This activity relates to MTCT (7179, 8122, 8185, 8698), HMBL (7223, 8860), HBHC (9637, 7163, 7177, 7191, 7245), HVTB (7162, 7169, 7180, 8146, 8147), HVCT (7178, 8164, 8168), HTXS (7161, 7174, 7164, 7176, 7190, 7246, 8172) and HLAB (7154, 7172, 7224).

The MOH and ONAPO conducted the 2001 Rwanda SPA, the first nationwide survey of its kind in Rwanda, with TA from ORC Macro and financial support from USAID.

With EP and PMI support, ORC Macro will begin initial preparations for a second SPA in FY 2006. Activities will include setting up the Steering Committee co-chaired by the MOH and the NIS, adapting the SPA modules for MCH, HIV/AIDS, laboratory and pharmacy, recruiting and training surveyors, and conducting field activities to collect information on the national capacity to deliver specific services and the quality of services using facility-based indicators required by the EP and PMI. The survey will assess all district, reference and university hospitals, the NRL, as well as government and private clinics and health centers, of which GIS coordinates will be confirmed during the survey.

In FY 2007, the EP will procure TA for the implementation of a national targeted facility survey through MEASURE/DHS., and also carry out a range of dissemination and capacity building activities.

To increase access to and use of the SPA data, ORC Macro will publish, in French and English, a final report and a summary of findings outlining the major results of the SPA; a wall chart listing major indicators; as well as organize a national dissemination seminar in Kigali.

ORC Macro will undertake additional activities to ensure that the SPA findings reach major policymakers, program staff, and evaluation specialists who need them most. These activities include both print materials and topic specific seminars targeting policymakers, researchers, program managers, and staff from the MOH and cooperating agencies.

In view of Rwanda's decentralized system of governance, ORC will conduct district seminars for major stakeholders to apply findings to district level planning, budgeting, and monitoring and evaluation activities will be organized. ORC will also develop district chart books and/or fact sheets, which will highlight the major indicators for each district, and compare each district to the national average.

This activity reflects the ideas presented in the EP Five-Year HIV/AIDS Strategy in Rwanda and the GOR National multi-sectoral strategic plan for HIV/AIDS Control (2005-2009) by directly supporting the development of a sustainable strategic information system for the national HIV/AIDS program.

MEASURE DHS will conduct an Interim DHS in FY 2007 adding a module on MC. The 2005 Rwanda Demographic and Health Survey results were released in November 2006. The RDHS III included HIV prevalence rates based on a population-based sample. Rwanda has a generalized HIV epidemic with a reported low prevalence of male circumcision. The inclusion of the MC module in the Interim DHS will better report on the prevalence of circumcision and also male attitudes towards circumcision. These data will inform on strategy and future activities regarding male circumcision services promotion and expansion within the context of ensuring universal access to comprehensive HIV prevention, treatment, care and support.

Table 3.3.14: Program Planning Overview Program Area: Other/Policy Analysis and System Strengthening Budget Code: OHPS Program Area Code: 14 Total Planned Funding for Program Area: $ 3,922,000.00

Program Area Context:

There is an acute shortage of qualified professionals in Rwanda. According to the 2005 RDHS-III, only 1.2% and 1.5% of men and women, respectively, have completed secondary school, which is a requirement for further technical training. Therefore, since its inception in FY 2004, the EP has invested significantly in at least four distinct strata of capacity building: 1) the health systems, 2) the organizational level, 3) the human resource level and 4) the individual/community level. The EP investments have supported a variety of activities including policy development, TA to key GOR institutions, and seconding staff. In coordination with the WB, GFATM and other donors, investment in each of these levels of capacity building has strengthened the GOR's ability to provide quality HIV national prevention, care and treatment services. Given that these four levels of capacity building are interlinked and collectively contribute to a strong health system, the EP has prioritized capacity building as a cross-cutting issue. Several activities listed in other sections of this FY 2007 COP also contribute to the dual objectives of both building the MOH's capacity of providing HIV services and advancing the sustainability of the EP program.

At the heath system level, the EP provides long-term TA to CNLS, TRAC, and PNILT for the development of national policies for HIV care and treatment and to strengthen GOR HIV coordination mechanisms. In FY 2005, the EP partners supported two technical advisors at PNILT and TRAC, which advanced TB and HIV integration thorough establishment of national protocols, policies and operational tools such as the revised TB/HIV register. In FY 2006, CHAMP is developing a national palliative care policy. CHAMP is also providing staff support to MIGEPROF to integrate policies that will advance gender equity in HIV services. In FY 2007, the EP will continue to support GOR at the systems level through funding for the National Health Account and by continuing to purchase output indicators through PBF. These activities will enhance the GOR's ability to map HIV resource flows in relation to other health sector funding.

At the organizational level, the EP has similarly supported capacity building for GOR and other Rwandan NGOs since FY 2004. The strategies used included: financial and management assistance; skills building in M&E; and commodities and logistics management. The EP has historically built capacity for HIV and CD4 testing at laboratories, particularly at the NRL. At the request of MOH, RPM+ supported CAMERWA at the central level and helped to establish a NDA at the district level to ensure and monitor drug quality in FY 2005 and FY 2006. In FY 2007, the NDA will create a quality control system and standardized training for district pharmacies. The EP will also provide commodities and logistics management to CAMERWA and district health pharmacies. This expansion of capacity building from the national to the district level parallels the GOR decentralization process. Concomitantly, the EP will expand its support beyond GOR institutions to civil society groups. CHAMP, which is funded to undertake the majority of EP community services, will support 12 local NGOs in financial management, and M&E through on-going training and skills-building.

