TWUBAKANE Decentralization and Health Program

QUARTERLY PERFORMANCE MONITORING REPORT #18 APRIL— JUNE 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 #18, April-June, 2009

TABLE OF CONTENTS

ACRONYMS ...... 1 TWUBAKANE PROGRAM HIGHLIGHTS APRIL-JUNE, 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 ...... 7 3.3 DECENTRALIZATION PLANNING, POLICY AND MANAGEMENT ...... 10 3.4 DISTRICT-LEVEL CAPACITY BUILDING ...... 12 3.5 HEALTH FACILITIES MANAGEMENT AND MUTUELLES ...... 16 3.6 COMMUNITY ENGAGEMENT AND OVERSIGHT ...... 18 4. MONITORING AND EVALUATION ...... 20 5. CHALLENGES AND OPPORTUNITIES ...... 21 6. PERSPECTIVES FOR NEXT QUARTER ...... 22 ANNEX 1: TWUBAKANE PROGRAM RESULTS FRAMEWORK ...... 23 ANNEX 2: TWUBAKANE’S INTERVENTION ZONE ...... 26 ANNEX 3: SHORT-TERM TECHNICAL ASSISTANCE PROVIDED ...... 27 ANNEX 4: DISTRICT ACTIVITIES SUPPORTED BY 2009 DISTRICT INCENTIVE FUNDS ...... 28 ANNEX 5: SAMPLING OF PAQ TEAM ACTIVITIES AND ACHIEVEMENTS ...... 38 ANNEX 6: PERFORMANCE MONITORING BY PROGRAM COMPONENT ...... 41 Twubakane Quarterly Report #18, April - June, 2009

ACRONYMS AMTSL Active Management of Third Stage of Labor MINISANTE Ministry of Health ANC Antenatal Care MIS Management Information System ARBEF Association Rwandaise du Bien-Etre de la MPA Minimum Package of Activities Famille CHIS Community-Based Health Information System MSH Management Sciences for Health CHW Community Health Worker MTEF Medium Term Expenditure Framework CNLS Commission Nationale de lutte contre le SIDA NDIS National Decentralization Implementation Structure COPEGOL Compétition pour l’Excellence dans la NHA National Health Accounts Gouvernance Locale CS/M/N Child Survival/Malaria/Nutrition OJT On-the-Job Training CTAMS Cellule Technique aux Mutuelles de Santé PAC Post abortion Care CYP Couple Years of Protection PAQ Partenariat pour l’Amélioration de la Qualité DDP District Development Plan PBF Performance-Based Financing DED Deutscher Entwicklungsdiesnt/German PMI President’s Malaria Initiative Development Service DIF District Incentive Fund PMTCT Prevention of Mother-to-Child Transmission DIP Decentralization Implementation Plan PNBC Community Based Nutrition Program EGPAF Elizabeth Glaser Pediatrics Aids Foundation PNILP Programme National Intégré de Lutte Contre le Paludisme EONC Emergency Obstetric and Neonatal Care PNP Policies, Norms and Protocols EPI Expanded Program of Immunization RALGA Rwandese Association of Local Government Authorities FARN Foyers d’apprentissage et de réhabilitation RH Reproductive Health nutritionnelle FC Field Coordinator RPRPD Rwandan Network of Parliamentarians for Population and Development FHI Family Health International RTI Research Triangle Institute FP Family Planning SWOT Strengths Weaknesses Opportunities and Threats GBV Gender-Based Violence TWG Technical Working Group HBM Home-Based Management UNFPA United Nations Population Fund HEARTH Hearth Nutrition Model UNICEF United Nations Children’s Fund HF Health Financing USAID United States Agency for International Development HIV Human Immunodeficiency Virus USG United States Government HMIS Health Management Information System VCT Voluntary Counseling and Testing IEC Information, and Communication VNG Netherlands International Cooperation Agency IMCI Integrated Management of Childhood Illness WB World Bank IUD Intrauterine Device WHO World Health Organization JADF Joint Action Development Forum LGA Local Government Authority MIGEPROF Ministry of Gender and Family Promotion MINALOC Ministry of Local Government

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TWUBAKANE PROGRAM HIGHLIGHTS APRIL-JUNE, 2009 Component 1: Family Planning/Reproductive Health/Gender  Refresher training in focused ANC for 26 providers,  Training of seven doctors and six nurses from and Ngoma districts in non-scalpel vasectomy  Supportive EONC supervision, Muhanga and Kirehe districts  Supportive FP supervision,  Training on IUD insertion, Gasabo and district providers, and IUD refresher training for Project San Francisco staff.

