Document of The World Bank FOR OFFICIAL USE ONLY IMPLEMENTATION COMPLETION REPORT (IDA-22720; IDA ) ONA CREDIT

Transcription

1 Public Disclosure Authorized Document of The World Bank FOR OFFICIAL USE ONLY Public Disclosure Authorized Public Disclosure Authorized IMPLEMENTATION COMPLETION REPORT (IDA-22720; IDA ) ONA CREDIT IN THE AMOUNT OF US$19.6 MILLION AND A SUPPLEMENTAL OF US$7.0 MILLION TO THE REPUBLIC OF RWANDA FOR A HEALTH AND POPULATION PROJECT Report No: RW Public Disclosure Authorized Human Development Unit m Country Department 9 Africa Regional Office 02/05/2003 This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization.

2 CURRENCY EQUIVALENTS (Exchange Rate Effective October 2002) Currency Unit = RwF (Rwanda Franc) 483 RwF = US$ 1.00 US$ 1.32 = SDR 1.00 FISCAL YEAR January 1- December 31 AIDS CAMERWA CAS CNLS CRCS CRIS DCA DHS ERC EPRU FOSOCOBA FP GOR HIPC HIV IDA IEC MCH MTP NGO ONAPO OPHAR PMU PNLS SDR STDs SWAP TFR TRAC UNFPA UNHCR UNICEF VCT WHO ABBREVIATIONS AND ACRONYMS Acquired Immuno Deficiency Syndrome Rwandan Central Drug Procurement and Distribution Agency Country Assistance Strategy National HIV/AIDS Commission Rwandan Health Communications Center Rwandan AIDS Information Center Development Credit Agreement Demographic and Health Survey Emergency Recovery Credit Economnic Policy and Research Unit Social Fund for Support of Community Activities Family Planning Govenmment of Rwanda Highly Indebted Poor Countries Human Immuno-Deficiency Virus Intemational Development Association Information Education and Communication Maternal and Child Health Medium-Term Plan Non-Governmental Organization National Population Office Office Pharmaceutique du Rwanda Project Management Unit National AIDS Program Special Drawing Rights Sexually Transmitted Diseases Sector Wide Approach Total Fertility Rate Research and Treatment Center on AIDS United Nations Fund for Population Activities United Nations High Commission for Refugees United Nations Children's Fund Voluntary Counseling and Testing World Health Organization Vice President Country Director. Sector Manager: Task Team Leader: Callisto E. Madavo Enmmuel Mbi Laura Frigenti Minam Sohneidman

3 RWANDA HEALTH & POPULATION PROJECT CONTENTS Page No. 1. Project Data 1 2. Principal Performance Ratings 1 3. Assessment of Development Objective and Design, and of Quality at Entry 2 4. Achievement of Objective and Outputs 4 5. Major Factors Affecting Implementation and Outcome Sustainability Bank and Borrower Performance Lessons Learned Partner Comments Additional Information 21 Annex l. Key Performance Indicators/Log Frame Matrix 22 Annex 2. Project Costs and Financing 34 Annex 3. Economic Costs and Benefits 40 Annex 4. Bank Inputs 41 Annex 5. Ratings for Achievement of Objectives/Outputs of Components 42 Annex 6. Ratings of Bank and Borrower Performance 43 Annex 7. List of Supporting Documents 44

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5 Project ID: P Project Name HEALTH & POPULATION Team Leader: Miriam Schneidman TL Unit: AFTH3 ICR Type- Core ICR Report Date: February 5, Project Data Nanme. HEALTH & POPULATION Countrv/Department: REPUBLIC OF RWANDA Sector/subsector. Health (85%); Central government administration (12%); General education sector (3%) L/C/TF Number: IDA-22720; IDA Region- Africa Regional Office KEY DATES Original Revised/Actual PCD: 01/30/1987 Effective- 08/12/ /04/1992 Appraisal: 09/20/1990 MTR. 06/01/ /09/1998 Approval: 06/19/1991 Closing: 06/30/ /30/2002 Borrower/Implementing Agency: GOVERNMENT/MINISTRY OF HEALTHIONAPO Other Partners: USAID, UNFPA STAFF Current At Appraisal Vice President: Callisto E. Madavo Kirn Jaycox Country Manager. Emmanuel Mbi Francisco Aguirre-Sacasa Sector Manager: Laura Frigenti Alain Colliou Team Leader at ICR: Miriam Schneidman Jacques Baudouy ICR Primariy Author. Miriam Schneidrnan 2. Principal Performance Ratings (HS=Highly Satisfactory, S=Satisfactory, U=Unsatisfactory, HL=Highly Likely, L=Likely, UN=Unlikely, HUN=Highly Unlikely, HU=Highly Unsatisfactory, H=High, SU=Substantial, M=Modest, N=Negligible) Outcome: S Sustainability. UN Institutional Development Inmpact: N Bank Performance: S Borrower Performance- S QAG (if available) Quality at Entrv. Project at Risk at Any Time* Yes ICR S Note: This ICR focuses on achievements in relation to the 1996 amendment, which involved a complete overhaul of the objectives and content of the initial operation approved in The period is only described briefly throughout the text, as relevant. Thus, the ICR ratings above reflect performance since While these ratings reflect the relatively good performance of a restructured project in an extremely difficult post-conflict environment, it should be noted that implementation deteriorated with the approval of a supplemental credit, as highlighted in the ratings below.

6 Restructured Project IDA Supplemental Credit IDA Outcome Satisfactory Unsatisfactory Bank Performance Satisfactorv Unsatisfactory Borrower Performance Satisfactory Unsatisfactory 3. Assessment of Development Objective and Design, and of Quality at Entry 3 1 Original Objective. The US$19.6 million IDA credit, signed on July 3, 1991, was designed to support the Government of Rwanda to implement its national population policy with a view to: (i) reducing fertility levels; (ii) improving maternal and child health; and (iii) integrating demographic dimensions in cross-sectoral development activities. The operation was one of the main vehicles for supporting the government's 1990 population policy and an essential element of the Bank's lending strategy. The project objectives were appropriate and timely. It responded to both Borrower and Bank concerns with the rapid rate of population growth that was impeding economic prospects. While the project objectives were focused exclusively on population and family planning issues, a parallel IDA operation provided support for health system development. 3.2 Revised Objective: To respond to the country's post-war needs the project was completely restructured in This involved a change in the project's name, objectives, and activities. As described in the June 1996 amendment letter, the original Population Project was restructured into a Health and Population Project in order to: (a) support the implementation of the National Health Policy by rehabilitating and strengthening the health system to establish a solid foundation for consolidating reforms in the areas of operationalization of health districts, health sector financing, and pharmaceutical policy; (b) strengthen the Government's capacity to formulate and implement a comprehensive and sustainable strategy of AIDS control on a national scale; and (c) strengthen the Government's capacity to formulate and carry out a population policy. The restructured project responded well to the changing situation in Rwanda by giving greater importance to basic health services and to the growing HIV/AIDS epidemic while de-emphasizing population and family planning activities. While the revised objectives get high marks on relevance to country conditions, two issues are worthwhile highlighting with the benefit of hindsight. First, in a difficult post-conflict environment, it might have been more realistic to set a modest goal of resuming health services rather than 'establishing a solid foundation for consolidating reforms in operationalization of health districts, sector financing and pharmaceutical policy'. Second, while the amendment package included a set of performance indicators it did not include explicit targets against which performance can be assessed at project completion. The bulk of the indicators focused on inputs and the targets for the output indicators remained to be determined. In November 2000, a US$7 million supplemental credit was provided to the government. The principal justification of the supplemental credit was to provide urgently needed funds to relieve the unexpected burden bome by six districts in the aftermath of the 1994 genocide. The Bank team felt it would be easier and faster to secure a supplemental credit rather than initiate preparation of a new health sector investment operation. The objectives of the supplemental credit were to provide continued support for: (i) AIDS control activities; (ii) supply of pharmaceuticals; (iii) health district activities; and (iv) -2 -

7 population activities. The supplemental credit was to serve as a bridge operation pending preparation of a health project that would be advanced to FY Original Cornponents The original project contained three components: (i) improving the quality and efficiency of family plannning (FP) services through in-service training, intensification of supervision and management procedures and the provision of contraceptives and FP equipment; (ii) expanding and promoting family planning services through the strengthening of FP posts, mobilization of community volunteers, and targeted Information, Education and Communication (IEC) activities; and (iii) supporting population studies and promoting multisectoral activities. 3.4 Revised Conmponents. The restructured project included four components: * The health component aimed to support the implementation of the National Health Policy (44 percent of total base cost) by: (i) rendering operational six districts in the regions of Cyangugu and Gikongoro, including strengthening of cost recovery mechanisms; (ii) assisting with the supply and distribution of essential generic drugs, including the establishment of an autonomous drug supply agency; and (iii) supporting the development of a national social communication/lec capacity. * The AIDS component (13 percent of total base cost) supported the development and implementation of the national AIDS control strategy through: (i) restructuring and decentralizing the functions of the National AIDS Control Program, including setting up a small social fund developed by communities and NGOs to finance micro-projects; (ii) strengthening the policy role of the National AIDS Control Program; (iii) restoring the national capacity to carry out epidemiological surveillance of HIV and STDs; and (iv) developing a national capacity for voluntary counseling and testing. * The population component (39 percent of total base cost) aimed to support the development and implementation of a national population policy by: (a) developing an awareness of the new aspects of population issues; (b) improving the integration of population education into all levels of the formal education system; (c) improving understanding of population phenomena in Rwanda; (d) educating officials at the national level on population issues; and (e) promoting family planning services. * A project coordination component (4 percent of total base cost) supported the overall coordination of the project. 3.5 Qualitv at Ent,y: Satisfactory Quality at entry is rated as generally satisfactory. Three strengths of the original project design are worthwhile highlighting. First, the objectives and activities responded well to the country's needs and to the Borrower's commitment to address population issues. The project was timely and relevant, to the extent that it built on the 1990 Population Policy, which was heralded as a major breakthrough in acknowledging the importance of population issues and in setting explicit demographic targets (i.e. reducing the population growth rate from 3.6 to 2.0 percent by 2000). It also built on a cost/benefit analysis of the family planning program, carried out by the National Population Office (ONAPO) with assistance from the Research Triangle Institute, that demonstrated the significant benefits to be reaped from supporting the national program. Second, the design was comprehensive in nature addressing both the demand for and the supply of family planning services through a set of mutually reinforcing investments. Third, project documentation was generally thorough with the Staff Appraisal - 3 -

