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RWANDA
Activity Data Sheet
>> AFR Regional Overview >> Rwanda Overview PROGRAM: RWANDA
TITLE & NUMBER: Increased Use of Sustainable Health Services in Target Areas, 696-002
STATUS: Continuing
FY 2001 PLANNED OBLIGATION AND FUNDING SOURCE: $6,667,000 CSD; $148,000 DA
FY 2002 PROPOSED OBLIGATION AND FUNDING SOURCE: $6,802,000 CSD; $300,000 DA
INITIAL OBLIGATION: FY 1997; ESTIMATED COMPLETION DATE: FY 2003Summary: By FY 2001, USAID's health sector interventions had transitioned from the post-genocide emergency phase where social protection is paramount to a more traditional service delivery approach. The main developmental challenges in the Rwandan health sector are the heavy burden of disease and limited access to quality health services for the population. Though major causes of illness and death have been malaria, respiratory infections, and tuberculosis, AIDS is rapidly becoming the number one killer in Rwanda. Infant and under-five mortality remain extremely high in Rwanda, even though immunization rates are still among the best in the developing world. High child and maternal mortality rates are linked to insufficient services for safe birthing in a country where less than 40% of births are assisted by a trained health worker, and 40% of women receive no pre-natal care whatsoever. While fertility rates have declined over the last 20 years, they are still high. Recent survey data indicate that 40-50% of women would end or delay childbearing if they could.
The purpose of this strategic objective is to increase the utilization of quality primary health care (PHC) and sustainable health services in target areas, and contribute to increased stability and strengthened development capacity. USAID's strategic objective is the primary conduit for the achievement of the U.S. goal which seeks to increase the use of health services related to preventable diseases, especially HIV/AIDS, and increase availability of information related to reproductive health and child spacing. In FY 2001, USAID will use Child Survival and Diseases (CSD) funding as follows: HIV/AIDS funds ($4,652,000) will improve treatment of sexually transmitted infections (STIs) and build awareness to combat HIV/AIDS, and strengthen information management and research work in the Ministry of Health (MOH); Child Survival funds ($1,217,000) will improve the quality of primary health services, strengthen local capacity to train health workers, and increase the sustainability of health services; Child Survival funds ($50,000) will be used for polio vaccination; Vulnerable Children funds ($499,000) will protect vulnerable children and orphans from HIV/AIDS; and Infectious Disease funds ($299,000) will be used to help combat the spread of infectious diseases with a focus on malaria and tuberculosis. Development Assistance (DA) resources ($148,000) will be used to fund the start-up of a family planning and reproductive health program to provide quality services to couples wishing to space or limit the number of children. The program will be designed to be culturally acceptable within the context of post-genocide Rwanda. More than one-half of the Rwandan population live in USAID's target areas. Other program beneficiaries include unaccompanied or orphaned children and their foster families.
Family planning agreements under this notification will incorporate clauses that implement the President's recent directive reinstating the Mexico City Policy.
Key Results: In the current non-emergency phase of its health sector assistance, USAID's main impact has been improvement in the quality of health and social welfare services in its target areas through better clinical practices, establishment of community-based education and communication networks, improved referral systems, technical training, and innovative STIs and HIV communication interventions. In addition, Government of Rwanda (GOR) policy and decision-making is now being favorably influenced by quality data collected from USAID-financed surveys and other data gathering activities.
Despite these positive developments, the data emerging from the recently completed Demographic and Health Survey and the Behavior Surveillance Survey present a sobering picture, particularly with respect to the population's knowledge of STIs and HIV/AIDS. Although there is greater awareness of STI/HIV/AIDS in USAID-targeted areas compared to other regions, the levels of knowledge and behavior change reported are less than expected. For example, a much lesser percentage of boys and girls aged 15-19 than anticipated know of two or more means to protect against HIV. Only 20% of boys and 15% of girls reported using a condom in their last high-risk sex act. Similarly, knowledge of STIs appears to be uniformly low, with 20% of women not aware of the existence of STIs and in some regions 45% having no knowledge of signs or symptoms.
Performance and Prospects: Despite an increased financial commitment to the social sector as part of its poverty reduction strategy, the GOR is looking to the population to support a greater share of health sector costs through various local payment approaches. Using CSD funding, USAID funded a pilot pre-payment program designed to develop and test locally based cost sharing models. Over the course of one year more than 70,000 people subscribed, providing valuable "lessons learned" to the GOR's cost recovery policy and strategy. This pilot is the main factor in stimulating the broad interest in the development of such cost sharing schemes throughout Rwanda. Although the pilot activity has ended, USAID will work closely with the MOH to help guide the growth of privately funded services through MOH health facilities, and will focus on the link between service quality and community willingness to pay.