Component 2: Child Survival/Malaria/Nutrition  Training of 233 CHWs and supervision of 1051 CHWs in integrated community health, Ruhango District  Training in clinical IMCI of 20 nurses in six districts (to replace previously trained staff who had relocated)  Clinical IMCI supervision in 11 HCs in and 13 HCs in  PNBC and HEARTH TOT in Nyarugenge and Kicukiro districts and training of 104 CHWs in Nyaruguru and Nyamagabe districts.

Component 3: Decentralization Policy, Planning and Management  Support to and participation in newly created health sector decentralization TWG  Ongoing collaboration with the Swiss TC PED project on the FORMADIS system of district capacity building  Collaboration with RALGA on network of local finance managers and network of local human resource directors  Participation in the MINALOC Decentralization Joint Sector Review  Dissemination of Twubakane Health Governance Assessment.

Component 4: District Capacity Building  Capacity building of district council members, district authorities and staff  Support to imihigo contract evaluations, support for district planning activities and alignment with NEPAD budget and planning cycle  Training of members of civil society in for greater participation in district affairs  Finalization and closeout of 2008 DIF grants and launch of 2009 DIF grants.

Component 5: Health Facilities Management and Mutuelles  Support to health facilities for health sector strategic planning and updating of the annual work plans  Ongoing strengthening of health facilities management, financial management, and accounting  Ongoing support to national mutuelles support unit and mutuelles managers.

Component 6: Community Engagement, Participation and Oversight  Assistance to Community Health Desk to develop national CHW database  Technical support to districts for quarterly coordination meetings of community health teams  Technical support and follow up to 68 PAQ teams  Support to Community Health Desk in the TOT of 25 trainers to Maternal and Newborn Community health workers (animatrices de santé maternelle, or ASM).

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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 Twubakane Program planning (FP) and reproductive health (RH); 2) child Participating Districts survival, malaria and nutrition; 3) decentralization policy, planning and management; 4) district-level 1) Nyarugenge, capacity building; 5) health facilities management and 2) Kicukiro, Kigali mutuelles; and 6) community engagement and 3) Gasabo, Kigali oversight. 4) Ngoma, Eastern Province 5) Kayonza, Eastern Province Twubakane’s strategy focuses on improving the 6) Kirehe, Eastern Province capacity to offer decentralized services but also 7) Rwamagana, Eastern Province 8) Kamonyi, Southern Province includes selective support for the development of 9) Muhanga, Southern Province health and decentralization policies, protocols and 10) Nyaruguru, Southern Province strategy guidelines at the national level. Working 11) Nyamagabe, Southern Province closely with ministries and other partners on nationally 12) Ruhango, Southern Province adopted manuals and programs, Twubakane supports the use of these materials in program districts.

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

As noted previously, in February 2009, it became apparent that the full amount of funding that USAID had hoped to provide to the Twubakane Program this year would not be available. This quarter, the Twubakane team finalized the revision of its workplan and budget accordingly, and resubmitted joint action workplans to the MINISANTE and MINALOC. This quarter, 2008 District Incentive Fund (DIF) grants were finalized, and 2009 DIF grants were launched for all 12 Twubakane-supported districts and for the City of Kigali. This quarter, Twubakane organized and facilitated an orientation meeting for the Peace Corps Volunteers posted in Twubakane- supported districts. The volunteers found the meeting useful as they were able to meet Twubakane’s technical staff and to discuss how they can collaborate with the Twubakane team.

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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. This quarter, field coordinators supported the districts in finalizing 2008 DIF grant technical and financial reports, and launching DIF-supported activities for 2009. Field coordinators also participated in district management meetings and district activity planning through the development of annual work plans. Field coordinators also worked with local authorities this quarter during the imhigo performance contract evaluation.

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

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 (TWGs), including FP, safe motherhood and prevention of and response to gender-based violence.

