RWANDA JOINT APPRAISAL
Draft De-brief
15-19 SEP 2014
Dr KARAN SINGH SAGAR, Gavi
Dr PROSPER TUMUSIIME, WHO AFRO
Dr NASIR YUSUF, UNICEF ESA
www.gavi.org
ACKNOWLEDGEMENT
•
•
•
•
•
•
•
•
•
Hon Minister and State Minister of Health
Hon Minister of Economic Planning
VPDP
SPIU
Staff of the District Hospitals and Health Facilities
Alliance partners: WHO & UNICEF CO
USAID
RBC
ICC members and all others
2
GAVI SUPPORT TO RWANDA (since 2000)
140,000,000
132,364,784
120,000,000
107,030,771
106,873,782
100,000,000
91,132,617
80,000,000
60,000,000
40,000,000
15,741,163
20,000,000
0
Total Commitment
3
Approvals
Disbursements
Amount in US$
Vaccine Support
Non vaccine support
AIM of Joint Appraisal
• The aim of the Joint Appraisal is to assess the
performance of GAVI support, identify
challenges and opportunities, review future
targets and suggest actions.
• Health System Strengthening (HSS) and all forms of New Vaccine
Support (NVS).
4
Process
• Preparatory work
• Gavi secretariat and in-country
• Review of documents
• Appraisal Mission from 15-19 Sep 14
• Meeting with MoH/ICC
• Meeting with Stakeholders (Partners: WHO, UNICEF,
USAID)
• Meeting with CSO, SPIU, VPDP
• Field visit: 3 DH and 3 HF
• Meeting with MINECOFIN
• De-brief
5
Achievements and Constraints
• Rwanda has achieved immunization coverage
above 95% for all antigens, and 94% FIC (Survey).
• Factors have contributed to the achievement
•
•
•
•
High political commitment
Improvement of health system delivery
Involvement of Community Health Workers (CHWs)
Highly motivated and dedicated staff
• VPD have been controlled in Rwanda.
• ​Tremendous progress in the reduction of child
mortality since 2000 (151 in 1990 to 55 in 2013)
6
PCV3 coverage analysis
Focus for routine coverage improvement
Rota last dose coverage analysis
**
*
*
*
2013 intros
•
Rota last dose coverage lags behind DTP3 in the first full year of intro, with age restrictions likely contributing to low
coverage; Ghana and Rwanda being an exception shows encouraging signs
* Partial year intros
** Data reporting issue in Armenia leading to artificially low coverage
Challenges
•
•
•
•
9
Sustaining the high coverage
New Vaccine introduction
Use of data for action
Financial Sustainability
Coordination and Governance
• Rwanda has a well functioning ICC & HSCC
• Broad representation: MoH, WHO, UNICEF,
USAID, RBC, CSO and others
• Advisory body to MoH and approves all technical
decisions (like NVI, HSS implementation)
• No National Immunisation Technical Advisory
Group (NITAG)- should be explored
• Maintain the momentum of committee
meetings and the representation of all
partners.
10
Programme Management
• M & E framework in place for management of GAVI
HSS and NVS
• Indicators are aligned with cMYP and HSSP
• Annual plans for EPI program exists at the national
and district level.
• At district and HF levels, these are mostly operational
plans.
• National and district plans are costed.
• Funding for traditional vaccines and vaccination
material from government, while it has increased its
co-financing to 0.35USD.
11
PM…2
• Target population for the various antigens was
previously based on projections from previous
census,
• After census in 2012 the proportion of children
less than 1 year has since been adjusted from 4.1
– 2.9%.
• This adjustment is leading to more than 100%
coverage at health centre level by end of year.
12
Planning
• At district hospital level, there are two sets
of plans:
• An integrated costed work plan for the entire districts that
has all the programs
• An EPI specific work-plan with details and costs for 4 – 6
months.
• Plans are based on previous performance and targets
the weak components of the program
• National level supports district level to conduct planning
every 6months.
13
Planning
• At health centre level:
• There is a weekly immunization service delivery schedule
• Integrated Outreach activities conducted once a month
• RED activities included in DH plan, but no
indication of REC micro plan at the health centre
level
• Need to improve quality of RED/REC
implementation with focus on Health centre
micro planning with focus on poor performing
health centres.
14
Supervision
• Supportive supervision sessions are conducted
from central to district level and from district level
to health centre level.
• Quarterly SS visits from national level
• There are both integrated and EPI supervisory
checklists at the district hospital level.
• District hospital conducts quarterly supportive
supervision to health centres targeting poor
performing districts.
• Reports, feedback and follow up plans available
15
Supervision
• There is also a monthly supervision visits to health
centres to monitor the PBF.
• In both cases, written feedback is provided, and
monitored subsequently to ensure that
recommendations are implemented.
• Need for periodic EPI specific M&E and
supervision visits
• Train EPI focal persons in data analysis and
use
16
Coordination meeting
• District hospital holds monthly meeting with
health centres to review status of
implementation of work plan, and address
gaps.
