Multi-sectoral ResponseMulti-sectoral ResponseRwandaRwanda

Anita Asiimwe, MD,MPH

Treatment and Research AIDS Centre [TRAC]

Rwanda

Rwanda ProfileRwanda ProfileGenocide in 1994 1 million killed

(Former leadership based on exclusion)8.6

5.8

2.61.6

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

9.0

Urban Rural

women

men

Current governance structures demonstrated better leadership with principles of equity

220

72%

52%

300

92%

70%

GDP per capita

Primary school enrollment

Access to clean water

20002000 20062006

povertypoverty

High maternal & infant mortality High maternal & infant mortality

IlliteracyIlliteracy

Rwanda Profile Rwanda Profile

Fertility rate: 5.6

Attend ANC at least once: 90%

Deliveries in health facilities: ~ 30%

Knowledge of individual HIV status among the

positives: 42%

DHS+ 2005

Government Strategy:CNLS (PMU), PSC, HIV Cluster.

Development Partners:GOR,USG PEPFAR,GF (3 diseases),WB /MAP,UN-family, ADB, Lux Development

Areas of Coordination:

management, supervision, training, common procurement (drugs, lab equipment, reagents), monitoring and evaluation, performance contracting

Strong GOR Coordination

project objectives Strengthen prevention measures to slow down the

spread of HIV/AIDS

Expand support and care for those infected or affected by HIV/AIDS

Progress was solid with virtually all targets met or surpassed

Background of MAP ProjectBackground of MAP Project2003-20072003-2007

Program managementProgram management

Established unit within CNLS to manage and coordinate activities (ownership)

Harmonized procurement procedures to facilitate joint procurement (economy and alignment)

Simplified logical framework (allows poor communities to manage) and synchronized indicators, ensuring consistency in reporting with national M & E plan and national tools e.g TRACnet

Key ComponentsKey Components

o Health Sector HIV/AIDS Support (US$10.9M): diagnosis, care & treatment

Public Sector Support (US$7.0M): prevention, care & support services

Civil Society Support (US$10.7M.): preventive interventions, OVCs, income-generating activities

o Program Management, M & E (US$3.4M.): capacity building, coordination

One Year extension US$ 10M end 2007

care and treatment

MAP has financed an expansion in treatment for AIDS patients which has provided life saving ARV therapy to individuals in 14 districts within the context of the national treatment plan

S1

381113413625931190581324383554366

41891253

870

139133938460

3120

1610

4 1

100

10000

1000000

PERIODE

NOMBRE DE PATIENTS ET NOMBRE DE SITES PAR PERIODE

MAP-Supported health MAP-Supported health facilities offering ARVfacilities offering ARV

•Nyagatare

MAP ARV ProgramMAP ARV Program

• First to extend ART services outside of Kigali, ensuring a pro-poor focus

• Developing replicable models of care and support, which are being scaled up with financing from other development partners

• Building capacity at sites with no prior experience through facility upgrading, laboratory capacity, HR which in turn has a positive impact on health systems

Schematic of participating Schematic of participating health facilitieshealth facilities

Gihundwe

HDHDHD

Cyangugu

Nyagatare

HDHDHD

Umutara

Butare Univ Hospital

HDHDHD

ButareProvincial and District

Health Teams

Provincial and District

Health Teams

Provincial and District

Health Teams

CHKPMU/CNLS

TRAC

CAMERWA

Central oversight and support structures

CS

HFHF

HFHF

HF

particular resultsparticular results

Majority of patients are poor females who are disproportionately affected by HIV/AIDS

Adherence rate is 96% which is in line with international standards

Patients on 2nd line ARV 1.7% compared to 2.5% national

SITES MAP ET TOUS LES SITES

SITES-MAP18%

SITES_National82%

PATIENTS SOUS ARV: MAP VS NATIONAL

SOUS ARV_National

86%

SOUS ARV-MAP SITES

14%

Patients on ART in MAP supported health facilities

5863

593520358246131

1796

2873

3965

5070

6456

5590

4323

3119

1927

0

1000

2000

3000

4000

5000

6000

7000

Jun-05 Dec-05 Jun-06 Dec-06 Apr-07

Enfants Adultes TOTAL

Juin 2005

Decembre2005 Juin 2006

Decembre2006 Avril 2007

SIT

ES

_MA

P

PA

TIE

NT

S

1927 3119 43235590 6456

1214

14 31

311

10

100

1000

10000

Evolution of health facilities and patients on ART: MAP

SITES_MAP

PATIENTS

Résultats cumulés de l'approche Résultats cumulés de l'approche

contractuelle (fin septembre 06)contractuelle (fin septembre 06) Indicateurs de performance MEMISA Cordaid

(ex Cyangugu)

Prévu Réalisé %

1 Nb de personnes testées (VCT) 27,852

122,789 441%

2 Nb de couples testés (VCT) 18,936 13,636 72%

3 Nb de femmes enceintes bénéficiant le PMTCT

21780 26,050 120%

4 Nb de couples bénéficiant le PMTCT 4,583 7,098 155%

5 Nb de mères VIH+ sous NVP 1,308 834 64%

6 Nb de nouveaux nés des mères VIH+ sous NVP

1,308 516 39%

7 Nb de personnes VIH+ recevant le CMX 23,532 12,996 55%

8 Nb de tuberculeux testés pour le VIH 264 380 144%

Performance Based FinancingPerformance Based Financing Trends in HIV Testing,

before/after introduction of PBF Scheme, ex-Kabutare District

0

200

400

600

800

1000

1200

1400

1600

1800

Before 395 36 335 80

After 1711 202 558 246

VCT Partners Pregnant Women Partners

Trends in Key HIV Indicators, before/after introduction of PBF Scheme,

ex-Kabutare District

0

5

10

15

20

25

Before 5 5 6 7

After 22 10 14 10

Preg. Women Rec NVP

HIV+ Women Inst Deliv

Children Rec NVP

Children tested 9 mos

Hospital UpgradingHospital Upgrading

Lab UpgradingLab Upgrading

0

1

2

3

4

5

6

7

Kabutare Hospital: Additional Personnel Funded by MAP

MAP 2 1 3

Government 5 6 0

PhysiciansLab

TechniciansAdministrative

staff

Population:Physician

Ratio dropped from

45,400 to 34,000:1

Lessons LearnedLessons Learned High level quality care can be offered in the remotest

areas and thanks to HIV and AIDS services that have re-enforced the health system that decentralization supports strongly at the onset

Joint planning and field visit including all partners is a way to accelerate harmonization thus supporting to improve care offered

Standardizing data collection forms is key to the national program

Training & supervising stakeholder in reporting results is key at improving the planning process

o Decentralize monitoring to district levelo Ownership of social programs by local authorities

problems to be addressedproblems to be addressed

o limited knowledge of planning, management & monitoring of activities & funds for small NGOS

o insufficient attention to key areas (OVCS, HBC)

o shortages of personnel, high turnover & lack of incentives

o time consuming in monitoring and implementation of activities

conclusionconclusion

The philosophy of the MAP project was a very useful innovation for the country and has served as the step stone for the replication of the services country wide.

Strong government coordination in the spirit of the 3 ones, and zero tolerance for corruption has fuelled this success

Thank

you!