MALARIA: Rwanda: Top down targets and donor-set priorities

The Rwandan government says that the main problem in making better use of existing resources is the development partners.13 In 2006,Rwanda had "$18m earmarked for malaria (the biggest cause of mortality and morbidity) and just $1m for the integrated management ofchildhood illnesses, compared to $47m for HIV/AIDS, grossly disproportionate in a country with a 3% infection rate." The emphasis on HIVmeans that: "physicians employed by NGOs to deliver HIV/AIDS services [are] paid almost six times as much as physicians paid by the[Ministry]. Such differences in salaries make it particularly challenging to keep well qualified health personnel in the public sector."The 2006 government analysis showed that an extra $20 per person could reduce maternal and child mortality to meet internationaltargets. The first $9 were "estimated to deliver three quarters of the reduction in child mortality, and 63% of the reduction in maternalmortality." Scaling up antiretroviral treatment for HIV/AIDS was judged to be the lowest priority, costing an additional $8.30 per person butmaking "little additional contribution to maternal mortality, while the 6% reduction in child mortality [was] achieved at high unit cost."But with foreign non-governmental organisations managing a larger share of total health expenditure than government, such systematiccost-benefit analyses do not influence national spending priorities. By 2008, the US President’s Emergency Plan For AIDS Relief hadinvested about $200m in HIV/AIDS programmes in Rwanda, including scaling up antiretroviral treatment, which remained one of its mainmeasures of success http://wwwbmj.com/cgi/content/full/341/jul16_1/c3651