Institutional arrangements Institutional arrangements for harmonization and for harmonization and alignment for aid for alignment for aid for

HIV/AIDS into EDPRSsHIV/AIDS into EDPRSs

Dr. Agnès BinagwahoExecutive SecretaryNational AIDS Control Commission (CNLS)Rwanda

Thursday, February 23, 2006

Rwanda ProfileRwanda Profile

8.2 million people; 83% rural

TB/HIV comorbidity: 40-60% of those w/ TB

70% below poverty level

Literacy: 48%

Life expectancy: 38 years

Prevalence (%) Prevalence (%) by residential areaby residential area

7.3

2.2

0,0

1,0

2,0

3,0

4,0

5,0

6,0

7,0

8,0Pourcentage

Urban

Rural

Prevalence (%) Prevalence (%) by residence and sexby residence and sex

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

Femme

Homme

Indicators value

Doctors 1 par 57 0000 inhabitants ( OMS :10 000) Health centers 400 HD 33 functional 3 on way RH 4 25 private clinics run by MD

Nurses 1 / 5 000 inhabitants (OMS:5000) 450 private clinics run nurses

Mothers deaths 1017 / 100.000 live births

Infants deaths 107/1000 live births (IMR ) 196 / 1000 (U5MR)

Malnutrition < 5 years: 24% 0-13 years : 27, 2%

family planning

4%

SituationSituation

Rwanda is one of the least developed countries Nearly one million people were killed during the genocide of

1994• Rate of HIV prevalence multiplied by 4 in rural area• Many highly-skilled people were lost• Infrastructure was lost

Other problems: • High number of orphans• High number of female-headed households (34%)• Impact of sexual violence• Psychological trauma

Political situation Political situation

11 years of reconstruction:Strategies for fighting poverty:

Democratization Decentralization National Reconciliation Process of participative justice - GACACA Involvement and empowerment of communities in

all processes

Response of the Response of the GovernmentGovernment

Government institutions

2000: CNLS/NACC (National AIDS Control Commission), under the Office of the President in replacement of 1987-2000: PNLS/NACP (National AIDS Control Program in MOH)

2001: TRAC (Treatment and Research AIDS Center) coordination body and M&E of care, treatment and drugs stock . Reports to CNLS

2002: MOS coordinates the major epidemics

Decentralization of CNLS30 District Committees for the fight against AIDS (CDLS)

Mission and Objectives of the CNLS

Assist the government to:• Develop national strategies in the fight against

HIV/AIDS• Plan and coordinate• Follow and monitor activities• Sensitize the population and its leaders• Mobilize resources

In a participatory process with sectors and stakeholders

Role of umbrellasRole of umbrellas

Public sectorPublic sector Heath sub-sector

– TRAC : coordination, M&E of care, treatment and drugs stock Non Heath sub-sector

– Focal points to fight HIV/AIDS in each Ministry. All Ministries have an action plan to fight HIV/AIDS

Cluster of HIV (GoR and Development partners)Cluster of HIV (GoR and Development partners)RRP+RRP+RICRRICRCNJCNJCNFCNFAPELASAPELASABASIRWAABASIRWA

Achievements1. National framework2. National multisectorial lan for the fight against AIDS3. National Plan for Monitoring and Evaluation

a. 63 national indicatorsb. 32 Priority indicators

4. National Treatment and Care Plan 5. Ministerial Instruction on Patient Care6. National Prevention Strategy (pending)7. Agreement (MOU with all stakeholders)8. Mapping of stakeholders9. National Strategy for Behavior Change and Communication 10. Specific strategy for BCC11. National Treatment Guidelines12. National Steering Committee for BCC13. Committee for the Approval of Projects14. National Steering Committee for research15. National Health Policy16. Policies and Guidelines on health care mutuelles

National Policy for National Policy for caring for people living caring for people living

with HIV/AIDSwith HIV/AIDS Improving links between TB, STI, malaria and

HIV/AIDS control (ex. Integrated VCT) Integrating HIV/AIDS into all sectors Reinforcement of education in all sectors at all

level with a focus on community, prevention and reverse the overall impact of HIV/AIDS.