8 Report (SAR) including a comprehensive analysis of sector issues, lessons learned, and major risks. Against these positive aspects, the project had a number of shortcomings: (i) reliance on a centrally driven, vertical, service delivery model for the provision of family planning services; while this strategy was common to other self-standing population operations prepared during this period it represented a missed opportunity in tenms of promoting the integration of family planning services into the Maternal and Child Health program; (ii) insufficient attention to the risk of not being able to bring about behavioral change and to attain the demographic targets; the SAR risk analysis does not mention the potential difficulties of bringing about behavioral change in a population with a long standing tradition of pronatalist views and high levels of illiteracy; and (iii) excessively optimistic contraceptive prevalence targets and impact indicators, which with the benefit of hindsight were not realistic for a six-year period. The quality at entry for the restructured project is also rated as generally satisfactory. The restructured project responded well to country conditions and the design of the four components was clearly linked to the revised project objectives. With the benefit of hindsight, however, some of the objectives proved to be overly ambitious for a post-conflict setting (e.g. promoting family planning services) and should have probably been articulated in a more modest fashion. Moreover, the absence of explicit targets renders the assessment more difficult at project completion. 4. Achievement of Objective and Outputs 4.1 Outcome/achievement of objective: Achievement of objectives and outputs under the restructured Health and Population Project are rated as moderately satisfactory, considering the exceptionally difficult post-conflict environment in which the project was carried out (e.g. massive loss of health and other professionals, destruction of infrastructure, and weakened institutions). The overall deterioration in socio-economic and health conditions stemming from the genocide is reflected in the sharp rise in infant and under five mortality during the first half of the 1990s, as can be seen from the figure below. These trends were partially reversed since the mid 1990s with the large influx of donor assistance, including from the restructured IDA project. As discussed in the following sections most of the relevant project objectives have been achieved with the health sector demonstrating remarkable resilience recovering from the effects of the genocide with a partial reversal of earlier trends. Infant and Under-Five Mortlity Rates , 129, t.7 '.- 50 I E 0 Infant mortality rate (per 1000 live births) Under-five mortality rate (per 1000 live births) -4 -

9 4.2 Outputs by components: Background The 1 1-year implementation record can be broken up into three phases: > Slow start up The original US$19.6 million Population Project, approved in 1991, experienced a slow start up stemming from both difficulties in adhering to conditions of effectiveness and to unstable country conditions. The 1994 genocide and subsequent war brought activities to a grinding halt. Hence, by the end of the first five years less than 10 percent of the original IDA credit was disbursed. The tragic events of the mid 1990s necessitated a complete overhaul of the project. > Solid performance in a post-war environment Following the 1996 restructuring, disbursements picked up quickly with the bulk of the activities effectively carried out during a 4-year period (i.e ), which reflects a well performing project in a difficult post-war environment. > Downturn in performance The project experienced a downturn in performance following the approval of a US$7.0 million supplemental credit in November 2000, which stemmed from difficulties in maintaining a well staffed Project Management Unit; delays in the provision of counterpart funds; administrative problems and poor internal coordination; and some delays in obtaining non objections. Of particular concem were the difficulties encountered with a US$3.0 million drug procurement package, which was nearly declared ineligible for IDA financing immediately prior to credit closing and required an exceptional retroactive non-objection, since approval was not sought for this large package that required prior review. Moreover, by project closing only 78 percent of the supplemental credit was disbursed with roughly US$1.6 million needing to be cancelled. The following sections summnarize the main outputs by component in relation to the revised objectives of the restructured operation. Component #1: Supporting the implementation of the National Health Policy With respect to the implementation of the National Health Policy the project is judged to be, on balance, satisfactory, particularly when taking into account the difficult post-war context. This rating is based on the fact that virtually all physical objectives were attained, implementation difficulties experienced are to be expected in a post-conflict environment, and there was at least a partial reversal in the deterioration of health sector indicators. * The operationalization of the Cyangugu and Gikongoro health districts has been partially accomplished. With regard to the rehabilitation and equipment of health facility infrastructure the results are generally good, as the project assisted in a resumption of basic health services. All activities programmed in 1996 were completed, all equipment was delivered, quality of facilities was generally acceptable in spite of some shortcomings, and the cost of construction was broadly similar to that of other facilities in the region. With other donors picking up the cost of rehabilitating health centers, the project focused on four rural district hospitals (Mibilizi, Gihundwe and Bushenge in Cyangugu and Kaduha in Gikongoro) and one urban hospital. The project also financed the acquisition of roughly 40 vehicles (ambulances and all terrain jeeps) and 20 motorcycles which strengthened district supervision capacities. * The ICR team found a number of shortcomings in the technical and procurement documents for the civil works and medical equipment and problems with local firms in the post-war period (e.g. personnel and equipment problems), which, in turn, led to some deficiencies in the quality of the construction and the appropriateness of the medical equipment. The Muhima Hospital in Kigali is worthwhile highlighting as it absorbed roughly three-quarters of project resources spent on civil works. The site was identified early on to have some major shortcomings but a decision was taken to retain the location -5-

10 because of the need to address the growing demand for health care in this area. While the ICR team found the quality of the construction generally satisfactory the site rendered the construction more complex and more costly. By project completion some structural shortcomings persisted (e.g. poor access of ambulances to the surgical block) and a number of aspects remained incomplete (e.g. construction of a hospital wing with shared rooms). In another case (i.e. Kaduha Hospital) poorly defined technical specifications resulted in the delivery of equipment that was no longer needed. While the emergency nature of these investments is understandable, the haste with which this was done may have neglected important aspects which, with the benefit of hindsight, should have been given more attention (e.g. need for well defined technical specifications; warantees for equipment; maintenance plans for vehicles). * District capacities were also strengthened in terms of human resources. The project provided trauning in management of decentralized health programs for about 55 district physicians; and courses on primary health care and reproductive health for roughly 450 community workers and 1200 traditional birth attendants. In order to address the serious national shortage of personnel in the post-war period, the government recruited 12 physicians from neighboring countries which was a good interim solution to the country's human resources crisis. Nevertheless, by project completion the government was having difficulties replacing this personnel with national staff. * While it is difficult to establish causality between project investments and results it is worth highlighting overall trends in health care outputs. As the PSRs focused primarily on input indicators, the ICR team has assembled a consistent set of output and impact indicators from the latest Demographic and Health Surveys (Annex 1). The results of this analysis shows that Rwanda has managed to maintain or attain coverages rates which in some cases are higher than those in other countries in sub-saharan Africa that have not experienced similar tragedies. According to the 2000 Demographic and Health Survey (DHS), BCG coverage has been maintained at 97 percent since the mid 1990s, DPT3 is about 86 percent and 76 percent of infants are fully immunized. Moreover, there are virtually no rich/poor differentials in immunization coverage rates such as are found in numerous other countries. A similar pattern is found for prenatal care coverage. According to the 2000 DHS, the proportion of women with access to at least I prenatal consultation dropped slightly but remains at about 92 percent with minor rich/poor differentials. The proportion of deliveries assisted by a health professional has risen slighly even though it remains relatively low (31 percent), as Rwandan women have an increasing preference to deliver with the help of traditional birth attendants (i.e. proportion of deliveries assisted by birth attendants rose from 15 percent in 1992 to 43 percent in 2000). * By contrast to trends in preventive services, utilization of curative care has been on a general decline nationwide, as Rwandans have become increasingly poor (i.e. over 60 percent of the population remains below the poverty line). The curative consultation rate in project health districts (i.e. Bushenge, Gihundwe, Kibogora, Mibirizi, Kaduha) followed the national trend, with a consistent decline from 1998 to These trends raise concerns with the use of user fees in post conflict situations, highlighting the need for developing alternative cost financing mechanisms. A pilot community financing scheme in three health districts (Byumba, Kabgayi, Kabutare), supported under the Partnership for Health Sector Reforn, has demonstrated initial promising results in raising utilization of curative care (see figure below) through the use of an innovative risk pooling mechanism. It is encouraging that the Ministry of Health is exploring possibilities of scaling up these pre-payment schemes. -6-

11 Curative consultaton rate In health centers (HC), by Disbict (Source: Health Information System SIS, MOH) SIS 1998 O SIS 1999 O SIS 2000 O SIS 2Do1 0.6 v0'v 0.5?'.,,->;.S,,,,.i.,,t s.,'~~~~~~~~~~~~~~~~~~~~1 04 'tx-.ff-,-* X. 0.3 III 0.1 C.) X E E 11 S BusLhwre Ghiudwe 16bogora Mibr Kaduha ByrTba Kabgayi Kabutare RNANf Districts The essential drug sub-component is considered highly satisfactory. The transformation of OPHAR ( Office Pharmaceutique du Rwanda) into an independent non-profit national drug procurement and distribution agency (CAMERWA) able to sell drugs to the public system can be considered as the major accomplishment of this project. Through 1999 the project assisted in funding initial drug stocks for all health districts and in providing staff training in management, procurement and operational support. By January 2000 CAMERWA was established as an autonomous agency with a tripartite body comprising of representatives of government, donors and beneficiaries. During the past 2.5 years CAMERWA has acquired solid capacities in the procurement and distribution of essential, generic drugs which is reflected in the relatively low cost of these drugs, as can be seen from the figure below. The ICR mission found that the availability of low cost, high quality, essential drugs in peripheral health facilities is good even though there are continuing concerns with distribution and logistics management and financial access. -7 -

12 Relative Unit Priices for Select Essential Drugs.,'- I,,, ' I : c [3~~~~~~~~~ Kipharma Product * In contrast to the excellent results attained by CAMERWA, there was only modest progress in strengthening national capacities to assure quality control of pharmaceuticals. The Pharmacy Directorate of the Ministry of Health benefitted from project support which enabled the provision of staff training in management of pharmaceuticals, and acquisition of a vehicle to strengthen supervision and control. The main outputs included the production of inspection and drug management manuals and legal texts on quality control. Nevertheless, the legal texts remain to be approved and the manuals need to be widely distributed. * The social communication/iec sub-component is rated satisfactory in terms of accomplishment of physical objectives and level of effort. As specified in the 1996 amendment, the establishment of a national social communication/iec capability was expected to strengthen the delivery of LEC messages at the district level. To this end, the project provided financial support to rehabilitate and equip the facility accommodating the Rwandese Health Communication Center (CRCS) that was damaged during the war. The goal was to provide technical and financial support so that the center could become self sufficient within two years. To this end, the project financed training abroad (i.e. U.S., France, Uganda, Kenya, Tanzania) in the use of the graphic and audio-visual equipment; and marketing, management and LEC strategies and funded the acquisition of equipment. The volume of activity has doubled from 2000 to 2001 (i.e. from about RwF 30 Million to about RwF 64 Million). According to the management of the center the following factors have impeded its performance: (i) high start up costs as technicians needed to be recruited and trained and equipment had to be purchased; and (ii) lack of competitiveness with local private sector firms providing similar services. In spite of the excellent efforts made by management and staff, the CRCS has not yet succeeded in becoming self sufficient, raising concerns over sustainability that are discussed in section 6. Component #2: Supporting the development and implementation of the national AIDS control strategy With respect to the implementation of the national AIDS control strategy, performance is - 8-

