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This report comprehensively summarizes the FHI/AIDSCAP program in Rwanda (1993-1997). The report includes a discussion of background and context, as well as accomplishments, constraints, implementation and management issues, outcomes, and lessons learned and recommendations for each of two components.
Table of Contents I. Country Program Description C. Accomplishments and Outcomes D. Implementation and Management Issues (See Below) II. Lessons Learned and Recommendations III. Refugee Intervention in Tanzania IV. Subproject Highlights I. Country Program Description (continued) D. Implementation and Management Issues 1. Implementation The USAID/Rwanda AIDS Prevention Project was implemented through a Cooperative Agreement awarded under the AIDS Technical Support Project to Family Health International (FHI). The program was executed and managed by the AIDSCAP Rwanda country office in Kigali, with support from the AIDSCAP Africa Regional Office in Nairobi, Kenya. Under the original program design as outlined in the AIDSCAP Rwanda Strategic Plan approved by USAID/Rwanda in August 1993, the primary organizations concerned with the project's implementation were USAID/Rwanda, AIDSCAP and the PNLS. All three organizations committed to ensuring that the project would be implemented in a collaborative manner within the framework of an effective and successful working partnership. Equally important was the recognition of AIDSCAP's responsibility for the project's overall management, including its programmatic success and financial management and oversight. In order to foster close collaboration with the PNLS, the program design demanded that the PNLS appoint one of its staff members as the AIDSCAP counterpart. Following the reopening of the AIDSCAP office in the Fall of 1994, and subsequent discussions between the Ministry of Health, USAID/Kigali, and AIDSCAP, it was agreed to reactivate the AIDSCAP program in Rwanda. The Memorandum of Understanding drafted and signed prior to the war by representatives of the three organizations, USAID, MOH and FHI remained valid. Furthermore, the STD Unit Chief at the PNLS was appointed as the PNLS AIDSCAP counterpart. The counterpart was responsible for participating in project coordination, and under the direction of the PNLS director, providing general policy and operational guidance; and ensuring that AIDSCAP's work was within the framework of the MTP and other key MOH planning documents. Support from USAID was received in the facilitation of importing goods and equipment. As for program and technical support, given the shortage of technical staff at USAID, their preoccupation with emergency relief, management support was not as close as envisioned in the original country document. The post-war AIDSCAP program, although it targeted the same populations outlined in the original country program document, was limited both in scope and geographical reach due to reduced financial and human resources1. From discussions between USAID/Kigali and AIDSCAP/Nairobi it was learned that no development funds would be available during the life-of-AIDSCAP project, originally slated to end on 26 August 1996. Under the USAID/Rwanda postwar emergency program, the only available funds were earmarked for emergency relief work. Therefore the AIDSCAP program had to be implemented with the remaining funds of the first OYB transfer of US $4.2 M received in 1993. Of the $4.2 million, over $600,000 had been obligated to CARE International, PSI and JSI in July of 1994 to carry out a one-year pilot AIDS intervention program for Rwandan Refugees in the Ngara district of Tanzania. In addition, close to another $600,000 were spent prior to the conflict to fund activities implemented PSI and CARE International, the establishment of the country office, relocation and subsequent evacuation of AIDSCAP expatriate staff. In addition to the 4.2 Million, the AIDSCAP Rwanda program received an extra US $175,000 from the closed Burundi Program. The post-conflict AIDSCAP/Rwanda program was implemented by the PNLS of the Ministry of Health, in collaboration with the Medical Services of the Ministry of Defense, the Gitarama Health Region, and CIDC, as well as international and national NGOs. The original country office structure called for two expatriate staff: a resident advisor and a behavioral scientist, and a Rwandan staff including a Deputy RA, IEC and financial officers and support staff. After the war, the "new" scaled-down country office was managed by the former deputy, now serving as the Resident Advisor, and a support staff including two accountants, an administrative assistant, driver and cleaner. Under the original structure, and to foster close coordination and reduce costs to both projects, AIDSCAP/Rwanda had shared office space with the USAID funded Rwanda Integrated Maternal Health (RIM) Project. After the