Facility supervision by the District Health Teams (DHTs) in Rwanda Track1 Meeting Maputo, Mozambique, August 10 th -12 th Dr. Ruben Sahabo

Background ICAP-CU has supported GoR in implementing HIV/AIDS activities since 2003, beginning with private funds and then PEPFAR in From 2005 direct sub agreement with DHs and HCs with distinct budgets and scope of work (SOW) for each health facility. Intensive technical support in clinical management, M&E, finance and administration. Establishment of 3 regional offices, in Kigali, Gisenyi and Kibuye, with multidisciplinary teams for DHT and site support and mentoring. 2

ICAP support By 31 st March 2010, ICAP with PEPFAR funding through CDC, supported: – 56 sites in 9 districts to provide HIV/AIDS services – Palliative care to 31,300 and ART to 19,321 patients 31% of the PEPFAR support to GoR 39% of patients on ART and 21% of PMTCT clients at PEPFAR supported sites Each quarter, ICAP supports testing for HIV of about 6000 pregnant women

ICAP-Rw : approach and perspectives for district and facility support Shift from direct site support towards capacity building in services integration, services delivery, management and program M&E

ICAP-RW approach and perspectives Technical assistance beyond HIV Build on the existing/accumulated expertise in HIV programs management to strengthen national and district health team (DHT) capacity to manage health services: – Integration and decentralization of services (TB, MH, SGBV, FP, MSM and other MARPs, etc) – Epidemiological surveillance – Lab systems including accreditation – Administrative and finance management: procedures and tools, capacity building in renovation management, etc

Strengthening the DHT capacity for facility supervision Integrated district planning and program review workshops Training and precepting of DHTs on national care and treatment guidelines Training and mentorship of DHTs on site support and supervision, Quality Improvement and assessment Joint facility supervision visits MoH/ICAP to DHT DHT/ICAP regional Team to Health Centers

Strengthening the DHT capacity for facility supervision (cont’d) Site supervision by DHT and sharing and review site supervision reports and recommendation with ICAP Joint follow up of recommendations and site improvement plans Supporting DHTs to organize outreach and community linkage activities and health care networking including Lab services.

Building Capacity Site capacity development framework for sustainability Site Start-up Time Site Maturity Implementing the HIV Model of Care (MOC) + + Site Support by Mentors + STAGE 1: Start-up Initial site assessment Training of health providers Evaluation by DHT Site accreditation by TRAC+ Services initiation Services coordination and follow-up Enhancing quality of Care (Standards of Care) STAGE 2: Maintenance Assessment of SOCs Repeat SOCs assessment on a quarterly basis Improvement of the quality of care Mature and High Quality program Passing the Baton to a National Institution STAGE 3: Maturation Assessment of Capacity Self assessment by site MDT

Trends in ART prophylaxis regimen for HIV pregnant women at ICAP supported sites: decrease in SD-NVP & increase in multi drug and HAART for pregnant women

Proportion of patients who have CD4+ results within one month of enrollment at Shyira DH

Lessons learned Decentralization is an effective way to improve efficiency of services and to sustain quality of care Integrated /joint planning is key to increase access to HIV services (eg. PEPFAR & Global Funds) Community participation and Involvement of PLWAs in care is an effective way to improve retention and adherence Direct SubAg with national institutions enhances ownership and culture of accountability Involvement, oversight and supervision by local leadership is a guarantee to the partnership and transparency

Some challenges High staff turnover at all levels: – How to address at both central and district levels? Available resources versus need and demand for broader health system strengthening: – How to use the available limited resources, mainly streamlined to HIV to meet broader health sector needs (HSS issues) ? How to transform vision into implementation in a rapidly and continuously changing environment? 13

Acknowledgment Government of Rwanda Site Staff PLWAs CDC and other USG agencies Partner organizations Support by PEPFAR "Teamwork is the ability to work together toward a common vision; the ability to direct individual accomplishment toward organizational objectives. It is the fuel that allows common people to attain uncommon results.” Andrew Carnegie