CSD funds have also been used to assist the MOH to improve its financial management and budgeting procedures through the provision of accounting expertise. For example, the MOH's multitude of bank accounts has been reconciled and the ministry's senior staff now holds regular budget and planning meetings to track progress in improving accountability and resource management. These achievements have attracted the attention of other parts of the GOR, including the Office of the Auditor General, and the MOH is eager to continue this activity, particularly within the context of the GOR's fiscal and management decentralization focus. There are plans for follow-on activities that will help to strengthen regional and district management of health services.
The largest segment of USAID's health portfolio is helping to provide quality primary health care and STI/HIV services. A key element of this assistance is focused on the design, planning, implementation and monitoring necessary for the integration and provision of STI/HIV services within existing primary health care delivery systems in target areas. Specifically, CSD funds have been used to train health workers in STI management in health centers in four out of five target areas, and to provide technical guidance to regional and district health teams in the supervision of these services. USAID has also assisted these target areas to execute annual block grants for locally planned HIV/AIDS prevention activities, and trained roughly 200 health workers in basic HIV counseling. Additional CSD funds will enable USAID to extend its STI/HIV/AIDS prevention efforts to the under-served Kibuye region. Moreover, the number of HIV voluntary counseling and testing centers operating in Rwanda is expanding: three centers offering rapid on-the-spot testing services were established in FY 2000; 20 additional centers will be established in 2001.
USAID will use DA funds to assist the MOH in updating policies and protocols for priority services such as prenatal care, safe motherhood issues, maternal and child nutrition, and mother-to-child transmission of HIV. USAID plans to coordinate this intervention closely with other donors, particularly in areas of clinical standards, family planning and contraceptive supply. A meaningful intervention will require a substantial increase in DA funds in FY 2002.
CSD funds, including Education for Development and Democracy Initiative resources, are being used to revitalize the National University of Rwanda's School of Public Health through partnerships with U.S. and African universities. Already 200 MOH staff in district health teams has completed the first round of in-service training on quality of care issues. Additional modules will cover topics to provide a broad background in public health management at the district level.
A strong community focus on information, education and communication (IEC) is an integral part of USAID's STI/HIV prevention and control activity. This IEC component will complement and enhance improved clinical services by promoting prompt treatment of STIs, partner notification and treatment, and mass media campaigns. Other activities through the network of Protestant churches in Rwanda strengthen HIV/AIDS prevention and provide support for affected families. The Catholic Diocese of Kigali has also requested help from USAID in educating its leadership about AIDS and compassionate care for infected people. The current focus of IEC work is materials development and distribution, establishing effective activities with people infected with HIV, and building capacity with local partners including MOH districts through joint IEC programs and sub-agreements. In addition, USAID funded a number of activities connected with World AIDS Day and a recent series of radio and television programs including a "National Town Meeting" that provided high visibility for HIV/AIDS issues.
Funding from the Displaced Children's and Orphan's Fund is enabling USAID to support community-based interventions focused on re-integration of marginalized and vulnerable youth and women. These activities, which are supplemented by a USAID Bureau for Humanitarian Response grant focused on nutrition and safe motherhood, strengthen the linkage between health providers and vulnerable populations, enabling greater access to needed health care.
Possible Adjustment to Plans: None anticipated.
Other Donor Programs: USAID and the World Bank collaborate with the MOH to decentralize and improve STI/HIV services nationally. USAID works with the MOH to implement its national health policy and action plans, and with the Ministry of Local Government and Social Affairs to strengthen coordination, develop policy and build a community capacity for the care and protection of children. USAID continues to assist the MOH to actively coordinate donor interventions in the health sector. Besides USAID, Belgium is the other leading bilateral donor to the Rwandan health sector. Considerable support is also provided through various United Nations agencies.
Principal Contractors, Grantees or Agencies: International non-governmental organizations: University of North Carolina, INTRAH (PRIME II), World Relief, Family Health International, Quality Assurance, Population Services International; contractors: Abt Associates, and Johns Hopkins University; and cooperating sponsor, Catholic Relief Services (CRS).
