RBF model is based on its success in achieving Millennium Development Goals 4, 5 and 6 and the ability of its national health systems to respond to the challenges confronting the population in terms of burden of disease and HIV prevalence. National HIV prevalence in Rwanda has held steady at 3% since 2010.
Global Fund Executive Director Mark Dybul, in Kigali for the signing of the grant, called Rwanda’s achievements impressive in tackling AIDS, TB and malaria, but said what was more impressive was “the system that [was] built” to tackle them.
Dybul suggested that the RBF model “will allow the government of Rwanda under its national strategy with its partners to use the money to achieve results”.
The RBF model assesses performance against a set of indicators included in the country’s national strategic plan (NSP) and agreed upon by technical partners. Before Rwanda was recommended as the pilot for the RBF model, the Fund’s Technical Review Panel was asked by the Grant Approvals Committee to verify the robustness and the coverage of the selected indicators.
These indicators include:
- % of infants born to HIV-infected mothers who are infected by 18 months
- % of adults and children with HIV known to be on treatment 12 months after initiation of antiretroviral therapy
- % of eligible adults and children currently receiving antiretroviral therapy.
- % of Female Sex Workers reporting the use of condom during penetrative sex with their most recent clients
- % of Men reporting use of condoms the last time they had anal sex with men partner.
- % of HIV/TB co-infected patients receiving both HIV and TB treatment.
Under the RBF model, block grants are allocated as budget support providing the government of Rwanda a certain flexibility in how funds are spent, with savings re-invested in the national response.
Fund grants will be pooled with financial assistance from other development partners, all of which will be in service to the full and successful implementation of Rwanda’s HIV NSP. Performance and subsequent grant disbursements will be assessed based on the achievement of the six indicators following an annual review by the Fund, technical partners and the Rwandan government. Should Rwanda fully achieve the targets, it could access up to $204 million over the next two years.
According to the NSP, the financing supports the scale up of anti-retroviral treatment (ART) to all people eligible according to the new 2013 WHO recommended ART guidelines. The new eligibility criteria would initially reduce the country’s coverage percentage of eligible adults and from 91.6% to about 78%. Targets for the next two years will be to again expand coverage to reach 90% of eligible adults.
Concurrently, the most at risk populations, especially female sex workers and men having sex with men (MSM), who constitute 25% of all new infections in Rwanda, have been earmarked as priority groups in the national HIV strategy.
The decision to pilot the RBF model in Rwanda was made concurrently with a Joint Assessment of National Strategies (JANS) assessment of the NSP 2013-18. The JANS report lauded strengths in the NSP but also highlighted some of the weaknesses related to the Ministry of Health’s ability to implement the plan in full.
Among the concerns were weaknesses with respect to the recruitment and retention of trained staff within the public health system and the supply and distribution of health commodities, including ARVs. The overall cost of the NSP – most of which is being borne by external funders, including the Global Fund – was also flagged for concern.
Millennium Development Goals (MDG) 4, 5 and 6 are: 4. Reduce child mortality rates, 5. Improve maternal health and 6. Combat HIV/AIDS, Malaria and other diseases.
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