40652 HIV/AIDS in Africa- Getting Results World Bank Global HIV/AIDS Program These reports describe activities, challenges and lessons learned during the World Bank's HI/AIDS work with countries and other partners. and ACTAfrica Rwanda MAP ­ empowering communities, harmonizing approaches This note provides a snapshot of the range of HIV and AIDS Beneficiaries report tremendous satisfaction with the services funded through the Rwanda MAP project, and how MAP approach which empowers them to find their own this project has changed lives and contributed to health solutions, channels funds directly to them, and holds systems development. them accountable for results. This highly participatory When the project was prepared in 2002, Rwanda was approach has fostered innovation in service delivery and classified among the ten countries most severely affected by contributed to strengthening social capital through HIV. The country had recently emerged from a genocide/war widespread use of solidarity mechanisms. The impact of and faced severe capacity constraints and human resources these activities often has been dramatic. Numerous shortages. Life-saving anti-retroviral therapy was available in a beneficiaries have reported on how a small amount of few urban facilities to those who could afford to pay. The money has gone a long way in assisting infected people Government requested assistance through the Africa Multi- to get back on their feet and providing alternative Country HIV/AIDS Program, and benefited from the IDA sources of livelihood for the vulnerable. HIV messages deputies' decision to provide grants for HIV for a limited time. have been effectively combined with poverty reduction Under the Government's leadership, performance has been strategies, and measures to enhance sustainability have consistently strong, with all project targets met or surpassed. increasingly been built into the design. The The US$30.5 million grant disbursed in three years, two years accomplishments of civil society organizations and the ahead of schedule. Results include: (i) voluntary counseling consistently high rate of fund disbursements reflect the and testing provided to nearly half a million persons, (ii) 12 program's success in providing services to targeted million condoms distributed; (iii) over 5,000 patients on life- populations, and its successful capacity building efforts. saving antiretroviral therapy; (iv) financial assistance for school fees provided to 27,000 orphans and vulnerable children; (v) Capacity to plan, implement and monitor projects has access to community health insurance subsidized for over been enhanced at all levels, and local groups have 52,000 households ­ reaching about a quarter million people; demonstrated their ability to manage funds effectively and (vi) about 100,000 people participating in income and transparently. generating activities. Personal testimonials confirm the positive impact on the lives of average Rwandans who live on less than US$0.70 per day. New Sources of Livelihood for Vulnerable Women Affected by HIV MAP community grants for HIV Turwanye Ubukene Association: Let's Fight Poverty initiatives Rwanda's MAP has an effective mechanism for channeling funds to civil society groups, which have received nearly half of the MAP project funds. A wide range of eligible organizations (NGOs and Community Development Commissions) were screened, accredited and recruited to assist smaller associations to prepare sub-projects and access MAP funds. In total, over 100 civil society organizations received MAP funding nationwide to provide a full range of preventive, medical and support services for people living with HIV. These activities were funded on a `demand driven' basis and reflect the needs of the community and civil society groups. Turwanye Ubukene Association members Women widowed or orphaned by the genocide or AIDS cycle of poverty and what can be learned from their have come together to find common solutions and break experience? There are several important lessons. the cycle of poverty and AIDS. Their stories are strikingly similar. They have shown determination and resilience which Saumura Tioulong, a Cambodian MP who Social Mobilization participated in a parliamentary visit to Rwanda in 2006 The first lesson is that local champions can make a characterized as a "phoenix emerging from its ashes". difference in mobilizing people. In the district that used to She echoed the views of the other 15 parliamentarians be known as Kanombe, authorities were proactive in who were all impressed with the work of the Turwanye working with these vulnerable women to start their Ubukene Association and their passion for living. income generating projects and to modify their sexual behaviour. It was a win-win proposition: the district authorities had an opportunity to tackle a major social problem; the women had the chance of an alternative livelihood. The deputy mayor in charge of social welfare on the district HIV/AIDS commission became personally engaged in the program design, demonstrating strong leadership and empathy. The two groups show how the public sector can work effectively with civil society groups to mount a successful intervention which has a real impact on the day-to-day lives of poor women. In late 2004, 150 women from all corners of the district responded to the initial call for interest in participating. Within two years, membership had grown to 350, with more women joining regularly, inspired by the success of their neighbours, friends and co-workers. District leaders ­ including the Deputy Mayor of Kanombe at the time ­ worked with women members of the Turwanye AIDS and Poverty Ubukene Association to start income-generating projects. The second key lesson is that preventive measures are One young woman explains how her life has changed as insufficient unless accompanied by mitigation actions. In a result of the new opportunities the Rwanda MAP offers a relatively short time, the program managed to provide to vulnerable women. Epiphanie used to engage in sex an alternative way to earn a living, with beneficiaries now work, like many of others who scramble to make a living receiving monthly salaries of RwF10000 (roughly in the crowded, poor and highly transient neighbourhood US$20). Many of the more entrepreneurial women have on the outskirts of Kigali. Sex work was not sustainable also accessed funds from local cooperative banks and and not a dignified way to earn a living. The Turwanye set up additional small scale businesses. Several Ubukene Association gave her "access to the right programs have built in elements of self sufficiency. For channels". Authorities