HHS/CDC Track 1.0 Transition in
Rwanda
Dr Ida Kankindi, Rwanda Ministry of Health
Dr Felix Kayigamba, CDC-Rwanda
August 2010
1
Rwanda and PEPFAR
• 9 million population, 3% HIV prevalence, ~178,680 PLHIV
• Major donors for HIV programs include PEPFAR and Global
Fund
– GF PR: $305 million since 2004 + $247 million for NSA recently
awarded
– 2010 PEPFAR Budget: $157 million
• 2 HHS Track 1.0 partners: ICAP and AIDS Relief
• Active, engaged government has led successful HIV program
– 96% of pregnant women attending ANC received HIV results via
PMTCT (2009)
– ~75% of PLHIV in need of treatment with CD4 <350 receive ART (2009)
– 1.5 million HIV tests through VCT in 2009
2
PEPFAR Contribution to Rwandan HIV
Program, Oct 2008 – Sept 2009
HIV Program Result
PEPFARsupported
sites
National
results
% support
by
PEPFAR
Pregnant women who received HIV
results in PMTCT
132,811
307,245
43%
HIV+ pregnant women who received
ARV prophylaxis in PMTCT
5,019
8,592
58%
HIV+ clients receiving TB treatment
2,253
5,342
42%
People counseled and received HIV test
results
861,737
1,560,863
55%
HIV+ persons currently receiving ART
46,341
73,769
63%
3
HHS Track 1.0 Supported HIV Clinical
Services in Rwanda, December 2009
AIDS Relief
ICAP
TOTAL
Health Facilities that provide HIV
services
20
56
(47 ART)
76
(60 ART)
Health Workers financed through
Track 1.0
166
580
746
3,063
18,708
21,771
396
2,079
2,475
8,468
46,664
55,132
301
5,539
5,840
104,000
158,992
262,992
Active Patients on ART
Children on ART
HIV Patients in Care
Women enrolled in PMTCT
People counseled and tested at VCT
4
Principles Behind
Track 1.0 Transition in Rwanda
• ICAP and AIDS Relief are transitioning programs to
the Rwanda MOH as the local partner
• Emphasis on maintaining quality of care while
increasing GOR ownership and management
• Quarterly site visits have been linked to already
existing PBF quarterly evaluations
• Technical support and capacity building from Track
1.0 partners during the whole transition process
• Gradual transition approach
– Transition one-third of sites during each year (2010, 2011,
2012)
5
MOH Agencies’ Distribution of
Responsibilities for Transition
Implementing
partner activity
MOH Agency
Mentoring
TRACPlus
Supervision,
UPDC/MOH
Decent
M&E and
Reporting
Health Facilities
Operations
Salaries
Districts
Performance
Based Financing
CAAC
(via UPDC)
(via UPDC)
6
Transition Planning & Implementation
Timeframe
Planning phase
• Establish Transition
Task Force
• Conduct site readiness
assessment
• Select 1st 24 sites for
transition
• Develop M&E plan
Implementation phase
• Transition sites (~25/yr)
• Strengthen MOH capacity
to manage and report
according to USG
requirements
• Monitor performance of
transitioned sites in
collaboration with GOR
Mar 2009 – Feb 2010
Mar 2010 – Feb 2012
TRANSITION
7
Rapid assessment of site readiness,
November, 2009
• Joint MOH, CDC, ICAP, AIDS Relief visits to 65/76 sites
• Completed rapid assessment tool (RAT)
– Administrative, managerial, financial aspects with score
• Reviewed routine HIV program performance indicators
collected quarterly
• Reviewed sites for transition based on criteria:
– Transition district hospital with associated health centers
– Clinical performance indicators: >75%
• Discussions within TTF on site selection
– 18 sites selected for transition March 2010
– 6 sites selected for transition October 2010
8
120
Readiness Assessment and Performance Indicator Results:
District Hospitals and Health Centers Selected for Transition
Starting in March 2010
* *
100
80
%
*
*
60
RAT Score (%)
CD4 Recorded
40
ART Retention
ARV Refill
20
0
Muhima Gisenyi DH Shyria DH Murunda Kabaya DH Muhororo Kibuye DH Kilinda DH Mugonero Kibogora Bushenge
DH
DH
DH
DH
DH
DH
Ngororero
ICAP-supported sites
Karongi
AIDS Relief –supported sites
9
Monitoring and Evaluation of Track 1.0 Transition
in Rwanda
• Objectives:
– Establish baseline level of performance of sites
– Monitor any changes in overall performance of sites
– Evaluate the quality of clinical services and management capacity
of sites throughout the transition process