13 considered satisfactory. The project provided technical and financial support to strengthen institutional capacities of the national AIDS Control Program with the following specific results: * The government took an important step forward by restructuring the program with the CNLS established as its coordinating body while the TRAC was created under the Ministry of Health to address the medical and research aspects of the epidemic. Plans were prepared to establish provincial (CPLS) and district (CDLS) committees to empower local and regional authorities to assume a greater role in the implementation of the program. These institutional reforms were relevant and timely, helping to pave the way for more sustained effort under the forthcoming MAP operation. * The experience with a social fund mechanism for channeling funds to NGOs was small but promising, generating rich lessons for the design of the Rwanda MAP. A small social fund (Fonds Social d'appui aux Initiatives Communautaires, FOSOCOBA) was established in 1997 to provide grants to community groups working on HIV/AIDS. The fund was successfully managed by the PNLS, providing approximately RwF26.5 million (US$80,000 equivalent) during Project support was typically in the RwF 3-4 million range with the largest being RwF 7.3 million. In total, 13 proposals were approved out of a total of nearly 40 received. Grants were made to community associations (e.g. women's groups, groups working with AIDS widows and orphans, religious groups) for the funding of a range of activities (e.g. outreach to youth; income-generating activities for orphans/widows). Several projects involved partnerships with larger groups (e.g. CARITAS, Episcopal Diocese of Shogwe, PSI). The coordinator of the fund followed up with grantees and reported that most had achieved their stated objectives and that in most cases activities initiated with grant funds were sustained. This modest experience highlights the need for building capacities amongst these organizations in order to expand their ability to scale up promising approaches. The management/review mechanism and procedural manual are serving to inspire the design of community-based activities under the Rwanda MAP. * With regard to the objective of strengthening the policy role of the national AIDS program, the performance can be judged as solid. The restructured CNLS, set up in the President's office, has begun playing a pivotal role in the fight against AIDS, demonstrating important leadership. The major accomplishments which can be cited include: elaborating the HIV/AIDS strategic plan, mounting a strong national consensus building process, improving mobilization of community leaders, grass roots organizations and civil society through promotional activities, and spearheading a multi-sectoral approach which has involved an increase in public sector and civil society involvement in the fight against the epidemic (e.g. youth, religious organizations, army, mass media). Awareness raising activities appear to have produced good results, as reported knowledge levels of HIV/AIDS were found to be over 99 percent with no major gender or geographical differences (2000 Demographic and Health Survey). Knowledge of specific means of avoiding HIV/AIDS is also high for both males and females. Given the high illiteracy rates in Rwanda, these knowledge levels are quite impressive, suggesting that national efforts to raise awareness have been effective. As in other countries, the main challenge at this stage is to translate these knowledge levels into behavior change. It is also worth highlighting the promising results in terms of raising condom use and STD screening and treatment in the defense ministry which was one of the key beneficiaries of this project. Finally, the strong leadership at the highest political levels and the President's personal involvement are factors which augur well for the future of the program. * The government team should also be commended for the excellent progress made in restoring national epidemiological HIV/AIDS surveillance capacities, which had been interrupted as a result of the war. In order to provide rapid, up to date information on the evolution of the epidemic, the project provided -9-

14 technical and financial support to facilitate the resumption of activities at 18 sentinel surveillance sites nationwide. o The project supported the establishment of one of the first voluntary counseling and testing centers in the country, which has served as a model for the network of VCT centers being established nationwide with funding from the Global Fund. The CRIS responded to a growing demand for VCT services as knowledge and awareness has gradually improved in recent years and more Rwandans are now keen to be tested. Even though the center has been performing well with a high attendance rate, by project closing it remained highly dependent on extemal funding with continuing financing and staffing constraints. Component #3: Supporting the development and implementation of a national population policy With respect to the population component the government should get high marks for its excellent efforts in an extremely difficult post-genocide environment and for accomplishing most of the activities under this component, hence a sadsfaceory rating. Given the resurgence of pronatalist views in Rwanda and the strong desire to replace those lost in the genocide, the government appropriately emphasized the need to develop a new national population policy. At the time of the 1996 restructuring both the Bank and Borrower acknowledged the limitations of what could be accomplished in the post-conflict environment Since the restructuring, progress has been slow but steady. As noted below, ONAPO has made a concerted effort to get population issues back on the national agenda with good progress in terms of raising awareness, integrating population education in school curriculum, and educating public officials. By contrast, the post-genocide environment has made it extremely difficult to re-establish family planning services as demand continues to be sluggish. The key accomplishments, problems encountered and results attained are sunmmarized below. e o o o With regard to the goal of raising awareness of new aspects of population issues for community leaders, the project supported roughly 225 debates and approximately 600 education skits at the community level. The project also funded knowledge and awareness raising activities for about 25 line ministries, some 75 NGOs, 60 associations and female groups; 50 journalists; 70 cooperatives; and 225 rural development workers. In addition, the key personnel of ONAPO were trained abroad. The project gets high marks in terms of the integration of population education into all levels of the formal education system. Some 4,400 primary and 450 secondary school teachers were trained in these subjects based on a revised curriculum. In terms of improving understanding of population phenomena in Rwanda, the project aimed to support a number of studies in order to have a greater appreciation of the changing attitudes and beliefs towards birth and contraception and the evolving aspects of the population phenomenon. According to the 2000 DHS, knowledge of contraceptive methods has remained very high (i.e. over 97 percent) irrespective of level of education or place of residence, suggesting that the program was effective in awareness raising. On the policy reform side, the government has taken the initial steps in revising the national population policy to reorient ONAPO's mandate from a provider of family planning services to a premiere research institute focused on population and reproductive health issues. The new population policy proposes that ONAPO take the lead on policy, planning and research. This policy document is under discussion and remains to be finalized. * The Ministry of Health has met with little success in trying to re-establish family planning services in an environrent where couples are keen to replace those lost in the genocide. The Ministry established a reproductive health unit and elaborated a sound national Reproductive Health Strategy. The strategy provides a comprehensive framework for service delivery and good guidance on how to link reproductive health, HIV/AIDS and other cross-cutting issues that affect reproductive health outcomes. -10-

15 A modest community based distribution scheme was initiated at three sites with roughly 4,900 pills and 14,000 condoms distributed through this network. The shift from ONAPO to the Ministry of Health appears to have resulted in declining support for family planning at the district level, as health personnel are dealing with other priority health needs. Authorities estimate that only 9 percent of health facilities have a contraceptive stock and 36 percent of facilities follow up women on a regular basis. The modest gains in improving access to family planning services attained prior to the genocide have been severely eroded. As can be seen from the figure below, the CPR (modem methods only) has dropped to a meager 3 percent by 2000 with the use of traditional methods stagnating at about 5 percent. Rwanda: Contraceptive Prevalence Rate (Source: Demographic Health Survey) 16 IN MDHS 1992 *DHS , t - -. i 1:.X.)t.t.z.st. '. rvsw.t 12 ' S. -.1C *. C.l X * i ¼ C 0 10 <½ *' X t,. t-.kz 6 s u'id i l_.-' At-st 6 42 S.., ti, * Modern Methods Traditional Methods All Methods 4.3 Net Present Value/Economic rate of return. Not applicable. 4.4 Financial rate of r eturn. Not applicable. 4.5 Institutional development impact: Negligible The institutional. development impact of th.is project is considered negligible. The most important institv.tional. achievement has been the establishment of an effective national essential drug program. As noted above, CAMERWA has been functioning as an efficient, autonomous, non-profit organization, providing a good supply of essential drugs in a timely fashion to the public sector. The national response to HIV/AIDS has also been strengthened substantially. TRAC is performing well within the Ministry of Health with good results in restoring national epidemiological surveillance capacities and in carrying out medical research. The CNLS has been established in the President's office to provide greater visibility to the national program and is now spearheading the preparation of the Rwanda MAP. The CRIS

16 operated as one of a few VCT centers in the country until very recently and has served as a model for the design of a new network of VCT centers. Institutional capacities of the Ministry of Health have also been strengthened with the training of a large number of physicians, nurses, and community outreach workers. While it is difficult to ascertain the full impact of this training it is clear that institutional capacities which had been decimated during the genocide have been partially restored. In spite of these efforts to strengthen capacities the institutional development impact is considered negligible overall, particularly as there are major concerns over the sustainability of the project investments (as discussed in following sections). 5. Major Factors Affecting Implementation and Outcome 5.1 Factors outside the control of government or inplementing agency: The 1994 genocide and subsequent war had ravaging effects on the country with massive loss of human lives and destruction of health facility infirastructure. Even though numbers are not available, it is believed that the health sector was particularly hard hit as personnel either fled the country or were killed. A large number of health facilities were damaged and/or pillaged during the hostilities of the 1 990s and were in need of rehabilitation. Moreover, during the post-war period, the Project Management Unit was highly dependent on the local construction market which also suffered from personnnel shortages and equipment problems. 5.2 Factors generally subject to government control: Three factors subject to government control impeded the execution of the project. Eirt difficulties in complying with the conditions of effectiveness which resulted in nearly a one-year delay in declaring the original IDA credit effective. Second, problems with the timely availability of counterpart funds as the government experienced financial difficulties. This implied that the Development Credit Agreement needed to be amended on several occasions to allow for a greater share of IDA financing of the total project cost. With the benefit of hindsight, perhaps the Bank should have granted more generous co-financing arrangements during the 1996 restructuring to take into account the country's precarious financial situation in the post-war period. Third. difficulties in maintaining a well-staffed Project Management Unit, which was a serious problem since the approval of the supplemental credit in The persistence of the Minister of Health to nominate a project manager who did not meet the necessary qualifications for IDA approval proved to be a major stumbling block. This combined with protracted discussions over salaries ultimately resulted in a situation whereby the project was run with only skeletral staff during the last couple years, which had serious consequences on the performance of the unit. 5.3 Factors generally subject to implementing agency control: The performance of the Project Management Unit was variable throughout the life of the project. While most of the problems experienced are understandable in a post-conflict environment a greater effort should have been made by the Ministry of Health to maintain a well staffed, competent group knowledgeable in Bank procedures. Of particular concern were the serious difficulties encountered in adhering to IDA procurement procedures and guidelines following the approval of the supplemental credit. A case in point relates to the procurement of US$3.0 million of drugs that did not follow IDA procurement procedures and which ultimately necessitated an exceptional, retroactive non objection in order to permit financing under the project. 5.4 Costs and financing: While the civil works activities absorbed a relatively modest proportion of both the original credit

