Rwanda’s Fight on HIV/AIDS: Strengths, Challenges, and the Catalyst

Interview with Highest Ranking HIV/AIDS Official in the Rwandan Government

High level executives at the UN Development Program described her as a wealth of knowledge. A Senior Advisor for PEPFAR praised her for her detailed approach and drive. An administrator from Partners in Health said she is the exact person you want to talk to. In every one of these meetings I thought - who is this Dr. Agnès Binagwaho? Well, she is the Rwandan government’s highest official in the field of HIV/AIDS. Her title reads Executive Director of the National AIDS Control Commission but she is much more than that. She is personable and insightful in her speech, straight forward in her talk, and pragmatic in approach.

I got the chance to interview Dr. Agnès during the break of a conference on monitoring and evaluating international aid effectiveness. Every African country was represented at this conference as its importance is crucial for achieving sustainable development. Money wasted literally costs people’s lives for many of these countries. It was in this setting that I got to discuss three key issues with the foremost authority on HIV/AIDS in Rwanda.

In a previous interview, the UNAIDS Rwanda Director highlighted the decentralized approach of Rwanda as one of its greatest successes. Dr. Agnès reponse built on this foundation. “What I am telling you is the government vision – we want to harmonize, to align people behind one unique action plan designed according to the needs of the country.” Some foreign governments, above all France, have been overly critical of the leading party, and in the past, some painted them as a new dictatorial regime. But how was this national plan created? “We put together all the constituencies, like the civil society, the development partners, the new private sector etc, and we ask them to tell us their needs”. Identifying needs is important, but what about the decision making? “They each have their own priorities but we try to figure out what we can work on at that time. They also decide with us what to take and leave out of the plan. It makes sure people are working with less frustration when they are part of the decision.” I stop and can not help smiling at the wisdom of that statement.

The National Strategic Plan is the heart of the successful approach, but where are the arteries and veins that circulate the vision and action? In 2006, Rwanda went through an administrative adjustment. It restructured its many districts into 30 larger ones and created 5 provinces (named in their relationship to the fifth province – Kigali City). The strategic plan is entirely implemented through the district level. Everyone at the above levels are coordinators and managers instead of implementors. Each district has an HIV/AIDS committee that is comprised of a multilateral membership. The director of each district’s health program, hospital, education, and gender initiatives are included and the committee is rounded off by two vital and crucial members of “civil society”; a religious leader chosen by the different denominations (mainly Catholic, Anglican, and Muslim) and a person living with HIV elected by the local network of people living with HIV. This committee is led by two officials that report directly to the mayor (who has the authority to make decisions but in conjunction with the national strategy and policies). This approach has led to a remarkable level of success throughout the entire country. Many of the measures of success, such as testing and people receiving treatment, have more than doubled since 2005.

There are a plethora of successes, but what are the challenges? Rwanda after all is one of the poorest countries in the world, and is heavily reliant on foreign aid; now ‘there’s the rub’. Although Dr. Agnes agreed with the UNAIDS Rwanda director that evidence and data are needed to target at-risk groups, she focused her response on the issue of foreign aid. “The big challenge is what is going on in this meeting right here. It is alignment harmonization of partners in our true priorities and action plans. People come and say we have come to do statistics but okay. They don’t come in and say, ‘We have come and want to help you. We have this amount of money. Where do you need to put it.’ This is the support we need. That is how you may have some critical sectors that are not funded. Without this approach it will be very difficult to create sustainable development and you can not fight AIDS without sustainable development.” What she is really saying is that their officials understand and have worked diligently to access and prioritize the needs of their own country. The call is for budget support and not vertical giving that is targeted based on the funding organization's priorities.

Dr. Agnes singles out PEPFAR as an example of the good that can come out of foreign aid working within the framework of the government. “PEPFAR is one of the success stories because PEPFAR here is aligned to our national strategy. They don’t do a vertical program. They integrate where they have to be. We still don’t like the way they break down the money and the cost of everything because it is not totally clear but they do it within our strategy. This is only because we had the political will to oblige them to do so.”

It leads right into our most interesting topic – what was been the catalyst for this united vision and this successful program on HIV/AIDS? Her simple two word answer is one that has stayed with me from a FACEAIDS conference keynote by Jim Kim – political will. She emphasizes that programs and initiatives that will help reach the Millennium Development Goals and other goals will be implemented. Politics used to be a deadly game in Rwanda, but this is the new Rwanda. “Really we never go for pockets, we always go for national. This is important to note also – it is because the previous regime before 1994 was based on exclusion and discrimination. The new orientation is inclusion and participation, which means no place in the country is left out, no portion of the population is left out, and everything is national. What is good for the north is good for the south. What is good for me is good for you. This is a policy that is implemented for the community and that is the difference. There are no pockets.” “No pockets” is another way of saying – favoritism and ethnicity no longer apply here.

My interview with Dr. Agnès was refreshing. It was a reminder that vision is vital to solve any problem and that a pragmatic approach can create hope even in the depths of devastating tragedy. Rwanda certainly has many challenges that lay ahead, but it can point to its health sector as a symbol of success. A symbol of something designed and coordinated by Rwandans for Rwandans with financial aid coming from an international community that perhaps is attempting to literally pay for past indifference.

Postmark: This entry has been published onto Rwanda's National Government AIDS Website