war, the RIM/AIDSCAP offices, spared from looting, were reoccupied by AIDSCAP and two of its implementing agencies: PSI and CIDC, both of whom had lost their offices, materials and equipment during the 4 months of civil war and unrest. The AIDSCAP Rwanda country office was responsible for the management and coordination of the program. This included close collaboration with USAID, the PNLS and the implementing agencies. The Resident Advisor had overall responsibility for the program, including monitoring of all subprojects. In order to ensure collaboration between projects and sharing of information, quarterly meetings were held at the AIDSCAP office with representatives of all implementing agencies. The country office was also responsible for coordinating technical assistance to all subprojects, whether provided by local or international experts. Requests and recommendations for regional and/or international technical assistance were forwarded to the regional office for approval and processing. Over the life of AIDSCAP, seven contracts and four rapid response fund activities were signed with government institutions and international and local NGOs. The subprojects were executed by each implementation agency under the supervision of the Ministry of Health, through the PNLS, or the respective headquarters of the International or local NGOs. Ministry of Health Projects Three projects were managed directly by the Ministry of Health. One focused on building capacity of the PNLS through strengthening its capabilities to manage and monitor STI and IEC activities on a national scale; the second one, in collaboration with the armed forces, was a peer educator program among the Rwanda military. The third public sector project concentrated on STI case management and was managed and implemented at the prefecture (provincial) health level, under the supervision of the Provincial Medical Director referred to as the MEDIRESA. A fourth project, focusing on Communication for Behavior Change was implemented by the CIDC. Although some of the CIDC staff were seconded by the Ministry of Health prior to the war, none of the CIDC staff received Government salaries for the duration of the AIDSCAP funding period. The CIDC, although at one time the IEC arm of the PNLS, was considered autonomous prior to the war. CIDC, with funds totaling almost $500,000, managed their funds directly and a project accountant was hired to ensure compliance with all USAID and FHI regulations. The Director of the PNLS managed the first two projects, whereas the MEDIRESA of Gitarama was responsible for the third project implemented in his health region. Funds were transferred to the respective accounts set up especially by the GOR for each subproject. Release of funds and reimbursement for services checks required two signatures: the project manager's and the appointed Ministry of Health official's signature. Complete records were kept by the PNLS administrator and the Gitarama Region accountant. Release of funds was often slow since checks needed to be sent to the MOH for the second signature. In early 1996, a USAID team from the Nairobi REDSO/ESA office visited Rwanda to assess the HIV/AIDS situation, and to make recommendations to the Mission for future programming. In their subsequent report and during meetings with AIDSCAP Nairobi, the REDSO Team requested that AIDSCAP no longer directly fund the Government implemented projects. These recommendations were not related to any inappropriately spent funds, but solely based on the perception of the REDSO team that AIDSCAP acted against USAID regulations in giving funds directly to Rwandan Government Agencies. The REDSO team and AIDSCAP/Nairobi agreed to amend the subagreements with the GOR and CIDC2. Each amendment letter included specific language stating how the AIDSCAP country office would handle future payments on behalf of the respective agencies, including payment for purchases, training activities, arrangement of printing of materials etc. Based on the REDSO report, USAID/Kigali notified the Ministry of Health that government subprojects would henceforth not receive funds directly but that the AIDSCAP Rwanda office would make all payments on their behalf. While there are weaknesses in the GOR's financial and administrative systems (which will be addressed by USAID in an upcoming program), it should be noted, that in spite of any existing weaknesses, unless an implementing agency is given the opportunity to manage funds and resources, it cannot be expected to build its capacity in these areas. It should also be noted that in subsequent discussions with the Legal Office at REDSO, Nairobi, no substantiation could be provided that AIDSCAP acted against USAID regulations, but rather against an unwritten REDSO policy not to direct-fund Government entities. Management constraints included the chronic shortage of qualified personnel within the Ministry