TWUBAKANE Decentralization and Health Program Rwanda
QUARTERLY PERFORMANCE MONITORING REPORT #17 JANUARY - MARCH 2009
USAID/Rwanda Cooperative Agreement # 623-A-00-05-00020-00
Distribution: USAID/Rwanda Twubakane Team Partners Government of Rwanda Ministry of Local Administration Ministry of Health National AIDS Control Commission Twubakane Steering Committee Members Twubakane Partner Districts NGOs, Bilateral and Multi-lateral Partner Agencies Twubakane Quarterly Report #17, January-March, 2009
TABLE OF CONTENTS
ACRONYMS ...... 1 TWUBAKANE PROGRAM HIGHLIGHTS, JANUARY-MARCH, 2009 ...... 2 1. INTRODUCTION...... 3 2. KEY ACCOMPLISHMENTS AND PROGRESS ...... 3 2.1 TWUBAKANE PROGRAM FIELD OFFICES ...... 4 3. PERFORMANCE REVIEW BY PROGRAM COMPONENT ...... 4 3.1 FAMILY PLANNING/REPRODUCTIVE HEALTH ACCESS AND QUALITY ...... 4 3.2 CHILD SURVIVAL, MALARIA AND NUTRITION ACCESS AND QUALITY ...... 11 3.3 DECENTRALIZATION PLANNING, POLICY AND MANAGEMENT ...... 13 3.4 DISTRICT-LEVEL CAPACITY BUILDING ...... 16 3.5 HEALTH FACILITIES MANAGEMENT AND MUTUELLES ...... 19 3.6 COMMUNITY ENGAGEMENT AND OVERSIGHT ...... 21 4. MONITORING AND EVALUATION ...... 23 5. CHALLENGES AND OPPORTUNITIES ...... 23 6. PERSPECTIVES FOR NEXT QUARTER ...... 25 ANNEX 1: TWUBAKANE PROGRAM RESULTS FRAMEWORK ...... 26 ANNEX 2: TWUBAKANE’S INTERVENTION ZONE ...... 29 ANNEX 3: SHORT-TERM TECHNICAL ASSISTANCE PROVIDED AND OTHER TRAVEL ...... 30 ANNEX 4: DISTRICT ACTIVITIES SUPPORTED BY DISTRICT INCENTIVE FUNDS ...... 31 ANNEX 5: SYNTHESIS OF PAQ TEAM ACTIVITIES AND ACHIEVEMENTS ...... 35 ANNEX 6: PERFORMANCE MONITORING BY PROGRAM COMPONENT ...... 37
Twubakane Quarterly Report #17, January - March, 2009
ACRONYMS AMTSL Active Management of Third Stage of Labor MIGEPROF Ministry of Gender and Family Promotion ANC Antenatal Care MINALOC Ministry of Local Government ARBEF Association Rwandaise du Bien-Etre de la MINISANTE Ministry of Health Famille CHIS Community-Based Health Information System MIS Management Information System CHW Community Health Worker MPA Minimum Package of Activities CNLS Commission Nationale de lutte contre le SIDA MSH Management Sciences for Health COPEGOL Compétition pour l’Excellence dans la MTEF Medium Term Expenditure Framework Gouvernance Locale CS/M/N Child Survival/Malaria/Nutrition NDIS National Decentralization Implementation Structure CTAMS Cellule Technique aux Mutuelles de Santé NHA National Health Accounts CYP Couple Years of Protection OJT On-the-Job Training DDP District Development Plan PAC Postabortion Care DED Deutscher Entwicklungsdienst/German PAQ Partenariat pour l’Amélioration de la Qualité Development Service DIF District Incentive Fund PBF Performance-Based Financing DIP Decentralization Implementation Plan PMI President’s Malaria Initiative EGPAF Elizabeth Glaser Pediatrics Aids Foundation PMTCT Prevention of Mother-to-Child Transmission EONC Emergency Obstetric and Neonatal Care PNBC Community Based Nutrition Program EPI Expanded Program of Immunization PNILP Programme National Intégré de Lutte Contre le Paludisme FARN Foyers d’apprentissage et de réhabilitation PNP Policies, Norms and Protocols nutritionnelle FC Field Coordinator RALGA Rwandese Association of Local Government Authorities FHI Family Health International RH Reproductive Health FP Family Planning RPRPD Rwandan Network of Parliamentarians for Population and Development GBV Gender-Based Violence RTI Research Triangle Institute HBM Home-Based Management SWOT Strengths Weaknesses Opportunities and Threats HEARTH Hearth Nutrition Model TWG Technical Working Group HF Health Financing UNFPA United Nations Population Fund HIV Human Immunodeficiency Virus UNICEF United Nations Children’s Fund HMIS Health Management Information System USAID United States Agency for International Development IEC Information, Education and Communication USG United States Government IMCI Integrated Management of Childhood Illness VCT Voluntary Counseling and Testing IUD Intrauterine Device VNG Netherlands International Cooperation Agency JADF Joint Action Development Forum WB World Bank LGA Local Government Authority WHO World Health Organization
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TWUBAKANE PROGRAM HIGHLIGHTS, JANUARY-MARCH, 2009
Component 1: Family Planning/Reproductive Health/Gender Formative supervision of providers trained in emergency obstetrics and neonatal care (24 in Kayonza, 22 in Kicukiro, 29 in Ngoma) On-the-job FP training of 90 providers in Ruhango District; preparation for OJT in Nyaruguru and Nyamagabe districts Training of 14 medical doctors from 10 district hospitals on short- and long-acting FP methods
Component 2: Child Survival/Malaria/Nutrition Training of 668 Community Health Workers on the Integrated Community Health Package in Ruhango District Clinical IMCI training of 25 providers from Kirehe and Ngoma districts; supervision visits of Muhanga providers trained in clinical IMCI Support for harmonization of National Malnutrition Care and Treatment Protocol as well as national nutrition communication and educational tools Training of 29 trainers on community-based nutrition and HEARTH model in Nyaruguru District
Component 3: Decentralization Policy, Planning, and Management Health sector decentralization technical working group established and functional Policies, Norms and Protocols for health services final draft posted to MINISANTE website for final review by stakeholders District management assessment (modified SWOT analysis) carried out in Twubakane-supported districts Health governance assessment conducted on impact and best practices of Twubakane Program
Component 4: District Capacity Building On-going implementation of the District Incentive Fund (DIF) grants; closeout of 2008 DIF grants and start-up of 2009 DIF grants On-going strengthening of district auditors and on-the-job supervision of trained auditors
Component 5: Health Facilities Management and Mutuelles Support to strengthen health facilities managment, focusing on effient accounting practices. Mutuelles survey carried in three districts on effectiveness of the capitation system of payment. Supervisions and the roll out a a new mutuelles database.to strengthen mutuelle management
Component 6: Community Engagement, Participation, and Oversight Training of 59 trainers from Kigali districts (Gasabo, Kicukiro and Nyarugenge) in integrated community health package Support to MINISANTE for the training of 20 trainers for Maternal Community Health Workers (animatrices de santé maternelle) in partnership with JHPIEGO/ACCESS PAQ team exchange workshop for 36 representatives in Rwamagana on accomplishments, experiences and sustainability strategies
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1. INTRODUCTION The Twubakane Decentralization and Health Program is a five-year, more than $30+ million program funded by the U.S. Agency for International Development (USAID) and the Government of Rwanda. The goal of this USAID/Rwanda partnership is to increase access to and the quality and use of family health services by strengthening the capacity of local governments and communities to improve health service delivery. The program is implemented by IntraHealth International, Research Triangle Institute (RTI) International and Tulane University in partnership with the Government of Rwanda. Twubakane also works with the RALGA, EngenderHealth, VNG (Netherlands International Cooperation Agency) and Pro- Femmes.
The Program has six integrated components: 1) family planning (FP) and reproductive health (RH); 2) child survival, malaria and nutrition; 3) decentralization policy, planning and management; Twubakane Program 4) district-level capacity building; 5) health facilities Participating Districts management and mutuelles; and 6) community 1) Nyarugenge, Kigali engagement and oversight. 2) Kicukiro, Kigali 3) Gasabo, Kigali Twubakane’s strategy focuses on improving the 4) Ngoma, Eastern Province capacity to offer decentralized services but also 5) Kayonza, Eastern Province includes selective support for the development of 6) Kirehe, Eastern Province health and decentralization policies, protocols and 7) Rwamagana, Eastern Province 8) Kamonyi, Southern Province strategy guidelines at the national level. Working 9) Muhanga, Southern Province closely with ministries and other partners on nationally 10) Nyaruguru, Southern Province adopted manuals and programs, Twubakane supports 11) Nyamagabe, Southern Province the use of these materials in program districts. 12) Ruhango, Southern Province
The name Twubakane, “let’s build together” in the Kinyarwanda language, reflects the effort of our many partners—the Government of Rwanda, USAID, members of our team, public and private sectors, health care providers, communities— to join forces to build a solid base for an effective decentralized health care system in Rwanda.
2. KEY ACCOMPLISHMENTS AND PROGRESS
In January 2009, the Twubakane Program held a one-day meeting with central- and district-level partners to present and validate its 2009 workplan. The meeting was well attended, and participants included MINISANTE and MINALOC counterparts, representatives of USAID, other development partners, district health officers and hospital and health center staff. Also in January, Twubakane submitted its joint action work plan (JAWP) to the MINISANTE for inclusion in the health sector JAWP.
In the month of February this quarter, it became apparent that the full amount of funding that USAID had hoped to provide to the Twubakane Program this year would probably not be available. The US Government officially informed the MINISANTE and MINALOC of the situation, and the Twubakane team met with ministers and district mayors to discuss the funding
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situation, then revised workplans and budgets accordingly. Twubakane appreciates the continued support and understanding of its key partners, and has worked closely with USAID and its GOR counterparts to ensure that the highest priority activities are reflected in the revised workplans, to the fullest extent possible. This quarter, some activities were delayed or cancelled as the Twubakane team worked to revise its workplan.
As described above, this funding shortfall would have had an impact on financing the District Incentive Funds, and did cause some delays in processing the DIF contracts. Recent increases in funding (in April 2009) will allow the Twubakane Program to fully fund the DIF grants at $100,000 per district for those districts who are able to expend and report on use of the funds in a timely manner.
This quarter, Twubakane worked closely with the US Peace Corps to help facilitate the posting of six volunteers in districts supported by the Twubakane Program. It is planned that the six volunteers will work in the sectors of Byimana (Ruhango District), Mageragere (Nyarugenge District), Mbuga (Nyamagabe District), Musambira (Kamonyi District), Nyamugali (Kirehe District) and Rubona (Rwamagana District). The Peace Corps volunteers will work closely with the sectors’ social affairs managers, and will support a variety of capacity-building activities, including data management and use, sector-level Joint Action Development Forums (JADF), linkages between the sector office and the health center, community health workers’ associations and the community-provider partnership (or PAQ—Partenariat pour la Qualité) teams.
