Multi-sectoral Response Rwanda Anita Asiimwe, MD,MPH Treatment and Research AIDS Centre [TRAC] Rwanda

Rwanda Profile Genocide in million killed (Former leadership based on exclusion) Current governance structures demonstrated better leadership with principles of equity % 52% % 70% GDP per capita Primary school enrollment Access to clean water poverty High maternal & infant mortality Illiteracy

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 Project

Program 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 Components oHealth 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 oProgram 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

MAP-Supported health facilities offering ARV Nyagatare

MAP 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 health facilities Gihundwe HD Cyangugu Nyagatare HD Umutara Butare Univ Hospital HD Butare Provincial and District Health Teams Provincial and District Health Teams Provincial and District Health Teams CHK PMU/CNLS TRAC CAMERWA Central oversight and support structures CS HF

particular 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 2 nd line ARV 1.7% compared to 2.5% national

Résultats cumulés de l'approche contractuelle (fin septembre 06) Indicateurs de performanceMEMISA Cordaid (ex Cyangugu) PrévuRéalisé% 1Nb de personnes testées (VCT)27,852122,789441% 2Nb de couples testés (VCT)18,93613,63672% 3Nb de femmes enceintes bénéficiant le PMTCT ,050120% 4Nb de couples bénéficiant le PMTCT4,5837,098155% 5Nb de mères VIH+ sous NVP1, % 6Nb de nouveaux nés des mères VIH+ sous NVP 1, % 7Nb de personnes VIH+ recevant le CMX23,53212,99655% 8Nb de tuberculeux testés pour le VIH %

Performance Based Financing

Hospital Upgrading

Lab Upgrading

Population: Physician Ratio dropped from 45,400 to 34,000:1

Lessons 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 level o Ownership of social programs by local authorities

problems 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

conclusion 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!