• Monitor only BCG and MCV as access and
utilization indicators
• Many HF performing over 100% or some
under 80%
• Need to have quarterly EPI specific review
at DH level
17
M&E Issues
• Monitoring of RI data is through computerized HMIS
• Data managers and M & E officers analyze program
performance and share with HF.
• Quality of data is discussed during monthly meetings and
measures to improve quality outlined.
• Rota PIE indicated that the use of data for program
planning is rare at the district hospital and health centre
levels.
• A number of program reviews in the country identified
data quality as concerns especially at the district
hospital and health centre levels.
18
Other assessments
•
DH & HF staff given DQS training in the past
years
Program reviews conducted
•
•
The integrated measles post SIAs coverage survey in
2013, showing more than 90% coverage for most of the
antigens
All seven key recommendations from the 2011 EVMA
were implemented. A follow up EVMA was conducted in
June 2014 and an improvement plan has been developed
for implementation.
Rota vaccine PIE conducted in 2013
Rota vaccine and PCV impact studies
•
•
•
.
19
VPD Surveillance
• Integrated VPD surveillance system in place
• Gavi/WHO supporting the system
• Core AFP and measles case-based surveillance
indicators achieved at national and sub-national
levels.
• WHO uses RI and AFP surveillance indicators to
identify high-risk districts for polio using standard
risk assessment tools
• Need to assess silent areas and improve
reporting
20
Programme Delivery
• GAVI support to NVS and HSS gives opportunities
to enhance RI
• RED implementation is good at DH levels and
health centres,
• Components of RED implemented but not well
structured.
• DH & HF visited are well organized, plans & report
exist
• Role of CHW is very important in IPC and defaulter
tracing
21
Program Delivery
• Delays in HSS funds transfer-Gavi
• Delays in implementation of HSS planned
activities
• Long processes in Govt procurement systems
• There is over-stoking of some antigens at
central level especial of RV, the shipment plan
is being revised and pushed for many antigens
for the planned shipment 2014.
22
Recommendation
•
•
•
•
•
Review HSS funds implementation plan and make a
catch-up plan and request that transfer of funds is timely
done
Procurement of cold chain equipment may be done
through UNICEF to reduce lead time & assure quality &
standards equipment.
Review immunization forecast and shipment plans at
regular basis to avoid over or under-stoking of vaccines
at all levels
Monitor the implementation of RED at all levels
especially micro-plans development and implementation
Documentation on the lessons learned
23
Global Polio Eradication Initiative
• Last case in 1993 from Nyamasheke District
• Surveillance supported through Gavi/WHO
• Surveillance indicators are being met
• Some silent areas not reporting AFP cases
• IPV introduction planned in Aug 2015
• Concern: 3 injections at same time
• Cold chain capacity at national and district
• Supervision needs to be strengthened
24
Health System Strengthening
• Of the 31 planned activities, 3 (9.7%) have been
completed, 16 (51.6 %) are on-going while 12
(38.7 %) have not yet been implemented.
• Out of the first year budget of USD 2,462,813,
USD 1,642,814 (66%) has been disbursed by the
SPIU, while, in total, USD 1,491,017 (60%) has
been spent or committed.
• All expenditure was for planned activities
25
HSS
• Delay in implementation: Gavi transfer
• Challenges related to turnaround time for
procurements (goods and services) associated
with the tendering processes
• Initial delays in transferring funds from
VPDD/RBC to District Hospitals caused by lack of
an MOU between them (this has now been
resolved).
• Sequential and depend on completion of others
that are yet to be completed.
26
HSS
• Some of the activities have been rescheduled to be
completed in first quarter of 2015.
27
HSS
• Out of the 7 outcome indicators for year one, 4
were achieved, 1 was not achieved while 2 others
could not be measured as they are obtained from a
DHS;
• Out of 8 intermediate result indicators, 5 were
achieved while 2 were not achieved and the other
was not measured as there was no DQRC done;
• 4 intermediate result indicators did not have
baselines and consequently the level of
achievement could not be assessed for the two
that had a measure for the year
28
HSS
• The M&E for HSS is satisfactory.
• Missing baselines should be established at least
for subsequent years and the periodicity of
measuring the indicators synchronised with the
timing of the sources of relevant data.
• The program and financial reporting needs to be
further improved by specifying the status of the
activities and to clearly spell out how much has
been spent and how much has been committed.
• MOH will update the status as agreed during the
appraisal.
29
TA
• During year one, only one activity for TA was planned for
development of the communication strategy for the health
sector for which money has been requested;
• The immunization program, received quality technical
support from WHO and UNICEF for training mid-level
health managers in M&E and for conducting EVM and cold
chain spare parts inventory;
• Technical assistance has been planned in year 2 for:
•
•
•
•
•
External evaluation of immunization program;
Operational research (HMIS/EPI Data Quality
Assessment and EVM) for monitoring and evaluation of EPI performance;
Creation of elimination model for measles/rubella surveillance;
Service availability and readiness assessment.