of Health. Furthermore, salaries were very low and often in arrears for up to 6 months. The shortage of qualified staff was especially felt at the caregiver/prescriber level. Health assistants (auxiliaire de sant), with an education level lower than the minimum normally required by the GOR, often provided health services (including STI treatment) due to severe shortages of more qualified and better trained personnel. This made project implementation that much more complex as training must take into account a very wide range in educational levels. Turnover at the MOH was also high, resulting in significant time and effort having to be placed in orienting new staff to project goals and activities. For example, over the life of AIDSCAP, the PNLS had three directors. The fact that Rwanda became a trilingual society after the war also complicated implementation. Contract negotiations with higher officials were held almost exclusively in English, and subsequent subagreements written in English were not translated into French. This resulted in most documents, including PIFs being in English, whereas the actual implementation of the program was often conducted by field staff who mostly spoke French, or others who felt even more comfortable in Kinyarwanda, the national language. The language of communication is Kinyarwanda and it should be noted that educational materials, messages, radio and drama performances were almost exclusively in Kinyarwanda. In the future funds need to be budgeted to ensure that all relevant documents and management tools for the successful implementation of any project are translated in the appropriate language(s). NGO Subprojects PSI, with funding from AIDSCAP at just over one million dollars, received one fourth of the total 4.2 million life of project funds. The project was managed by an expatriate Resident Representative who was responsible for interacting with the AIDSCAP Resident Advisor. Project funds supported a large local staff comprised of an administrative/financial director, IEC, sales, and women's social marketing coordinators, sales agents and supervisors and assorted project assistants and day labor condom packers. The Resident Representative reported directly to PSI headquarters in Washington, DC. Financial transaction were between FHI and PSI headquarters. Backstopping was provided by AIDSCAP regional and PSI headquarters personnel. Major management and implementation constraints were periodic shortages of condoms, and problems with timely delivery of project vehicles and equipment. CARE International was also the recipient of a sizable grant under the AIDSCAP Rwanda Program, over 300,000 dollars for a one year pilot program. The overall program and financial management of the Peer Educator project in Gitarama was provided by the CARE office in Kigali. The field activities were supervised by a specially-hired expatriate project manager who managed the CARE sub-office in Gitarama. The Project Manager was assisted by a locally hired deputy manager, a two-person IEC team and 15 paid Peer Educator supervisors. As with the Government managed projects, CARE Rwanda submitted its financial reports to the AIDSCAP Resident Advisor for review and approval, who in turn would submit the financial reports to AIDSCAP for reimbursement. Rapid Response Funds (RRF) Rapid Response Funds grants were awarded to four local NGOs, with international affiliations. Rapid Response Funds were instituted by AIDSCAP as a quick response mechanism at the country level for funding cost effective, innovative HIV/AIDS prevention activities, institutional development and training needs of NGOs and community groups. Local NGOs submitted a project proposal and budget to the Resident Advisor, who in turn submitted the proposal to USAID/Rwanda and AIDSCAP/Nairobi for approval. Funds were distributed directly by the country office to the respective recipients. Recipients were required to submit a complete financial report on a quarterly basis or at the end of the project, whichever came first. Rwanda Refugee Program in Tanzania The CARE International implemented refugee project in Tanzania was managed by the Regional AIDSCAP office in Nairobi. The first year of the project was funded from the 4.2 Million received by AIDSCAP, while phase II was implemented with funds received from the Africa Bureau. During the first year pilot phase two Task Orders, respectively with PSI and JSI, and one subagreement with CARE International were signed and approved. An additional subagreement was negotiated with CARE International and funded with Africa Bureau funds for Phase II of the intervention. Financial transactions between JSI and PSI were between their respective US headquarters offices in Washington and FHI. CARE International received its funds through their Tanzania country office located in Dar-Es-Salaam. Endnotes
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