helped her and her co-workers to example, association members have used the income organize themselves into an association of former sex generated through the hygiene and environmental workers, and to design their own income generating protection project to buy a tract of land for their various activities. Now she engages in a productive trade, has a activities and a truck for transporting solid waste stable source of income, and most importantly, has collected from households. The goat rearing project is regained her self esteem and desire to have children. another good example of self sufficiency and solidarity being incorporated into the design. Each member of the Emmaculette has five children and is landless. When her association in turn will take care of the goats, and will be husband died, she tried to start a small business, but her able to keep at least one kid for herself, which will success was limited. When district authorities put out a encourage individual entrepreneurship and provide a call to interested women, Emmaculette responded stable source of income. eagerly. She and many of her friends now claim to be `born again' as a result of what is perceived to be a successful project that is providing women with a stable The Turwanye source of income. The association now pays her Ubukene children's school fees and materials and their local Association's community health insurance scheme (mutuelle) goat rearing premium. Nineteen year old Faida explains that her project family disowned her when she engaged in sex work. She now has regained their confidence as she participates in a vocational training scheme supported by the association. How did these women manage to break the 2 MAP support has means of maintaining a decent standard of living". They changed many lives. experienced `"discrimination, social isolation, and fear for Turwanye Ubukene their future". Association members like this young woman say: Acquiring Skills "We feel the impact because we are no longer After a nine-month MAP-financed training program, the excluded from society". majority of these youths have acquired new tailoring skills. At graduation, they were given sewing machines and assisted to form an association, in an effort to foster self reliance. They successfully negotiated a contract to produce school uniforms for their district. These recent Empowerment of Women graduates say they now earn a stable income and can afford to buy food, soap, and clothes, and are members A third lesson worth highlighting is that empowering of the community health insurance scheme. They also women has multiple benefits for the whole family'. At the report a marked improvement in their self esteem, as outset, many of the children of these destitute women they gain the respect of their peers and community did not attend school or have access to health care. members. Their association has opened a local bank Membership in the Turwanye Ubukene association has account to collectively save part of their income to enabled the women to enrol their children in school (with reinvest in their business. school materials provided) and to receive health care through membership in the mutuelles. HIV AIDS Messages On-going Challenges The project has successfully combined information about HIV and AIDS, reproductive health and life skills with the The program's initial success has motivated and inspired income generating activities. Many of the youths reach others to emulate this example, but it is probably still out to other orphans and marginalized children in their early to claim success and a word of guarded caution is communities to raise awareness about the risk of HIV warranted. Behavioral change takes time and will hinge and how to protect themselves. on continued and sustained success of these income generating activities. Program managers know that these women remain highly vulnerable and could easily Strong Impact on the Lives of the Vulnerable get disillusioned and resume their former line of work. Three young women trainee's stories ring a common Hence, these women need on-going support from their note. Jeanne d'Arc says: local leaders and program managers as they face new hurdles and challenges. The original leaders of this "Prior to coming in the tailoring school project, my life initiative are in the process of replicating this successful was fixed in a dilemma because I did not have any hope experience nationwide. These Kanombe champions are to live a happy life as I was a complete orphan. But now not deterred by the enormous challenge of scaling up. the mental skills I acquired from the tailoring school They are highly motivated and inspired by their initial have helped me to earn some daily income... my life has success and determined to enable other Rwandan changed and improved." women to escape the AIDS/poverty trap. Kibungo Vocational Training: Assistance for Orphans and Vulnerable Children The 1994 Rwanda genocide left a generation of orphans and vulnerable children who are exposed to child labor, sexual abuse, delinquency, and HIV. Many lost their parents and struggle to meet basic needs. In this context, the Kibungo vocational training school was established in a densely populated border area in the Eastern Province with high unemployment and deep- seated poverty. The Kibungo training school started with about 40 young beneficiaries from single parent or child- headed households. The beneficiaries explain that The Kibungo vocational training school provided this young before the school opened, "vulnerable children and woman with new skills and a sewing machine, and much better orphans were living a miserable life and had no reliable life chances. 