MAXIMIZING POSITIVE SYNERGIES - World Health Organization

In terms of PEPFAR, respondents suggested the one-year funding cycle was too short. Many
resources went into completing the application each year, and there was not sufficient time to
evaluate the previous grant before submitting the next proposal:
This [PEPFAR monitoring and evaluation] was a nightmare! At the beginning you
would receive money to be spent in one year, but this would come way past the
middle of the year, around July or August. This I think was as a result of the
schedule of the American Congress. The funds would come in when the state
budget is already running, and you would try to disburse it. But before you are
even half way through it, around the month of December, you are asked to
submit project proposals for another round of funding before you even find out
the results of round one. We tried to set up a steering committee, but it failed to
streamline the working modalities. The reporting of PEPFAR was only
understood by one or two people.
Limitations of GHI funding models
Informants repeatedly commented that there was a significant unmet need for investments in
infrastructure. The expansion of the Mutuelle de Santé programme was an important step in
expanding access and increasing demand for services (including voluntary counseling and testing
[VCT] opportunities), but more investment of the system-level sort was needed.
In particular, PEPFAR’s restriction on renovation of facilities (as opposed to construction of new
facilities) was seen as a significant impediment to implementing HIV programmes in some
locations. In addition, its stipulation of the percentages of funding that had to be spent on
different programme components (i.e. prevention, treatment, support) was considered limiting.
Health Workforce
GHI funding impact on staffing levels, training and retention
GHI funding helped Rwandan health facilities achieve their target levels of staffing at public
facilities, largely by increasing the total number of doctors working in the health system. PEPFAR
and the Global Fund have increased the availability of training within Rwanda for community
health workers and doctors. The Global Fund allowed Rwanda to use some of its training funds on
non-target diseases, strengthening the overall health system. The informants linked increases in
workforce retention rates with Global Fund training. Informants appreciated the Global Fund’s
outside consultants conducting trainings, crediting them with building capacity in the public
sector. One informant commented, “Global Fund found good consultants who trained the
personnel, and the personnel learnt a lot from them. And that is why the reports we now submit to
CCM in Geneva are quite well made because there are people who got trained in doing it, and they
are also training others.”
Some informants commented that the quantity of PEPFAR trainings had resulted in frequent
absenteeism in health facilities. PEPFAR’s training had also extended to Rwanda’s national supply
chain management entity (CAMERWA), from which it had sent staff to several other countries for
training.
Salary increases made possible by GFATM monies generally had a positive impact on recruitment
and retention in the public sector. Respondents cited the Global Fund as supporting the GoR in
hiring district level staff. However, some informants commented that they lost public sector
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