2.1 Twubakane Program Field Offices The Twubakane Program field coordinators continue to play pivotal roles in the program, acting as liaisons between the Twubakane office and operations in Kigali and local program activities in districts. Twubakane’s field officers continued to work closely with the districts to participate in and help facilitate meetings of the Joint Action Development Forums. The field coordinators worked closely with the Cellule Technique aux Mutuelles de Santé (CTAMS) to support the transition to the new mutuelles database and information system. Support was also provided to the district teams in planning and revising their medium-term expenditure frameworks (MTEFs). Also this quarter, Twubakane field coordinators provided technical assistance to the Southern Province to evaluate district imihigo, and provided assistance to some districts to evaluate sector imihigo. Results of these imihigo reviews will be presented in April and will help guide MINALOC, the National Decentralization Implementation Structure (NDIS), and other development partners to identify strengths and weaknesses of the districts and sectors. The reviews will also help this group review any staffing and capacity problems, identify solutions, and identify short term capacity-building needs and interventions.
3. PERFORMANCE REVIEW BY PROGRAM COMPONENT
3.1 Family Planning/Reproductive Health Access and Quality
■ Increase access to and quality/use of FP and RH services in health facilities and communities
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To support increased access to and use of quality FP/RH services, the Twubakane Program works in close collaboration with the Government of Rwanda and a variety of partners and, at the central level, participates actively in technical working groups, including FP, safe motherhood and prevention of and response to gender-based violence.
Repositioning family planning: Twubakane continues to support repositioning of family planning in Rwanda at both the central and district levels. At the central level, Twubakane participated actively in the family planning technical working group and technical review of the protocol for the assessment for community-based distribution of Depo-Provera. This assessment is awaiting approval from Ministry of Health (MOH) officials and the National Ethics Committee.
Twubakane contributed to two national exercises, one on supplies and drugs quantification for contraceptives and medicines for emergency obstetrics, neonatal care and child survival for 2009-2011, and one on integrated supervision tools harmonization. The quantification “ This [OJT] is a good approach, because it exercise revealed gaps in procurement of didn’t require the personnel to leave their work. contraceptives, magnesium sulfate and All of the personnel were trained, too, which oxytocin, which is essential for the prevention definitely will facilitate the integration of FP in of post-partum hemorrhages. A donor all of the services. However, OJT requires a roundtable was identified as an urgent next step commitment on the part of the providers, and of to close the gap and ensure supply of needed commodities. Ongoing participation of the trainer in each site. My recommendation Twubakane technicians in this exercise adds would be to strengthen the supervision and expertise and on-the-ground experience, while coaching to ensure that the participants stick strengthening their skills in quantification and with the program.” logistics monitoring. Twubakane staff also Dr. Valens Habimana,Gitwe Hospital Director participated in a workshop on integrated supervision tools, but found it a bit premature, as supervision tools should logically be linked to the revised norms and standards, which have not yet been officially adopted by the Government of Rwanda.
At the district level, several advocacy and sensitization activities took place, first on FP on-the- job training (OJT) in Nyamagabe and Nyaruguru districts, from January 12-15 and February 10- 12, and later on surgical permanent contraceptive methods in Muhanga District on January 30. The objectives of Nyamagabe and Nyaruguru meetings were to explain to local administrative and medical authorities advantages of OJT, and their roles and responsibilities in ensuring success of planned FP OJT. The Muhanga and Ngoma sessions aimed at informing local administrative and health authorities, health providers and community health workers (CHWs) on FP surgical methods to allow them to sensitize and inform their communities of planned availability of services.
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The launch of FP OJT in Nyaruguru and Nyamagabe, as well as Kirehe and Rwamagana, has now been postponed due to unforeseen budgetary constraints. Twubakane feels strongly that OJT is a successful approach to ensuring full “This training was really necessary for me; integration of FP services and to fostering before, I thought that family planning wasn’t my greater sustainability of FP at the health center problem, and that I didn’t even have the right to (HC) level. Twubakane has already invested get involved. I didn’t know the difference, for in procuring OJT materials for the additional example, between microgynon and ovrette, I had four districts (including Nyamagabe and no idea how to inject Depoprovera . . . when you Nyaruguru). Twubakane is collaborating with come back for supervision, I will be the best FP USAID and USAID-supported clinical provider in our health center !” Emile Bizimana, a nurse from Nyarurama HC services partners to seek cost share to ensure that the OJT is able to take place this year as originally planned.
OJT in Ruhango District: In January, Twubakane launched family planning OJT in Ruhango District. OJT, which includes all health center providers, has been designed to minimize providers’ time away from health care delivery, to support improved integration of FP in other services, and to ensure sustainability in FP service provision. OJT is supported by trained providers who serve as trainers within their health centers, under the supervision of the health center manager and hospital supervisor.
To ensure a smooth roll-out of FP OJT in Ruhango district health centers, the OJT district coordination team organized a preliminary training of the health center providers who would serve as OJT trainers, but who had not been validated in insertion of intrauterine devices (IUDs) and insertion and removal of implants during their previous training. This training was conducted January 19-23 for Gishweru, Gitwe, Karambi, Mbuye and Nyarurama health center trainers and the Kigeme Hospital supervisor. A total of 59 IUDs and 80 Jadelles were inserted, allowing all participants to be validated in IUD and implant insertion; however, only the Kigeme Hospital supervisor was validated in implants removal, because only four cases required Jadelle removal. (Note: These four clients all decided to shift to IUD.) This supervisor will help HC providers perform implant removals as needed.
On-the-job training took place over an eight-week period, from January 26 to March 20, 2009. Eleven of Ruhango’s 14 health centers participated in the training. (Note: The three Catholic- supported facilities, Kizibere, Muyunzwe and Ruhango, did not participate). A total of 97 providers began the training, 92 A2 nurses, and 5 medical doctors from Gitwe Hospital. Unfortunately, the five doctors and two nurses from Kigoma Health Center were not able to complete the training, due to other duties. Of the 90 participants who completed the training, 79 participated in the final evaluation. The OJT began with a pretest to ascertain knowledge levels at the beginning; the average level of knowledge was 65%, and the top score 80%.
At the end of the OJT period, 54 of the 79 participants had a level of knowledge of 75% or higher, and the average grade in the post test was 75%, with the highest grade being 96.6%.
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Following the training, the Health Director of Ruhango District, Froduard Nyirishema, said “This on-site training in FP was wonderful, and allows us to train a maximum number of providers with minimal financial resources. The results I saw in those health centers where I was able to participate in the final evaluation definitely showed that this was a success. We do, however, need to follow up and support ongoing training and coaching.” According to Donatha Mujawamaliya, a nurse from Kinazi HC, who participated in the training, the OJT was successful. “The training was very useful,” she said. “A family planning client can be received by any of our nurses now. I myself feel capable to give accurate information, whether it’s in the maternity ward, during VCT (voluntary counseling and testing) or PMTCT (prevention of mother-to-child transmission). I can give advice about side effects, too… in the past, I always sent clients with questions about FP to my colleague; now I don’t have to do that.” And Hilarie Mukamana, a nurse from Mukoma Health Center agreed that, “This training was necessary. Before, I thought that inserting a Jadelle or IUD was some kind of magic. Now, I am capable of doing it myself. I would only ask you to think about organizing this kind of training in other areas, especially in EONC.”
During the final evaluation, participants recommended that the MINISANTE evaluate the advantages of this new training approach to better support it and extend it to other areas, recommend that other partners in the health sector adopt the OJT approach in the trainings they support, and ensure supervision of the providers trained through OJT to facilitate sustainability of the approach.
Cervical cancer screening: In collaboration with the Women’s Equity in Access to Care and Treatment (WE-ACTx) project, Twubakane sponsored the participation of five national and district FP trainers and contributed technically to the national training of 15 providers in cervical cancer screening. The training took place at the Kigali Health Institute and at WE-ACTx’s clinic January 12-30. All five Twubakane-supported participants were validated as competent in cervical cancer screening and cryotherapy of precancerous lesions. A total of 256 patients were screened; 24 had a positive acetic acid visual inspection and received cryotherapy. At the end of the training, the participants recommended the integration of cervical cancer screening into the MINISANTE’s reproductive health package. The five Twubakane-supported trainers will now transfer their new skills to their trainees and supervisees in their districts (Kamonyi, Ngoma, Nyarugenge and Ruhango).
Training of medical doctors in short and long-term FP: At the specific request of medical doctors working in district hospitals, who had shared with the Twubakane team their need for a clinical update in FP, especially long-acting methods, Twubakane supported a training in
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February of 14 medical doctors working in maternities of 10 Twubakane-supported district hospitals (Kamonyi, Kayonga, Kirehe, Muhanga, Ngoma, Nyamagabe, Nyarugenge, Nyaruguru, Ruhango and Rwamagana). Participants had an average pre-test score of 54%; the post-test average was 95%. During the practical training, 518 new clients were consulted; 19 chose oral contraceptives, 37 Depo-Provera, 65 IUD, 156 Jadelle and 4 condoms. For returning clients, 67 received oral contraceptives, 153 Depo-Provera, 5 IUD, 10 Jadelle and 2 condoms, with 4 clients coming for removal of implants.
Emergency obstetrics and neonatal care (EONC): To ensure that Access Project’s activities complement those of Twubakane, both at the central level and in joint intervention districts (Gasabo, Kicukiro, Nyamagabe and Nyaruguru), a joint Twubakane-Access 2009 planning meeting was held.
To assess the quality and effectiveness of services provided by Ngoma District providers trained in EONC in July 2008, a joint supervisory team, including district EONC trainers and Twubakane staff, conducted supportive supervision January 12-29. Positive changes were noted since the training: the active management of the third stage of labor (AMTSL) for the prevention of post-partum hemorrhage is routinely implemented in 12 of the 13 health centers (Rukira health center did not have oxytocin in stock). In addition, 11 health centers were effectively implementing all infection prevention measures, all were using partographs to monitor deliveries and there was, overall, more rational use of antibiotics, and timely and justified references. In addition, health center managers expressed their satisfaction in the overall improvement of the quality of services. Unfortunately, some HC managers have expressed reluctance to ensure the availability of manual vacuum extractors due to an out-of-date ministerial instruction forbidding use of such material at HC level. (Note: The official adoption of the revised policies-norms- protocols document should alleviate this confusion.) Another noted area for improvement included the proper use of partographs, as some district supervisors are apparently not fully trained in their use. In addition, most health centers lacked magnesium sulfate, necessary for eclampsia treatment (found only at the Kibungo Hospital and Gituku Health Center). Apparently, the hospital director was not informed that the new EONC protocols allow for the basic package of EONC at the health center level, including the use of magnesium sulfate. The hospital director promised to correct this. Trained providers also promised to put available protocols on their office walls for ease of reference.
Similar supportive supervision was conducted in Kicukiro (22 providers) and Kayonza (24 providers) districts, in February. In general, positive changes were noted in the HC including use of partographs, AMSTL and episiotomy performed according to standards, and purchase of necessary equipment and materials (i.e. oxytocin). However, other aspects need improvement, like the recurrent problem of partographs filing and lack of magnesium sulphate and vacuum extractors. Nyarurama HC is problematic since its infrastructure does not respect HC norms (almost all services are rendered in a single room with non-compliant equipment). At the end of supervision visits, corrective advice was given to providers, HC directors and district authorities.