3 Ernestine says she was: "living a miserable life as a peasant farmer, and during Social mobilization was done through various channels, the drought period cultivation came to a stand still ... I including anti-AIDS clubs, and sports and cultural remained redundant without any alternative". activities which were a very popular way to reach this As a result of the program she had the "chance to learn target group. The Council trained a total of 230 peer and acquire new skills". Sonia adds that in addition to educators in behavioral change communication and the new skills she has learned, she is now able to carried out activities in over half the provinces. "interact with people of different backgrounds and exchange ideas on development issues". Second, they designed a simple voucher system which enables youths to go to local health facilities on Key Lessons and Challenges designated days, minimizing waiting times. Facilities are According to program managers and beneficiaries, the reimbursed for these services using MAP funds. This main lessons from this program relate to the importance innovative approach has two main benefits. It is cost of (i) establishing solidarity mechanisms by bringing effective: the $2 per person cost is only a fraction of vulnerable children together to find solutions to their what it would cost (US$10) to reach these youths problems and design their own interventions; (ii) through mobile units. And it enhances the returns on enabling beneficiaries to be role models for behavioral investments in facility-based VCT services which were change; and (iii) tackling the underlying causes of AIDS, funded through a Global Fund grant. A snapshot of namely poverty and vulnerability. The success of the results at the end of the initial four months was program has generated new challenges: mounting costs impressive: 120,000 youths were reached through the of materials, space constraints, and growing demand for massive mobilization efforts, and nearly 70,000 were the program, and some prospective students have tested. About 6 percent tested HIV positive. traveled long distances to participate and require special assistance (e.g. food). Ultimately, the success of this Modifying Behavior initiative will hinge on behavioral change and sustaining the new business endeavors. Rwanda National Youth Council The National Youth Council campaign ­ An Innovative Voucher Program for persuaded Nicolas Expanding HIV Testing Niyonsaba to take an HV test and made him Enabling people to learn their HIV status is a first critical aware of how to protect step in changing behavior. The Rwanda National Youth himself and his wife Council (CNJR) has devised an innovative voucher from HIV infection system for expanding access to HIV testing for youths (10-24), who represent close to 40 percent of the population. Program designers used a two-prong approach. First, they mobilized all key stakeholders (i.e. youths, health staff, and local youth leaders) and raised awareness of the need to know one's HIV status, the importance of using condoms, and the existence of local During the National Youth Council campaign, 29-year services. old Nicolas Niyonsaba, who was to be married soon, was encouraged to be tested, which revealed his negative status. "Before the National Youth Council campaign under MAP financing, I had neither an idea nor much knowledge about VCT. I have now dropped all previous prejudices," he says. "I was able to prompt my partner to be tested before we married and now we live Young man at a Butare Youth a happy life together, knowledgeable of our HIV status. I Center have learned the importance of being faithful," Nicolas says that increased HIV awareness has also changed his views about condom use from "shame to pride". Moreover, Nicolas now hopes to serve as a role model and help others, saying: "I have successfully mobilized 4 peers to help the infected people in my area, including validity of this approach was demonstrated by the quick using holidays to build houses for those who lack basic results achieved -- large numbers of youth were reached accommodation." in a relatively short time. The voucher program is now Tackling Stigma and Discrimination being considered as a model for testing other groups. Twenty-six year old Madine Kayitesi was an initiator of an anti-AIDS secondary school club. "I always feared The beneficiaries note three principal lessons: HIV testing, for five years I remained at the level of slogans," she says. When Madine adopted a child of a · HIV testing is critical to modifying sexual behavior deceased neighbor she assumed that the child was and expanding condom use. infected. "It was really a feeling of being discriminative · Enhanced knowledge leads to greater empathy and when the child was tested and found to be negative," solidarity with people living with HIV. she acknowledges. · Awareness campaigns foster a culture of Madine summoned up the courage to be tested when responsibility, trust and faithfulness among young she was elected as a leader in the Youth Council's couples. campaign financed by the MAP. The young woman explains how her knowledge about the disease has improved, and how she now understands the importance In spite of the initial success of this initiative several of testing: important challenges persist. First, while program managers did an excellent job mobilizing health staff and "I learned strong lessons after the VCT campaign, involving them in this initiative, some VCT sites were discovering that HIV status is not reflected by mere unable to cope with the rapidly growing demand for sight but rather by testing. I have now started an these services. Second, in some cases youths had to association which does advocacy for children who are travel long distances and this proved to be an infected and affected with the scourge," Madine impediment to taking advantage of the voucher scheme. announces proudly. Finally, the post-counseling services were not always easily accessed as some youths became disillusioned and did not follow up, suggesting a need to strengthen psycho-social support for those found HIV-positive. Combining HIV Messages with Income Generating Activities ­ Examples from the City of Gisenyi Local governments have played a supportive role in disseminating HIV prevention messages and assisting local associations to access MAP funds. The mayor of Gisenyi acknowledged his appreciation for the work of the eight associations of people living with HIV, which is making a huge difference in the lives of ordinary people. Madine Kayitesi The unsung heroes of these associations are doing a remarkable job in organizing and supporting vulnerable A Moslem whose own denomination accepts polygamy, people to design their own income generating activities. Madine says that "the campaigns financed under the Gisenyi is a local tourist destination in the North of the MAP operation have empowered me to ... stand strong country, on the border with the Democratic Republic of against polygamy for my future partner and this to me Congo. The lack of employment opportunities and high shall be a condition before marriage. People can no levels of mobility left women and young girls with few longer be bound by cultural or religious denominations alternatives to prostitution. where the latter are seen as possible causes/threats to getting infected with HIV", she insists, underscoring the importance of greater individual responsibility. Associations and Income Generating Activities Local leaders organized beneficiaries into associations Lessons and Issues and made a concerted effort to raise awareness through multiple channels -- anti-AIDS clubs, cultural events and The Youth Council's large scale mobilization campaign sport tournaments. The associations benefited from and voucher program proved highly successful in reaching young people like Nicolas and Madine. The 5 MAP funding and now report enthusiastically some of Prevention their initial successes. Their stories are broadly similar. Religious leaders have been encouraged to play an The Tuvugibyayo Association, which supports about 50 increasingly important role in responding to AIDS which men and women, reports that at the outset members deeply affects their parish members. They are role were in a "desperate state". Today, they practice various models for their constituencies in speaking regularly small scale commercial activities and are fruitfully about HIV and AIDS, urging parish members to get employed. Buying `conteneurs" -- small makeshift stores, tested, and encouraging fidelity. The FBO network has which are then rented out to prospective vendors, turned helped to strengthen capacities of members. out to be highly remunerative. Part of the rental income generated by beneficiaries has been used to set up a small credit scheme through which they extend financial Stigma & Discrimination support to other association members. The modest The culture of acceptance and solidarity that FBOs loans need to be paid back within three months, freeing encourage helps fight stigma and discrimination. up resources to be lent to the next group. Religious leaders organize monthly collections to assist One association member remarks how the income- vulnerable parish members (photo below) and provide generating activities have "helped them to feed their spiritual support to those living with the illness. The FBO families". Another member explains that the scheme has network estimates that these activities occur in about 70 also reduced stigma and discrimination. "In the future we percent of churches and mosques nationwide. will no longer be called People living with HIV/AIDS because our situation continues to improve daily." Association members have also developed solidarity The AGAPE Association is a faith-based association created mechanisms through which each contributes to financing in 2001 under the auspices of the Evangelical Restoration home visits for people who are ill and bedridden. Church, to provide holistic support to those who teeter on the fringes of life and face numerous risks, including HIV. Program Membership in the association offers the benefit of administrators note that the rapidly growing town of access to new sources of livelihood, as well as social Rwamagana where they are based faces many challenges as and psycho-social support of peers. a result of the legacy of the genocide which left scores of orphans, widows and rape victims. The 500-member Demand for HIV Testing association of 175 adults and 325 orphans and vulnerable children has used their MAP grant of about US$9,000 to Health providers in Gisenyi say there has been rapid support the children, start income generating activities, offer growth in demand for HIV testing, which they attribute in home based care, and to access community health insurance. large part to the social mobilization activities of the various associations. They note that individuals became particularly keen to be tested so that they could become Orphans and Children Affected by AIDS members of the associations and benefit from the Although the total number of children reached income generating activities. The number of people nationwide remains modest in relation to those in need, tested rose from about 400 in 2004 to 1000 in 2005 and FBOs have proven effective at identifying those in need, close to 3,000 by end 2006. channeling funds to them, and monitoring the use of funds and the results attained. FBOs aim to provide holistic care. Roughly 12,200 children have received National Faith-Based Organizations support to enroll in health insurance schemes, about Network Against HIV/AIDS in Rwanda 5,000 children have benefited from food aid, secondary school fees paid for about 8,600 children, roughly 90 young people have benefited from vocational training, Faith-based organizations (FBOs) historically have and more than 2,200 have received various other forms played an important role in the HIV/AIDS response in of support. Rwanda. They have provided important financial, spiritual and moral support to those affected or infected by this impoverishing illness. In recent years, FBOs have Faith-based expanded the range and scope of their activities and organizations better structured their support through a coordinating are doing a great body which is currently funded primarily through the deal to care for Rwanda MAP. The FBOs reach virtually all Rwandans -- and help Muslims, Protestants, Evangelicals, Episcopalians and orphaned Catholics -- through their nationwide networks of children churches, mosques, dioceses and parishes. The FBO network has played a pivotal role in mobilizing religious leaders and in guiding and coordinating investments. 6 At the Shakina Primary School, founded by the AGAPE counted on me. I was compelled to discontinue my association, Macrine's eyes fill with tears as she explains primary school studies at form 4 level and take the her situation. responsibility to sustain the family. I sacrified myself for my siblings's feeding and .. now the Almighty God has used MAP/Restoration Church through AGAPE Association to restore my lost hope". "My mother is ever in sickbed and my father has died. MAP is covering all my studies. I am afraid when it stops it will be the end of my studies". (Macrine) Income Generating Activities Several religious groups serve as umbrella organizations for the MAP, helping smaller associations and community-based organizations access funds and Sylvie, in the Freedom in the Sun International Center. develop income generating projects. Religious groups tend to have close ties to community members, and the trust, respect and compassion they have are great Treatment assets for reaching out to vulnerable people. FBOs were Health facilities run by religious missions (that administer among the first to assist those affected by AIDS and to roughly 40 percent of the health network in Rwanda) organize them into associations. These associations have played a key role in expanding access to a full have served as forums of solidarity as well as effective range of HIV-related services, including HIV testing, mechanisms for joint income generating activities. A full preventing mother to child transmission, and range of income generating activities has been antiretroviral therapy. These services