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      Transitioning to Country Ownership of HIV Programs in Rwanda

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          Abstract

          Agnes Binagwaho and colleagues describe how Rwanda achieved country ownership of its HIV programs.

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          Reduced premature mortality in Rwanda: lessons from success

          Paul E Farmer, Cameron Nutt, Claire Wagner … (2013)
          Some errors went uncorrected in the table of this article by Paul Farmer and colleagues (BMJ 2013;346:f65, doi:10.1136/bmj.f65). The figures for malaria were incorrect, the subheadings wrongly appeared at the top of the table, and the source references should have been 2, 33, 34, 35, and 36. The correct table is here. In addition, the affiliation for Soline Dusabeyesu Mugeni should be the Clinton Health Access Initiative [not Partners in Health]. Table Premature mortality in Rwanda, 2000-112 33 34 35 36 2000 2011 Total reduction (%) Annual rate of reduction (%) Regional rank Global rank* HIV/AIDS HIV incidence/ 100 000 207 88† 57.5 9.5 5 8 AIDS deaths/100 000 190 41† 78.4 17.0 1 1 Tuberculosis Incidence/100 000 326 94 71.2 11.3 1 4 Mortality/100 000 48 11 77.1 13.4 1 5 Malaria Total cases 1 654 246‡ 208 858 87.4 34.45 NA NA Total deaths 2 581‡ 380 85.3 31.9 NA NA Child and maternal mortality Deaths/1000 live births 183 54 70.4 11.1 1 1 Total deaths 61343 22 813 62.8 9.0 2 4 Maternal mortality ratio/100 000 live births 840 340§ 59.5 9.0 1 6 *Only countries with populations greater than 500 000 included. †2009 data. ‡2005 data. §2010 data.
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            How the Avahan HIV prevention program transitioned from the Gates Foundation to the government of India.

            Ashok Alexander, P. Piot, Sameer Kumta … (2013)
            Developing countries face diminishing development aid and time-limited donor commitments that challenge the long-term sustainability of donor-funded programs to improve the health of local populations. Increasing country ownership of the programs is one solution. Transitioning managerial and financial responsibility for donor-funded programs to governments and local stakeholders represents a highly advanced form of country ownership, but there are few successful examples among large-scale programs. We present a transition framework and describe how it was used to transfer the Bill & Melinda Gates Foundation's HIV/AIDS prevention program, the Avahan program, to the Government of India. Essential features recommended for the transition of donor-funded programs to governments include early planning with the government, aligning donor program components with government structures and funding models prior to transition, building government capacity through active technical and management support, budgeting for adequate support during and after the transition, and dividing the transition into phases to allow time for adjustments and corrections. The transition of programs to governments is an important sustainability strategy for efforts to scale up HIV prevention programs to reach the populations most at risk.
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              PEPFAR, health system strengthening, and promoting sustainability and country ownership.

              John Blandford, Ann Lion, Wafaa El-Sadr … (2012)
              Evidence demonstrates that scale-up of HIV services has produced stronger health systems and, conversely, that stronger health systems were critical to the success of the HIV scale-up. Increased access to and effectiveness of HIV treatment and care programs, attention to long-term sustainability, and recognition of the importance of national governance, and country ownership of HIV programs have resulted in an increased focus on structures that compromise the broader health system. Based on a review published literature and expert opinion, the article proposes 4 key health systems strengthening issues as a means to promote sustainability and country ownership of President's Emergency Plan for AIDS Relief and other global health initiatives. First, development partners need provide capacity building support and to recognize and align resources with national government health strategies and operational plans. Second, investments in human capital, particularly human resources for health, need to be guided by national institutions and supported to ensure the training and retention of skilled, qualified, and relevant health care providers. Third, a range of financing strategies, both new resources and improved efficiencies, need to be pursued as a means to create more fiscal space to ensure sustainable and self-reliant systems. Finally, service delivery models must adjust to recent advancements in areas of HIV prevention and treatment and aim to establish evidence-based delivery models to reduce HIV transmission rates and the overall burden of disease. The article concludes that there needs to be ongoing efforts to identify and implement strategic health systems strengthening interventions and address the inherent tension and debate over investments in health systems.
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                Author and article information