17 and the supplemental credit (roughly over 8 percent) there was a substantial rise in costs (i.e. roughly 230 percent in relation to the 1996 restructuring). These cost increases stemmed from a combination of factors, including under-estimation of the initial cost of the Muhima Hospital, delays in start up, and an increase in the cost of materials. Moreover, the relatively low initial allocation of the special account prevented quick replenishments, which in turn contributed to cost overruns. The size of the special account was raised from US$0.5 million in 1996 to US$1.0 million in Finally, it should be noted that in spite of problems with counterpart funding, following the resumption of project activities, the government made a concerted effort to respect its obligations to the firms involved in the civil works. 6. Sustainability 6.1 Rationale for sustainability rating: The project's sustainability is rated as unlikely unless certain measures are taken as discussed in the next section. The modest gains attained since the mid 1 990s remain fragile and run the risk of being eroded in the absence of sustained external financial support. While the health system has shown remarkable resilience in recovering from the effects of the genocide, many constraints persist, raising concerns over the sustainability of project activities. The HIV/AIDS epidemic is having an erosive effect that compounds the human resource losses from the genocide. Population and family planning are still delicate issues in this post-genocide society where pronatalist views dominate. Institutional development has been negligible with continuing human resources shortages. Institutions such as CRCS and CRIS remain dependent on external support to continue and expand their activities. Moreover, the heavy emphasis on HIV/AIDS and other infectious diseases (malaria and TB) runs the risk of diverting attention from broader health systems development. Finally, the government's financial difficulties have resulted in occasional delays in meeting even the modest counterpart funding requirements during the life of the project and in replacing the expatriate personnel recruited under the project with Rwandans at project completion, raising additional concems with regard to the operation of the facilities supported under the project 6.2 Transition arrangement to regular operations: With the completion of the IDA-funded Health and Population Project the government has not yet developed a clear roadmap for sustaining the investments initiated under this operation and for addressing broader systemic problems affecting health sector performance. While the Ministry of Health hired a consultant to prepare a follow-up IDA health operation there was little discussion or follow up of the recommendations of this report. Likewise, there was little follow-up of the recommendations of the HERA (Health Research for Action) study on costs and financing, which addressed some of key issues affecting the Rwandan health system. The Ministry of Health has expressed concerns that funding for HIV/AIDS runs the risk of draining resources from important health priorities, as donor funding for health appears to be declining. The ICR team agrees that many of the modest gains attained to date remain precarious. Moreover, as in other post-conflict countries, Rwanda has a long way to go towards the attainment of the Millennium Development Goals (MDGs). The figure below illustrates the trends in the Infant Mortality Rate (IMR) during the previous decade and the challenges lying ahead in terms of attaining these goals by While the IMR has progressed back toward pre-conflict levels, the maternal mortality ratio (MIvIR) is still high (i.e. around 1000) by any standard. This is not surprising, as the MMR is more dependent on a continuum of health system performance measures. For example, effective management of obstetric emergencies requires recognition and action to seek care by households and birth attendants, access to transport, and timely/effective care and treatment at the referral facility. In essence, it requires a well functioning outreach effort and a strong health system response. In order to assist Rwanda to move towards the goal of attaining the MDGs and to address systemic issues there is a need for long-term, - 13-

18 sustained financial and technical support from both IDA and other development partners. Rwanda Trends In Infant Mottilty, with proj.cton to l 100 -L qz ddnws 112dedhw 2B3dedne The Bank needs to consider a two-prong approach for sustained support to the health sector: (i) preparing a follow up IDA operation to support health systems development and attainment of the MDGs; and (ii) addressing policy and institutional reforms affecting health sector performance through the Poverty Reduction Strategy Paper and the proposed Poverty Reduction Strategy Credit. IDA Health Sector Support: A follow-up IDA health sector operation would assist the government to continue developing its decentralized health system to complement support provided by other development partners. There is a clear commitment and a growing capacity to implement the district model. Priority areas for investment include management, procurement and logistics systems, health education, health information systems, health financing, and human resources. Human resources are a particularly critical soft spot in Rwanda's capacity to sustain efforts to effectively scale up health programs. Traditional birth attendants and the animateur system developed under the Health and Population Project are a valuable resource at the community level, but need to be strengthened and complemented by more trained nurses and midwives. While the policy frameworks for HIV/AIDS and reproductive health are well designed, capacity to implement them depends on the availability and effective deployment of appropriately skilled health providers at all levels of the health system. Strengthening of capacity through training, effective incentives and a strategic approach to the deployment of human resources need to be urgently continued. There is also a need to scale up the successful piloting of the mutuelle scheme to assist households to improve their financial access to health services through this risk pooling mechanism that has yielded good initial results. PRSPIPRSCIHIPC Support. The PRSP/PRSC offer an opportunity to tackle issues which can not be easily addressed in a health sector operation, such as policies related to the deployment, recruitment and remuneration of health sector personnel. Annual review of the government's expenditure program will also offer opportunities to engage authorities in discussions over the efficiency and equity of health sector spending. The HIPC initiative provides a further opportunity to reorient resources towards priority health sector investments

19 7. Bank and Borrower Performance Bank 7.1 Lendinig: The Bank performed in a generally satisfactory manner during the identification, preparation and appraisal of the original project. As noted in previous sections, the Bank responded in a timely fashion to the govermment's 1990 Population Policy which was viewed as a major breakthrough in acknowledging population issues and setting explicit demographic targets. The project was generally well designed and the documentation was thorough. With the benefit of hindsight, there was excessive reliance on a centrally driven, vertical, service delivery model and insufficient attention to the risk of not being able to bring about behavioral change and to attain the demographic targets. 7.2 Supervision. The Bank team should get high marks for the 1996 restructuring, following the genocide and war, and for its intensive supervision efforts during the next four years. The Bank responded quickly and effectively to the Borrower's post conflict needs, processing a series of amendments to address the emergency rehabilitation needs and the government's deteriorating financial situation. In total, there were 8 amendments to the Development Credit Agreement, including the major restructuring of 1996 and the 2000 supplemental credit. Many of the amendments allowed for IDA to fund a larger share of total expenditures and for three extensions of the closing date (1.5 year extension accorded in September 1997; 1-year extension provided in June 1999; and 1.5 years provided in November 2000 with the supplemental credit). As noted earlier, it might have been better to include a larger percentage of IDA financing up front (i.e restructuring) rather than making periodic revisions. Supervision was generally strong and missions were well staffed. There was remarkable continuity on the Bank side with a couple of task team leaders involved in supervision for the bulk of the project years. On average, there were two missions annually throughout the life of the project. The quality of advice and supervision was generally good in spite of some lapses. For example, the restructuring mission and subsequent supervision missions did not benefit from the services of an architect, which was reflected in the lack of technical details in the 1996 amendment and in supervision reports. The restructuring mission also did not carry out a financial analysis of the feasibility of establishing the CRCS as an autonomous public sector health communication center, which might have highlighted concerns which emerged in later years about the viability of this center. Finally, even though the 1996 restructuring involved the selection of a set of performance indicators, most focused on inputs and not on outputs or outcomes. With the benefit of hindsight it might have been better to have a shorter, strategic list of indicators, focusing on indicators which are readily available. A Quality Enhancement Review (QER) carried out in January 2001 commended the Bank team for its perseverance under difficult conditions as well as for its entrepreneurial approach to ensuring the full use of the proceeds of the original credit. Overall, the panel concluded that the project had been satisfactorily supervised, with a focus on resolving the many challenges to successful implementation through creative and timely use of restructuring and willingness to adjust project focus in response to the changing epidemiological and political conditions. At the same time, the panel raised concerns with the multiple extensions and ultimate supplementation of the original project design, suggesting it might have been more efficient to pursue a dialogue through a program of analytic work and new lending rather than through continued reshaping of the original project. The panel also raised concerns with the excessive

20 focus on recording the number of particular activities or inputs employed rather than the effects of these investments. Supervision and technical support under the supplemental credit fell somewhat short of expectations and is rated as unsatisfactory. While the Bank tearn rightly stood its ground in preventing the nomination of staff who did not meet Bank standards it proved unable to resolve the impasse that emerged. With the benefit of hindsight, the Bank team probably missed an opportunity to take strong corrective action (e.g. suspend disbursements). Moreover, even though implementation deteriorated during the last 1.5 years, performance remained rated as satisfactory, with neither the staff nor management picking up the potential disconnect between the ratings and results. Finally, even though the supplemental credit was to serve as a bridge operation, the Bank failed to allocate resources for its preparation and to foster a dialogue with the Ministry of Health on future needs of the health sector, leaving a gap between the completion of one project and the start up of the next operation. By project closing the country's overall precarious debt sustainability situation (stemming from a deterioration in export commodity prices) may require a contraction in external borrowing, including IDA lending, as outlined in the November 21, 2002 Country Assistance Strategy. Nevertheless, IDA expects to continue providing support for the health sector through the Poverty Strategy Reduction Credit. 7.3 Overall Bank performance: Satisfactory for the restructured project. Unsatisfactory for the supplemental credit, as noted above. Borrower 7.4 Preparation: The Borrower performned in a satisfactory manner during the preparation of the original Population Project which benefitted from strong ownership and built on the government's recently issued population policy. During the 1996 restructuring the borrower worked closely with the Bank team to design an operation which responded to country needs. 7.5 Government implenientation performance: Given the difficult post-conflict environment the ICR mnission found that the Borrower's performance was generally satisfactory. With regard to the civil works, the evaluation mission found that all activities programmed in 1996 were completed; all equipment was delivered to each facility; quality of the facilities was generally acceptable in spite of some shortcomings; and the cost of construction was broadly similar to that of other facilities in the region, in spite of cost overruns. In hindsight, more attention should have been given to the preparation of technical specifications, enhanced coordination between rehabilitation/construction and equipment installation, and to introduction of a maintenance system for newly purchased equipment and vehicles. Government performance under the supplemental credit is rated as exceptionally poor with serious consequences in terms of implementation, results and staff morale. The government should have taken greater care and responsibility to ensure that adequate management, procurement and financial management capacities were maintained following approval of the supplemental credit. The deterioration in implementation with the supplemental credit resulted in a missed opportunity to use the last couple years of this project to draw lessons and to prepare a follow-up operation. 7.6 Implementing Agency:

21 The performrance of the implementing agency was patchy. The Project Management Unit performed exceptionally well during the first 4 years following the 1996 restructuring and experienced a downturn subsequently with serious staffing problems. In spite of the excellent efforts made by the remaining staff it proved difficult to run a unit with skeletal staff. As discussed in other sections these staffing problems had negative ramifications on project performance. 7.7 Overall Borrowverpeiformance: Satisfactory for the restructured project. Unsatisfactory for the supplemental credit for the reasons described above. 8. Lessons Learned The key lessons learned from the Health and Population Project can be summarized as follows: * With the benefit of hindsight, the population control rationale in the original project design had a narrow focus. Though Rwanda suffered from population pressures, a people-centered health and welfare approach would have been more appropriate and effective in bringing about behavioral change. Rwandan authorities are aware of this and are rethinling messages about family planning based on its contribution to the better health and welfare of mothers and their children rather than for macro demographic goals. The comprehensive approach which is currently being adapted at the policy level in Rwanda provides an excellent framework for a holistic approach. The IDA-funded HIV/AIDS Multi-Sectoral Project (MAP) will provide opportunities for supporting activities which will benefit both the national HIV/AIDS and reproductive health programs. * While the restructuring of the project addressed important issues that Rwanda faced during the period of emergency reconstruction a greater attention should have probably been given to demand-side issues. As in other countries in the region, there appears to have been insufficient attention given to the population's ability to pay for health services. While in the immediate post-war period (1994/95) health care was provided largely free with the support of humanitarian organizations, cost recovery measures which have been in effect since the mid 1970s were subsequently enforced, with an adverse effect on health care utilization. This suggests the need for complementing capital investments with measures to strengthen ability to pay. As mentioned in previous sections, health districts which put in place effective community financing schemes (mutuelles) experienced an increase in utilization of health services, highlighting the importance of complementing capital investments with demand-side measures. * Public-sector communication units are generally better suited to planning and overseeing communication activities rather than producing materials in house. Drawing from similar experiences in other countries, setting up production capacity in the public sector generally turns out to be costly and difficult to sustain, suggesting that it may be more cost effective to contract production of these materials to the private sector. * The relatively small but successful experience with the socialfund managed by the PLNSfor channeling funds for HIVIAIDS activities to community groups has generated rich lessons for the design of the Rwanda MAP. This experience has demonstrated the potentially important role which community associations can play and the types of modalities which can be used for channeling funds to

22 these groups. It has also highlighted the need to build capacities amongst these organizations in order to expand and scale up promising approaches. * In order to ensure a sustained development of the health system in Rwanda the issue of human resources needs to be addressed more comprehensively. The massive brain drain experienced following the tragic events of the 1990s, combined with the AIDS epidemic, have exacerbated Rwanda's human resources problems. Thus, human resource deficits remain a serious obstacle to health sector performance. While the project provided support for staffing some health centers, a more systematic effort to address human resources may have been warranted. Particular attention needs to be given to rebuilding capacities, replacing the personnel recruited on a temporary basis, and developing incentives for staff to be deployed to under-served areas. * The relatively poor experience with the supplemental credit highlights the importance of maintaining a strong project management unit with staff who are qualified and knowledgeable with Bank procedures and guidelines. Staff need to be recruited on a competitive basis using transparent procedures to ensure the best candidates are selected; periodic trainining and re-training on Bank procedures must be provided; and streamlined procedures need to be adapted in order to faciltate internal approval. Interference in staff selection needs to be avoided as it has a high cost. In the case of this project, the problems experienced prevented the Ministry of Health from taling advantage of the supplemental credit for preparing a follow-up health sector investment For the Bank, these difficulties highlight the importance of taling strong corrective action when things are not going well. Another important lesson for the Bank is that it may sometimes be more efficient to clean the slate and prepare a new operation rather than request a supplemental credit. 9. Partner Comments (a) Borrower/implenmenting agency: COMMENTS ON THE FINAL DRAFT OF ICR FOR THE HEALTH AND POPULATION PROJECT Our comments focus on the following areas of the ICR, with specific reference to the assessment of performance of the supplemental credit: Areas include the following: Overall document on ICR document Major factors affecting implementation outcome (chap. 5) Sustainability (chap. 6) Overall performance of supplementary credit Borrower performance and; Lessons learned Overall comment on ICR document Generally, we do appreciate the ICR, as it objectively highlights the major events of project and draws lessons learned which will help the GOR to learn from the mistakes in order to improve future performance

23 Major factors affecting implementation outcome Our attention here is drawn on the following comments highlighted by the report on which we generally share the same opinion. These include that there are factors outside government implementation agency's control which impeded the agency's performance. These include the effects of Genocide on the availability of the health sector personnel and destruction of health sector infrastructure. We do share the same view on this and there are already strategies to address this in particular the human resource issue. A case in point is that the government has of recent established a human resource development. With regard to factors subject to government control that have impeded project performance, we do agree with the report that there were difficulties at some point particularly in complying with the conditions of effectiveness which resulted in a nearly one year delay in declaring original IDA credit effective. To address this problem however, the government has established a Central Bureau of Public investments and External financing (CEPEX) to improve disbursement and make a follow up for proper utilization of project's resources. These and other government efforts will in the long run improve project performance. As regards to timely availability of counterpart fund, we do appreciate that the bank recognizes the fact that the government was experiencing financial difficulties at the time. We would like to point out that the GOR has made payments of counterpart funds for all projects a top priority with effect from the budget year According to the ICR, another factor that is identified as having impeded performance is non adherence to IDA procurement procedures. An example that is cited is the procurement of drugs by CAMERWA worth US$3.0 millions. This is a fact and we do appreciate that the Bank accepted the government's explanation that there was an urgency for the drugs in the health centers. This was however not due to incompetence of the project staff but rather to the urgency circumstances to quickly acquire the drugs. Sustainability of the project achievements In as far as sustainability of the achievements is concerned, we do agree with the ICR that many of the modest gains attained by the project to date, remain precarious. It is on this basis that the ministry of Health has prepared a proposal for Population and Health Project II which is meant to save the achievements of PSPI that otherwise indeed risk erosion if no appropriate measures are taken after the closure of PSPI. Overall performance of the supplementary credit Implementing agency: The report generally indicates that performance of this extension credit was unsatisfactory. We do not share the same opinion on this. The report goes further to say that the implementing agency was generally to blame for the poor performance of the supplementary credit. This is strongly supported by chap. 5 para. 5.2, where it is said that: there was difficulty in maintaining a well staffed project management unit. This is further supported by chap. 7 para 7.6. which says that: inspite of the excellent efforts made by the remaining staff, it proved difficult to run a unit with a skeletal staff. This is further strengthened by chap. 5 para 5.2 where it is mentioned as the third problem affecting performance that: the minister persistently nominated a project coordinator who did no meet the required qualification and this became a stumbling block leading to poor performance. We strongly disagree with this view. Our opinion here is as follows:

24 (i) Difficulties to recruit project staff, which lead to the so-called "skeletal staff' was mainly due to unnecessary delays to receive non-objection from the World Bank. This caused abandoning of the project by some highly qualified staff who had shown interest to join the project. (ii) Secondly, the coordinator that was appointed by the minister of health was qualified. However, given the skeletal staff that was running the project the persistent refusal by the bank to approve the coordinator, couple with with the bank's decline to provide supervision, definitely adversely affected the performance of the management unit. Borrower performance Much as we do agree that there were some problems in procurement procedures and staffing, we disagree with the report that government performance was exceptionally poor. Based on the fact that despite all the above mentioned difficulties encountered, disbursement for the supplementary credit was over 75% and to a great extent activities were implemented as planned, the performance can indeed not be assessed as exceptionally poor. Lessons learned We do share the same opinion on lessons learned. We do appreciate them and we will have them incorporated in the design and implementation of project that will follow. Received at the World Bank Washington D.C. on January 28, (b) Cofinanciers UNFPA, Dirk Jena, Resident Representative Overall, the country has made progress in the formulation of a new population policy which is truly multidisciplinary and has a better coordination structure in place in respect of HIV/AIDS. In respect of quality of RH service and family planning much still remains to be realised. The lessons leamed chapter captures quite well the reality, but we may need to add that more exchange of information and complementarity with other donor-supported programmes would need to be ensured in order to generate a cost-effective and lasting impact. In fact, there is a need for better coordination and time-efficient exchange of information in order to avoid overlap and duplicate funding. We have, for example, also heavily invested in the new population policy. I therefore much appreciate your and the recent consultations under the MAP as this will certainly help to provide the necessary information on which resources should be used for doing what. I hope that this short feedback is of any help. The most important, however, is that we continue to consult and try to identify some priorities around which we would then be able to build the necessary synergies. (c) Other partners (NGOs/private sector)

25 10. Additional Information The ICR team was led by Miriam Schneidman (Senior Health Specialist and Task Team Leader). The team included the following specialists: * Toni Kayonga, Operations Officer * Prosper Nindorera, Procurement Specialist * Pia Schneider, Economist, Consultant * Souleyman Kanon, Public Health Specialist, Consultant * Daniel Dupety, Architect, Consultant * Anne Anglio, Language Program Assistant The team also benefitted from inputs and ideas from staff/consultants working on the preparation of the follow-up HIV/AIDS Multi-sectoral Project: * Sheila Dutta, Health Specialist, ACT Africa * Tom Merrick, Reproductive Health Specialist, Consultant -21 -

26 Annex 1. Key Performance Indicators/Log Frame Matrix Indicator Comments Source Infant Mortality Rate Both infant and under-5 mortality DHS Under-5 Mortality Rate rose during the mid-i 990s and have (per 1000 live births) declined since then. Maternal Mortality Ratio This indicator remains high by any DHS (per 100,000 live births) standard and reflects systemic problems in the health system. Life Expectancy at Birth HIV/AIDS has erased earlier gains. UN Pop (years) Div. Contraceptive Prevalence Genocide/war experience reversed DHS Rate, earlier trend in family planning use. modern methods (%) Total Fertility Rate Most of the decline can be attributed DHS to decreases in proportion married and in unions. Adult HIV Prevalence Rate 11.2% UNAIDS (%) Immunization Coverage Immunization coverage was DHS BCG (%) maintained for BCG, dipped for DPT3 (%) DPT3, but declined overall (fully Fully immunized immunized) since the mid 1990s. Nevertheless, it should be noted that Rwanda still has maintained coverage rates which are higher than many countries in sub-saharan Africa that have not experienced a genocide and war. There are virtuall no rich/poor differentials in coverage rates. Prenatal Coverage In spite of the genocide/war, the DHS at least I prenatal visit (%) country has succeeded in maintaining relatively high prenatal coverage rates; nevertheless, continuity of prenatal care is very low with only 10% of mothers reporting at least 4 prenatal consultations. Deliveries assisted by a The proportion of deliveries assisted DHS health professional (%) by a health professional has risen slightly even though it remains relatively low. Rwanda has very few trained midwives; most rural deliveries are assisted by traditional birth attendants