are provided in an supported, such as: (i) vocational training (e.g. plumbing, atmosphere of confidence and trust and in a spirit of woodwork, mechanics, sawing); (ii) small scale compassion and with moral support. Many of these commerce (e.g. food, drinks, animal husbandry, clinical services are linked to community-based support, fisheries); and (iii) service activities (e.g. taxis, bikes). giving patients access to an integrated package of FBOs aim to ensure that these income generating services which is essential for AIDS patients. Nearly half activities benefit all association members to promote of the MAP-supported treatment sites (i.e. Gikonko, `unity, equity, transparency and compassion'. The Gakoma, Kiziguro, Gahini, Mibilizi, Kibogora) are run by network estimates that 80,000 people have benefited religious missions, as described below. from these activities through 600 sub-projects, of which over 70 percent have been funded through the MAP A Mother's Story operation. Gloriose Murebwayire's story is a source of inspiration to other women in similar predicaments. Gloriose has gone Restoring Hope from denial to acceptance and has assumed At the AGAPE association in Rwamagana, 24-year old responsibility for herself and her son. Sylvie describes how she acquired new tailoring skills at "My son Oliver was born HIV positive. My husband died the Freedom in the Sun International Center. in 1996 and I was not aware it was from AIDS. I always "After my father was killed in the 1994 genocide and my feared to get tested. That changed in 2004 when I was mother was handicaped, it was as if the bridge to cross sensitized by the pastor from the MAP-sponsored for my future was cut down. I was the first born and still AGAPE Association." too young to care for my two younger siblings who 7 The 34-year old woman adds that "it was too hard · Faith based organizations have a comparative accepting I was positive even though I felt unhealthy advantage in working with vulnerable people. and my child was ever sickly". The counseling They are often close to the beneficiaries and have a sessions of the association helped her come to grips good understanding of their situations, and tend to with her status and seek care. Gloriose and Oliver are treat them with respect and compassion. FBOs have now on Bactrim (used to fight pneumonia in AIDS nationwide structures and channels for reaching patients with weak immune systems) and receive vulnerable people and can fairly easily add HIV nutritional support. She notes assertively, "Now who interventions to their other activities. notices that we have AIDS?" · Coordination of FBO activities through a network Pride shines in her words and face as she tells visitors organization is an effective way to expand that 10-year old "Oliver is always the first in his class activities. The `Reseau des Confessions with 95% marks. He is no longer sickly." In the Religieuses' has proved to be an effective structure absence of the government's widely available treatment for guiding investments, coordinating and monitoring program, Oliver's young life might not have been spared. activities, and minimizing duplication. Plans are underway to further strengthen coordination by having a single consolidated plan of activities covering all denominations, and one monitoring and evaluation system. · Intensifying links between HIV interventions and poverty reduction. Many people infected or affected by HIV live in dire poverty. Given the impoverishing nature of the illness, the non-medical aspects of this disease, such as food security, need greater attention. · Flexibility in the use of MAP funds has allowed innovation. The MAP approach of encouraging stakeholders to identify their own solutions and design their own program encourages innovative responses and ownership of the intervention. Gloriose and her son, Oliver Gloriose, like other association members, benefits from Scaling up and Decentralizing Access to income generating activities which increasingly are building in measures to enhance sustainability. "I am a Life Saving Anti-Retroviral Therapy beneficiary of the rotating loan scheme. I have a -- a Pro-poor Focus small business to sustain my family," she says. Gloriose reports that she was able to save money in the The World Bank was one of the first donors to support a local bank, supplement the school materials paid for by major scale up of antiretroviral therapy (ART) in the project, buy community health insurance and provide Rwanda. The program has a strong pro-poor focus, a healthy diet to her family. "MAP is saving the life of targeting three underserved provinces. Two-thirds of the thousands of people infected and affected by beneficiaries are women, who are disproportionately HIV/AIDS", Gloriose says. affected by HIV. A growing number of children have been enrolled as the government has increasingly focused on pediatric care. ART has prolonged lives and Main Lessons improved quality of life for people on the margin who The program managers list five key lessons stemming might have otherwise succumbed to HIV-related illness. from the wide range of MAP activities supported by faith- It has also enhanced capacities at rural health facilities based groups: that serve 2 million people in some of the most remote · The commitment and engagement of religious and destitute provinces in the country. leaders in the fight against HIV/AIDS is critical. The network of faith-based organizations has proven A Harmonized Approach to be an effective mechanism for mobilizing religious The success of these activities is largely due to the leaders to be advocates and role models. AIDS, harmonized approach promoted by the government. previously seen as a punishment from God and a Rwanda's early commitment to providing treatment taboo topic, is slowly being demystified. helped rally partners and mobilize resources. Authorities developed a treatment plan with the support of the 8 Clinton Foundation and introduced a user fee policy with The MAP program is now being decentralized to an a sliding scale. Most Rwandans receive free care as additional 18 health centers which will shorten travel they live below the poverty line. Under the government's time for patients and lower costs to the system. Overall, leadership, the Bank developed strong partnerships with Rwanda has made excellent progress in expanding the Clinton Foundation, Global Fund, and US treatment with roughly 32,000 patients on ART at 130 Government/PEPFAR to design, implement and monitor sites nationwide, which represents well over 50 percent the treatment program. of those who need care (i.e. those at an advanced stage of the disease) in