Integrate the HIV programs into the EDPRS, Vision 2020 and MDG ( gender inequity , and social development)

MitigationMitigation

Women empowerment (axe 4)– Access to micro credit with one national

project approval committee for MAP PEPFAR, UNDP, ADB and in framework of programs of Prime Minister and Minister of Finance

– National Constitution and law and Ministerial instruction for C.T. HIV (familly approach)

Loss of Loss of Human resourcesHuman resources

Capacity building on the job training and increase formal training (MOH, MINEDUC)

Performance based financing of health services delivery

Better conditions of life for up country medical personnel

Using public servants for HIV programs and direct supports to sectors facilities

Workplace policy for HIV/AIDS

e.g. of impact of HIV: e.g. of impact of HIV: maternal AIDS orphansmaternal AIDS orphans

0%1%2%3%4%5%6%7%8%9%

10%

0-6 years 7 - 12 years 13 - 16 years

3% of S3 orphaned by long illness of mother. 8% of S3 students had lost at least their mother and 19% their father to genocide/war

As school genocide orphan numbers decline, a large percent will be replaced by AIDS orphans

Responses for OVCResponses for OVC

Minimum package for OVC (mutuelle, school)(MAP, GF, PEPFAR)FARG for genocide survivors and community

education funds at districts level for other OVCsUniversal free primary educationUnit for HIV/AIDS in the MINEDUC

Access to care Access to care and treatmentand treatment

– Cost sharing (sliding scale for payment based on family income, free for poor/vulnerable (Ministerial Decree)

– Negotiation with pharmaceutical companies for increased reduction in cost

– Common basket approach (to coordinate purchases, distribution and control stockouts)

– Geographic equity for VCT, PMTCT, ARV

– Problem of long-term sustainability for access (ARVs, human resources for other care)

e.g. Partnership with the e.g. Partnership with the private sectorprivate sector

1. National Multi sectorial approach Private sector

Encouraging the Private sector and cooperating partners to support the national and regional efforts in place to promote the economic empowerment and the fight against HIV/AIDS (specially for women )

Mainstreaming of economic empowerment in the fight against HIV/AIDS (34% of households are headed by women) focus on women, especially the disadvantaged ones for microproject and mocrofinance support)

e.g. Actions in regional e.g. Actions in regional frameworksframeworks

Encouraging sub regional networks and network them ( GLIA, OAFLA, PAYA, GLNPLWA, COMESA)

Country Resource Country Resource Mobilization ContextMobilization Context

HIV required rapid expansion as an emergency program Simultaneous emergence of PEPFAR Global Fund

and World Bank/MAP Initiatives in country Strong commitment on the part of the Rwandan

government to coordinate all initiatives to avoid duplication and gaps

Recognition of need for permanent coordinating

bodies to establish and develop all programs and

plan. e.g.: Partnership forum, SC of PEFAR, CCM, HIV Cluster, DPCG (Development partner coordination group).

Partnerships strategyPartnerships strategywith whom and howwith whom and how

“Country ownership”“Country ownership” Development Partners

1. GOR

2. USG PEPFAR

3. GF (3 diseases)

4. WB /MAP

5. UN family

6. ADB

7. Lux Development

Government Strategy

1. 3 ones (CNLS, CCM, MSU, SCP, Cluster)

2. Integration in sectors

3. Common basket for procurement

– ARV done– Consumable in process

Outcomes: 3 ones (1)Outcomes: 3 ones (1) Success because the GOR, leads, owns and coordinates the response to HIV/AIDS

Involvement of civil society Involvement of all GOR institutions concerned

All partners are required to have their workplans developed with and approved by their Rwandan counterparts resulting in…

Better coordination for all partners Equitable geographic coverage (building with GOR, PEPFAR, GF, MAP, others ….)

Funded projects became + operational

Outcomes: 3 ones (2)Outcomes: 3 ones (2)

Egalitarian co-management (North-South) Better coordination and utilization of resources through joint routine planning, monitoring and evaluation of projects Traditional partners have become more flexible (USG, WB, GF (Joint procurement for ARVs, FDA approved and WHO prequalified) Partners working together with improved synergy The activity development and implementation is accelerated due to real collaboration (decision-making) of institutions at all levels

What next forWhat next for harmonization and harmonization and

alignmentalignment Some partners still want the project support

approach. Ongoing discussion for direct budget or sector programme support BUT GoR wants development partners to:

Fully align their assistance to the national planning and budgeting structure.

Coordinate aid into sector wide approaches Support establishment of joint funding

mechanisms and sector budget support.

Thank you