Repositioning family planning and support to safe motherhood: The Twubakane Program continues to support repositioning of family planning in Rwanda at both the central and district levels. At the central level, Twubakane participates actively in the family planning TWG and in rolling-out of the assessment for community-based distribution of Depo-Provera. Twubakane continued to actively ensure its secretariat role for the safe motherhood TWG and its participation on the reproductive health logistics committee.

The Twubakane team participated in a training session on maternal death audits organized by MOH, UNFPA and WHO in Rwamagana for Southern and Eastern province hospitals. At the end of the training, each partner was requested to support the roll-out of maternal death audits in its supported districts. Due to Twubakane’s shortfall in funding and the imminent close-out of the program, the audits have not been added to the program’s 2009 workplan. The Twubakane team will nonetheless provide technical assistance to the districts as needed.

Also this quarter, the Twubakane team actively participated in the preparation, abstract submission, selection and successful staging of the first international conference on maternal and neonatal health in Rwanda, organized by the MOH and partners from May 25-27, 2009. Four Twubakane presentations were accepted and presented on FP secondary posts, post-abortion care, EONC, and the PAQ approach.

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Twubakane’s RH team supported trainings in reproductive health and family planning for 87 journalism university students and Southern Province secondary school teachers in April 2009 and 58 Southern Province Catholic university journalism students in June 2009. These trainings were organized by the Rwandan Center for Health Communication. Twubakane also contributed to a reproductive health training session for primary school teachers organized by the Ministry of Education.

Twubakane also collaborated with the Rwandan Network of Parliamentarians on Population and Development in training parliamentarians and senators on gender and reproductive health and, through our Hewlett-funded initiative, in training Western and Northern Province mayors in family planning and population. The workshops brought together district mayors, vice mayors, directors of health units, hospital directors, district counselors as well as women and youth councils. Also with the support of the Hewlett Foundation, a network of 25 journalists on population and family planning was formed in March 2008.

This quarter, an evaluation workshop took place through which the network of journalists evaluated their articles, programs and stories, providing a learning experience “I’m very happy to win the first prize. through which journalists benefited from critical I feel very encouraged in my career; I analysis and feedback. Following the evaluation call upon my colleague journalists to workshop, the Rwanda Center for Health put more efforts in raising awareness Communication, MINECOFIN and Twubakane of our population problems and family examined and graded the journalists’ work, and on June planning as one of the solutions to 29, 2009, the parliamentarians’ network hosted a most of those problems. After all, we ceremony during which three journalists who excelled in are also concerned.” reporting on family planning and population issues - Brigitte Mutanguha, after winning received prizes. The three recognized journalists were first prize. Brigitte Mutanguha – from Urunana Development Communication, Eugen Mutara – from New Times, and Alice Kanyamanza, from Rwanda Television.

Focused Antenatal Care (FANC): A refresher training in FANC was organized from April 14- 20 for 26 providers from Ruhango District. The mean pre-test score was 74% and the mean post-test score was 85.2%. Acquired competencies included the systematic use of vaginal examination and checks of vital signs (e.g. blood pressure) during first and subsequent ANC visits. Participants also learned to apply quality focused ANC versus routine ANC, and expressed their intent to reorganize service delivery to increase the availability of FANC services. They also recommended that their other colleagues be trained in FANC and that the duration of practical training be extended.

Training in non-scalpel vasectomy (NSV): To expand access to permanent FP methods, this quarter two training sessions in NSV were organized for Muhanga and hospital providers. The original objective was to train and validate two providers per hospital and select vasectomy champions to support sensitization campaigns at the community level. However, during the training preparation, more staff than expected expressed interest and requested to be trained. Thus, four medical doctors and three nurses from Hospital (Muhanga) and three

- 5 - Twubakane Quarterly Report #18, April - June, 2009 doctors and three nurses from Kibungo Hospital (Ngoma) participated in the training. At the end of the training, all participants mastered the theory and counseling components, as reflected in a mean pre-test score of 55% (Muhanga) and 40% (Ngoma) and a mean post-test score of 90% and 84.5%, respectively. Unfortunately, due to lack of clients, only six NSV were performed and none of the doctors were validated for the practice. Post-training recommendations included the need for trained doctors to go to Shyira Hospital and perform more procedures in order to be validated and the need for more sensitization on vasectomy at the local level. Thus, two doctors, one from each hospital, were later validated by performing vasectomies in Shyira Hospital and vasectomy kits were distributed to both Kabgayi and Kibungo hospitals.