A two-week follow up supervision was implemented in March for providers trained in EONC in Gasabo District; the team included a national EONC trainer, two district supervisors, and a Twubakane staff member. The team spent one day in each health center to observe and
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contribute technical advice. At the end of the two-week supervision, the team noted many improvements in the quality of EONC care, including: systematic use of active management of the third stage of labor to prevent postpartum hemorrhage in all but two HCs systematic application of infection prevention techniques use of partogrammes to monitor delivery widespread availability of delivery kits appreciation on the part of health center managers, who noted that the training in EONC had allowed them to identify and meet the needs of their maternity wards in terms of supplies, equipment and organization of services abandonment of the practice of systematically performing episiotomy abandonment of the practice of systematic use of antibiotics in most facilities
The supervision team noted some practices that merited improvement, including the accuracy of partogramme use, lack of availability of magnesium sulfate for management of eclampsia, and the non-systematic posting of protocols. Another problem noted was the transfer of trained providers; this was the case in the health centers of Kayanga, Nyacyonga and Gikomero.
Focused Antenatal Care (FANC): A total of 33 providers from Nyarugenge (14) and Rwamagana (19) districts participated in weeklong trainings in FANC in March. For Rwamagana providers, the average pretest score was 66.5%, and average posttest score was 79%; for Nyarugenge, the pretest average was 70% and the posttest average was 85%. The participants pledged to apply what they had practiced, and to systematically use the FANC approach. They recommended that the mutuelles collaborate to ensure that the FANC approach is fully supported and reimbursed by the mutuelles. The trained providers also said that they will seek the support of their health center managers to organize on-site trainings in FANC for their colleagues. Another overall recommendation was that health centers seek to expand the size and capacity of their maternity wards to better serve their populations—and to reduce the high number of women who deliver at Muhima Hospital. Twubakane will will work the districts to ensure supportive supervision for the providers trained in FANC.
Baby Basket Initiative: This quarter, IntraHealth launched the Healthy Mothers—Baby Basket Initiative, supported by private donors, to promote and encourage the use of antenatal care and delivery services in health facilities in Rwanda. Through the initiative, launched by the Minister of Health in Nyaruguru District in January, mothers who have participated in the four recommended antenatal visits and who have delivered in a health facility, receive prizes to welcome their newborn. The baskets include a bucket, an umbrella, baby clothes, flannel sheets
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and a t-shirt for the baby with the words “Navukiye kwa Muganga,” Kinyarwanda for “I was born in a health facility.” At the ceremony, Rwanda’s Minister of Health Dr. Richard Sezibera congratulated the mothers on following their health care provider’s advice and encouraged women to space births through family planning to improve their own health and the health of their children. “We have a very big challenge to reduce maternal and child mortality; we have to ensure that pregnancy is not a death hazard, but a chance to live for both the mother and the baby,” said Sezibera at the ceremony.
Gender-Based Violence/ANC/PMTCT: Twubakane has continued its efforts to strengthen the prevention and response to gender-based violence (GBV) in the three districts of Kigali (Nyarugenge, Kicukiro and Gasabo). In January, interactive discussions of the GBV assessment results and next steps were held in the health centers of Kacyiru and Biryogo (completing these sessions for the five HCs involved in the assessment).
In February, with support from an international consultant, Twubakane made progress in the development of sensitization and training modules for health providers, local administrative and health authorities and the civil society. Planning and coordination meetings were held with different partners, including UNIFEM, Haguruka, National Women’s Council and Avega. Two GBV sensitization workshops were held this quarter, one for health center directors and partners working in GBV and HIV in these health centers, and the other for police officers working in these districts. At the request of the Rwanda National Police, Twubakane is supporting the update and revision of the national police GBV standard operating procedures. Twubakane also supported and presented our GBV work during the Rwanda Medical Association’s workshop on the health sector’s response to GBV, organized in collaboration with the Physicians for Human Rights.
IntraHealth’s three projects’ staff in Rwanda celebrated International Women’s Day together with a variety of presentations and activities related to this year’s theme, “Women and Men: United to End Violence against Women». Participation included representatives from MIGEPROF, MIFOTRA, UNICEF, UNFPA, CDC, Pro-Femmes, and health care providers. The representative of MIGEPROF congratulated IntraHealth for its work in GBV prevention and response. In addition to organizing this celebration, Twubakane staff participated in the International Women’s Day events organized by Pro-femmes, and the national celebration in Nyagatare.
Also in March, Twubakane supported an awareness-raising day for the three districts of Kigali. The 72 participants included providers from the five focal health centers (Biryogo, Kacyiru, Kicukiro, Masaka and Gikomero), police officers, the director of health and gender at the district level, social affairs officers, community police representatives, PAQ team members, the districts’ gender officers, the vice mayors of social affairs, the police commandant, community-based organizations working in GBV response, and a district representative of the Ministry of Justice. During her opening ceremony speech, the Vice Mayor of Social Affairs for Nyarugenge District congratulated Twubakane for its support, underlining the importance of addressing GBV as a public health and social problem. One of the participants, the social affairs officer of Kicukiro District, said, “I appreciated learning more about GBV today; this is the first time that I have actually participated in discussions about responding to and managing cases of GBV.”
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3.2 Child Survival, Malaria and Nutrition Access and Quality
■ Increase access to and quality/use of malaria, nutrition and child health services in health facilities and communities
Twubakane continues to work closely with the MINISANTE and other partners to support a variety of child survival activities and this quarter provided support for communications and social mobilization for the National Mother and Child Week which took place from March 24- 27. Twubakane also provided technical support to the MINISANTE for the harmonization of the National Malnutrition Care and Treatment Protocol emphasizing the integration of HIV/AIDS, tuberculosis, malaria and diarrhea. Technical support also was provided for the standardization of national nutrition communication and educational tools through elaboration of messages emphasizing breastfeeding and weaning practices, nutrition and pregnancy, nutrition and HIV/AIDS, malaria, acute respiratory infections, family planning and the role of fathers, communities and local authorities in child survival.
President’s Malaria Initiative (PMI): Twubakane continues to assist the United States Government (USG) PMI team and the National Malaria Control Program (PNILP) in the implementation of PMI activities including home-based management (HBM) of fever, community IMCI, and the introduction of the integrated community health package. As described above (in Component 1), this quarter Twubakane supported trainings in focused antenatal care (FANC) with PMI funds. Twubakane participated in a dissemination workshop on HBM evaluation results organized by the TRAC plus malaria unit on March 11. Representatives of different hospitals and malaria partners had been interviewed during the evaluation and the field assessment conducted in Kirehe, Kamonyi, Nyanza, Nyamasheke, Gasabo, Rwamagana, Gicumbi and Gakenke districts. The evaluation showed positive results in terms of children under five receiving malaria treatment through HBM, but also revealed weak supervision of CHWs by health center supervisors, and strengthening supervision at all levels was recommended by the evaluators.
Community IMCI and the Integrated Community Health Package: As part of the Twubakane’s PMI work, Twubakane continued to roll-out community health from HBM to Community IMCI in the three Kigali districts. In February, two trainings of 59 trainers in community IMCI were conducted in Gasabo (31), Kicukiro (16) and Nyarugenge (12) districts, targeting health center providers already trained in IMCI, FP and EONC, and community health coordinators. These trainers will support the training of community health workers previously trained in HBM in these three districts. Training of CHWs in Community IMCI, and then the integrated package of community health, will begin next quarter.
Also in February, advocacy and orientation workshops were held in the three districts of Kigali for political and administrative authorities on the integrated community health package. A total of 115 participants from Gasabo (52), Kicukiro (30) and Nyarugenge (33) attended. The workshop was opened by Emmanuel Ruziga, the Executive Secretary of the Kicukiro District, who thanked Twubakane for the support and for having organized this workshop and for the program’s support of the community-providers partnership (or PAQ) teams in their role in changing performance in the HC. The sector authorities appreciated the workshops, showed
- 11 - Twubakane Quarterly Report #17, January - March, 2009 great enthusiasm for community health, and pledged their support for the program and the CHWs.
Building on the community IMCI training already provided in Ruhango, Twubakane continued support for training in the integrated community health package for CHWs. A total of 668 CHWs were trained in four five-day sessions in January and February, covering eight of the 13 health centers in the district. Each session was facilitated by four trainers. The CHWs reported satisfaction with the training, but also expressed the need for ongoing refresher training courses, as well as supplies and supportive supervision. CHWs from the remaining health centers will be trained next quarter.
Integrated Management of Childhood Illness (IMCI): A training in clinical IMCI was conducted from February 16-28 from 25 providers from Kirehe (11) and Ngoma (14). As a result, each health center in these districts now has three providers trained in clinical IMCI; this should facilitate the systematic application of IMCI for integrated pediatric care on a daily basis.
A supervision visit of Muhanga District providers trained in clinical IMCI in January was conducted in six health centers: Buramba, Cyakabiri, Kabgayi, Mushishiro, Nyarusange and Rutobwe. Two of the health centers are performing high-quality IMCI on a daily basis (Kabgayi and Mushishiro), two others are offering IMCI services irregularly as trained providers are managing other services at the same time, and in the other two HCs, the trained providers were transferred to other facilities, and IMCI is not being offered. Other noted issues are related to the lack of proper infrastructures and proper supervision from the district hospital. Muhanga District’s health director promised to work with the hospital director in order to improve the overall situation.
Also this quarter, the Twubakane IMCI team supported the training of 22 trainers in Clinical IMCI from districts outside of the Twubakane zone (Karongi, Murunda, Rubavu, Nyabihu, Musanze, Burera and Ngororero district)s organized by the MOH in collaboration with other IMCI partners, including USAID-funded BASICS and the Expanded Impact Project.
Community-based nutrition and HEARTH: This quarter, ongoing monthly monitoring of 23 HEARTH sites in Rwamagana District (14 sites around Karenge Health Center and nine sites around Muyumbu Health Center) was conducted by CHWs and health center providers and Twubakane staff. A total of 148 malnourished children had been treated, 93 around Karenge and 55 around Muyumbu. All children under treatment gained weight in Karenge and more specifically, out of the first 93, 34 achieved good nutritional status (green color), 53 stayed in a moderate malnutrition status (yellow color) and 6 HIV-positive children were recovering very slowly (red). Out of the 55 in Muyumbu, only 49 recovered with 27 completely (green), 23 still with a moderate malnutrition (yellow) and six still severely malnourished (red). Another success of the program is that mothers showed a high interest in monitoring their children’s weight and in improving their children’s nutritional status. During the monitoring visits, weakness were discovered as well. The providers noted the persistence of diarrhea episodes when children start complementary feeding, lack of drugs against parasitic diseases, lack of food rich in protein, lack of means to continue children’s diet once back home, and poor participation due to lack of food to contribute during HEARTH sessions.
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Health providers, community health workers and the volunteer model mothers (mamans lumières) have expressed the need for more sensitization of fathers on the importance of buying needed food, the need to provide HEARTH sites with Mebendazol and anti-diarrheal drugs, and the need for CHWs to have bicycles to facilitate their transportation. Recommendations were made to extend HEARTH sites in surrounding villages though on-the-job orientation of CHWs, identify support for income-generating activities to allow mothers to purchase necessary food, and increase home follow-up visits to identify causes of non-recovery. Twubakane staff also recommended that supervisors from the health centers discuss these issues and requests with HC authorities and advocate for them to supply mebendazol and packets of oral rehydration salts. An additional four HEARTH sites have been created this quarter by the Muyumbu Health Center in the villages of Gitaraga, Bujyuyu, Kajororo and Mumena.
