25 February 2019
Since 2014, the Global Fund has implemented a Results Based Financing model in Rwanda, the only major portfolio with such a model. The model, known as National Strategy Financing, emphasizes country ownership, allocates funding in support of costed National Strategic Plans, and allows for flexible use of funds within pre-defined parameters. The model is premised on a country’s track record of achieving effective programmatic results, established institutional safeguards, and strong systems and controls, and is supported by a number of flexibilities and exceptions to Global Fund standard operating procedures.
Under the model, annual disbursements are directly linked to reported programmatic results. The model’s effectiveness is thus critically dependent on the availability of good and reliable data to gauge results and to support decision making. The audit found that Rwanda’s systems and controls to safeguard data quality are adequately designed, and reported results are generally aligned with available registers at health facilities. However, weaknesses in the implementation of these systems and controls could impact data integrity, especially for malaria. In particular, the current system allows health facilities to make unauthorized changes to malaria data after the reporting period.
In response to the significant increase in malaria cases, the Ministry of Health revised its guidelines to enable community health workers to manage malaria cases in adults, as of December 2016. This increased workload has further strained the already low capacity of community health workers, who are inadequately supervised by the health centers.
There is effective assurance on financial information, which is regularly audited by the Office of the Auditor General (OAG) of Rwanda, a competent and independent body. The scope of assurance provided by the OAG, which is determined by the Global Fund Secretariat, is currently limited to financial assurance and does not extend to validation of data or assessment of internal controls over data.
Any weaknesses do not necessarily call into question the relevance of the Results Based Financing model in Rwanda, a country that has demonstrated strong accountability mechanisms and a track record of effective program implementation. A separate review, commissioned by the Secretariat in 2018, confirmed the continued relevance of the model. However, failure to strengthen controls over data and the scope of assurance would undermine, over time, the reliability of the results based on which the Global Fund is supporting Rwanda’s health programs.