Institutional arrangements for harmonization and alignment for aid for HIV/AIDS into EDPRSs Dr. Agnès Binagwaho Executive Secretary National AIDS Control Commission (CNLS) Rwanda Thursday, February 23, 2006

Rwanda 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 (%) by residential area

Prevalence (%) by residence and sex

Situation

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

 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 Government

Government institutions 2000: CNLS/NACC (National AIDS Control Commission), under the Office of the President in replacement of : 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 CNLS 30 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 umbrellas Public 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) RRP+RICRCNJCNFAPELASABASIRWA

Achievements 1.National framework 2.National multisectorial lan for the fight against AIDS 3.National Plan for Monitoring and Evaluation a. 63 national indicators b. 32 Priority indicators 4.National Treatment and Care Plan 5.Ministerial Instruction on Patient Care 6.National Prevention Strategy (pending) 7.Agreement (MOU with all stakeholders) 8.Mapping of stakeholders 9.National Strategy for Behavior Change and Communication 10.Specific strategy for BCC 11.National Treatment Guidelines 12.National Steering Committee for BCC 13.Committee for the Approval of Projects 14.National Steering Committee for research 15.National Health Policy 16.Policies and Guidelines on health care mutuelles

National Policy for caring for people living with 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)

Mitigation 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 Human 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: maternal AIDS orphans 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 OVC Minimum package for OVC (mutuelle, school) (MAP, GF, PEPFAR) FARG for genocide survivors and community education funds at districts level for other OVCs Universal free primary education Unit for HIV/AIDS in the MINEDUC

Access to care and 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 private 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 frameworks Encouraging sub regional networks and network them ( GLIA, OAFLA, PAYA, GLNPLWA, COMESA)

Country Resource Mobilization 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 strategy with whom and how “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)  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)  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 for harmonization and alignment 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