MAXIMIZING POSITIVE SYNERGIES - World Health Organization

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Rwanda: The Impact of Global Health Initiatives on the Health System: A mixed methods analysis Abstract Mukherjee JS, Jerome JG, Sullivan E, May MA, Mayfield A, Lambert W, Dhavan N, Carney N, Rhatigan J, Ivers LC With acknowledgment to Ruzindana K, Wroe E, Kersten E. Increasing attention is being paid to the impact that GHIs such as the Global Fund and PEPFAR have on health systems as a whole. We aimed to evaluate the impact of these two GHIs on the health system in Rwanda. We used mixed qualitative and quantitative methods: semi-structured interviews, observation, examination of documentary material, and collection of quantitative data. Fifteen key informants from NGOs, international organizations and the Ministry of Health (MOH) participated in semistructured interviews. The Global Fund and PEPFAR were largely associated with strengthening of the health system in Rwanda, with clear credit for the success of the programmes attributed to the strong national framework and to coordination by the government of Rwanda. GHIs such as the Global Fund and PEPFAR can successfully strengthen health systems if this objective is included in planning and design, and if leadership and coordination are ensured. Background The Rwandese Republic is a small, landlocked country in East Africa. Bordered by the Republics of Burundi, Uganda and Kenya, and the Democratic Republic of Congo, it has a population of 9.7 million and is expected to average a 2.7% annual population growth rate between 2005 and 2010 [1]. After decades of colonial rule by Germany and Belgium, Rwanda gained independence and held its first parliamentary elections in 1962. Violent outbreaks between the majority ethnic group, the Hutus, and the minority Tutsis, characterized the following decades. In April 1994, ethnic tensions between the extremist Hutu-led government and the Tutsis culminated in a 100-day genocide in which approximately 800,000 Tutsis and moderate Hutus were killed. In July 1994, Rwanda Patriotic Front (RPF) troops, led by Commander Paul Kagame, defeated the extremist regime. In the years following the genocide, a single-party coalition government was established, and a new constitution was adopted in 1995 [2]. Rwanda held its first post-genocide local elections in March 1999, and its first presidential and legislative elections in August and September of 2003, respectively. In the parliamentary elections of 2003, the RPF won 33 of 53 seats and became the ruling party of Rwanda. Later that year, Kagame was elected President by a direct popular vote. 144
Since 1994, Rwanda has pursued a policy of decentralization, granting local entities some degree of administrative and fiscal autonomy, while allowing the Central Government to retain responsibility for policy formulation, monitoring, and analysis [3]. Power has shifted from the country’s five provinces, to its 30 districts, 416 sectors, and finally, 2080 local cells [4]. Rwanda - Table 1 Basic Socioeconomic, Demographic and Health Indicators* (*) Full data sources for all indicators are provided in Annex 1. Indicator Value Year Source Population (thousands) 9,734 2007 World Bank Geographic Size (sq. km) 24,670 2007 World Bank GDP per capita, PPP (constant 2005 international $) 818.24 2007 World Bank Gini index 46.68 2000 World Bank Government expenditure on health (% of general government expenditure) 18.8 2007 WHO NHA Per capita government expenditure on health (current US$) 17 2007 WHO NHA Physician density (per 10,000)
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Table of Contents Key Acronyms Intr
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Policy analysis of the impact of Gl
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OIs Opportunistic infections OVC Or
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core section of the document then p
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Figure 1: Analytic framework for MP
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studies. MPS researchers have linke
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Burundi: Building a health system t
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at between US$ 14.5 and US$ 18.5 pe
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collaborations with European school
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epresent only US$ 1.75 per month pe
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Service Delivery The decentralizati
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Long term HSS will require governme
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Cameroon: Evaluation of the Nationa
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Table 1 Basic Socioeconomic, Demogr
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of treatment interruptions (>two da
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side effects) were associated with
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Prevention behaviours Nearly half (
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References [1] The World Bank Group
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Out-of-pocket payments account for
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as well as the number of community
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Table 1: Characteristics of facilit
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Table 4: Estimated changes in human
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Central African Republic: Impact of
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Objectives and Methodology In this
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Financing There was a general appre
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NGOs and Civil Society The overall
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Discussion Interviews with key info
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China: The Impact of the Global Fun
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Table 2 Global Health Initiative In
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In Yunnan and Henan, the epidemic i
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funded only from the MOH Pilot Prog