Also this quarter, a training of 29 trainers on PNBC and HEARTH was conducted in Nyaruguru District from February 16-21. Those trainers included 26 providers from the 13 Nyaruguru HCs, one nutritionist from Munini Hospital, the Nyaruguru health unit director and one provider coming from Kaduha hospital in Nyamagabe District. Trainers were trained on the community nutrition package, in-depth-analysis of malnutrition causes, breastfeeding, newborn and infant feeding practices, the positive deviance approach, and HEARTH site feasibility. These trainers are now planning trainings of CHWs for next quarter and district authorities expressed their support for the implementation of nutrition activites in their districts.
3.3 Decentralization Planning, Policy and Management
■ Strengthen capacity of the Ministry of Local Administration (MINALOC) and the MINISANTE to put policies and procedures in place for decentralization, with a focus on health sector integration and decentralization
Collaboration with and support to MINALOC: In February, Twubakane participated in a meeting of the Decentralization, Citizen Participation, Empowerment, Transparency & Accountability (DCPETA) cluster to review sector progress on achieving the Economic Development and Poverty Reduction Strategy, the Decentralization Implementation Plan and the Rwandan Decentralization Strategic Framework objectives and activities. A first draft compilation of activities and budgets for 2008 for MINALOC and development partners was presented and reviewed. Partners were asked to provide additional information for the Joint Sector Review scheduled for March, focusing on correcting 2008 information and providing plans and budgets for 2009. (Note: There were several attempts to schedule the meeting in March, but due to competing demands, the meeting is now scheduled for early April.) Twubakane and other development partners have noted that staff shortages within MINALOC, especially the NDIS unit, have made regular communication challenging. This situation should improve once the NDIS unit and the M&E and Planning unit are fully staffed and operational, which is scheduled to be completed by the end of April 2009. (The new NDIS Director began in March, replacing the former director who is now heading up the national Itorero Program.)
Collaboration with MINECOFIN for district auditors’ trainings and procedures manual for district: In collaboration with MINECOFIN and the German Development Service (Deutscher Entwicklungsdienst/ DED), Twubakane continued to support the finalization of the
- 13 - Twubakane Quarterly Report #17, January - March, 2009 trainers’ manual for district auditors. This quarter, training material was developed for the orientation of local government authorities on their responsibilities to support the audit function at the district level. (See Component 4 for more details.)
Twubakane has contracted a local consultant who will finalize the District Auditors’ Training Manual and field guide in April—May 2009. The guide will be used for training sessions planned in May 2009, and will be distributed to central government authorities and other development partners that may support district auditors’ training activities in other districts (not supported by Twubakane).
Collaboration with the MINECOFIN this quarter has focused on activities supported through IntraHealth’s Hewlett Intiative, including preparation for provincial-level training of district mayors and other local authorities as family planning and population champions. These trainings will begin in April 2009. Twubakane also has participated in the final review of the MINECOFIN-spearheaded revised National Population Policy.
District Capacity-Building Needs Assessment (CBNA): Twubakane staff participated in meetings by the PED (Paix et Decentralisation) project, a Cooperation Suisse Project in four districts in the Western Province, to further the goals of the FormaDis capacity-building system, document local government authority 2008 training activities and planned 2009 training activities, establish quality norms and standards for local government authority training programs, and establish the database of district training events and participants. Twubakane provided input, and assured the inclusion of Twubakane-supported capacity-building activities. When the NDIS unit is staffed up, it is expected that it will validate these materials to authorize their use at the district level.
Support to MINISANTE: This quarter, Twubakane supported the MINISANTE in producing a final draft of the policies, norms, and protocols for health care delivery; the document is now posted on the MINISANTE’s website for peer review, reference and field testing.
Twubakane also collaborated closely this quarter with the MINISANTE, CTB and other partners to establish a health sector decentralization technical working group. The TWG met twice this quarter and reviewed the decentralization of the health sectorwide approach (SWAp), decentralized roles and responsibilities for health service delivery, and health governance and decentralization issues and practices that needed to be included in the Health Sector Strategic Plan II document. During the next quarter, Twubakane will present more detailed information to this TWG about its experiences in decentralization and health service delivery in Rwanda and generate a list of the laws and legal documents that regulate decentralized health care. The group will also review how to improve the planning and budgeting processes for the health sector, including the need to clearly identify and distinguish the differences and relationships of health strategic plans, operations plans, annual work plans and budgets, and MTEFs.
Twubakane also contributed to reviews of the HSSP II document and participated in the Joint Health Sector Review meeting.
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Collaboration with RALGA for district capacity building: As described above, RALGA and Twubakane collaborated closely on the district management assessment conducted in February. RALGA's support facilitated active participation of local government leaders.
In March, the Twubakane program, GTZ, DED and other partners contributed to a RALGA- sponsored forum for the district directors of finance. The forum covered the draft law on local taxes and taxation procedures, results of the pilot studies on privatizing local market tax collection, and a study on districts’ financial absorptive capacity. Regional representatives were elected to represent the districts in advocating for local economic development improvements and capacity building.
Twubakane and RALGA had several meetings to improve alignment of their respective 2009 work plans and budgets and to determine how Twubakane can support RALGA in implementing its capacity-building strategy developed in November 2008. (The RALGA senior program officer attended the presentation of the Twubakane 2009 work plan in January.)
Due to adjustments to Twubakane program funding, RALGA was notified that Twubakane’s support for the position of RALGA’s capacity building program officer, as well as technical assistance from partner VNG, will end in April 2009. Twubakane and RALGA have agreed to continue collaboration, and RALGA has identified other funding sources to support the capacity building program officer position beyond April.
Health governance assessment: In January, staff from RTI International and IntraHealth headquarters came to Rwanda to conduct, in collaboration with in-country Twubakane staff, a health governance assessment. The overall objective of the assessment was to investigate how Twubakane’s efforts to support the decentralization of Rwanda’s health system and to build the capacity of local governments to plan, budget for, and deliver health services have enhanced health governance, and contributed to improved health outcomes. The exercise examined a number of research questions: How and in what ways have Rwanda’s governance and decentralization reforms changed the relationships, accountability, and incentives between government and citizens regarding health services? Have the governance reforms and innovations that decentralization has introduced, and Twubakane has supported, led to increased capacity and performance of government institutions in the areas associated with good health governance? Have the changes in capacity and performance of government institutions led to impacts on: health facilities management, health services delivery, and health outcomes?
Interviews were conducted and data collected at the central level (MINISANTE, MINALOC, MINECOFIN and RALGA) and at the local government level (the City of Kigali, Southern Province and Gasabo, Ngoma and Nyamagabe districts). A number of development partners were also interviewed. Data analysis and compilation took place in February-March, and the final report of the assessment will be available in April; a dissemination workshop is planned for mid-May 2009.
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3.4 District-Level Capacity Building
. Strengthen capacity of districts to plan, budget, mobilize resources and manage services, with an emphasis on health services
District Joint Action Development Forums (JADF): Technical assistance was provided by Twubakane to support the JADFs in Ngoma, In Ruhango, Twubakane co-facilitated a Nyaruguru, Ruhango, Muhanga, and Gasabo JADF meeting during which development districts. This quarter, Twubakane also assisted partners presented their performance Nyamagabe District to launch and monitor the contracts and commitments to the district to JADFs at the sector level. Twubakane staff ensure a coordinated partnership between assisted in organizing meetings and helping the development partners and the district in the forums to prepare their budgeted work plan for district’s achievement of its performance 2009 - 2010. A review of prior year achievements contract (imihigo) objectives. Eighteen of the JADF was performed as well as a review of development partners presented their Imihigo each district’s performance contract. RALGA has contracts, which were evaluated at been playing an oversight role in the functioning 1,258,388,482 RwFr for the 2009—2010 budget and planning cycle. This Ruhango of JADFs and has agreed to help districts and JADF is being documented as a best practice JADF committees in the recruitment process for to share with other districts. key staff and a permanent secretary for the forums.
In Gasabo, a total number of 67 participants During the second quarter of 2009, attended the JADF, during which sector programs Twubakane staff will coordinate its activities were reviewed and recommendations for follow-up with the SNV project and other development actions were made by the district’s stakeholders and partners. To sustain the financial partners in supporting the districts to set up independence and viability of the JADFs, functional JADFs at the sector level and to participants agreed to continue paying the create special technical review committees membership fees. for various service delivery programs.
District Planning and Management Analysis: An annual district management assessment was carried out in February with support from Twubakane and RALGA. The goal of the assessment, which was a modified strengths-weaknesses-opportunities-threats (SWOT) analysis, is to support participatory tracking of indicators related to district management, tracking the percentage of districts who have: (1) mechanisms in place for public reporting on health sector activities; (2) mechanisms in place for public reporting on their financial performance; (3) annual plans and a Medium-Term Expenditure Framework (MTEF) that include a full range of health activities; and (4) plans and budgets documented to reflect citizen input.
Data collection in all 12 Twubakane-supported districts, and included focus groups composed of the mayor, vice mayor, executive secretary, a representative of the district council, a representative of the executive secretaries of sectors, the directors of health, good governance, planning, finance and human resources and the hospital director. During the focus group meetings, Twubakane staff provided brief presentations on the 2007 results and provided an opportunity for discussion of district strengths and weaknesses documented in the 2007 exercise. Analysis of the 2008 data demonstrates that there is an improvement in the indicators over
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previous years (2006 and 2007). The detailed results are presented in the 2008 Twubakane Annual Report. In April, Twubakane will prepare and disseminate results to the 12 districts to support districts in tracking their progress on the indicators and developing their self-evaluation and monitoring skills.
Audit training supervision: This quarter, district auditors from nine districts received supportive supervision visits; the remaining three districts (the Kigali districts) will be visited in the second quarter of 2009.
During the supervision missions, Twubakane staff visited the auditors and procurement officers trained in September 2008. Districts authorities involved in the financial management and tender board processes and procurements also were consulted. A supervision checklist of good audit management practices was developed based on the content of the audit training and recommendations of the participants. The supervision focused on frequency of audit reports, regularity of reports, collaboration and support from the local authorities, management decisions taken due to the auditor’s reports, and problems and successes. The supervision missions revealed that: the audit reporting is now much more regular and frequent and the number of audit reports has increased monthly plans and quarterly reports are regularly “Before the training I was frustrated produced, with formal copies sent to the mayor and about the reporting system and now district council with copies forwarded to provincial we collaborate very well with the mayor. The mayor himself asks me officials, MINALOC and MINECOFIN the reports and for the next meeting district auditors and government officials confirmed of the council four reports will be that the management and accountability of sectors, discussed by the District Council” mutuelles, schools and health centers have improved Ambiance Genesbard, Rwamagana due to visits by the auditor and sector audits carried auditor out the local institutions most typically audited include: district technical units, sector offices, primary and secondary schools, health centers and mutuelles, and water distribution association recommendations of the audit reports are discussed in district council meetings many district auditors trained the accountants and secretaries of the sectors after participating in the auditors’ training
During the supervision missions, the following problems were raised by the district auditors and authorities: The district monitors and supervises a large number of public institutions and processes; one auditor is not enough. (In Rwamagana District, a council decision was made to hire and use external auditors.) The management of the district tax collection system is problematic; increasing the mobilization of local resources, and updating taxpayers lists is challenging for the auditor and district officials. The tender committees are not fully functional in schools and health centers, and sector staff members are not involved in tender review processes for items that they are ordering or supervising.
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In general it was observed that the local government authorities demonstrated their support for the audit function, but still need orientation and guidance on how to be more supportive.