At the human resource level, the EP supports pre-service, in-service, and refresher training of health professionals. Since FY 2005, the EP has actively supported pre-service nursing training and the Rwanda HIV/AIDS Public Interest Fellowship to develop a cadre of program managers. In FY 2006, CAPACITY and Columbia University collaboratively developed pre-service nursing curricula. CAPACITY also supported a Human Resource Advisor at the MOH to help develop the national HRH policy and strategic plan, and established a human resource database to track and properly distribute health workers countrywide.

In FY 2007, many existing implementers will continue their capacity building efforts: CAPACITY will implement the national curricula in collaboration with the GOR; ASCP will conduct pre-service training of laboratory technicians in the HIV, TB and malaria; CDC will assign a dedicated staff member to monitor the EP laboratory portfolio and provide TA to the NRL and other key MOH institutions; and Columbia will provide staff support to NRL to build its technical, financial and commodities management systems.

In FY 2007, the EP will also continue to support at least three pre-service training initiatives given the acute

shortage of health care providers and HIV program managers. The EP will complete and implement the nursing curricula, expand the number of participants in the Public Interest Fellowship, and initiate a social work certificate program to strengthen the continuum of care for PLWHAs. The EP will continue to support in-service training and supervision through PBF and other activities.

At the individual and community level, the EP uses its community partners to conduct TOT on an integrated health message. In FY 2006, CHAMP is training individuals to link clinical services and community care. Individuals will discuss and strategize ways to improve the quality of HIV services with representatives from health facilities. CHAMP will also train women leaders about a recently passed GOR bill that addresses rights for victims of GBV. In FY 2007, the EP will increase the number of individuals trained and expand the geographical coverage from 20 to 22 districts. According to the 2005 RDHS-III, 33.9% of the total households in Rwanda are women-headed. Moreover, 33.2% of widowed women reported being dispossessed of property. The EP will also continue to develop policies affecting PLWHA and widows who are dispossessed of their land.

Host government and donor collaboration is a critical element of system strengthening for the Rwanda EP. At the request of the GOR, the WB will decrease its HIV activities in Rwanda beginning in December 2006 and intends to stop the MAP by December 2007. The EP will continue to coordinate with the GFATM to absorb the existing WB MAP activities. To support the GOR, the EP will also continue TA and staff support to MOH, MIGEPROF, MINALOC, and MINEDEF.

In order to measure the link between multi-sector investment in the health system and long-term sustainability of HIV/AIDS programs in Rwanda, the EP will conduct a strategic assessment to inform and refine its medium- to long-term strategy on capacity building. The assessment, which will be followed by a comprehensive evaluation in FY 2008, will examine the efficacy of past EP approaches to capacity building and provide recommendations on all four levels, including effective strategies to work with the GOR. The EP has invested in activities with measurable outputs in FY 2007. The Rwanda team aims to advance the EP's global objectives on sustainability.

Program Area Target: Number of local organizations provided with technical assistance for 20 HIV-related policy development Number of local organizations provided with technical assistance for 76 HIV-related institutional capacity building Number of individuals trained in HIV-related policy development 8 Number of individuals trained in HIV-related institutional capacity building 215 Number of individuals trained in HIV-related stigma and discrimination 3,000 reduction Number of individuals trained in HIV-related community mobilization for 3,000 prevention, care and/or treatment

Table 3.3.14:

[CONTINUING ACTIVITY FROM FY 2006 -- NO NEW FUNDING IN FY 2007] Funding for this activity will cover ORC Macro participation at the national dissemination seminar for the 2005 Rwanda Demographic and Health Survey (RDHS-III) in spring 2006, production of a key indicators report that can be unfolded as a wall poster to display indicators by region for quick reference, and the English translation of the final report.

ORC Macro will finalize the tables for the final report in November and December 2005, and write the report January through March 2006. The initial report will be written first in French because that is the main language of the technical group. The key indicators brochure should be produced about the same time as the final report. The national dissemination seminar will take place in April 2006, with ORC Macro participation at the seminar. When the French version of the final report is finalized, ORC Macro will translate it into English.

ORC Macro initiated discussions regarding the RDHS-III with ONAPO in December 2003. These discussions included the main topics to be added to model DHS questionnaires, including anemia and HIV sero-prevalence testing. This initial plan was delayed when the GOR dissolved ONAPO in May 2004. New discussions began with the Department of Statistics, the new implementing agency, in May 2004. Consequently, the MOU, work plan, budget and calendar of activities were revised and updated.

Development of survey instruments started in June 2004 through consultations with other partners and the RDHS-III steering committee; the household listing and mapping fieldwork took place from August to November 2004. Written approval of HIV testing procedures was obtained from the National Ethics Committee in September 2004 and pretest training and fieldwork, including biomarkers, took place in November to December 2004. The main survey training, including biomarkers, took place in January and February 2005.

Survey fieldwork took place from February to July 2005. The data entry for questionnaires took place from March to September 2005 and HIV analysis on blood samples also took place from March to September 2005. Data cleaning and merging of questionnaires and HIV results data began in September 2005. The preliminary report writing and dissemination is scheduled for October 2005.