27 Objecttfl strat6glelactuvtte Unit6 QuanUteTri QuantotiTrt QuantoTrT QuantiteTri Quantit6Trl QuanUttTri QuanUt6Tr m.1 m.2 m.3 m.4 m.5 m.6.1a6 REDUIRE LES PROBLEMES DE SANTE ET DE POPULATION DU RWANDA REDUIRE LINCIDENCE ET L'IMPACT DE L'INFECTION A VIH _ Contrlbuer au fonctlonnoment de to Commission Nationale de Lutte contre to SIDA (CNLS) Doter la CNLS d'un vahicule 4x4 au deuxieme vehicule trimestre de 2001 tout4errain I Doter la CNLS d'un lot de matriaels de bureautique (2 lot ordinateurs et accessoires, logiclels ddto, 1 photocopieuse et accessoires, retroprojecteur, 6cran et divers) au deuxibme trimestre de 2001 Doter, chaque trimestre, la CNLS en foumitures de lot trimestiiel bureau necessaires pour le fonctionnement de ses services administratifs (A raison de 1 lot par trimestre) Recruter, en 2001, le personnel technique et agent administratif necessaire au foncbonnement du CNLS recrute Financer los frais de personnel pour 2 consultants personne-m pour le CNLS (a raison de 1000 dollars par mods et ols par consultant, pdt 15 mols) Financer leas frais de personnel pour 3 agents personnt-m d'ex6cution/support pour le CNLS (A ralson de 700 ois dollars par mois pdt 15 mols) Organiser deux atelbers pour l'adopton d'un Plan atelier strategique natonal revise de lutto conbre le SIDA, au dodeuxem tnmestre de 2001 (A raison de dollars par atelier) Mettre a jour le Plan strat6gique national de lutte consultation contre le SIDA, au deuxisme tiimestre de 2001 nabonale Reproduire le document du Plan stratgique national cople de lutte contre le SIDA (A raison de 100 exemplaires par tnmetre et 5.00 dollrs par exemelalre) Organiser, tous los 6 mols, 1 comp6tition/foire a foire idees pour la s4lection des meilleurs projets de lutte contre le SIDA Organiser, tous leas 6 mois, 1 concours pour identifier concours et reoompenser les trols meilleurs projets de lutte contre le SIDA Appuyer financierement des projets de lutte contre projet les comportements sexuels A risque en favour des elements do rapr, A raison de 6 projets en 2001 et 2 en 2002 Appuyer financidrement des projets de lutte contre projet les oomportements sexuels a risque en faveur des jeunes, b ralson de 1 projet en 2001 et 1 en 2002 Appuyer finanrcirement des projets de lutte contre projet les comportements sexuels a nsque en favour des associabons feminines, A ralson de 1 projet en 2001 et 1 en 2002 Appuyer financderement des projets de lutte contre projet les oomportements sexuels A risque en faveur des oommunautes locales, A raison de 1 projet on en 2002 Appuyer finandorement des projets de lutte contre projet leas comportements sexuels a risque en faveur dos associations religieuses, A raison de 1 projet en 2001 et 1 en 2002 Appuyer financdrement des projets de prise en projet charge dos personnes vivant avec le VIH. a raison do 1 projet en 2001 et I en 2002 Organiser un voyage de IO jours A Washington de 7 personne-vo experts nabonaux pour relaboration du document du yage Projet Multisectoriel do Lutte contre le SIDA (MAP) (A - 23-

28 raison de dolars par expert et par voyage) I_I Assurr la partcpatior des cadres nationaux a des cadr-voyag ateliers Intafatbonaux sur la SIDA et les autos IST, e a ralson de 6 cadres par an Organiser 3 runlons semestrbilles 6argles du CNLS reunbon (A raison do 1500 dollars par reunbon) elargi Assurer la diffusion des spots radio (b ralson do 2 spot-semahn spots par semaine pendant 40 semalnes) a Assurer la diffusion des spots tevlss (a raison de spot-sefahn spots par semaine pendant 40 semaines) e Assurer la producfion des 6missbons radio (b raison mlsslon de 1 emisslon par semahne pendant 40 semaines) Organiser es actvits de la Journ6e mondiale du JMS SIDA (JMS) en 2001 (A ralson de dollars par Finanoer rassurance dun v6hicule du CNLS (A vehicuboan raison drune moyenne do (500 dollars par an, pdt 2 ans) Assurer Is fonctonnement et la maintenance d'un vhkcule-mol vehicules du CNLS (a raison drune moyenne de 200 s dolars par vehicule et par mols, pdt 16 mols) Assurer le fontonnement et lmanteonanos de mos materiel de bureautique du CNLS (a ralson de 125 dollars par mois, pendant 16 mols) Contribuer aux frals de tl6phone, Fax, lntemet du rnois CNLS (A ralson do 300 dolars par mols, pendant 16 mois.) Assurer l achat de carburant n6essaire pour vahicule-mol rex6cutlon des deplaoements de service du CNLS (a s raison de dollars par mois, pdt 16 mols) Contribuor au tonct/onnement de l'unlta du Programme Nationale de Lutte contre le SIDA au sein du Mlnist6ro de la Sante (PNLS) Doter, chaque trimestre, ie PNLS en foumitures de lot trimestnel bureau necessaires pour le fonctonnement do ses services administratits (A ralson del lot par tnmestre) Assurer le fonctionnement et la maintenanoe et vahicule-moi rassurance de 5 vhicules du PNLS (a ralson d'une s moyenne de dollars par vehicule et par mnos, pdt 16 mols) Contribuer au foncdonnement et a namantenance de mols nateriel do bureausique du PNLS (a raison de 315 dollars par mols, pendant 16 mols) Susciter des projets valables de utt contre le SiDA projet on faveur des beunes, des militaires, des groupes f6minins, des camionneurs et d'autres groupes a nsque (a ralson do 2 projets par trimestre) Assurer ie gardlennage/sacurita et lentretien des mois bauments du PNLS (a raison de 200 dollars par mdos, pendant 16 mols) Fhnancer les frals de personnel pour 1 consultant personne-m pidemiologiste pour Ie PNLS (A ralson do 1000 ods dolars par mols et par oonsultant, pdt 16 mols) Fnaner esfrais de personnel pour 1 oonsultant personne-m comptable pour le PNLS (a raison de 1000 dollars dls par mois et par consultant, pdt 3 mols) Contrlbuer aux frals de telphone, Fax, internet (3 mols lgnes) du PNLS (A raison do 375 dollars par mols, pendant 16 mols) Assurer la producon des emissons rado (A raison emisslon de 1 emisseon par semanne pendant 68 semahnes) Assurer la formation onunue du personnel agenttamia Appui fnancier et technique A la rchrche en millu projet hospitalier et universitaire ( A raison de 2 projets en 2001 et 1 en 2002 ) -24 -

29 Visitor, chaque semestre, tous les districts sanitaires toumbe dans la cadre de la supervision des activitas m6dicales de lutte contre le SIDA (b rmison do 1000 dollars par toumbe) Contribuer au fonctonnement du Centre Rwandals d7nformatlon sur le SIDA (CRIS) _ Doter, chaque trimestre, le CRIS en foumftures de lot trimestriel 1 1 I bureau nbcessaires pour le foncuionnement de ses services administratifs (A rabson de 1 lot par timestre) Assurer to fonctionnoment et la maintenance de 1 v6hiculo-mol vehicule du CRIS (a rasson d'une moyenne de 300 s dollars par vehicule et par mois, pdt 16 mois) Susciter des projets de counseling et de testing projet volontaire en favour des jeunes, des miltaires, des groupos f6minins, des camionneurs et d'autres groupes a risque (a raison de 1 projet par timestre) Contribuer au fonctonnement et A la maintenance de mois materiel de bureautique du CRIS (a raison de dollars par mois, pendant 16 mols) Conribuer aux frals deau et d'electriat6 des mots bauments du CRIS (a raison de dollars par mois, pendant 16 mols) Contribuer aux trals de telephone, Fax, Intemet (3 mois lignes) du CRIS (A ralson de dollars par mois, pendant 16 mois) Assurer l achat de carburant necessaire pour la v6hicule-mol supervision desdiff6rents programmes du CRIS (A s relson de dolars par mois, pdt 16 mois) Rdduire la transmission sexuello du Virus de 0 I lmmuno-deflclence humalne (VWI _ Appuyer techniquement des projets de lutte contre projet les comportements sexuels a risque en favour des elements de rapr, a raison de 8 projets en 2001 et 4 en 2002 Appuyer techniquement des projets de lutte oontre projet los comportements sexuels A risque en favour des Jeunes, A raison de 2 projets en 2001 et I en 2002 Appuyer techniquement des projets de lutte oontre projet les comportements sexuels A risque en favour des associaaons feminines, A raison de 2 projets en 2001 et 1 en 2002 Appuyer techniquement des projets de lutte contre projet los comportements sexuels a risque en faveur des communautes locales, A raison de 2 projets en 2001 et 1 en 2002 Appuyer techniquement des projets de lutte oontre projet les comportements sexuels A risque en faveur des associabons reugieuses, A raison de 2 projets en 2001 et 1 en 2002 Assurer rachat de condoms (au prix de 20 cart.a Fnw par paquet de 4 condoms) condoms Approvisonner 350 oentres de sant6 en condoms, A cart.b ralson de 5000 condoms par oentre et par taimestre condoms Approvbisonner les gamisons de PAPR en condoms, cart.a ,500 2,500 2,500 2,500 2,500 2, a ralson de 5000 oondoms par gamison et par condoms trimestre R6dulre /a transmission sanguine du Virus de 0 Iilmmuno-deflcence humalne (If _ Assurer l achat de tests VIH et 2 (a raison lot de de 350 dollars par 100 tests) tests Elaborer un guide sur la transfusion sanguine A consultadon l1ntention du personnel de santb natonale Reproduire le Guide sur la transfusion sanguine (a copie raison de 500 exempaires et 10 dolars par exemplaire) -25-