• Methods:
– Conduct comprehensive assessment of sites at baseline and at 6,
12 months after transition
– Quarterly site visits aim to be integrated with routine supervision
through MOH, use routinely collected indicators
– Two components:
• Capacity assessment survey to monitor overall management
• Performance indicators approved by MOH to monitor clinical performance
10
Baseline Assessment Management Results: Health Centers
Health
Partner Center
ICAP
AIDS Relief
District
Hospital
Financial
Mgt
HR
Clinical
Mgt
Supply
Chain
QI
SI
Lab
Overall
Score Color
(%)
Code
Rugarama
Muhima
79
PCK
Muhima
60
Mwendo
Muhima
71
Kabusunzu
Muhima
74
Rubengera
Kibuye
81
Kirambo
Kibuye
73
Mukungu
Kibuye
79
Munzanga
Kirinda
77
Gatare
Kibogora
73
Ruheru
Kibogora
76
Karengera
Kibogora
76
Kibogora
Kibogora
64
Nyamasheke
Kibogora
74
Overall average
76%
Average Performance of Health Centers in the Muhima DH catchments area
72%
Average Performance of Health Centers in the Kibuye DH catchments area
79%
Average Performance of Health Centers in the Kibogora DH catchments area
74%
Above average
Average
Below average
11
Baseline Assessment, Clinical Performance Indicator
Results: Health Centers
Partner
Health
Center
District
Hospital
New ART
initiation
N/A
Currently
on ART
ANC
partner
testing
N/A
N/A
PCK
Muhima DH
Rugarama
Muhima DH
8
187
Kabusunzu
Muhima DH
26
Mwendo
Muhima DH
Rubengera
CTX
initiation
CD4
Control TB screen at
ART
at 6 mo enrollment retention
Pharmacy LTFU
pick-up tracing
1.00
0.80
1.00
0.80
0.80
N/A
0.96
1.00
0.95
1.00
0.79
0.79
0.61
277
0.94
0.95
0.89
1.00
0.94
0.94
0.67
51
1108
0.99
0.76
1.00
0.97
0.80
0.80
0.29
Kibuye DH
12
151
0.62
1.00
0.94
1.00
0.97
0.97
0.96
Kirambo
Kibuye DH
41
665
0.84
1.00
1.00
1.00
0.93
0.93
0.39
Mukungu
Kibuye DH
10
225
0.98
1.00
1.00
1.00
0.81
0.81
0.88
Munzanga
Kirinda DH
11
141
0.73
0.57
1.00
1.00
0.91
0.91
0.59
Kibogora HC
Kibogora DH
2
152
0.89
1.00
0.80
0.91
0.87
0.87
0.68
Nyamasheke
Kibogora DH
35
143
0.78
0.90
0.62
0.97
0.91
0.91
0.50
Karengera
Kibogora DH
19
385
0.95
1.00
0.75
0.91
1.00
0.71
0.60
Gatare
Kibogora DH
14
262
0.97
1.00
0.50
0.88
0.93
0.47
0.50
Ruheru
Kibogora DH
17
298
0.89
1.00
0.56
0.88
1.00
0.67
ICAP
AIDS Relief
Above average
Average
Below average
N/A
12
Baseline Assessment Dissemination Workshop:
Discussions with Districts and Health Facilities
13
Discussion: Impact of M&E for
Track 1.0 transition
• Detailed review of site performance identified individual sites,
clinical, and health systems issues in need of improvement
–
–
–
–
Supply chain management: ARV stock-outs noted
Financial planning and reporting
Staffing/HR: insufficient staff at some sites
CD4 control and ART retention need improvement in some sites
• ICAP, AIDS Relief, MOH, and CDC are now organizing intensive
TA to improve these areas in these transitioned sites
• Transition M&E process will improve district-level supervision
– Linked to performance-based financing for facilities
14
Conclusions
• Track 1.0 transition in Rwanda demonstrates country
ownership, leadership, management
– Inclusive planning involves GOR, USG, partners
– M&E builds on existing MOH systems
• M&E with feedback to health facilities has led to sitespecific action plans to address clinical and
management deficits
– MOH also investigating cross-cutting health systems issues:
supply chain, personnel
15
Next Steps
• MOH, TRAC-Plus, IPs and CDC will collaborate to
accomplish the following:
• Phase I:
• Continue to conduct quarterly assessments in 24
transitioned sites
• Phase II:
• Readiness assessment for the remaining 52 sites to be
transitioned
• Conduct baseline assessment for the selected sites
• Transition the selected health facilities
• Overall:
•
•
•
•
Address action points derived from dissemination workshop
Strengthen MOH financial and administrative capabilities
Continue monitoring the quality of services
Define long-term plans for technical support
16
Acknowledgments
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Health facilities
MOH
UPDC
TRAC Plus
ICAP
AIDS Relief
CDC-Rwanda transition team
17
Thanks
Questions/discussion
18