Rwanda AFR Consultation Kigali

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					                                                                           Rwanda
                                                                            HIV/AIDS MultI-SectorAl Project




                                         BACKGROUND:
RWANDA HIV/AIDS MultI-SectorAl Project




                                         W
                                                    hen the project was prepared in 2002, Rwanda was classified among the ten most severely HIV-affected countries in Africa. Funding was
                                                    inadequate in terms of the scope and scale of the epidemic. The country had recently emerged from a genocide/war and was facing severe
                                                    capacity constraints and human resources shortages. Life saving anti-retroviral therapy was provided at a few
                                         urban facilities and was limited to those who could afford to pay.

                                         The government of Rwanda demonstrated strong leadership and commitment on both HIV prevention and treatment. It
                                         recognized the negative development impact of the AIDS epidemic, adopted a multi-sectoral approach and developed a
                                         national HIV/AIDS strategic plan. The government requested Bank assistance through the Multi-Country Action Program
                                         against HIV/AIDS in Africa, and benefited from the decision of the IDA deputies to provide ‘grant’ funding for HIV/AIDS.

                                         The project aimed to support the full range of preventive, medical and support services for those living with HIV/AIDS and
                                         to strengthen capacities to manage the epidemic. Most activities had a nationwide focus and were funded on a demand
                                         driven basis.



                                         IMPACT:
                                         The Bank was one of the first development partners to support a major expansion in AIDS care and treatment reaching poor Rwandans who live on less
                                         than US$.70 per day. Over 5,000 patients have benefited from life saving antiretroviral therapy in three rural provinces. The majority of beneficiaries are
                                         poor women who might have succumbed to the disease.

                                         The capacity to diagnose, treat and follow up AIDS patients has been established at 12 district hospitals serving about 2 million Rwandans. These up-
                                         graded facilities have strengthened their capacity to provide non-AIDS care, as most benefited from laboratory upgrading, renovations, logistical support,
                                         and additional human resources.

                                         Beneficiaries report satisfaction with the MAP approach which empowers them to find their own solutions, channels funds directly to them, and holds
                                         them accountable for results. This highly participatory approach has fostered innovation in service delivery and contributed to strengthening social capi-
                                         tal as many use solidarity mechanisms.

                                         The impact of these activities has often been dramatic. Numerous beneficiaries report on how a small amount of money has gone a long way in terms of
                                         assisting those infected to get back on their feet and providing alternative sources of livelihood for the vulnerable. HIV messages have been effectively
                                         combined with poverty reduction strategies and sustainability enhancing measures have increasingly been built into the design.



                                         HIGHLIGHTS:
                                         Prevention: The project has contributed to greater reported awareness of HIV/AIDS by supporting a wide range of activities, including HIV testing for
                                         about 500,000 individuals, distribution of 12 million condoms, 400 IEC/BCC events and introduction of innovative approaches (e.g. vouchers, perfor-
                                         mance contracting for HIV testing and other key services). The percentage of females who correctly identify ways of preventing sexual transmission and
                                         reject misconceptions rose dramatically (from about 23% in 2000 to over 51% in 2005). There are also encouraging news of a decline in HIV infection rates
                                         among youth in Rwanda (UNAIDS 2006), results to which the MAP funding has contributed.

                                         Care and treatment: Program performance has been solid with only 3% lost to follow up and virtually all patients on cost effective first drug regimens.
                                         The program is being decentralized to an additional 18 health centers which imply shorter travel time for patients and lower costs to the system. Rwanda
                                         is well underway to reaching the 3 by 5 goals with some 32,000 patients on ART at 130 sites nationwide, in comparison to 870 patients/7 sites in Decem-
                                         ber 2002. In the words of a provider the:


                                                          “availability of life saving ARV drugs is not only providing hope to people who are desperately ill
                                                                      but is also leading to a greater acceptance of people living with HIV/AIDS
                                                                                         and a discernible reduction in stigma”.


                                         Mitigation: The project has provided financial support to over 100 civil society organizations to mitigate the impact of the epidemic on poor house-
                                         holds. It has funded school fees of 27,000 orphans and vulnerable children, subsidized access to community health insurance to roughly 52,000 house-
                                         holds, reaching roughly 250,000 individuals, and organized income generating activities for some 100,000 individuals. These activities have had positive
                                         spill over effects for other family members (e.g. payment of school fees, health insurance access, and sending money back to their villages). As noted by
                                         Epiphanie, her life has changed as a result of the MAP:



                                                         Prior to the onset of the project she engaged in sex work, like many of her co-workers who scramble
                                                                   to make a living in this crowded and poor neighborhood on the outskirts of Kigali.
                                                                       Sex work was not sustainable and not a dignified way of earning a living.
                                                             Once she came to the Turwanye Ubukene Association she had access to the ‘right channels’.
                                                             Authorities helped her and her co-workers to design their own income generating activities.
                                                                         Now she engages in a productive trade, has a stable source of income
                                                                             and has regained her self esteem and desire to have children.




                 Contact :
                 Dr. Agnes Binagwaho
                 Executive Secretary, CNLS
                 cnls@rwanda1.com

                 Dr. Daniel Ngamije
                 MAP Project Coordinator, CNLS
                 dngamije@gmail.com

                 Ms. Miriam Schneidman,
                 Senior Health Specialist
                 MAP Task Team Leader
                 Africa Region
                 The World Bank
                 mschneidman@worldbank.org