30 Disponibiliser Is Guide sur la transfusion sanguine au copla niveau dz chaque atabfissem=nt sanitzira (a raison do 6 sxemnp!ares par taxbussmant) 00 RMd00re to mrlsmioszion m7or-enfn1 do O Mattre A lour to Gu!da sur la pravantion ds Ia consultaton transmission rnbr3-enlant do l'infction A VIH Raproduire la Guide sur la prsvention ds is copis tansmission mire-onfent de rinection A VIH (A raison dz 500 ex3mplairss at 17 dollars per exemplare) Disponibti&sr Is Gu!dz sur [a pravention de la copts transmission mare-enfant au niveau do 10 structurs sandtaires (b raison da 10 exemplaires par 6tablisscm3nt), Assurer la formation do 250 agents dans la agent forme prevenbon de ia trensmission mbre-enfant (b raison de 50 agants par trimastre at 40 dollars par agent) Doter 10 cantres d'un lot do mat6rials n6cessaires lot timestbiel pour la prv3ntton de is transmission mare-enfnt da rinfection VIH au dsuxiama trimestre de 2001 (A raison de 20C0 dollars par lot) Doter, chaque trimastre, 10 centres en madicaments lot btimestiel et autres consommabls n-cessaires pour ta pr6vention de la transmission do l'lnfecton VIH (A ratson da 1000 dollars par lot) Am6NIIas lb pz7lo on cherge dss6 coo dn Infaectlon sezuelesmant tirnsmisslb.es(i"f) a Eisbormr un guide sur is pnss en chargs des cas consultaton d'ist nationals Reproduire Is Guida sur la priso en charge copie 0 1, ,000 syndromique des [ST (b raison do 1000 examp!eires et 10 dollars par exempiaire) Disponibiliser le Guide sur la prise en charge copbs syndromique dss IST au niveau do chequ3 6tablissement sanitaire (A raison de 5 exemp!aires par 3abbliss3m2nt) Disponibilissr le Guide sur la priss en charge copis syndromique des IST au niveau dss pharmedcs at officines (A raison do 5 exemplaires par 6tablisssment)_ Assurer a formation da 85 agants dns la prse on agent form charge syndomiqu3 des IST (a raison do 17 egents par trimostre at 40 dolisrs par agant)_ Prooder a l achat de tssts repide GAnia1 at lit de (b raison ds 330 dollars par 100 tests) tests Proceder b rachat do tests da confirmation (A bolte ds raison do 435 dolisrs par 100 tests) tests Doter Ia centre do dapistags d'un lot do meatrle!s lot pour Is dspistage du VIH (centrifugousas, chronomatr3s, groupo Alsctrcgtnes, ordinateurs portables, stabilisateurs at divers, A raison do dollars par lot) Doter, cheque bifmstre, Is centre en consornmabies lot trimestrial ncssaires pour is dapistago du VIH (aigutlzs. vacutainers, tubss do prfatvamnnt avec EDTA, ouats, alcool, tubes A s6rum, et divers) Arnl6lorw Ihccrss ouz scmces de coune-ning et 0 testinq volont3lm pour li'nfectlon 6 VWN (CM Elaborer un guldz sur l prise en charga das consultation personnes consuliant lse servicas de CTV Reproduirs Guide sur la ptis en charge des copts parsonnes consultant las servics ds CTV (A ralson da 100 exempteires par ttimsstr3 at 10 do!lars par exemplaire) -26-

31 Disponibiliser le Guide sur la prise en charge des copie personnes consultant les services de CTV (a raison de 5 exemplaires par etablissement) Etablir des mrcanismes de collaboration entre les consultabon centres CTV, les districts sanmtaires et les autres intervenants communautaire de facon A faciliter rodentation et le sum des personnes test6es dans les centres CTV Assurer la formation en CTV de 200 conseillers des agent forme communaut6s en 2001 (A raison de 50 dollars par agenq _ Doter lacentre dun lot de materiels de counseling et lot de de testing volontaire (a raison de 5000 dolars par lot) materiel CTV I Integrer les services de VCT dans au mons 12 district nouveaux districts de sante Assurer la formnation continue du personnel ( agent formr counselling, technique de labo et gestion des donnees statistques et hnfornnauque ) Amdllorer la prise en charge des personnes 0 vivant avec le VIH. Ebaborer un guide sur la prise en charge consultation psycho-medicale pour la prise en charge des personnes vivant avec le VIH Reproduire 2000 exemplaires du Guide sur la prise cople 0 2, ,000 en charge psycho-medicale des personnes vivant avec le VIH (a reison de 10 dollars par exemplaire) Disponibiliser le Guide sur la prisa en charge copie psycho-medicale des personnes vivant avec le VIH au niveau de chaque distrid sanitaire (a raison de 100 exemplaires par distnct) Assurer la fomation de 50 formateurs en prise en agent forme charge des personnes vivant avec la VIH (a raison de 30 cadres par an. 6 jours par formation et 40 dollars par agent) Assurer la formation de 6 medecins dans rutlisauion agent forme des anti-ratroviraux (a raison de 3 cadres par an, 6 jours par formation et 2514 dollars par agent) Appuyer tachniquement et financiarement des projet projet de prbe en charge des personnes vivant avec le VIH, A raison de 4 projets en 2001 et 2 en 2002 Sulvre l'evolutlon de llnfectlon A VWH et dautres 0 Infections sexuellement transmissibles (IST) Assurer Iachat de reactifs pour la lot mensuel surveillance Apidemiologique des IST, y compris rinfection a VIH (a raison de 350 dollars par lot de 100 tests) Doter 14 sites sentinelles dun lot de ractifs pourla lot mensuel surveluance ApidAmiologique des IST, y compris linfecton a VIH (a raison de 1 lot par centre et par tilmestre et 500 dollars par lot) Assurer ie recyclage de 30 technicians sanhtaires technicien dans la surveillance epidbmiologique des IST, y compris l'infedtion A VIH, a raison de 20 cadres en 2001 et de 10 en 2002 (a raison de 40 dollars par technicien) Organiser des reunions trimestrielles dcrchange raunmon dinformation sur les donnaes recentes de la organisee recherche (A ralson de 1500 dollars par rbunion) Assurer la partcipation des cadres a des ateliers cadre-voyag intemationaux sur le VIH / SIDA /IST y compris e rinfecuon a VIH a raison de 3 cadres en 2001 et 3 en 2002 (A raison de 1813 Dollars par cadre et par wayage)_ ASSURER UN ACCES CONTINUE AUX 0 MEDICAMENTS ESSENTIELS GENERIQUES (MEG) I I I_I_I_ -27-

32 Am6llorer 1enreglstrnment. IlInspectfon et to 0 contrme de qualito des prodults pharmaceutlquos Elaborer des decrets et autres textes d applicabon de consultaton la Lol sur IArt phamiaceutlque, sp6clalement sur renregistrement rlnspectlon et le controle de qua.9tb des produfts pharmaceutlques Signer et pubier les d6crets et autres txtes textes d'application de la Loi sur IArt pharmaceutique Installer une CommIssion dcenregistrement des commission mdicaments au soin do la Direction de Pharmacle (DPh) Dotor, chaque timestre, la Directon do la Pharmacie lot tdmestriel en foumitures de bureau necessalres pour le fonctiornement de ses servioes administratifs (b raison de 1086 US$ par trimestre) Recruter, en 2001 l personnel technique et agent administratif supplbmentaire n6cossaire pour le bon fonctionnement de la DPh Flnancor les frals do personnel pour un consultant personne-m pour la DPh (a raison de 2000 US$ dollars par mois ods et par consultant, pdt 15 mois) Financer ls frais de personnel pour 3 agents personne-m dexacution/support pour la DPh (A raison do 740 ods dollars par mols et par agent, pdt 15 mols) Organiser deux atelbors de formation sur la ligisation atober pharmaceutique, au dewdume trimestre de 2001 b lintention de 100 pardcipants (A raison do dolars par ateller) Etaborer un guide dlnspection des pharmacies et consultation officines nationale Reproduire 100 exemplaires du Guide d'inspecuon cople des pharmacies et officines (A ralson de 35 dollars par exemplaire) Disponibliser le Guide dcinspectuon des phamaiades cople et officlnes au niveau de chaque district sanitaira (A raison de 5 exemplaires par district) Recruter une Agence pour rinspection des agence pharmacies et officines pour un contrat A durbe de 1 recrut6e an renouvellable Assurer le paiement des activitbs dlinspecuon des forfait I pharmacies et offidnes effectubes par ragence trimestiel Financer rassurance drun vbhicule de Is DPh (A vehicule-mol ralson d'une moyenne do 700 dollars par mols, pdt 24 s mobs) Assurer le foncuonnement et l maintenance drun v6hicule-moi v6hlules de la DPh (A ralson d'une moyenne de 145 a dollars par vehicule et par mois. pdt 16 mols) Contribuer a rrmaintenance des batiments de la mois DPH (a ralson de 400 dollars par mols, pendant 18 mobs) Assurer le fonctionnement et la mantenanoc de mols matbriel de bureautique do Is DPh (A ralson de 85 dolars par mobs, pendant 16 mobs) Contribuer aux frabs de tblphone, Fax, lntemet (5 mols Ugnes) de Is DPh (A ralson de 193 dollars par mois, pendant 16 mois) Assurer I'achat de carburant n6cessalre pour v6hicule-mol rex6cution des d6placements de servole de la Dph (A s rison de 250 dollars par mois, pdt 16 mdos) Am6llorer Ia gesuon et lusage des modlcaments aux nhveaux pdrph6rigue, Intenrmdlaro et central Elaborer un Guide sur la gestion et b bon usage des consultation medicaments nationale I I_I I_I Reproduire 500 exemplaires du Guide sur Is gestion copie etil bon usage des modbcaments (b raison de

33 dolbars par exemplire) I Assurer la formation de 40 cadres (m6decns, agent form pharnnadens et infirmiers) dans la gestion etis bon usage des m6dicaments (a raison de 40 cadres par an, 6jours par formation et 150 dollars par agent) Organiser, chaque semestre, une enquete legere sur enquete la gestion et l'usage des medicaments _ Doter la DPH d'un v6hicule 4x4 au deuxilme vhicule tout timestre de 2001 terrain Amellorer la disponiblllta des MEG au nlveau des DlstHcts sanltalres Doter, chaque trnmestre, 5 Dlsbicts sanitalres en lot trlmestrlel m6dicaments et autres consommables medkcaux necessaires pour le soins des malades (a raison de USS par lot) ASSURER UN ACCES CONTINUE AUX SOINS DE SANTE PRIMAIRES AU NIVEAU DE 5 DISTRICTS SANITAIRES Amdllorer la quallte des seivices foumis au ntveau de 5 Districts sanitaires Achever la constructon de l HOpital de Muhima ensemble de travaux Achover l6quipernent de rhopial de Muhima lot equipement Contibuer la r6novation de I5 centres de sant6 centre dans 5 Districts sanitaires (a ralson de _ doulars par contre de sante) Equiper 28 centres de sante dans 5 Dlstricts lot sanitaires et 5 hopitaux de district en equipement radbcommunication Dotr, chaque trimestre, 5 Districts sanitaires en lot trimestrb foumitures de bureau necessaires pour le fonctionnement de ses services administratifs (A raison de 400 dollars par lot) Recnuter en 2001 l personnel technique et agent admhnistrauf suppiementaire necessaire pour le bon foncionnment de 5 Districts sanitaires Financer les frais de personnel pour O m6decins personne-m expatries pour 5 Disbicts sanltaires (a raison de 750 ols dodars par mois et par consultant, pdt 18 mois) Effectuer des visfes d supervision des contres de toumee sante par les medecins ou les superviseurs de oomplete district (A ralson do 1 toumee par distrit et par moi et 200 dolars par visite) Assurer rachatde carburant necessalre pour la vehkcule-mol r6alisation des d6placements de servies do 5 s Districts sanitaries (a raison de 318 dollars par mods et par district, pdt 18 mois) Financer laswrance de 10 v6hicules de Districts vehicule-mol sanitaires (a raison d'une moyenne de 145 dollars pa s an, pdt 2 ans) Assurer le fonctionnement et la manteriance de 10 v6hicule-moi vehicules de Districts sanitaires (A ralson dcune s moyenne do 145 dollars par vehicule et par mols, pdt 18 mots) Assurer le fonctionnoment et la mantenance des dustrict-mds equipements m6dicaux de 5 Districts sanitaires (A raison de 77 par mois et par district et pendant 18 mols) Renforcer Is fonctionnement de la Direction des Soins de Sante (DSS) Mettre A lour le Guide de fomiation des animateurs consultation de sante natbonale Mettre a jour le Guide de supervision Int6gr6e dos consultaion activit6s de Districts sanitaires nationale Rediger, chaque semestre un rapport sur l consuitation

