WASHINGTON — When the United States President’s Emergency Plan for AIDS Relief funds first arrived in Rwanda in 2004, the country had many people with little access to treatment. But the way the government used the funds has created a lasting legacy for its health system, in part due to the work of Agnes Binagwaho.
Binagwaho, now vice chancellor of the University of Global Health Equity and former Rwanda minister of health, is a strong advocate for countries using donor funds to further their country plans. And while it wasn’t always easy, she worked for PEPFAR funds to contribute to holistic improvements in Rwanda’s health system, rather than only serving those with HIV/AIDS or going to build parallel systems, she told Devex.
“HIV is a disease that has taught us so much. It taught us the multisectoral approach, it has taught us advocacy using government, civil society. It has taught us how it’s important to have compassion and fighting stigma and this can be applied to other disease — and to continue the fight against HIV/AIDS,” she said.
On May 27, 2003, U.S. Congress authorized the largest-ever investment in a single disease in U.S. global health history. Fifteen years later, PEPFAR has saved millions of lives and transformed global development. But to end an epidemic, the flagship HIV/AIDS program will have to go even further — and advocates fear budget pressure could jeopardize the fight.
“And what you do with PEPFAR is what you do with any fund, put all those funds in your national plan. So first step, have a national plan and a national coordination.”
Countries have the ability to dictate how donor funds are spent, or choose not to accept them if they’re not in alignment. But to do so they need a country strategy and a participatory planning process that includes civil society, the private sector, clinicians, and others, Binagwaho said.
“Whatever you do needs to be aligned to policy, needs to be aligned to national strategies, and needs to be aligned to laws and legal framework, and the constitution, and everything. So when you are not there things continue as per national strategy, national policies, national laws, and give a voice to the people. And that’s what the government of Rwanda has done and I was proud to be part of that,” she said.
As PEPFAR marks its 15th anniversary, Devex spoke with Binagwaho about the program, its impacts in Rwanda, and what’s needed both in the fight against HIV/AIDS and to improve health systems.
The conversation has been edited for length and clarity.
What can you tell us about the early days of PEPFAR and when Rwanda first began getting funding through the program?
In the beginning there was not much because PEPFAR came in 2004, and in 2004 the Global Fund to Fight AIDS, Tuberculosis and Malaria was already there but just starting disbursing to countries — and there was still little access to treatment in terms of the number of people who needed treatment. So PEPFAR was really welcome and allowed us to build a system that gives access to quality drugs, to quality diagnostic, to quality follow up to the patients.
So starting from the beginning, we just put our conditions to receive the funds in order to have an action plan and a national strategy. There was no one who came to say we have to do this or we have to do that.
Were there challenges in getting PEPFAR to provide funds in line with your action plan? Did PEPFAR buy into the idea of supporting the whole sector, rather than focusing only on the disease?
No. PEPFAR chose to finance what was in our action plan. Of course it was not a sector support, it became that later. It has improved with time, but they didn't finance something that we didn't plan.
PEPFAR was there just for the Americans to take care of the HIV people. However, in Rwanda it doesn't work like that. We take care about the health of Rwandans, so whatever things we did, we integrated and we refused vertical programs.
We created labs for everybody for instance. So that means because we have integration we built the health sector from day one. If we do a supply chain we don’t do a separate system to supply the goods and the drugs for HIV positive patients, we create a supply chain system for all.
If you tell them you will help them inside the system, then they will help inside the system, by doing so you create an international system — no parallel clinic for pregnant women, no parallel delivery for pregnant women, no parallel follow up for HIV positive mothers and children, no parallel vaccination system, no parallel pharmacy, no parallel supply chain, no parallel lab for doing diagnostic or doing follow-ups — you improve the system for all.
Rwanda was able to do that successfully, why do you think that was the case? Why do you think it did so better than other countries?
A person who comes to help you can never dictate to you except if you're ready to be dictated to. However you need to have a plan. The ball is in our hands and, of course, not all of the development partners are good, not all of the NGOs are good, there are some who just want to do something that doesn’t suit your country, you have to be firm and say ‘not here.’
Nobody is an angel, you need to work, work hard to put everybody around the table and go for your plan. And also to reassure the partners you do the plan and you invite them to review the plan, so they understand where you are with transparency because it’s a double accountability. That's what you ask — ‘I'm ready to be accountable, but I will make you accountable also.’
Don’t blame the donors for not making your life easy. Your plan has to be done nationally and all sectors of the society need to participate so that the partner can go nowhere and find opposition. Because we have all done that together — taking into account the view of the youths, the women, the public sector, the private sector: What can we do the best with this amount of money for all of us to be served. When everybody is with you behind a plan that you have done together, the partners in general, they align. And you fight for it, if they don’t align you refuse them. But you are not refusing alone — all the country is with you.
What have been the impacts of PEPFAR?
PEPFAR has helped build the health system, they have helped educate, have helped us to improve the socio-economic status of vulnerable people by putting vulnerable children in school, they have addressed poverty increases from disease.
PEPFAR has helped buying equipment for the labs, educating people in the labs to use it, and helping quality services through education — helping educating doctors and nurses.
Rwanda is 1 of the 13 countries PEPFAR is focusing on in its new strategy, with the goal of getting them to epidemic control by 2020. What will it take to get there in Rwanda?
It will take continuing what is ongoing, but also, I think it will take Africa having access to treatment, diagnostic, education, et cetera. Rwanda is surrounded by several countries so it’s not the stop of the incidence. It’s to continue exactly what we do for mother-to-child because we have an incidence that is lower than 2 percent, that is really good, we have great survival so it’s continuing the mobilization, the treatment, the sensitization, and the economic growth of the country. Putting people in schools, giving them a better life, and caring about the people living with HIV/AIDS like we do.
What happens when Rwanda meets that epidemic control benchmark? What changes?
Nothing changes. We still have a number of people with HIV that we need to accompany all their lives. The control will mean less new cases but the cases that are there still need the same support. So I don't see any change.
They still need to have their treatment, they still need a good follow up, they still need to know that HIV increases immunity on treatment, they still need to have more follow up than a citizen that doesn’t suffer from immunodepression. That means the course of treatment and follow up will not change and the quality of treatment should not change because the success of controlling HIV will be linked to the quality of service.
What do you think of the PEPFAR strategy to focus on 13 countries nearing epidemic control?
I know that countries that are out of control, that don’t control their epidemic, need support. Those countries can still find support through the Global Fund. But there is a lot of internal duty to succeed to control the epidemic — it's not only the foreign money.
What can other countries learn from Rwanda’s experience? How can they also look to build health systems that are more integrated?
That’s the reason we have created this University of Global Health Equity, it’s really to teach how to build a health sector that serves a maximum of people and the maximum of disease. And it’s how you go for the four S’s: System, space, staff, stuff — meaning you have to create a system, not fragmented systems — a system — and you need to create the space for everything you want to care for, but you also need the staff and you also need the equipment.
And all this is not necessary to be going for the last DNA sequencing for the virus, it’s starting with integration at primary care. That is what we teach, we create a system that is integrated, no vertical programs, whatever you do, whatever you do, whatever you do, it’s not HIV only. Knowing that HIV is a disease like another, that helps you to build a system that cares about the health of the people. People-centric, not disease-centric.