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References [1] China at a glance. W
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1994, private spending and emergenc
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understanding of their roles and re
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References [1] Human Development Re
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In 2003, the government launched th
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Objectives and Methodology The data
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Health Workforce Ghana is challenge
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Discussion GHIs are critical for ra
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Haiti: Maximizing Positive Synergie
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Table 1 Basic Socioeconomic, Demogr
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with need. With GHI funding, distri
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I know that within [the organizatio
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Much of the initial enthusiasm abou
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services, or for measures of qualit
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funds and more funding focused on i
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INDIA: Exploring how disease-specif
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PEPFAR* Year Amount Disbursed (in U
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Primary data collection - facility
Page 100 and 101: The Global Fund has strengthened th
Page 102 and 103: References [1] The World Bank Group
Page 104 and 105: Background The Republic of Kenya li
Page 106 and 107: Results Leadership and Governance D
Page 108 and 109: Informants noted that a general lac
Page 110 and 111: time periods. Informants believed t
Page 114 and 115: A comprehensive, long-term reform o
Page 116 and 117: The effects of GHIs on the capacity
Page 118 and 119: their budget was comprised of Globa
Page 120 and 121: Quality of services The majority of
Page 122 and 123: References [1] Kyrgyzstan at a glan
Page 124 and 125: Commission (NAC) in 2001 as a multi
Page 126 and 127: Objectives and methodology The main
Page 128 and 129: Discussion The findings of the Mala
Page 130 and 131: Pakistan: The impact of the Global
Page 132 and 133: international standards. The Under
Page 134 and 135: the US Centers for Disease Control
Page 136 and 137: Some negative effects are also attr
Page 138 and 139: to country health systems by way of
Page 140 and 141: Peru: Effects of the Implementation
Page 142 and 143: Table 2 Global Health Initiative In
Page 144 and 145: HIV/AIDS, mainly around the Compreh
Page 146 and 147: without substantial emphasis on pre
Page 152 and 153: Rwanda was US$ 584.9 million in 200
Page 154 and 155: International Health Partnership, t
Page 156 and 157: PEPFAR’s funding practices were l
Page 158 and 159: medical staff to higher-paying admi
Page 160 and 161: system (CPDS), in which many stakeh
Page 162 and 163: needing medical transport. Both GHI
Page 164 and 165: Some informants felt that local NGO
Page 166 and 167: Senegal: The effects of Global Heal
Page 168 and 169: Table 1: Basic Health System and Ep
Page 170 and 171: case study. Data analysis was condu
Page 172 and 173: of respondents aware of treated net
Page 174 and 175: South Africa: The effects of Global
Page 176 and 177: Table 2 Global Health Initiative In
Page 178 and 179: of South Africa (GHI2, ND6). 26 Don
Page 180 and 181: NDOH to disburse external funds in
Page 182 and 183: The lack of effective monitoring an
Page 184 and 185: Despite these problems, GHI funding
Page 186 and 187: [19] The Global Fund for Aids Tuber
Page 188 and 189: Official Development Assistance (OD
Page 190 and 191: The study employed both purposive s
Page 192 and 193: Figure 1: Number of Clinicians at S
Page 194 and 195: There were very significant increas
Page 196 and 197: GHIs created an opportunity to cond
Page 198 and 199: Ukraine: Effects of the Global Fund
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GAVI (in US$) Disease Priority Amou
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government and nongovernmental prov
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• The introduction of new service
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References [1] Data are from the Mi
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The health system struggles with a
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Objectives and Methodology This stu
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Nonetheless, efforts to recruit and
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References [1] The World Bank Group
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average annual population growth of
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2006 149,022,153 2007 216,012,780 2
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isks duplication of services but al
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centres have only one qualified hea
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Policy analysis of the impact of Gl
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countries” [6]. The TRP apply sev
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PEPFAR I & II The newest PEPFAR leg
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Types of fundable HRH interventions
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Global Fund In two country applicat
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TABLE 3: Selected Countries: MPS Ca
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HRH Intervention Categories GAVI: C
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HRH Intervention Categories GLOBAL
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HRH Intervention Categories PEPFAR
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Conclusion: Directions for future r
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GHIs and health systems. Civil soci
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Annex 01: Data sources for tables i
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Annex 02: Contributing Institutions
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