The auditors have expressed deep appreciation to Twubakane and DED for the practical training and the supervision missions. They recommend maintaining a regular program of supervision missions and more peer exchanges. Twubakane and DED staff will continue orientations and meetings with district officials to support good management of the audit function.
Open house and accountability days: Twubakane staff assisted the districts of Nyaruguru and Nyamagabe to organize several accountability days at district and sector levels. As usual, these sessions focused on accountability mechanisms and informing civil society and local citizens about district and sector services and operations. The districts noted increased participation of local citizens, CSO, NGO, and cooperative groups.
District Incentive Fund (DIF) grants: Twubakane continues to support the 12 districts, as well as the City of Kigali, through its technical assistance and DIF grants implementation. The DIF grants remain one of the Twubakane Program’s main tools for providing districts not only with direct funding but also with the opportunity to strengthen budgeting, planning and management skills. This quarter, Twubakane DIF Grant staff focused on the completion of 2008 DIF Grants and the launch of 2009 DIF Grants. This quarter, extension contract were signed for the 2008 DIF Grants. In addition, Twubakane worked closely with the districts to develop 2009 DIF Grants projects and proposals and reviewed and provided feedback on the 2009 DIF Grants proposals. Following the announcement of apparent budget cuts, Twubakane staff visited all 12 district mayors and other authorities to review priorities for the financing of and reductions in 2009 DIF Grants funding levels, then assisted the districts in revising their 2009 DIF grants proposals.
2008 DIF grants: The Twubakane team is working with the districts to finalize reporting on 2008 DIF grants; a total of four have fully justified and reported on all 2008 funding (Kigali and Gasabo, Ngoma, and Muhanga districts). The other districts are finishing their financial and technical reports for the close out of the 2008 DIF Grants. Unfortunately, three districts— Kayonza, Kirehe and Nyarugenge—needed additional extensions on their 2008 DIF grants agreements to complete renovation works which were delayed because of contractors and late payments. The cost share documentation for 2008 grants is satisfactory, with districts overall meeting 89% of their projected cost share. (Only one district, Nyaruguru, has not yet documented cost share for 2008.) Twubakane’s finance team has worked closely together with the districts’ accountants on the production of financial reports for the close out of 2008 DIF Grants.
2009 DIF grants: In January 2009, the DIF team organized a planning session for 2009 DIF grants at Twubakane’s office in Kigali, bringing together districts’ technicians, planning directors, and the health directors of Kigali City and 11 districts (Nyamagabe District was unable to attend). This session allowed participants to focus on the development of priority projects as previously identified by the health centers’ and hospitals’ leadership and by executive secretaries of the sectors and as summarized in the districts’ respective action plans. The technicians
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received a general orientation on the planning process of 2009 DIF activities, on required documentation, and on unallowable costs and activities.
All the districts have submitted a proposal for 2009 DIF Grants. Eight contracts for 2009 DIF Grants are ready to be submitted to IntraHealth headquarters for review and signature. A list of activities planned for the first tranche for each district’s 2009 DIF Grants is available in Annex 4. Next quarter, Twubakane will proceed with contracting the 2009 DIF grants activities with an initial maximum amount of $75,000. (Note: Recent increases in funding—in April 2009—will allow the Twubakane Program to fully fund the DIF grants at $100,000 per district for those districts who are able to expend and report on use of the funds in a timely manner.)
3.5 Health Facilities Management and Mutuelles
. Strengthen capacity of health facilities, including health centers and hospitals, to better manage resources and promote and improve the functioning of mutuelles
Strengthening health facilities management: Twubakane provided technical assistance through supervision visits to a select number of health facilities, including Byimana health center and the district hospitals of Kibagabaga, Kanombe, Muhima, Kibungo, Rwamagana, Kigeme and Rumera-Rukoma. The supervisions focused on reviewing health service planning processes, health facility organization and staffing, and management of supplies, equipment and pharmaceuticals. The following site observations were made and solutions reviewed with the health facility managers: Each of the health facilities have made progress on preparing key planning documents and an overall strategic plan that aligns with MINISANTE high-level objectives; however, these documents are incomplete and health facilities managers do not differentiate between the various documents nor consult them for ensuring that they are on track and meeting MINISANTE and District objectives. Staff is organized, improvise a lot, and do task-shifting; however there remains a persistent shortage of numbers of qualified staff (doctors, nurses, technicians, and accountants). Standard accounting practices and tools are not being rolled out and used at the health facility level. Rwamagana Hospital has set a good standard, and has received guidance from Lux Development in setting up a functional accounting system that includes an accounting plan, software, expense reporting for 2008 and 2009, and bank reconciliation procedures. Fixed asset management is basic. Only inventories are being done, but no valuing and amortization is being done for equipment, buildings and land. This means that the true costs of operations are not being fully considered. Pharmaceutical supply inventories are being done, but no valuation of the stock is being carried out.
During each of the site visits carried out by Twubakane staff, advice and simple tools were provided to health facility managers and accountants to improve their efficiency and performance. Twubakane has been focusing on improving the accounting practices, closing out 2008 books and opening new books for 2009.
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Twubakane held a two-day workshop for 16 health facility managers (hospital directors and accountants) and district health officers in February in Rwamagana to review best practices and present simple management tools. A detailed report and recommendations were produced with a check list of best practices to be used at the facility level by the accountant. This was distributed to participants and the MINISANTE’s health facilities managers. Directors of hospitals and health centers were asked to be more involved and supportive of the accounting processes. As a result of the workshop, the Minister of Health prepared a letter requesting health facility managers to follow up on the work being supported by Twubakane and other development partners to improve overall health facility management practices.
Also this quarter, Twubakane attended a validation workshop held by MINSANTE to review the planning documents and tools that health facilities and district health officers will use to carry out their health strategic planning, operations planning and budgeting/costing of health services and operations & management. These documents and tools include the district health strengthening assessment and framework, the JAWP 2009 data, and HSSP II objectives. Development partners are asked to help orient district and health facility managers to update the data during the months of April and May to align with the 2009—2012 budget and planning cycle.
National support for mutuelles: Twubakane continues to participate regularly in the mutuelles technical work group and sub-work groups, supporting the roll-out of the mutuelles web-based database; the 2009 work plan of CTAMS; a review of the mutuelles audit report; discussions on setting up a performance-based financing system for mutuelles managers and a list of indicators; follow up on the September 2008 technical recommendations; and a review of co-payment systems in use throughout Rwanda.
CTAMS put in place a technical subgroup to ensure a successful roll out of the new web-based community health insurance data collection system that will track 22 indicators and the performance of mutuelles managers. Twubakane staff participated in training programs in the new system throughout the month of January. Unfortunately, since February, there has been some confusion over roles and responsibilities and the level of effort required to supervise and carry out this activity. CTAMS is delegating much of the responsibility to development partners supporting mutuelles operations. Twubakane staff prepared a check list of actions and activities and estimated the level of effort required in each of the Twubakane-supported districts, and carried out an informal survey in our intervention zone during the month of March to assess the accuracy and completeness of the data collection efforts thus far, using the new database system. This next quarter, Twubakane will focus on assisting districts and mutuelles offices where there are problems with data collection and reporting.
A major milestone was achieved with the public presentation of the audit report of mutuelles at the mid-year Joint Health Sector Review. The audit report highlighted particularly that while there are implications of fraud at several mutuelles offices, most of the problems identified are due to mismanagement and lack of capacity of the mutuelles managers and health center accountants.
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In March, Twubakane and other development partners carried out three visits to survey and assess the use of the “capitation” system of health insurance payments. CTAMS and the MINISANTE wish to standardize the payment system and are evaluating capitation system, stratified payments, and fees/payment per specific health interventions. Results from this review revealed that a more indepth survey needs to be carried out in order to choose the best system. The visits to three districts revealed that there are mixed results, views, understanding and uses of capitation systems and that managers really do not understand the benefits and risks of either option.
Mutuelles in Twubakane-supported districts: Supportive supervision missions were carried out in Kamonyi (11 mutuelles and HCs) and Ngoma (8 mutuelles and HCs). District health officers, district mutuelles directors and HC mutuelles managers were visited. The supervision missions focused on the progress and status of mobilizing the local population for the 2009 subscription season, registering beneficiaries, providing cards, and collection of fees, the correct use of mutuelles management tools, accurate accounting, paying of bills, and reconciling bank accounts; and overall transparent financial management.
In Kamonyi, the supervisions revealed that district authorities and local health committees were involved in mobilizing the local population to subscribe to mutuelles for the 2009 open season, current subscription rates varied between 70% and 80%. In Ngoma, the supervisions revealed that the district did not have a director of health, nor a district mutuelles director. However, the open season subscription period for 2009 was well managed and there was good turn out for subscriptions and payment of fees. In all districts, mutuelles managers are burdened with a heavy work load during the open season subscription period and, as a result, there are noticeable delays and omissions in filling out reports, accounting records, verification and recording billings of health centers, and bank book balancing. In addition, there are still unpaid bills from the 2008 billing period that need to be paid and reconciled in the accounting books.
3.6 Community Engagement and Oversight
■ Increase community access to, participation in and ownership of health services
Twubakane continues to support community health activities and community participation in health to accompany and support the decentralization process as well as improved community- level health services in Rwanda. The existence of PAQ teams throughout the Twubakane- supported districts, the increasingly large number of trained and active CHWs, and the engagement of local authorities, hospital and districts supervisors, are all milestones in increased community participation. This quarter, Twubakane was also called upon by the MINALOC to support the Vision 2020 Umurenge Program, and pledged to continue to support the reduction of poverty through the PAQ teams and other approaches and to support the extension of Joint Action Development Forums to the sector level.
National Community Health Strategy: This quarter, the Twubakane team supported the community health desk to finalize and translate into Kinyarwanda registers for integrated case management of the community IMCI illnesses (malaria, diarrhea and respiratory infections) within the integrated community health package. Twubakane also worked with the community
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health desk in the recruitment of a consultant to develop the national community health worker database.
As described in Component 2, trainings and supervision support in the integrated community health package continued for the community health workers in Ruhango District. Also as described in Component 2, this quarter Twubakane supported the MINISANTE’s community health desk by planning and implementing a training of 59 trainers from the three districts of Kigali - Gasabo, Kicukiro and Nyarugenge. The trainings of CHWs for these three districts is scheduled for May 2009. (Note: This training was delayed due to funding constraints, as described elsewhere in this report.)
This quarter, on the national level, Twubakane team contributed to the preparation of the community maternal health worker (animatrices de santé maternelle) training in collaboration with JHPIEGO/ACCESS and the MINISANTE. Following this preparation, Twubakane provided technical assist for the training of 20 trainers for maternal CHWs. This training will reinforce rollout of the MINISANTE’s community health and maternal health strategies.
National Community-based Health Information System (CHIS): Twubakane staff continues to participate in meetings and discussions focused on aligning and integrating the community- based health information systems with the community performance-based financing system.
Partenariat pour l’Amélioration de la Qualité (PAQ) teams: Through the community-provider partnership approach, called Partenariat pour l’Amélioration de la Qualité, or PAQ, Twubakane supports increased community participation in planning and management of health care and health care facilities and in improving the quality of health care services.