FY 2002 Performance Tables
Performance Measures:
Indicator FY97 (Actual) FY98 (Actual) FY99 (Actual) FY00 (Actual) FY00 (Plan) FY01 (Plan) FY02 (Plan) Indicator 1: Percentage of youth reporting condom in most recent sex act with non-regular and non-commercial partner - male NA 42 NA 19.6 50 NA 35 Indicator 2: Percentage of youth citing at least two effective means of protecting themselves from HIV infection - male NA NA 90 59.5 NA NA 75 Indicator 3: Percentage of target group citing at least three effective means of protecting themselves from HIV infection - female NA NA 82 55.7 NA NA 71 Indicator 4: Percentage of youth reporting condom in most recent sex act with non-regular and non-commercial partner - female NA 27 NA 15.2 35 NA 26 Indicator 5: Percentage of population enrolled in pre-payment schemes NA NA 0 6.4 40 20 35 Indicator 6: Percentage of health centers meeting functional requirements (as defined by established criteria) in STI service delivery in target areas 67 NA 84 NA 90 95 NA Indicator Information:
Indicator Level (S) or (IR) Unit of Measure Source Indicator Description Indicator 1: IR Percent - men BSS Survey Numerator: Number of persons reporting condom use during most recent sex act with non-regular and non-commercial sex partner. Denominator: Number of persons in target group (youth age 15-19) interviewed. Data for 1998 not directly comparable with BSS data reported for 2000. Indicator 2: IR Percent - male BSS Survey Numerator: Number of persons from target group correctly citing at least two effective means (primary sexual prevention methods: abstinence, using condoms, and mutual monogamy) of protecting themselves from HIV infection through prompted questions. Someone giving fewer than two methods is not included in the numerator. Denominator: All respondents surveyed from target group regardless of whether they have heard of AIDS or not. Data cited for 1999 was proxy. BSS results are reported for 2000 and focus on youth age 15-19 and refer to two effective means of protection. Data will be gathered every two years and proxy data will be used in off years. Indicator 3: IR Percent - female BSS Survey Numerator: Number of persons from target group correctly citing at least two effective means (primary sexual prevention methods: abstinence, using condoms, and mutual monogamy) of protecting themselves from HIV infection through prompted questions. Someone giving fewer than two methods is not included in the numerator. Denominator: All respondents surveyed from target group regardless of whether they have heard of AIDS or not. Data cited for 1999 was proxy. BSS results are reported for 2000 and focus on youth age 15-19 and refer to two effective means of protection. Data will be gathered every two years and proxy data will be used in off years. Indicator 4: IR Percent - female BSS Survey Numerator: Number of persons reporting condom use during most recent sex act with non-regular and non-commercial sex partner. Denominator: Number of persons in target group (youth age 15-19) interviewed. Data for 1998 not directly comparable with BSS data reported for 2000. Indicator 5: IR Percent PHR Percentage of target population (for current purposes the PHR target population can be used and eventually, when pre-payment activities are scaled up the total population's participation can be reported) enrolled in pre-payment schemes. Indicator 6: IR Percent Situational Analysis, STI service quality tool (MOST) Numerator: Number of health centers in target areas which meet predetermined, internationally accepted functional criteria in STI service delivery. Functional criteria are grouped as follows: Infrastructure, Equipment (including materials and aids such as the STI treatment algorithm and condoms), and laboratory facilities. Drugs are not included in the evaluation criteria at this point. Denominator: Total number of health centers. Data not collected for 2000.
U.S. Financing
(In thousands of dollars)
Obligations Expenditures Unliquidated Through September 30, 1999 3,464 DA 2,710 DA 754 DA 9,295 CSD 2,625 CSD 6,670 CSD 0 ESF 0 ESF 0 ESF 0 SEED 0 SEED 0 SEED 0 FSA 0 FSA 0 FSA 8,114 DFA 5,963 DFA 2,151 DFA Fiscal Year 2000 0 DA 585 DA 6,950 CSD 548 CSD 0 ESF 0 ESF 0 SEED 0 SEED 0 FSA 0 FSA 1,000 DFA 1,352 DFA Through September 30, 2000 3,464 DA 3,295 DA 169 DA 16,245 CSD 3,173 CSD 13,072 CSD 0 ESF 0 ESF 0 ESF 0 SEED 0 SEED 0 SEED 0 FSA 0 FSA 0 FSA 9,114 DFA 7,315 DFA 1,799 DFA Prior Year Unobligated Funds 0 DA 0 CSD 0 ESF 0 SEED 0 FSA 0 DFA Planned Fiscal Year 2001 NOA 148 DA 6,667 CSD 0 ESF 0 SEED 0 FSA 0 DFA Total Planned Fiscal Year 2001 148 DA 6,667 CSD 0 ESF 0 SEED 0 FSA 0 DFA Future Obligations Est. Total Cost Proposed Fiscal Year 2002 NOA 300 DA 0 DA 3,912 DA 6,802 CSD 0 CSD 29,714 CSD 0 ESF 0 ESF 0 ESF 0 SEED 0 SEED 0 SEED 0 FSA 0 FSA 0 FSA 0 DFA 0 DFA 9,114 DFA
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Last Updated on: May 29, 2002 |