                Journal
                Journal ID (nlm-ta): PLoS Med
                Journal ID (iso-abbrev): PLoS Med
                Journal ID (publisher-id): plos
                Journal ID (pmc): plosmed
                Title: PLoS Medicine
                Publisher: Public Library of Science (San Francisco, CA USA )
                ISSN (Print): 1549-1277
                ISSN (Electronic): 1549-1676
                Publication date (Electronic): 9 August 2016
                Publication date Collection: August 2016
                Volume: 13
                Issue: 8
                Electronic Location Identifier: e1002075
                Affiliations
                [1 ]Rwanda Ministry of Health, Kigali, Rwanda
                [2 ]Harvard Medical School, Boston, Massachusetts, United States of America
                [3 ]Geisel School of Medicine – Dartmouth, Hanover, New Hampshire, United States of America
                [4 ]Division of Global HIV/AIDS, Centers for Disease Control and Prevention, Kigali, Rwanda
                [5 ]CTS Global Services, Los Angeles, California, United States of America
                [6 ]ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, New York, United States of America
                [7 ]AIDSRelief, Catholic Relief Services, Kigali, Rwanda
                [8 ]Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
                Author notes

                AB is a member of the Editorial Board of PLOS Medicine.

                Contributed to the writing of the manuscript: AB IK EK JPN SN FM RKK VM RS CB LI AA WMES PLR KWS. Wrote the first draft of the manuscript: AB IK EK PLR. Agree with the manuscript’s results and conclusions: AB IK EK JPN SN FM RKK VM RS CB LI AA WMES PLR KWS. All authors have read, and confirm that they meet, ICMJE criteria for authorship.

                Author information
                http://orcid.org/0000-0002-6779-3151
                http://orcid.org/0000-0003-1305-2208
                http://orcid.org/0000-0002-2159-4800
                http://orcid.org/0000-0002-0180-1649
                Article
                Publisher ID: PMEDICINE-D-15-01386
                DOI: 10.1371/journal.pmed.1002075
                PMC ID: 4978459
                PubMed ID: 27505355
                SO-VID: bb2df88d-78ae-41b5-8f62-0b031f405135
                License:

                This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.

                History
                Page count
                Figures: 1, Tables: 1, Pages: 8
                Funding
                This article was supported by Cooperative Agreement No. 1U2GPS002091 from the US President’s Emergency Plan for AIDS Relief through the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the official view of PEPFAR and the Centers for Disease Control and Prevention. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
                Subject: Policy Forum
                Subject: Biology and Life Sciences
                Subject: Microbiology
                Subject: Medical Microbiology
                Subject: Microbial Pathogens
                Subject: Viral Pathogens
                Subject: Immunodeficiency Viruses
                Subject: HIV
                Subject: Medicine and Health Sciences
                Subject: Pathology and Laboratory Medicine
                Subject: Pathogens
                Subject: Microbial Pathogens
                Subject: Viral Pathogens
                Subject: Immunodeficiency Viruses
                Subject: HIV
                Subject: Biology and Life Sciences
                Subject: Organisms
                Subject: Viruses
                Subject: Viral Pathogens
                Subject: Immunodeficiency Viruses
                Subject: HIV
                Subject: Biology and Life Sciences
                Subject: Organisms
                Subject: Viruses
                Subject: Immunodeficiency Viruses
                Subject: HIV
                Subject: Biology and life sciences
                Subject: Organisms
                Subject: Viruses
                Subject: RNA viruses
                Subject: Retroviruses
                Subject: Lentivirus
                Subject: HIV
                Subject: Biology and Life Sciences
                Subject: Microbiology
                Subject: Medical Microbiology
                Subject: Microbial Pathogens
                Subject: Viral Pathogens
                Subject: Retroviruses
                Subject: Lentivirus
                Subject: HIV
                Subject: Medicine and Health Sciences
                Subject: Pathology and Laboratory Medicine
                Subject: Pathogens
                Subject: Microbial Pathogens
                Subject: Viral Pathogens
                Subject: Retroviruses
                Subject: Lentivirus
                Subject: HIV
                Subject: Biology and Life Sciences
                Subject: Organisms
                Subject: Viruses
                Subject: Viral Pathogens
                Subject: Retroviruses
                Subject: Lentivirus
                Subject: HIV
                Subject: People and Places
                Subject: Geographical Locations
                Subject: Africa
                Subject: Rwanda
                Subject: Medicine and health sciences
                Subject: Diagnostic medicine
                Subject: HIV diagnosis and management
                Subject: Medicine and Health Sciences
                Subject: Health Care
                Subject: Health Care Policy
                Subject: Health Systems Strengthening
                Subject: Medicine and Health Sciences
                Subject: Infectious Diseases
                Subject: Viral Diseases
                Subject: AIDS
                Subject: Medicine and health sciences
                Subject: Epidemiology
                Subject: HIV epidemiology
                Subject: Medicine and health sciences
                Subject: Public and occupational health
                Subject: Preventive medicine
                Subject: HIV prevention
                Subject: Medicine and Health Sciences
                Subject: Health Care
                Subject: Health Care Policy

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                ScienceOpen disciplines: Medicine

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