In January, the Twubakane team organized a three-day PAQ exchange workshop in Rwamagana, bringing together 36 PAQ team representatives. The workshop focused on exchanging the innovative accomplishments of various PAQ teams and strategies to ensuring the sustainability of the teams. (See Annex 5 for accomplishments of specific PAQ teams.) To ensure sustainability of this much-appreciated mechanism that encourages community empowerment and civic participation, PAQ team members suggested: (1) that the MINISANTE officially promote the PAQ approach, and encourage partners to support it; (2) that Twubakane and, if possible, other partners continue to provide supportive supervision in collaboration with district and sector authorities, and (3) that the GOR and partners provide both technical and financial support to the PAQ teams.
In February, Twubakane worked with district supervisors for hands-on supportive supervision of 16 of the 37 PAQ teams in Kayonza, Ngoma and Nyarguru districts. The PAQ teams visited are all involved in income-generating projects, following DIF-supported activities and overall community mobilization activities. In Nyaruguru District, the PAQ teams decided to support the prevention of malnutrition by promoting vegetable gardens at the household level, and planting model vegetable gardens in health centers.
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4. MONITORING AND EVALUATION Twubakane’s M&E system includes data collection, analysis and reporting on program indicators at community, health facility and district levels. Ongoing activities of the M&E team include strengthening Twubakane staff’s practice of using data for decision-making through the use of monitoring tools, data collection and analysis for needs assessments, and implementation of refined data quality strategies. This quarter, in an effort to improve quality and simplify the process of reporting on trainings, the M&E team developed a comprehensive Twubakane training database, a new tool updated monthly that is meant to provide timely, reliable and updated information on all trainings conducted by the Twubakane Program. The M&E team also facilitates and coordinates the regular planning, coordination, and integration of activities for the Twubakane Program.
This quarter, data entry and analysis was completed of the annual health facilities assessment conducted in November and December 2008. The purpose of this assessment was to complete data collection for Twubakane’s performance monitoring for the Twubakane Program Annual Report and to create a geographical mapping of program results across its intervention zone. Preliminary findings and feedback from the health facilities were presented to technical staff to provide staff with feedback so priorities identified could then be incorporated into the draft 2009 workplan. Quality control of the data from the assessment was monitored through reviews with assessment supervisors to ensure data quality, completeness, and consistency. Data entry was done in Epi 6 and analyzed in SPSS. Tables and graphs of this data, along with quarterly HMIS and program data, were incorporated into the Twubakane Program Annual Report.
In January, Twubakane collected data from FP secondary posts supported by Twubakane in order to have comprehensive FP data from all health facilities. Unlike last quarter, the majority of Twubakane-supported family planning secondary posts data were correctly reporting up to the district level, except the newly launched secondary posts in Ngoma District. Following a visit to FP secondary posts in Ngoma, the M&E team reported its findings and recommendations to program staff to ensure functionality of these secondary posts by strengthening follow up and supervision and fostering ownership of these FP secondary posts by local administrative and health officials.
Also this quarter, the M&E team provided support to special studies and evaluations initiated by technical program staff, including the district annual self-assessment or SWOT analysis. Results from this assessment were incorporated into the annual report.
See Annex 6 for the updated performance monitoring plan with quarterly indicator data.
5. CHALLENGES AND OPPORTUNITIES Challenges and opportunities this quarter included:
Unexpected shortfall in funding: As described above, in February 2009, Twubakane learned that the full anticipated funding for this final year of the project would not be available.
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Although additional USAID funding has recently been identified and is forthcoming, this funding shortfall led to delays this quarter, as workplans and budgets were revised.
Delay in national policies, norms and protocols: As described in past quarterly reports, the process of revising, finalizing and disseminating the policies, norms and protocols for health services documents began in 2007. Because these documents have not yet been validated and disseminated, health care providers at the hospital and health center level do not currently have access to the final documents. This is creating some confusion, especially since the revised document introduces some important changes in services offered at each level. Twubakane continues to advocate for field testing and dissemination of this document.
Community health package: As noted in previous quarters, the success of the integrated community health package depends on the commitment of health centers to support and supervise community health workers. Thus far, community health has been highly depend on partner organizations. It is hoped that the community PBF system will soon become functional.
District Incentive Fund grant execution: As described above, funding shortfalls led to delays in start-up of 2009 DIF grants as overall budgets were reviewed and DIF requests analyzed. Twubakane visited each district to review grants requests and help districts in determining priority needs this year. The districts’ activities have now been prioritized according to the availability of funds. Twubakane is now proceeding with a first obligation of $25,000 per district. Depending on available of funds and districts’ rate of execution and reporting, districts may receive up to the full planned funding amount of $100,000 per district.
Joint Action Work Plan: Twubakane appreciates the efforts of the MINISANTE to, as a part of the sector wide approach, develop an annual workplan that represents a budgeted plan of the Rwanda’s health sector. As described above, Twubakane submitted its section of the JAWP in January then, due to funding changes, revised and resubmitted the plan. As several partners have noted, the JAWP process could be strengthened by clarifications in the categorization of activities and cost elements. Of particular concern is the way costs related to technical assistance and overhead were presented and interpreted differently by different partners. In addition, presentation of the plan according to HSSP II categories led to an apparently verticalized approach when, indeed, the approach is actually integrated, especially at decentralized levels. Twubakane staff are interested in contributing to the ongoing dialogue to improve the overall presentation and representability of the JAWP.
National HMIS data and Twubakane reporting: The Twubakane Program collects data to monitor performance indicators. In order to avoid creating a parallel information system, Twubakane uses data collected routinely by health facilities and submitted to the districts through the national HMIS. The Twubakane M&E staff continues to face delays in data collection because of the letter sent in July 2008 by MINISANTE to district hospital managers requesting that they not share HMIS data. While the MINISANTE assured us that this letter was not inclusive of partners, hospital managers sometimes require a letter or an email providing them permission to share HMIS data. The emails sent by the MINISANTE in January (for October–December quarterly report data collection) stated that this would be our last data collection as we would be able to collect data from the central level in 2009. Due to time
- 24 - Twubakane Quarterly Report #17, January - March, 2009 constraints for the Twubakane quarterly report and the inavailability of data at the central level, this continues to be impossible. Thus, data collection continues to be a problem as some hospital director are reluctant to share data. This quarter, M&E staff noted that although data completeness has improved since the last data collection exercise, data quality is still an issue for many indicators including standard ANC visits, community health indicators, malaria indicators for pregnant women and children diagnosed with severe malaria.
6. PERSPECTIVES FOR NEXT QUARTER During the second quarter of 2009, key activities that were delayed during revision of the workplan and budget will be implemented. Twubakane will continue to collaborate with other partners, including those funded by USAID, to leverage costs and ensure that key activities are carried out. This quarter, the health governance assessment and PAQ approach evaluation will be disseminated. Also this quarter, the 2009 DIF grants exercise will be launched.
- 25 - Twubakane Quarterly Report #17, January - March, 2009 Annex 1
ANNEX 1: TWUBAKANE PROGRAM RESULTS FRAMEWORK Twubakane Decentralization and Health Program Goal Components/ Results Objectives To increase access to and the quality and Component 1: Norms and protocols (MPA and CPA) for utilization of family FP and RH FP/RH revised to expand package of services health services in offered at health centers health facilities and Increase access to and Increased use of modern FP communities by the quality and Improved quality of FP services in health strengthening the utilization of FP and facilities capacity of local RH services in health Quality of RH services, including safe governments and facilities and delivery and management of obstetrical communities to communities emergencies, improved in health facilities ensure improved Health care providers following norms for health service referral/counter-referral for FP/RH delivery at Functional rapid response system for decentralized levels obstetrical emergencies exists at community
level package of family Increased utilization of antenatal services health services includes FP/ RH and child survival/malaria Component 2: and nutrition services Norms and protocols for IMCI, malaria and Child Survival, nutrition to expand package of services Malaria and Nutrition offered at health centers
Quality of child survival/malaria/nutrition Increase access to and services improved in health facilities the quality and Improved community-based nutritional utilization of child surveillance and community-based case health, malaria and management of moderate malnutrition nutrition services in Improved capacity for case management of health facilities and severe malnutrition in health facilities communities Pregnant women receiving intermittent
preventive treatment for malaria during
antenatal consultations increased
Increased use of insecticide-treated nets
Improved home-based case management of
malaria and other childhood illnesses
Increased immunization coverage (DPT3)
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Twubakane Quarterly Report #17, January - March, 2009 Annex 1
Twubakane Decentralization and Health Program Goal Components/ Results Objectives
To increase access to Component 3: Increased capacity of central level and the quality and Decentralization (MINALOC and MINISANTE) to support utilization of family Policy, Planning and local governments to plan, finance and health services in Management monitor health service delivery health facilities and Improved policies for effective communities by Strengthen central-level implementation of decentralization, strengthening the capacity to develop, especially fiscal decentralization, developed capacity of local support and monitor NHA institutionalized and used as planning governments and decentralization and monitoring tools communities to policies and programs, National HMIS assessment conducted ensure improved with an emphasis on RALGA’s capacity for supporting good health service health services governance at local levels improved delivery at decentralized levels package of family health services includes FP/ RH and child survival/malaria and nutrition services Component 4: Local government capacity for integrated District Level planning strengthened, including health Capacity Building sector planning
Local government capacity for mobilizing
Strengthen capacity of and managing resources strengthened
districts to plan, Community participation strengthened in
budget, mobilize planning and budget decisions, including
resources and manage ongoing review of service delivery and other
services, with an expenditures and attention to building citizen
emphasis on health oversight to mitigate corruption services
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Twubakane Quarterly Report #17, January - March, 2009 Annex 1
Twubakane Decentralization and Health Program Goal Components/ Results Objectives
To increase access to Component 5: Capacity of health facilities (district hospitals and the quality and Health Facilities and health centers) to effectively mobilize utilization of family Management and manage diverse resources strengthened health services in Improved HMIS data collection, analysis and health facilities and Strengthen capacity of use (in Twubakane-supported zones) communities by health facilities, Health committees effectively functioning to strengthening the including health centers strengthen health facility management capacity of local and hospitals, to better Increased rate of membership in mutuelles governments and manage resources and Capacity of mutuelles to manage and ensure communities to promote and improve quality of services strengthened ensure improved the functioning of Participation of mutuelles in the prevention health service mutuelles and promotion increased delivery at decentralized levels
Component 6: Community-based health agents capable of package of family Community providing information and advice related to health services Engagement and FP/RH and child survival/malaria/nutrition includes FP/ RH and Oversight Community-based services delivery system, child survival/malaria supported by districts/sectors, effectively and nutrition services Increase community functional and providing a variety of access to, participation commodities and services in, and ownership of Community-provider partnership committees health services active in evaluating and solving problems related to health service delivery (in health facilities and communities) System of community-based surveillance of morbidity/mortality functioning to track illnesses/deaths and to mobilize community responses
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Twubakane Quarterly Report #17, January-March, 2009 Annex 2
ANNEX 2: TWUBAKANE’S INTERVENTION ZONE
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Twubakane Quarterly Report #17, January-March, 2009 Annex 3
ANNEX 3: SHORT-TERM TECHNICAL ASSISTANCE PROVIDED AND OTHER TRAVEL
Twubakane Program-Funded Travel
TRAVELER IN-COUNTRY DATES SCOPE OF WORK
SARA STRATTON, January 10—24, 2009 Conduct a case study of Twubakane’s experience with improving health governance and its effect on CATHY FORT, health systems and services. DERICK January 10—29, 2009 BRINKERHOFF
WENDY DUFOUR February 1—12, 2009 Provide instructional design technical assistance to GBV activities: GBV sensitization modules, provider training modules, and police SOPs.
