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Rwanda's experience reinforces the need to invest in health systems to improve outcomes for AIDS, TB and malaria and other diseases.

In addition to COVID, that has been casting a shadow over the world for more than a year now, Africa is still home to the world's deadliest pandemics: AIDS, tuberculosis and malaria. The Global Fund to Fight AIDS, TB and Malaria supports countries to provide care and contributes to strengthening health systems.

The  African Constituency Bureau was specifically established to ensure that African countries are well represented and Government implementers from the continent are effectively heard in the Global Fund Board and committees. As the Global Fund develops its new post-2022 strategy, the African constituency countries are laying a strong emphasis on investing in building Resilient and Sustainable Systems for Health. Supporting health systems will require focusing on the management and supply of necessary inputs for prevention and care, supporting the community and laboratory system, and ensuring the collection and meaningful use of data.

On the African continent in particular, health systems remain fragile, especially due to a shortage in material, financial and human resources, but also to governance and leadership issues. Thus, over the years, many have come to realize that well-functioning and efficient health systems are essential to achieving national and international health goals. Strong health systems are not only critical to ending HIV, tuberculosis, and malaria as epidemics, they also produce broader health outcomes. Aware of this challenge, in February 2020, the Initiative supported the organization of a sub-regional workshop on "Investing in the health system: a powerful lever for increasing the impact of grants in West and Central Africa" as part of the "Project to support Francophone Countries in the West, Central, East and Southern Africa Constituency", implemented by the ACB and AIDSPAN. This workshop aimed to help countries improve on the quality of their funding requests by structuring dialogue on health systems strengthening and program integration.

Indeed, Resilient and Sustainable Systems for Health are needed to hasten progress towards universal health coverage (to name but one), and they help countries deal with new pandemics such as COVID-19 and prepare for emerging threats to global health security.

Often the poor relative of health systems, the community-based approach is proving to be more effective and efficient, and the results can be clearly seen. The current health crisis has shown in many ways that Resilient and Sustainable Systems for Health cannot exist without a community foundation to ensure continuity of care, follow-up, and the presence and proximity that are required for certain diseases.

Case Study: Rwanda

On the continent, with rather modest incomes, Rwanda illustrates what we have just discussed. The country has made unprecedented progress in its investment and in ensuring universal health coverage and health for all Rwandans. Over 90% of the population is covered by community and private insurance schemes. Mandatory participation in mutual health insurance schemes, and public subsidies for the poor has substantially enhanced public health and health care with virtually unprecedented results over the past two decades.

Rwanda has recorded significantly improved results in controlling the malaria epidemic. Thanks to the nationwide scaling up of community-based management, strong social behaviour change communication interventions between November 2016 and March 2017 for example, there was a 50% decrease in severe malaria cases. Other measures include implementation of various control interventions, mass distribution campaigns of long lasting insecticide treated nets, indoor residual spraying.

At the same time, according to the 2018-2019 Rwanda Population-Based HIV Impact Assessment survey, the country has made tremendous progress against the 90-90-90 targets of the Joint United Nations Programme on HIV. Key findings indicate that Rwanda has achieved 84-98-90, particularly among women, and was expected to exceed each of these targets by 2020. Indeed, 83.8% of adults living with HIV knew their status. Of the adults who knew their status, 97.5% were on antiretroviral therapy (ART), 90.1% of whom had a suppressed viral load. To eliminate mother-to-child transmission of HIV, a package of services was implemented, including community support, counseling, and HIV testing, among others.

Other health outcomes are also impressive in Rwanda

Rwanda has achieved Millennium Development Goals 4 and 5, namely reducing child mortality and improving maternal health. The maternal mortality rate has steadily declined from 476 per 100,000 live births in 2010 to 210 per 100,000 live births in 2015. Since 2016-2017, 98% of women now deliver in health facilities. Neonatal mortality rates have dropped to 20 per 1,000 live births. In addition, under-five mortality rates decreased to 50 per 1,000 live births and infant mortality rates fell to 32 per 1,000 live births.

More than 98% of Rwandan children are vaccinated with 12 antigens that protect them against tuberculosis, polio, diphtheria, neonatal tetanus, pertussis, hepatitis B, haemophilus, influenza B, streptococcus, pneumonia, rotavirus and rubella. It should also be noted that the country is the first in Africa to introduce the human papilloma (HPV) vaccine with a 97% coverage and that pregnant women are vaccinated against tetanus during antenatal consultations.

In Rwanda, there are approximately 58,000 community health workers throughout the country, 66% of whom are women. Elected by their communities, CHWs are the first point of contact for communities to link with the health sector, including for COVID. Trained by the Ministry of Health, community health workers are able to screen and treat moderate cases of malaria, diarrhoea, and pneumonia, provide family planning methods, and conduct growth monitoring and malnutrition screening. They also provide pregnancy tests to promote early use of antenatal care and reduce maternal and neonatal mortality, and growth stunting.

On the other side, it should be noted that the average time, in minutes, to reach the nearest health facility decreased from 95.1 minutes in 2010 to 49.9 minutes in 2017. The number of primary health care services, including hospitals, health centers, specialized clinics, and dispensaries, increased from 490 facilities in 2008 to 1,497 in 2017.

In addition, Rwanda is experiencing some innovations in the health sector, including the use of medical drones, in partnership with Zipline, to deliver vital medical supplies such as blood and vaccines to the country's more remote hospitals benefiting more than 8 million people.  Also worth noting is the use of digital systems implemented to enhance health service delivery.

How did Rwanda achieve such results?

It should be noted that this phenomenal development of the health sector in Rwanda is due to a combination of several factors. First of all, the substantial investment in this sector but also initiatives such as the introduction of community health workers (unpaid but whose cooperatives are financially supported by the Government and partners) and the general policy of the Government which does not tolerate mediocrity and is meticulous in its management. In the same vein, it is important to acknowledge the considerable contribution made by partners under the auspices of the World Health Organization, the Global Fund to Fight AIDS, Tuberculosis and Malaria, and the Global Alliance for Vaccines and Immunization (GAVI) in strengthening health systems.

In 2017, President Paul Kagame, speaking at the opening of the 37th Global Fund Board meeting  held in Kigali commended the Global Fund's pivotal role in advancing the health sector: "It is fair to say that the Global Fund is perhaps the most consistent and effective development partnership in history. The Fund itself was an innovation, a fundamentally new way of doing business. Coming together so strongly to raise the funds needed to fight major health threats shows that we also have the means to address the many other global challenges we are facing today."

Importance of Government Leadership

The Global Fund's financing and intervention in the fight against the three diseases has worked well in Rwanda because the country's vision established clear strategies based on good leadership and especially good coordination and complementarity between donors and the Government. This tells us that it can work elsewhere. This is why we need to invest in Resilient and Sustainable Systems for Health, by especially taking into consideration areas where the Global Fund has comparative advantages: data, community systems, supply chains, and laboratory.