contrast to 870 patients at seven sites Strong Partnerships at the end of 2002. The Bank recruited the US Centers for Disease Control and Prevention (CDC) to do a baseline assessment and Saving Lives propose alternative models of care for MAP-supported The impact of this massive scale up on people's lives facilities. The analysis was done in close collaboration has been remarkable. Edouard, a 36-year old man, was with the Treatment and Research Center on AIDS of the bedridden and needed to be cared for by his HIV- Rwanda Ministry of Health, which promoted ownership positive wife. When he arrived at the MAP-sponsored and assured continuity in implementation and oversight. Butare Hospital he weighed just 35 kilos. He had Criteria to assess and accredit sites were developed and previously been treated for meningitis, TB, pneumonia used to support the national scale up. The district and other infections. hospital model developed for the MAP inspired the scale up of the Global Fund and USG/PEPFAR-supported Following the initiation of ARV therapy, his weight rose sites and the experience of these partners, in turn, to 56 kilos and his CD4 count jumped to about 650. benefited the MAP sites. Harmonization of strategies Edouard was able to take advantage of the and instruments has been critical to the success of the government's highly subsidized services -- like most scale up. The strong partnership with CDC has resulted other Rwandans participating in the program, his low in an additional US$4.0 million for MAP-related activities earnings of just US$.70 per day qualify him for free care. and technical backstopping on laboratory monitoring. Edouard's health improved and he was able to return to the fields and to start growing food for his family once again. His wife, who had recently given birth, was Solid Performance referred to the ART program to determine whether she Performance of MAP sites has been solid. In less than 3 needs treatment. years over 5,000 patients have been placed on ART in comparison to a MAP appraisal target of 2,350 (figure below). Only 3 percent are lost to follow up and virtually In the words of one of the nurses at the Butare Hospital, all patients are on cost effective first drug regimens. The "The availability of life saving ARV drugs is providing capacity to diagnose, treat and follow up AIDS patients hope to people who are desperately ill, and also is has been established at 12 district hospitals and 1 health leading to greater acceptance of people living with center. These upgraded facilities have also strengthened HIV/AIDS ­ you can see the reduction in stigma their capacity to provide non-AIDS care, as most associated with expanded access to ARV therapy." benefited from laboratory upgrading, renovations, logistical support, and additional human resources. Decreased stigma is reflected in lower numbers of patients reporting abusive behavior by community Cumulative number of people on ARV at members, greater willingness to talk openly about their MAP sites HIV status, and increased demand for HIV testing. 6000 5000 Service Delivery Innovations 5000 Innovations in service delivery and management of 4000 drugs and human resources have benefited both 3093 3000 individual patients and the health system. Three notable examples are worthwhile highlighting. 2000 948 1000 Basket Funding of Drugs Coordinated, basket funding of ARV drugs using the national procurement system 0 has generated important cost savings, promoted 2004 2005 2006 standardized drug regimens, and enhanced planning and forecasting skills. Under this arrangement, the Bank Source: Rwanda Ministry of Health and Global Fund finance generic drugs and the USG/PEPFAR pays for brand name drugs. Collaboration with the Clinton Foundation has helped 9 lower the prices paid for drugs and diagnostics, and payments have increased the incomes of personnel and enabled the Rwanda MAP to pay for far more people on participating sites were able to invest part of the ART than originally planned. additional revenues in their facilities. The administrator Rapid Information System The TRACNet system uses of the Nyanza Hospital reports that absenteeism mobile phones to transmit information. It provides declined as staff became increasingly motivated. As part managers with up-to-date information on patient and of the national policy the government has decided to program outcomes (i.e., numbers of patients on ARV condition future payments for HIV services on treatment, drugs dispensed, etc). It was funded by improvements in the quality of basic health services, PEPFAR and implemented nationwide, including in all showing how funding for a single disease can focus MAP-funded treatment sites. In addition to the system- attention on broader quality of care and services. An wide benefits of being able to manage and monitor the impact evaluation of this scheme is underway to assess treatment program and supplies efficiently, patients are the impact of bonus payments on the quantity and better off because the alert system built into TRACNet quality of services provided and on health outcomes. helps avoid drug shortages (which lead to interruptions in treatment and raise costs). "When someone feels empowered and their views are Performance Contracting The introduction of taken into account, this is more important to motivation performance-based contracting for HIV-related services, than the actual payments received" which was led by the MAP sites and subsequently "Performance contracting has liberated the adopted as part of the national policy and supported by entrepreneurial spirit" PEPFAR and others, has contributed to health system "Money has no color...irrespective of the source it strengthening. Service targets were set for each facility, improves incomes of health workers" and staff could earn bonus payments by meeting and exceeding the targets. It was left to staff at each facility Views of providers and program managers to find ways to increase service coverage. The performance-based contracting resulted in a rapid Hospital Grants When the contracting approach was expansion in key HIV services in a relatively short time. introduced, all MAP-funded ART facilities received small This figure shows large increases in the number of HIV grants (i.e. up to US$60,000 annually), which were used tests before and after the contracts were introduced: to tackle staff shortages and improve the overall functioning of the facility. Focus group discussions with Number of HIV Tests Performed Before and After providers revealed a high degree of satisfaction with the MAP-funded Performance-Based Contracting empowering effects of these small grants