MICHAEL February 9—20, 2009 Provide M&E technical assistance: analysis and HAINSWORTH reporting of Rapid Facility Assessment data; health facility mapping; continued analysis of PAQ evaluation and linking PAQ results with health services use and outcomes.
Travel funded by IntraHealth International (non-Twubakane Program) Funds
TRAVELER IN-COUNTRY DATES SCOPE OF WORK
JEFFREY BROWN February 6—20, 2009 Staff training in IT (both IT staff and general staff), IT systems improvements, deployment of Office 2007 (including initial training) for IntraHealth Kigali offices.
LAURA HOEMEKE February 21—March 7, 2009 Attend IntraHealth Field Leaders Meeting at HQ (USA) office in Chapel Hill, NC.
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Twubakane Quarterly Report #17, January-March, 2009 Annex 4
ANNEX 4: DISTRICT ACTIVITIES SUPPORTED BY DISTRICT INCENTIVE FUNDS Activities to be financed with 2009 District Incentive Funds
KIGALI Metropolitan KIGALI (MVK) - 8,250,000 FrRw - first disbursement Activities
1 Orientation/awareness-raising sessions for communities/authorities of Kigali districts on prevention of and response to gender-based violence; as verified by carrying out, documenting and disseminating the resultss of a one-day workshop of 150 community leaders and local government authorities in the three districts of Kigali 2 Capacity building of authorities and technicians for the 2009-2012 budget and planning cycle; as verified by implementing two planning & budgeting workshops; production of the City’s Medium Term Expenditure Framework (MTEF 2009-2012) and preparation and documentation of the performance contract – imihigo 2010 1. GASABO - 13,750,000 FrRw - first disbursement Activities
1 Purchase and distribution of materials and equipment for the district police office in charge of the management of gender-based violence; as verified by the purchase, delivery and use of the supplies and equipment 2 Purchase and distribution of medical supplies and equipment for Nduba and Gikomero health centers; as verified by the purchase, delivery and use of the supplies and equipment. 2. KICUKIRO - 13,750,000 FrRw - first disbursement Activities
1 Purchase and distribution of medical supplies and equipment for the new health center of Betsaida; as verified by the purchase, delivery and use of the supplies and equipment 2 Expansion of community-based family planning outreach strategy and activities at 15 new sites; as verified by the purchase of supplies and materials and the technical reports of activities carried out at the 15 new sites. 3. NYARUGENGE - 13,750,000 FrRw - first disbursement Activities
1 Purchase and delivery of medical supplies and equipment for emergency obstetrics and neonatal services in Gitega Health Center; as verified by the purchase, delivery and use of the supplies and equipment
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Twubakane Quarterly Report #17, January-March, 2009 Annex 4
EASTERN PROVINCE 4. NGOMA - 13,750,000 FrRw - first disbursement Activities
1 Purchase and delivery of medical supplies and equipment for the health post of Rujaramba, Ruramba sector; as verified by the purchase, delivery and the use of the supplies and equipment 2 Renewal of the contract for broadcasting weekly radio shows by Izuba community radio station on decentralization and health issues; as verified by the documentation of the scripts of the weekly messages recorded and broadcast by district authorities on the radio station 3 Improved hygiene through the purchase of four plastic water tanks for rain water harvesting and storage for the health centers of Nyange and Kirwa; as verified by the purchase, delivery, installation and use of the tanks 5. KAYONZA - 13,750,000 FrRw - first disbursement Activities
1 Purchase and delivery of medical supplies and equipment for health centers; as verified by: their purchase, delivery, and the use of the supplies and equipment. 2 Increased capacity building of local government authorities and technicians through the purchase and use of IT equipment for cells and technical units; as verified by the purchase, delivery, distribution and use of laptop computers by the staff 6. RWAMAGANA - 13,750,000 FrRw - first disbursement Activities
1 Purchase and delivery of medical supplies and equipment and non-medical consumables for Karenge health center; as verified by purchase, delivery and use of the supplies and equipment. 7. KIREHE - 13,750,000 FrRw - first disbursement Activities
1 Capacity building of local government officials and technicians in improving their performance on services delivery, reporting systems, human resources management, planning and budgeting; as verified by implementing a three-day training workshop and follow-up supervision reports. 2 Capacity building of the local government officials and technicians by organizing a best practices competition on project management, good governance, and service delivery at the cell level; as verified by the documentation of the results of the evaluation committee, the site visit reports at the Cell and carrying out a workshop to publicly present the results. 3 Support to PAQ teams operating at Kabuye and Nyabitare health centers to put in place income- generating activities for the population; as verified by the two signed agreements for providing financing and establishing income-generating projects, and the implementation of activities.
4 Improved hygiene through the purchase of one water tank for rain water harvesting and storage at Ntaruka Health Center; as verified by the purchase, delivery, installation and use of one large plastic water storage tank.
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Twubakane Quarterly Report #17, January-March, 2009 Annex 4
Activities
5 Capacity building of district staff in local government budgeting & planning processes; as verified by the preparation of the imihigo performance contract, the 2009-2010 budgeted work plan, and the Medium-Term Expenditure Framework (MTEF 2009-2012)
SOUTHERN PROVINCE 8. MUHANGA - 13,750,000 FrRw - first disbursement Activities
1 Purchase and delivery of medical supplies and equipment for Gasagara Health Center; as verified by the purchase, delivery and use of the supplies and equipment. 9. RUHANGO - 13,750,000 FrRw - first disbursement Activities
1 Capacity building of district authorities and technicians for the 2009-2012 budget & planning cycle; as verified by the production of the annual work plan and budget - July 2009- June 2010; revision of the Medium Term Expenditure Framework (MTEF); reporting on and evaluation of the 2009 imihigo performance contracts and indicators; and the preparation of the 2010 Imihigo performance contracts. 2 Support provided to district authorities and technicians to implement an Itorero program, focused on decentralized service delivery, health services and civic participation; as verified by the training of trainers at District – Sector - Imudugudu levels, followed by these trainers orienting the local population on their civic duties and responsibilities. 10. KAMONYI - 13,750,000 FrRw - first disbursement Activities
1 Support for improved functioning of PAQ teams; as verified by the documentation of minutes of PAQ meetings between the public and administrative authorities; the signed agreements for income-generating projects; and monitoring and supervision reports of PAQ activities. 2 Purchase and delivery of medical supplies and equipment for Karama, Kayumbu and Nyamiyaga health posts; as verified by the purchase, delivery, and the use of the supplies and equipment. 11. NYAMAGABE - 13,750,000 FrRw - first disbursement Activities
1 Capacity building of the district technical staff in planning, budgeting, use of ICT equipment, and improved communications; as verified by the production of the Medium-Term Expenditure Framework - MTEF 2010-2012; the annual budgeted work plan for 2010; the evaluation of 2009 performance on work plans and the imihigo performance contract; the purchase and distribution of eight modems to eight executive secretaries of the administrative sectors of the district.
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Twubakane Quarterly Report #17, January-March, 2009 Annex 4
12. NYARUGURU - 13,750,000 FrRw - first disbursement Activities
1 Technical assistance and support to the technical staff to implement the urban habitat and zoning policy of the district through the production of a master plan of the Kibeho zoning area; as verified by production of the final zoning plan of Kibeho and the cadastral surveys of the land plots. 2 Capacity building of the district authorities and technicians for the 2009-2010 budget and planning cycle and use of ICT equipment; as verified by the production of the annual work plan and budget - July 2009- June 2010; revision of the Medium-Term Expenditure Framework (MTEF); reporting on and evaluation of the 2009 imihigo performance contracts and indicators; preparation of the 2010 Imihigo performance contracts; meetings and preparation of the Joint Action Development Forum work plan and the purchase and distribution of computers and printers for the district staff and television sets for sensitization.
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Twubakane Quarterly Report #17, January-March, 2009 Annex 5
ANNEX 5: SYNTHESIS OF PAQ TEAM ACTIVITIES AND ACHIEVEMENTS
Districts Activities and Achievements Gasabo 8 of 10 PAQs of Gasabo District successfully improved the HC hygiene and hours of services. Kimironko HC’s PAQ advocated for another HC to address the overload of clients at this HC; financing was identified by the Kigali district for this construction. The Kimironko PAQ is an exemplary team, and other PAQ teams have visited it for an exchange of lessons learned. Kicukiro Two PAQ teams from Betsaida and Gikondo HCs successfully lobbied local authorities to support the construction of 20 public latrines in marketplaces and to support the extension of the maternity ward at the new Betsaida Health Center. Nyarugenge 6 of the district’s 8 PAQ teams are actively engaged in problem-solving and organize regular meetings with local authorities to discuss quality of care issues. PAQ teams demonstrated impact on the quality of services by improving hours of service at the HCs, working to support HC management and supporting mutuelles de santé. Kayonza 6 of 12 PAQ teams were visited. In Kabarondo, Gahini and Ndego HCs, all the clients who come to their first ANC visit in the first quarter of their pregnancy receive a basin as motivation and encouragement. PAQ teams have organized postpartum home visits to encourage women to attend Eastern postnatal consultations. Province Kabura health post was built by the population through community work (Ubudehe) thanks to PAQ advocacy. Two income generating projects were selected and submitted to the district for financing by DIF 2009. Gahini is implementing a motorbike transport project financed by DIF which brings back 3000 RWF per day. Also in Gahini, visits were made to Imidugudu for the implementation of an Association for Hygiene. Ndego PAQ is struggling with the implementation of their honey project which was funded by DIF due to management problems. Resolution of the problems was decided jointly by the Sector and the district supervisor. Kirehe All PAQ teams have regular meetings and have improved service delivery in most health centers. Local authorities and civil society are involved in PAQ activities and have influenced changes in the management and functioning of health centers. Rwamagana 6 of the 10 PAQ teams were funded through the 2008 DIF grants for income- generating activities and have organized sub-committees for community mobilization on mutuelles membership, family planning and facility-based delivery.
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Twubakane Quarterly Report #17, January-March, 2009 Annex 5
Ngoma 4 of 12 PAQs were visited this quarter. Remera and Rukumberi HC PAQs focus on visits to the cell level for mobilization on priority topics: family planning, Hygiene, assisted delivery, mutuelle enrolment and vaccination.
