Assessing the Financial Priority of Malaria in Rwanda; Who Spends? How Much? And for What Services?

RATIONALE: Malaria is the leading cause of morbidity and mortality in Rwanda. Given this and the surge in targeted funds for HIV/AIDS, policymakers are concerned about the level of available funds for malaria. This prompted comprehensive reviews of malaria expenditures as part of ongoing health resource tracking efforts. OBJECTIVE: The goals of these reviews were to inform the resource allocation process, assess the relative financial priority of malaria in the health system, and to serve as both an advocacy and monitoring tool. METHODS: Conducted by the Rwanda Ministry of Health, the process of expenditure estimation entailed the collection of data from numerous primary and secondary source that targeted households (including a survey of 1400 individuals with a malaria episode in past 4 weeks), providers, government, donors, and non-governmental organizations. As the first reviews of their kind, the Rwanda experience was incorporated into international guidelines for tracking malaria resource flows. FINDINGS: The report finds that about one fifth of all health funds (18%) go towards malaria. This is similar to levels consumed by HIV/AIDS and Reproductive health prior to the surge of donor targeted financing (such as Global Fund, PEPFAR). Within the malaria portion, donors contribute 38%, followed by households (29%), and then the Government (24%). While donors are the largest financier of malaria resources, malaria expenditures (distinct from disbursments) accounted for only 16% of their health contributions in 2003 and decreased further in absolute and relative terms in 2005. Although not the leading financier of malaria services, the financial burden on households to pay for care is nevertheless heavy, particularly for the poorer income levels. Households spend more than the Government for medical treatment on malaria. Access to treatment is strongly dependent on wealth of individuals. The richest quintiles are twice as likely as the poorest quintile to use hospitals, clinics, or health centres when suffering from malaria. The poor, by contrast, are more likely to see traditional healers (TH); in fact, of those who reported seeing TH, all were in the poorest quintile. In addition, 20% of the richest quintile self-medicates and this rate doubles at the poorer income levels. SIGNIFICANCE OF FINDINGS: The findings highlight the relative low financial priority of malaria among stakeholders and reveal disparities with respect to accessing care. Such data have been used by the Ministry of Health in its offical strategy for acheiving the millinnium development goals. Given the low levels spent on malaria, the strategy has called for donor harmonisation and alignment with national priorities. Other stakeholders are investigating mechanisms for delivering malaria treatment to the poor.