which allowed 2500 staff at MAP sites to decide on the number, profile, and payment levels of additional personnel. Providers report that the additional staff (e.g. doctors, nurses, laboratory 2000 technicians) are not assigned exclusively to HIV care and support the district hospitals more generally. Pay 1500 scales are comparable to those of existing personnel to avoid creating distortions. Financing of recurrent costs Before (e.g. maintenance of vehicles and equipment, office 1000 After materials, communications) was modest but helped with the overall running of the hospitals. These grants were 500 combined with minor refurbishing of facilities, (including new incinerators for waste management) and an important upgrading of laboratories that served not only 0CyanguguButare Cyangugu Butare Cyangugu Butare AIDS patients but others as well. Travel time was reduced for those who no longer needed to go long distances for various laboratory tests. A provider at the VCT VCT PMTCT PMTCT Couple Couple recently renovated Kiziguro Hospital run by a religious Testing Testing mission says: "MAP has assisted to improve the quality of care for both AIDS and non-AIDS patients. We are now able to Source: CORAID; Rwanda School of Public Health program data provide ARVs and medications for opportunistic infections. We no longer need to refer our patients to Performance contracting has stimulated innovations in Kigali but can perform a full range of lab services on service delivery (e.g. outreach activities to expand HIV site." testing, promotion of couple testing). The bonus 10 Solid, productive and mutually beneficial partnerships were established for monitoring the national HIV/AIDS response in Rwanda and the Bank has played a key role in this process. The MAP team plays an active role in the national monitoring and evaluation technical working group. The World Bank provides intensive technical support for the MAP and for the national response more broadly, working in close partnership with other key stakeholders (e.g. UNAIDS and USG/PEPFAR partners). How was the money spent? Technician in the upgraded laboratory at Nyagatare hospital Mitigation New Challenges Roughly 30% of the MAP funds were spent on mitigation, including: (i) income generating activities Financial sustainability The rapid scale up of combined with HIV prevention messages; (ii) school fees treatment has brought new challenges. The single most and vocational training for orphans and vulnerable important challenge is the financial sustainability of these children; and (iii) paying premiums for vulnerable people investments as the cost of ART remains beyond the to expand access to the community health insurance means of most Rwandans, and the government faces scheme (mutuelles), reaching about a quarter of a numerous trade-offs within constrained budgets. In the million poor people. These mitigation investments medium-term, the government will need to absorb the targeted people affected by HIV and other vulnerable additional personnel and recurrent costs supported by groups; thus, there has been a potentially important IDA at MAP facilities. The government has already poverty alleviation impact on beneficiary households. assumed responsibility for financing performance They have gained new sources of income, and are now contracting for basic health services at health centers able to send their children to school and seek health and will be doing the same for the district hospitals. The care, as described in the testimonials. Ministry of Health is in the process of integrating HIV care into general health services, in an effort to give Prevention greater attention to cost effectiveness and sustainability. The decentralization of HIV care also is quite advanced. Prevention activities captured about 17% of the MAP This will bring services closer to patients and help funds and were implemented by a wide range of maintain high adherence levels. institutions. The activities included: social mobilization, IEC/BCC, advocacy, condom promotion and HIV testing. Monitoring and Evaluation - a harmonized approach Rwanda HIV/AIDS Multi-Sectoral Project, Harmonized monitoring and evaluation are a key focus How was the money spent? of the Rwanda MAP. Indicators and a routine reporting 10.0 system were developed from the start. The MAP 9.0 reporting system was linked to the national HIV/AIDS 8.0 monitoring and evaluation system. The project M&E 7.0 system drew all its outcome level data from national n 6.0 surveys, ensuring that there was no duplication of effort. iolli M 5.0 The MAP routine data collection system has now been $SU 4.0 adopted by the National AIDS Control Commission 3.0 (CNLS) as the national standard to be used by all 2.0 projects to plan and report data on a quarterly basis at 1.0 the district level -- the so-called 'tronc commun' system - of reporting (i.e. main branch of a tree, from where all t ng en others originate). The "Most Significant Changes" d Care pport em an technique ­ a participatory methodology to enable ent e Ba sed CareI Prevention Mitigationcity Buildit Manag beneficiaries to analyze and record the changes that eatm HIV/ST have resulted from a project ­ was initiated under the Health Systems SuHom Projec MAP, and has now been adopted as a national model for HIV/AIDS Treral lti-Sectoral Capa preparing best practice case studies. Gen Mu 11 Capacity Building, M&E About 19% of the funds were used for institutional Rwanda MAP: Treatment and General Health support, capacity building, and M&E. The MAP played a Sector Spending pivotal role in establishing and funding the operations of the National AIDS Commission, other coordinating bodies, and supported development of the national M&E system at provincial and district levels. These investments were essential building blocks in building national capacity, particularly in the first couple of years. The MAP also financed training for beneficiaries in how to prepare, implement and monitor sub-projects and annual actions plans. Finally, the MAP co-financed the 2005 Demographic and Health Survey to enhance knowledge of the epidemic, a beneficiary assessment to measure client satisfaction, and an important impact evaluation of the performance contracting scheme. ARV and OI drugs Condoms, Reagents, Consumables Human Resources Health Response Logistical Support The health sector response absorbed slightly less than Medical & Waste Management Equipment 30% of the total funding. In parallel, the US CDC funded Civil works (upgrading) about US$1.0 million of laboratory equipment and supplies for MAP district hospitals, the introduction of the TRAC Net system at an estimated cost of US$.4 