The following results were presented by the PAQ teams: 39 new users of
long-term contraceptive methods, childbirth at HC (68%), vaccination (95%). The 25 members of the PAQ and the CHW co-operative and PVV met to plan for rehabilitation and installation of a mill for honey production and all the members of the Co-operative decided to make a contribution of 1000 RWF each for the perpetuation of the project. Each of the district’s 12 PAQ teams has its own annual action plan, and all
PAQ teams have supported behavior change communication for avoiding
self-medication and the use of traditional healers, increasing use of VCT services, increasing facility-based deliveries and increasing use of ante-natal care. PAQ teams are supporting community-based nutrition program by supporting community demonstration kitchens in every imidugudu. Kamonyi Several of Kamonyi’s PAQ teams are not functional and problems need to be addressed. The district is developing a revitalization plan to reinforce the involvement of local health and administrative authorities. The Musambira PAQ team initiated an audit to improve the financial Southern management, but the health center accountant disappeared during the audit. Province The Cyeru PAQ team monitored and sensitized the population against self- medication, and encourage support to CHWs. The Kayenzi PAQ team conducted community outreach and mobilization for improvements mutuelle enrollment, FP use and use of mosquito nets. Muhanga 10 of the 12 PAQ teams have benefitted from support for income-generating activities which has contributed to their overall functioning and sustainability. Nyamagabe 12 of 13 PAQ teams have actively supported community mobilization for the use of family planning services. Kigeme HC team reports that 57% of women are using modern methods of family planning, up from 27% in 2006. They contribute the change to their mobilization, the integration of ANC& FP, and the fact that each staff member has been instructed to talk to clients about FP and ANC. Nyaruguru 6 of 13 PAQ teams were visited. PAQ teams have been focusing on fighting malnutrition through the promotion of vegetable gardens. PAQ teams have advocated in the integrated sector plan. PAQ teams have created commissions which specifically address Mutuelle enrolment, family planning, and HC management. Ruhango All PAQ teams in Ruhango are organized into subcommissions to improve quality of services delivered at the HC, promote HBM and IMCI, promote hygiene at umudugudu and cells levels and installing water tanks in each HC All 13 PAQ teams elaborated, in conjunction with HC & Sector administration, income generating projects to be financed through the DIFs.
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Twubakane Quarterly Report #17, January-March, 2009 Annex 6
ANNEX 6: PERFORMANCE MONITORING BY PROGRAM COMPONENT COMPONENT ONE: FAMILY PLANNING/ REPRODUCTIVE HEALTH ACCESS AND QUALITY Quarterly Results for January ‐ March 2009 Nyamagabe Gasabo Kicukiro Nyarugenge Kayonza Rwamagana Ngoma Kirehe Muhanga Kamonyi Ruhango Nyaruguru
Indicator Total
FAMILY PLANNING Couple years of protection 55,846 2,720 4,115 8,588 4,365 3,849 4,328 6,159 6,033 4,302 5,351 3,079 2,957 offered by public facilities in USG‐supported programs1 # People that have seen or 270,684 30,400 8,983 18,578 16,450 23,041 17,621 19,539 52,497 28,349 17,786 12,584 24,856 heard a specific USG supported with FP/RH messages # People trained in family 189 1 2 1 40 1 49 1 91 1 2 planning/ reproductive health2 Female 97 Male 92 # new family planning users 28,199 2410 1345 1811 2601 2138 3055 2657 3091 2389 2770 2399 1533 at health centers Pills 5,727 558 595 353 476 357 638 418 532 473 771 261 295 Injectables 19,024 1620 604 1338 1939 1655 2139 1934 1844 1555 1553 1736 1107
1 Twubakane receives CYP figures from the USAID|DELIVER Project which they calculate based on pharmacy data. 2 Training events carried out this past quarter in family planning and reproductive health are: o Mobilization of community health workers, skilled health providers and political and administrative authorities on permanent methods of family planning in the districts of Ngoma (38), and Muhanga (47). o Training of 14 hospital doctors from the districts of Ngoma(2), Nyarugenge(1), Ruhango(1) , Kamonyi(1), Muhanga(2)Nyaruguru(1), Nyamagabe(2), Rwamagana(1), Kayonza(2), and Kirehe(1) on clinical family planning. o Training of health providers in family planning using the OJT approach in the district of Ruhango (90)
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Twubakane Quarterly Report #17, January-March, 2009 Annex 6 Gasabo Kicukiro Nyarugenge Kayonza Rwamagana Ngoma Kirehe Muhanga Kamonyi Ruhango Nyaruguru Nyamagabe
Indicator Total
FAMILY PLANNING Implants 2,453 83 31 57 141 96 191 239 599 286 272 376 82 IUDs 183 0 2 10 26 1 0 2 26 6 110 0 0 Standard Days Method 247 19 12 31 3 9 25 12 49 12 36 6 33 Condoms 478 130 23 22 16 20 56 52 41 55 27 20 16 Periodic abstinence 87 0 78 0 0 0 6 0 0 2 1 0 0 SAFE MOTHERHOOD AND REPRODUCTIVE HEALTH # ANC visits by 61,005 5,946 3,656 7,068 5,138 4,058 5,230 5,239 4,680 4,767 5,283 3,913 6,027 skilled providers # women with four standard 2,179 139 42 108 196 171 293 281 307 95 277 28 242 ANC visits # Deliveries with Skilled Birth 22,415 2,121 1,559 2,348 2,289 2,024 2,293 1,520 2,546 1,377 1,640 1,253 1,445 Attendants (SBA) # Postpartum/newborn visits 22,415 2,121 1,559 2,348 2,289 2,024 2,293 1,520 2,546 1,377 1,640 1,253 1,445 within 3 days of birth3 # People trained in maternal / 14 19 33 newborn health 4 Female 4 Male 29 # pregnant women diagnosed 3,889 416 156 88 557 454 864 396 179 73 501 100 105 with malaria
3 # Postpartum/newborn visits within 3 days of birth is the same as # Deliveries with Skilled Birth Attendants (SBA) because there is no reliable data source at the health facility level for # women who delivered at home and came to the hospital or health center within 3 days or who were reached via outreach within 3 days at home. 4 Trainings in maternal / newborn health consisted of a refresher training in Focused Antenatal Care for health providers from the districts of Nyarugenge (14) and Rwamagana (19). -38-
Twubakane Quarterly Report #17, January-March, 2009 Annex 6
COMPONENT TWO: CHILD SURVIVAL, MALARIA AND NUTRITION ACCESS AND QUALITY OF SERVICES Quarterly Results for January ‐ March 2009 Kamonyi Ruhango Nyaruguru Nyamagabe Bugesera Gasabo Kicukiro Nyarugenge Kayonza Rwamagana Ngoma Kirehe Muhanga
Indicator Total
CHILD SURVIVAL 27,473 6,262 3,918 4,488 1,492 826 1,848 3,644 974 620 1,323 816 1,262 # Diarrhea cases treated
# Children less than 12 months 29,168 3,105 1,992 1,618 2,710 2,491 2,500 2,655 2,457 2,290 2,519 2,188 2,643 who received DPT3 MALARIA # People trained in treatment 867 83 46 45 14 11 668 or prevention of malaria 5 Female 446 Male 421 # children < 5 years diagnosed 48,355 8,639 4,963 1,928 6,250 6,287 4,075 6,858 3,829 3,186 1,878 4,848 2,548 1,705 with simple malaria at health centers # children < 5 treated for 45,863 4,333 4,243 1,714 1,115 3,171 5,565 5,894 9,413 3,129 7,386 4,227 6 0 malaria through HBM6
5 Trainings conducted in treatment and/or prevention of malaria were: - Orientation meetings with local authorities on Community IMCI in the districts of Kicukiro (30), Nyarugenge (33) and Gasabo (52). - Training of 668 CHWs of Ruhango district during two training sessions on the Integrated Community Health Package - Training of 59 trainers of CHWs on the Integrated Community Health Package from the districts of Gasabo (31), Nyarugenge (12) and Kicukiro (16). - Training of 25 health providers of Ngoma(14) and Kirehe(11) districts in clinical IMCI
6 Data completeness on community indicators is still problematic. Only two districts ‐ Kamonyi and Gasabo – received 100% of the HBM data from health centers. Other district HCs reported inconsistently from month to month. Missing reports this past quarter were as follows: - 1 HC monthly report missing from: Kirehe, Nyarugenge, Kicukiro - 2 HC monthly reports missing from: Ngoma, Bugesera - 4 HC monthly reports missing from: Ruhango, Kayonza - 5 HC monthly reports missing from: Rwamagana - 8 HC monthly report missing from: Muhanga
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Twubakane Quarterly Report #17, January-March, 2009 Annex 6
Kayonza Rwamagana Ngoma Kirehe Muhanga Kamonyi Ruhango Nyaruguru Nyamagabe Gasabo Kicukiro Nyarugenge
Indicator Total
NUTRITION # children <5 who received 384,994 49,322 18,976 5,607 23,512 15,041 41,487 30,773 62,032 42,526 20,117 34,651 40,950 Vitamin A in the health facilities & Community7 # Children reached by 185,536 8,160 6,308 5,398 10,984 8,139 20,022 5,072 56,132 12,548 24,063 12,040 16,670 nutrition programs # People trained in child 896 83 46 45 14 11 668 29 8 health and nutrition Female 468 Male 428
7 The Vitamin A data was high this past quarter due to the mass vaccination campaign during the mother and child week in March. However not all health centers have reported mass vaccination campaign data in their March monthly HMIS report. 8 Trainings conducted in child health and nutrition were: - Orientation meetings with local authorities on Community IMCI in the districts of Kicukiro (30), Nyarugenge (33) and Gasabo (52). - Training of 668 CHWs of Ruhango district during two training sessions on the Integrated Community Health Package - Training of 59 trainers of CHWs on the Integrated Community Health Package from the districts of Gasabo (31), Nyarugenge (12) and Kicukiro (16). - Training of 25 health providers of Ngoma(14) and Kirehe(11) districts in clinical IMCI - Training of CHWS trainers in the Community Based Nutrition Program in Nyamagabe(29) -40-
Twubakane Quarterly Report #17, January-March, 2009 Annex 6
COMPONENT FOUR: DISTRICT LEVEL PLANNING, BUDGETING AND MANAGING Quarterly Results for January ‐ March 2009 Nyaruguru Nyamagabe Kigali City Central Gasabo Kicukiro Nyarugenge Kayonza Rwamagana Ngoma Kirehe Muhanga Kamonyi Ruhango
of
Indicator Total
USG ASSISTANCE FOR CAPACITY BUILDING IN PUBLIC SECTOR # Sub‐national government entities receiving USG assistance to improve their 12 performance # Sub‐national governments receiving USG assistance to increase their annual 13 own‐source revenues # Individuals who received USG‐assisted 83 68 1 1 2 1 1 1 1 1 1 2 1 2 training, including management skills and fiscal management, to strengthen local government and/or decentralization9 Female 24 Male 59
9 Capacity building activities in decentralization this past quarter were: - Support to JADF Gasabo (67 participants) - Workshop for 16 health facility managers, district health officers, and MINISANTE staff to review best practices and present simple management tools for the closeout of 2008 accounting books and the opening of 2009 accounting. -41-
Twubakane Quarterly Report #17, January-March, 2009 Annex 6
COMPONENT FIVE: HEALTH FACILITIES MANAGEMENT AND MUTUELLES Quarterly Results for January ‐ March 2009 Gasabo Kicukiro Nyarugenge Kayonza Rwamagana Ngoma Kirehe Muhanga Kamonyi Ruhango Nyaruguru Nyamagabe
Indicator Total
# Service Delivery Points (SDP) with 186 12 12 9 16 17 19 15 21 12 15 19 18 USG support10
District Hospitals 14 1 1 1 2 1 1 1 1 1 1 1 2 Health centers 136 10 7 8 13 11 12 12 13 11 13 13 13
Health posts 10 1 0 0 0 4 2 2 0 0 0 0 0 FP Secondary Posts 26 0 4 0 1 1 4 0 7 0 1 5 3
10 # Service delivery points (SDP) with USG support includes public and religiously affiliated district hospitals, health centers, health posts and family planning secondary posts in Twubakane intervention zone; however, it does not include private clinics, dispensaries or prison health facilities.
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