34 rendement des animateurs de santa I I_I Rediger, chaque semestre, un rapport dataimio sur le consultation rendema nt des Distrits sanitaires Assurer 4 sessions de formatons en santa session reproductive et en IEC pendant 6 jours chacune pour au moins 2 agents de santa par FOSA, A ralson de 3500$ par session Assurer des sesslons de formation de 5 jours pour session les 1200 animateurs de santl nouvellement alus, selon le module ravisa a ralson de 1 session de fomation par district et par semestre et 2000$ par session _ Assurer rachat de 1200 lots de materiel (cahier stylo, Lot ,200 fiches de rapport, classaurs,..) pour les animateurs de santa fommes, A raison de 10 dollars par lot Financer les frals d'un consultant Intemational pour homms l'oirganisation dans un district pilote de rorganisation mols du financement des services selon le rendement du districta raison de 5000$ par mois _ Assurer la participaion des cadres de la DSS et des hommes/ Districrts de sante a des confarences sur le mols financement et la gestion des programmes de sante Recniter, en 2001, 2 consultants pour le sum agent technique et comptable des activites de Distncts sanltaires Financer les frais de personnel pour un personne-m Gestionnazre-comptable charge du suivi des activitbs ois des Dtstricts saniltaire (a raison de 1000 dollars par mots, pdt 16 mods) Contnbuer aux frais deau et d6lectricit des moas beatiments de la DSS (a raison de 347 par mois, pendant 18 mois) Contribuer aux frais de telephone, Fax, Intemet (5 mois lignes) de la DSS (a raison de 434 dollbrs par mois, pendant 18 mois) Assurer fachat de carburant necessaire pour la vehicule-moi supervision des diffbrents programmes de la DSS (a s ralson de 318 par moms, pdt 18 mols) Visiter, chaque semestre, tous las districts sanitaires toumbe dans le cadre de la supervision integrbe des activitbs de soins de sante primaire (A ralson de 900 dollars par toumrrbe) Financer rassurance de 2 vehicules de la DSS (A vehicule-moi raison d'une moyenne de 145 dollars par an, pdt 2 s ans) Assurer le fonctionnement et la maintenance de 2 vahicule-mol vehicules de la DSS (a raison d'une moyenne de 14c s dollars par v6hicute et par mads, pdt 18 mois) _ Contribuer au fonctionnement et Ala nmaintenance forfait des equipements de bureau de la DSS (A raison de mensuel 77 dolars par mols et par district et pendant 18 mads) Renforcer te fonctuonnement du MEPS (ou Rwanda Center for Health Communicaton) Doter l MEPS d'une presse d'imprimnrie et unite de accessoires presse Doter b MEPS dun lot de papiers drimprimerle rouleaux de papier Effectuer Ilaudit du MEPS consultaton nationae _ Assurer ls salaires du Personnel National (araison mols d'une moyenne de dollars par mois, pdt 9 mois) Assurer le carburant de 2 vhicules du MEPS (A vhbicule raison de 450 dollars par vbhicule et par mois, pendant 15 mods) Assurer la rbhabilitation dune salle dlmprimerie pour lot travaux

35 le MEPS genie dvil i Effecteur une etude sur la capacite d'auto-finacemen consultation du MEPS nationale Financer l'assurance de 2 -Ahicules du MEPS (a v6hicule-mol raison d'une moyenne de 145 dollars par an, pdt 2 s ans) Contnbuer au fonctlonnement eta la maintenance forfait des equipements de bureau du MEPS (A raison de 1 mensuel 350 dollars par mols et pendant 15 mols) Contribuer au fonctonnement et la nmaintenance forfait des equipements techniques du MEPS (a ralson de 1 mensuel 500 dollars par mois et pendant 15 mois) ATrENUER LES PROBLEMES DE POPULATION _. Amillorer la comprdhenslon des phenomenes de populatfon Realiser une etude sur la Population et l'habitat consultation regroup6 nationale _' I Publier, chaque semestre, un rapport commente sur rapport Iletat des indicateurs-cles du phenomene de la population au Rwanda Rentorcer to consensus natonal sur la nature et los solutons des problimes de population Assurer la diffusion des spots radio (a ralson de 2 spot-semain spots par semaine pendant 78 semaines) Le contrat e est semestriel Assurer la diffusion des spots televisbs (A raison de 2 spot-semain spots par semaine pendant 78 semaines). Le contrat e est bimesbiel Assurer la producion des 6missions radio (b ralson Amission de 1 emission mensuell pendant 16 mois) mensuelle Organiser, chaque ann6e, une Semaine Nabonale de semalne la Populabtion (SNP) Organiser, chaque mols, 1 concours radio-diffuse sa concours les questions de population, avec remise des prix Organiser, tous los 6 mois, 1 concours pour identfier concours et recompenser [es trols meilleurs projets de lutte contre les problemes de population dans les categories suivantes: publicauon scientblque, chanson, Plce de theatre, Organmser, chaque mois, une conference-debat sur conference un probleme de population A l'intenuon d'un des groupes-cibles suivants:cadres communaux, associatons de jounes, autorites religieuses, autontes administrauves, membres des comites iocaux. Organiser, cheque semestre. I seminaire pour la seminaire vulgarisaton des resultats des etudes realis6es sur une quesbon de populabtion (a raison de 2320 dollars par seminaire) I Assurer la traduction, en kinyarwanda, des resultats consultaton des Atudes realisees sur une question de population Rediger 1 livret tilingue (en kwnyrwanda, frangais et consultation anlais) sur des questons de populabon Produire 2000 exemplaires de 1 livret tbilingue (en exemplaire 0 0 2, ,000 kinyrwanda, francais et anglais) sur des questions de population (A raison de 10 dolars par exemplaire) Developper les competences natlonales sur les quesuons de populaton Elaborer, en 2000, un Guide pour l'laboration des consultabon plans communaux qui Inthgre la variable populabon ainsi qu un modble-type de plan communal developpe selon ce guide Assurer la formaton sur los questions de populaton personne de 50 formiateurs des ministeres-cies (a raison de 50 form6e cadres par an, 6 jours par formaton et 120 dollars par agent) -31 -

36 Assurer la formatlon sur les questons de populaton personne de 450 cadres des assodations de jeunes (a raison form6e de 450 cadres par an, 6 jours par formation et 120 dollars par agent) Assurer la formaiton sur les questions de population personne de 450 cadres des associations f6minines (a raison form6e de 450 cadres par an, 6 Jours par formation et 120 dolars par agent) Assurer la formnation sur les questions de population personne de 200 responsables des cooperatives et des fonmne associations de developpement communautaire (a raison de 200 cadres par an, 6 jours par formation et 120 dolars par agent) Assurer la formation sur los questions de population personne de 80 membres des ONGs locales (a ralson de 80 formie cadres par an. 6 jours par fomation et 120 dollars par agent) Assurer la formation sur les questions de populaton personne de 30 joumalistes (a raison de 30 cadres par an, 6 formma lours par formation et 120 dollars par agent) Assurer la formaton, sur les questons de populabon, personne de 1080 enseognants du primaire (A ralson de 1080 tommie cadres par an, 6 jours par formation et 120 dollars par agent) Assurer la fofnaton sur ls questions de population personne de 228 enselgnants du secondaire (a rabon de 228 fofmioe cadres par an. 6 jours par fomialon et 120 dollars par agent) Rnwforcer le tondlonnomont de I /MTlco Natonal de Population (ONAPO) Doter, chaque trlmestre, l'onapo en foumitures de lot trimestrel bureau necessaires pour lo fonctionnement de ses services administratifs (a ralson de 1250 dolars par lot) Assurer le fonctonnemnt et la maintenance de vihicules do lonapo (a raison d'une moyenne de vehiculbs-m 145 dolars par vehicub et par mols, pdt 16 mols) ois Contribuer au fonctionnement et a maintenance de mois materiel de bureauuque de ronapo (A ralson de 60o dollars par mdos, pendant 16 mols) Contrtbuer la malntenance des batmentsde mole ronapo (A ralson de 145 dollars par mols, pendant 16 mols) Financer les frais de personnel pour - consultants personne-m 0 pour l'onapo (a raison do - dollars par mols et ods par consultant, pdt 15 mols) Financer les frals de personnel pour - agents personner-m 0 d'ex6cutionrsupport pour ronapo (a raleon de _ ois dolars par mobs et par agent, pdt 15 mods) Contribuor aux fais d'eau et d'lectidtcli des mobs 0 bauments de lonapo (A ralson do par mols, pendant 18 mols) Contribuer aux fais de telephone et Fax de ronapo mole 0 (A raison de - par mols, pendant 18 mols) Assurer rachat de carburant nbcessaire pour la supervision des dlfmrents prgrammes do ronapo vhloule-mol (a ralson de 3000 dollars par mole, pdt 16 mols) s Vister, chaque semestre, los prfelctures dans le toumrne cadre de la supervision des acthvttts do population (A raison de 395 dollars par toumeie) ASSURER LE FONCTIONNEMENT DE L'UNIE DE GESTION DU PROJET (UGP) Rdiger, chaque semostre, un rapport synthtique rapport sur les depenses et les rsultats du Projet Organbser, chaque semestre, une reunlon du Comite reunlon du do piltage du Projet Comrte _ Reallser, chaque annee, un audit exteme du Projet consultation