30
CSO engagement
• CSO have been supporting MoH for various EPI
and SIA related activities (SM, BCC)
• For current HSS process for selection and
engagement of the CSOs is not yet finalized
• The publication of expression of interest is for the
week of the appraisal.
• This should be expedited
31
Next Year Plan
• The proposed GAVI-funded HSS activities are in
accordance with the approved grant activities.
• There is no change in objectives and no shifts in
the budgets. The only change is with regard to the
activity on allowances to five RBM provincial
mentors, where the budget line will be reallocated to PBF.
• MOH will need to officially notify GAVI
Secretariat on this change.
32
HSS
• The GoR wishes to align the GAVI HSS funding to
the government planning cycle (June/July)
• GAVI Secretariat agreed to explore the
feasibility of the request to use year 2 tranche
and balance from year 1 for the period up to
June 2015 and thereafter carry over the
remaining balance, if any, into year 3.
33
Use of non-HSS Cash Grants from GAVI
• Rwanda planned and implemented an integrated
Measles and Rubella vaccination campaign (for
under 15),
• The campaign targeted 4,278,528 under 15 and
reached 97.5% (as per the PCE).
• WHO received USD 3,064,954 for the campaign
and as per the financial statement received from
WHO 99.6 % of funds were utilized.
34
MR Campaign
• The PIE noted that VPDD staff should undertake
supervisory visits to DH & HF to provide on job
training/support to field staff on better delivery
of immunization service as well as conduct a
real time monitoring of the EPI program.
• Introduction of MR in the routine program in Jan
2014.
• The country received US$ 299,500 as VIG in Nov
2013. Not able to use the funds in the reporting
period (till Dec 2013)
• To submit a workplan for utilization of these
funds.
35
Financial Management
• The Ministry of Health is the lead implementer of
Gavi support in the country.
• The funds are handled by SPIU (Single Project
Implementation Unit)
• For HSS funds, the sub-recipients VPDP and MCH
• The funds disbursement is approved after the
relevant program submits a workplan (usually on
quarterly basis, which has been approved by the
ICC) along with financial statements of previous
quarter.
36
FM
• The system appears to be functioning well;
• Some delays at the start up (signing of MoU
between PR and SR, between SPIU and
districts and opening of Gavi fund bank
accounts).
• Fund flow to DH & HF is timely and there are no
issues of delayed financial reporting.
37
FM
• The next tranche of US$ 1,977,144 has
been approved and will be released after
the country submits the reports and
financial statements for the current tranche.
• The country is eligible for a PBF payment
• Need to keep asset register for all
procurements made through Gavi funds.
• Promote culture of keeping assets in
good-condition
38
RBC
• The country has decided to use the Rwanda
biomedical centre as the implementing arm,
• To submit a note & relevant documents
informing Gavi about this change by Oct
2014.
• The PFA and annex 6 may need to be revised
based on the new organizational structure
and fund management procedures that will be
adopted by RBC.
39
NVS Targets
• The coverage for all antigens is over 90% and
there aren’t major issues related to the
coverage, equity and quality of service delivery.
• The country was calculating its targets as 4.1%
of the total population but has now revised the
estimates to 2.9%.
• This drop of 30% in number of surviving infants
will have an impact on the vaccine doses
required, co-financing payments etc.
40
NVS targets
• During the field visit it was observed that when
the target was based on 4.1%, the coverage was
almost 100% and after calculating target
population based on 2.9%, the health facilities
and district coverage’s are over 100%.
• This needs to be investigated in detail by the
country to get a real estimate of the target or
else it can impact the performance of the
program (affecting the vaccine supply,
coverage etc.).
41
Immunisation Financing and Sustainability
• Rwanda is a low income country with a GNI of
US$ 620.
• Vision is to become middle income country by
2020 (GNI of US$ 1240)- co-financing
• In 2013 the total spending on immunization was
reported to be US$ 25.55 million, out of which
the government spent US$ 3.88 million (15.2%),
Gavi funded US$ 19.07 (74.63%) and rest US$
2.59 million (10.1%) was provided by WHO,
UNICEF and MERCK.
42
Immunisation Financing and Sustainability
•
The overall health sector budget has increased from Rwf
66.28 billion in 2010/11 to Rwf 79.45 billion (20% increase).
The increase in immunization budget over the same period
has been from Rwf 1.65 billion to XXX billion.
• EPI program has a separate line item budget in the national
budget and the country funds the purchase of the traditional
vaccines and part of operational costs.
• The country has not defaulted on its’ co-financing payments
since 2009.
There is a need to increase the government funding,
especially for operational costs (currently under Gavi
HSS).
43
Technical Assistance
•
•
•
The country offices of WHO and UNICEF provide
coordinated assistance to the MoH/EPI on proposal
development, guidelines, trainings, conducting special
studies (like HPV and Rota surveillance).
Rwanda is requesting for technical assistance for
developing financial sustainability strategies for both
running day to day immunization related activities, cofinancing vaccines and updating costing tool for cMYP.
The country also needs assistance with documentation of
the success stories in the health sector program.
44
Thank You
www.gavi.org