As world leaders gather for the International AIDS conference, see how a program in Rwanda used strategic funding to improve the lives of former sex workers and sow the seeds of broader health improvements for Rwanda's citizens.
The World Bank has supported Rwanda in its fight against HIV/AIDS with good results
HIV/AIDS funds supported former sex workers to develop alternative ways of making a living
Performance-based financing for HIV/AIDS was piloted and later scaled up nationwide
Rwanda has achieved universal access to antiretroviral therapy and strengthened HIV prevention
KIGALI, July 22, 2012—Between 2003 and 2008, the World Bank’s Multi-Country HIV/AIDS Program (MAP) provided associations of people living with HIV/AIDS in Rwanda with grants to help them find alternative livelihoods. Many of these associations were later transformed into cooperatives with support from the government and local leaders.
As the global HIV/AIDS community gathers in Washington, D.C. for the biannual International AIDS Conference, the time is right to salute the courage of one of these groups of Rwandan women, and recognize their government’s efforts to reach out to them with HIV testing, access to health insurance, and income-generating opportunities.
In Kanombe district, on the outskirts of Kigali, Claudine looks proudly upon the results of her work—the manicured rows of trees lining the road leading to the airport. She and her friend Marceline belong to the Koranintege Cooperative, which supports former sex workers—many HIV-positive—to find work.
The cooperative succeeded in securing a lucrative landscaping contract with Kanombe district. Using a truck bought some years ago with a grant from the MAP, the women now run a profitable business, and are able to access community insurance.
“When women take control of their lives, that is the first key step towards turning the tide against AIDS,” said Charles Muvara, a soft-spoken former deputy mayor of Kanombe district. Muvara played a pivotal role in the mid-2000s, helping groups of women formerly engaged in sex work to access MAP funding.
Koranintege: “Work with vigor”
Women like Claudine were once trapped because their families rejected them; they were at risk of exploitation, abuse, and AIDS; and they were not considered suitable to marry. But as new opportunities for work and healthcare came their way they were able to find a new life, and the work continues today through cooperatives.
“We did not lose hope when the MAP ended nearly four years ago, we continued to persevere,” said Claudine, who is raising three young children alone. Claudine’s perseverance is in the spirit of the Cooperative’s name, which means “work with vigor.”
The Cooperative president notes that “while the monthly incomes are highly attractive there is insufficient work for all members.” The women take turns being gainfully employed. This requires collective decision making, and a strong sense of solidarity.
“It is encouraging that these groups have been transformed into cooperatives. We need a more systematic focus on the sustainability of World Bank investments,” said Laura Frigenti, World Bank Chief of Staff and Director of the Office of the President, and sector manager for health in Africa at the time the Rwanda MAP was launched.
Using HIV funding strategically for long-term impact
When HIV/AIDS funding is used strategically, as in Rwanda, it can have a long-term impact that goes far beyond the treatment and care of those living with HIV/AIDS. For example, using MAP funds, Rwanda was able to not only help sex workers know their HIV status but also to build solidarity and tackle their underlying vulnerability.
Also, grants to district hospitals under the MAP were used to boost human resources, allowing facilities to determine how the additional personnel were remunerated and deployed. Grants were combined with refurbishing of facilities and upgrading of laboratories which served other purposes beyond tackling HIV/AIDS. The performance-based financing for HIV/AIDS provided additional incentives to boost HIV testing, and other services.
As a result of government leadership and donor support, Rwanda has made important strides in the fight against HIV/AIDS, expanding access to HIV testing, enhancing knowledge, improving coverage of key services, and stabilizing the epidemic.
For example, according to the 2010 Rwanda Demographic and Health (DHS) Survey, nearly nine in 10 women (88 percent) who were pregnant in the previous two years received HIV counseling, were offered and accepted an HIV test, and received their test results. This is up from 22 percent in 2005.
Between 2005 and 2010, Rwanda has also quadrupled the use of modern contraception, increased the share of assisted births, nearly halved the child mortality rate and appears to be on the way to meeting its Millennium Development Goal (MDG) target for reducing maternal mortality.
“It has been a long journey and our partners have accompanied us along the way,” said Dr. Agnes Binagwaho, Minister of Health of Rwanda. “We emerged from a legacy of genocide, but over the past decade, we have built trust and respect with our partners. Today, they have confidence in us, as they see that we produce results, and we do it in a transparent and efficient manner.”
Developing a national HIV/AIDS program
The 2012 Millennium Development Goals Report cites Rwanda as one of three countries in the world with a generalized HIV epidemic to have attained universal access to antiretroviral therapy (that is, at least 80 percent of those who need treatment receive it).
“When we negotiated the $30 million MAP grant for Rwanda, the country had roughly 870 patients on antiretroviral therapy at several urban facilities and all of them were paying out of their pockets,” said Miriam Schneidman, Lead Health Specialist, in the World Bank’s Africa Region.
Under the government’s leadership and with support of the U.S. Centers for Disease Control and Prevention, the Clinton Foundation, and others, the MAP led the decentralization of AIDS treatment and care to underserved and vulnerable groups in Rwanda.
“The World Bank played a pivotal role at a critical juncture in the scale up of our national HIV/AIDS program. With the clear vision of government and the support from our partners, we have now achieved universal access to HIV care and treatment,” said Dr Anita Asimwe, Deputy Director of the Rwanda Bio Medical Center.
Putting people at the center of development
“Putting people at the center of development and focusing on individual welfare has been our overriding strategy,” concluded Minister Binagwaho, who celebrates Rwanda’s huge recent gains in poverty reduction—one million people lifted out of poverty in a short space of time. “Sustained economic growth will ultimately be critical to reducing our dependence on external financing,” she notes.
While Rwandan authorities continue to make solid progress towards the attainment of the MDGs, the sun sets in Kanombe district and a fresh cool breeze blows in.
Claudine, Marceline, and their friends stand up and, on a whim, begin to dance. They exude a renewed sense of confidence.