million for the MAP-supported provinces, and US$2.8 million for Operating Costs strengthening linkages between health facilities and communities and providing home based care in Butare The costs of administering this project were kept in and Cyangugu provinces. check at about US$1.9 million or roughly 6% of the total grant over the life of the project. Given the complexity of the project and the large number of beneficiary Treatment & Care: About US$3.1 million was used to organizations in the public and NGO sectors, these costs finance treatment and care for people living with AIDS. appear quite reasonable. The MAP team provided close This included: (i) ARVs and medicines for opportunistic oversight to the beneficiaries, coordinating project infections (US$2.3 million); and (ii) laboratory equipment activities and managing the funds. and reagents (US$0.8 million). Evidence of MAP oversight improving over time Home Based Care: US$2.1 million was spent on home 1000 940 based care for people affected by HIV, including psycho- 900 853 social support, nutritional support and home based kits. 785 800 700 644 Health Systems Support: Roughly US$3.1 million was 600 used in a flexible manner for general health system 500 strengthening at the MAP-supported sites, paying for: 400 344 (i) recruiting additional staff where there were shortages and/or shortcomings in specific services; (ii) financing 300 performance bonuses which raised staff incomes; (iii) 200 120 providing modest support for operating costs; (iv) 100 refurbishing facilities, including building incinerators for 0 waste management; and (v) upgrading laboratories to 2004 2005 2006 enhance their capacity to serve all patients. These investments have positive spillover effects for the health Number of supervision visits Number of planning, coordination and M & E meetings system, in comparison to the treatment and care investments where the benefits accrue primarily to AIDS patients. 12 Conclusion Even with strong support from all the partners, this Looking back at the MAP experience, Dr. Agnes young program will require sustained financial Binagwaho, Executive Secretary of the National AIDS assistance to maintain the progress made to date in Control Commission, says: containing the epidemic. The Government and partners will need to ensure that sustainable long-term financing "The MAP has shown how holistic, high quality care can is available to provide treatment to all who will eventually be provided effectively to those living in remote areas. need it, and that a concerted effort is made to continue Small amounts of money have played a catalytic role in strengthening health system capacity to provide a broad generating new economic opportunities. Start-up range of high quality care, helping the next and future funding has built institutional capacities that will be generations to remains AIDS free. sustained by government." 13 About the MAP and Rwanda HIV/AIDS Multi-Sectoral Project: The Africa Multi-Country AIDS Program (MAP) was designed to help countries intensify and expand their multi-sectoral national responses to the HIV epidemic, to dramatically increase access to HIV prevention, care, and treatment. To qualify for MAP funding, countries were asked to: (i) develop HIV-AIDS prevention, care, treatment and mitigation strategies and implementation plans through a participatory process; (ii) have a national multi-sector coordinating authority with broad stakeholder representation from public and private sector and civil society, with access to high levels of decision-making; (iii) empower and mobilize stakeholders from village to national level with funds and decision-making authority within a multi-sectoral framework; and (iv) agree to use exceptional implementation arrangements such as channeling money directly to communities and civil society organizations, and contracting services for administrative functions like financial management, procurement, monitoring and evaluation, IEC etc as needed. The Rwanda HIV/AIDS Multi-Sectoral Project was part of the second group of MAP projects, and received grant financing. The US$30.5 million grant was approved on March 31, 2003 and became effective on August 11, 2003. By the end of 2006, the grant was fully committed and almost fully disbursed. Additional financing of US$10 million was approved by the Board of Directors on February 2, 2007 to consolidate gains from the initial investments and plan for their sustainability. Specifically, the additional grant aims to: (i) reinforce prevention activities in priority sectors by consolidating voluntary counseling and testing services and strengthening condom promotion; (ii) support decentralization and integration of AIDS care and treatment in the former MAP provinces and plan for their sustainability; (iii) respond to the unmet demand from civil society groups to fund school fees and income generating activities; and (iv) put in place capacities in the newly established districts and consolidate institutional strengthening. More information on the project can be found on the World Bank website, www.worldbank.org, search within projects, using project numbers P071374 and P104189. Acknowledgments: We sincerely thank the Government of Rwanda for creating a strong enabling environment; Dr. Agnes Binagwaho, Executive Secretary, National AIDS Control Commission (CNLS) for her outstanding leadership, commitment and vision; Dr Daniel Ngamije and the staff of the Project Management Unit for their dedication and hard work; Clement Kayitare, the MAP communications Officer, for carrying out the interviews and collecting the testimonials; and the many stakeholders and partners for their collaboration and support. Our deep gratitude goes to the beneficiaries who have shared their stories and given us permission to publish them, which we hope may give courage and hope to others. For further information, or feed-back, please contact: Government of Rwanda: World Bank: Dr. Agnes Binagwaho, Executive Secretary, CNLS (for more Miriam Schneidman, Senior Health Specialist and Task Team information on the national HIV/AIDS program): Leader, World Bank (for more information on the methodology cnls@rwanda1.com for developing case studies and World Bank support for Rwanda's HIV/AIDS response): mschneidman@worldbank.org Dr. Daniel Ngamije, Project Management Unit, CNLS (for additional information on the Rwanda HIV/AIDS Multi-Sectoral Joy de Beyer, Global HIV/AIDS Program (for additional copies Project): dngamije@gmail.com of this note, or more information on the "HIV/AIDS - Getting Results" series): jdebeyer@worldbank.org www.worldbank.org/AIDS Getting Results May 30, 2007 14