Changing donor behaviour: an interview with the Ministry of Finance in Rwanda
Before the IHP+ Technical Briefing at the WHO World Health Assembly in May 2013, IHP+ interviewed Kampeta Sayinzoga, Permanent Secretary in the Ministry of Finance, Republic of Rwanda. Ms. Sayinzoga discussed the important role that the Ministry of Finance plays in the development effectiveness process, and described some of the specific approaches that Rwanda has used to achieve better results.
Before the IHP+ Technical Briefing at the 66th WHO World Health Assembly last month, IHP+ interviewed Ms Kampeta Sayinzoga, Permanent Secretary in the Ministry of Finance, Republic of Rwanda.
Why is it important for the Ministry of Finance to be involved in aid effectiveness processes?
Aid effectiveness, before anything, is about money. It is about results, but it is also about money. If the money flows and is not matching what you are expecting and the kind of results that you are expecting for what you pay for, then you have a disconnect. The Ministry of Finance is normally accountable; they have a mandate to ensure that the Government gets value for money at all levels. That includes money that originates from taxes, but also from development partners and other financial flows. The Ministry of Finance holds out the carrot and the stick because they allocate resources and a plan without resources is basically hope or a wish list. So it is very important that Ministries of Finance understand the kind of reforms that are necessary to get better value for money for aid and be able to provide both the carrot and the stick for the sectors.
What is the role of the Ministry of Finance in relation to the health sector?
The health sector is at the heart of our economic development. One because of productivity and two, it is the sector that affects everybody. I don’t know anyone who does not get affected by health. Where the Ministry of Finance can have a productive discussion with the Ministry of Health is ensuring value for money. Ensuring health can be very expensive; as we have seen, even very developed countries still have issues with footing the health bill. So it is very important for countries to have a discussion between Ministries of Finance and Ministries of Health, to look at big impact interventions that allow us to have better value for money. That conversation has to be comprehensive, it can’t just be about building a hospital. It has to be about immunization, how do we involve communities, how do we involve people who are not doctors or health staff, how do we build human resources? It has to be a comprehensive discussion that not only looks at money spent but how is it spent, how do we get value for money and more importantly how do we ensure sustainability? Where is the money going to come from to make all these good interventions sustainable over time?
Rwanda has been a leader in aid effectiveness processes and you’ve used some very unique approaches in terms of mutual accountability. Could you describe those approaches?
The first thing, before you can talk about mutual accountability between donors and recipient countries, is that you have to be accountable yourself as a recipient country. The first we did is to ask how can we hold ourselves, as a government, accountable to our people? And then reflect the same spirit to the way we deal with our development partners. So you start at the bottom, you start with the grassroots. We have a performance contract between our communities, and the Government to make sure the Government delivers on results for the population.
Then on that basis, we sat down with the donors and said, ‘Look, this is what we are committed to do for the next three years but this is our specific commitment for next year in terms of how we are going to use your money, how we are going to use resources available and what are the results that we are going to deliver against this money’. And we asked them the opposite question, ‘How are you going to facilitate us to be able to reach these results?’ At the time we told them, ‘We are not going to reinvent the wheel, let’s look at the Paris Declaration Commitments that you have made. You have agreed at the global level that these are the ways to have best value for money so tell us at the country level, how is this going to affect us as Rwandans and as Rwandan citizens?’ So we did a scoring methodology where we looked at the baseline and we looked at each donor and we said you are green for this indicator that is in the Paris Declaration. To the donors that were red, we said, ‘Give us an action plan of what you are going to do to become green and to obey by the action plan.’ Then we published the results.
Peer pressure works, not only for teenagers but also for donors, and we realized that as you publish these results, they get quite interested in getting better results in the following years. This has changed their behaviour. Now we have a two-way discussion. Not only about Government being held accountable about how they use donor money, but donors actually being accountable as to the quality of the money that they provide to Government.
Could you describe the cross-sector, cross-governmental working that you have been doing?
When we look at interventions we try to look across the board. We always start with the community because we think it is the only way for it to be sustainable so we look at what the Government is going to initiate but more importantly, how is the Government going to have ownership of it? Once you look at the citizen, it stops mattering whether you are dealing with the Ministry of Finance, the Ministry of Water, or the Ministry of Health because as one Government you are making a commitment towards one citizen. So it changes the dynamics within Government and makes coordination much easier. At the end of the day, if we want to have clear results, what is important here is that you cannot promise to the population 150 things and expect them to hold you accountable to those. So you need have very few things that are transformational for them.
In the case of Rwanda we said we want every single Rwandan to have financial access to healthcare. We said that is important to us and we put in place a micro-health insurance and right now over 90 percent of the population has health coverage. That is transformational for someone to know that if they fall sick, they have a social safety net or they have a health insurance that can back them up. The second thing we said is that there are so many diseases where people don’t need to go to hospitals, so instead of building more hospitals or more health centres, let’s see how we can train the local members of the community to tackle fever, diarrhea as these are not things that need a doctor or specialist. So we looked back at interventions and said, ‘How do we do high impact but life changing interventions for the majority for the majority of the population?’ Then we try and address those and look at how we make this sustainable. This is why – and it is a bit controversial – Rwanda has not been one of the countries that opted for fee-free health care for example. We do not believe that in our case, this would be a financially sustainable model. It may work for some countries, but we knew with our narrow tax base it would not work for us.
So we prioritize results but also very importantly sustainability and that can only be done if the entire government chain understands what we do and is able to be a bit visionary and look at twenty years down the line. So we pool resources from the community, we pool resources from Ministry of Finance, we pool resources from Ministry of Health and more importantly, even from the private sector. But we have one plan; the commitment that we make to the Rwandan citizen is only one plan and we commit to this with all the stakeholders around it and that really helps the dialogue.
Have the aid effectiveness and development effectiveness approaches that you’ve used help you get a better fit between your agenda and the resources that are available?
Yes, I must say that when we started there was a lot of fragmentation. It was after the genocide, there were a lot of NGOs, a lot of development partners, a lot of action plans and zero strategic plan. Today, we have one strategic plan and it has helped. Through the mutual accountability system, we have managed to encourage donors to change their aid modalities, to stop using third parties and to start using government systems. We perfected our government system to the decimal, so that it is not only good enough for donors but it is also good enough for us to be accountable to our citizens. So with that we have seen aid modalities changing, there are fewer fragmented partners, there are fewer fragmented action plans, and we have a common monitoring and evaluation mechanism. We have more projects channelling money through Government that actually strengthens ownership, it reduces transaction cost and it reduces wastage on overheads. So we have seen that if you are able to get your house together, but stand also your ground very firm, you can actually change the behaviour of donors.
- Join our UHC Day Geneva public event on 12 December
Act with Ambition: Universal Health Coverage (UHC) Day 2016
- SDG Indicator 3.8.2 refinement agreed
Advocacy is successful to influence IAEG-SDG decision
- UHC2030 at HSR2016: domestic research for health systems strengthening matters
Discussions in Vancouver 2016