Supportive supervision in EONC: Supportive supervision was conducted with trained providers in EONC in Kirehe and Muhanga districts in May. In both districts, it was noted that EONC trainings have had a positive impact on effective active management of the third stage of labor (AMTSL) to prevent post partum hemorrhage, good infection prevention practices, use of the partograph, availability of essential drugs (except magnesium sulfate), and rational use of antibiotics. Constraints noted include lack of resuscitation and personal protection equipment, lack of incinerators and waste disposal equipment, and some incorrect use of the partograph. Trained providers received additional guidance during this formative supervision and specific recommendations were made to district health authorities.

In June, supportive supervision was conducted with providers trained in EONC in . It was noted that resuscitation equipment was available in all HC, AMTSL is correctly and consistently conducted, infection prevention practices are observed, and partographs are widely used. Constraints noted included the lack of action plans and the need to post protocols on some delivery room walls for treatment of eclampsia and AMTSL.

Supportive supervision of providers trained in FP: This quarter, FP supportive supervision visits were conducted in Rwamagana and Kicukiro districts in HCs and in Kicukiro’s FP secondary posts. Observations showed that the trainings have had a positive impact on the quality of services. Recommendations to district health authorities included improvement of infection prevention procedures and the need for additional training on IUD insertion and more frequent supportive supervision. It also was noted that collaboration with CHWs is needed to trace “lost” patients and sensitize communities.

Supervision of secondary posts was also conducted this quarter in Muhanga and Ngoma districts. All six posts are operational and offer FP services at least one day per week in Muhanga around Kabgayi, Nyarusange and Kivumu HCs. Kivumu HC has also taken the initiative to integrate FP into the mobile immunization strategy. In Ngoma, only Jarama and Zaza secondary posts (two out of four) are functional, but discussions were held with local authorities to relaunch the Rukoma-Sake and Gituku secondary posts.

Supervision was also conducted in Ruhango District following FP on-the-job training (OJT). Positive OJT results were noted, including integration of FP services into other services. (For example, in Gitwe Hospital, the antiretroviral therapy (ART) provider inserted 15 Jadelles to her patients during the previous month.) Other improvements noted included an increased number of long-term FP clients and improved infection prevention procedures. Thanks to the success of

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OJT, more than 82% of Ruhango District providers are now able to offer the full package of short and long-term FP methods. Validated providers were recognized and rewarded for their work this quarter with such prized as head lamps, basins, buckets, sterilizing equipment and FP T-shirts.

Training on IUD insertion: This quarter, to meet the need expressed by our district partners three trainings were held on IUD insertion. During the training in Gasabo District four providers from four HCs (Kinyinya, Kagugu, Nyacyonga and Gatsata) were validated and 31 clients received IUDs. During the training in , providers from Kabusunzu and Gitega HCs were validated. At the request of Project San Francisco, this quarter the Twubakane team conducted a refresher training on IUD insertion for 13 Project San Francisco staff who had previously been trained in short and long-term methods by Twubakane and Capacity trainers.

IEC/BCC Activities: At the request of the USG, USG FP partners, including Twubakane, contributed this quarter to a health fair for USG staff and families. The health fair, which took place on June 26, aimed to raise awareness of family planning efforts in Rwanda. The health fair was officially launched by the US Ambassador, and was attended by members of the staff and their families. Twubakane team members gave a presentation on all the FP methods available in Rwanda.

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 April 2009, Police Standards of Operation and Procedures (SOP) for Prevention and Care of Domestic Violence, GBV and Abuse Against Children were translated into Kinyarwanda by Twubakane staff. In June, the Police SOP were again revised and translated and the draft training module on care and treatment of GBV by health facilities providers was revised in collaboration with different GBV partners. Trainings using these modules will take place next quarter. Also this quarter, Twubakane participated in the validation of the MIGEPROF revised strategic plan and gender policy implementation plan, in a meeting of GBV clinical partners called by the MCH Task Force, and in a meeting organized by the GTZ on GBSV in Rwanda.

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. At the central level, our child survival team participated in several important activities this quarter, including providing significant technical assistance for Rwanda’s emergency plan to eradicate malnutrition and participating in the workshop to revise the national nutrition training guide.

President’s Malaria Initiative (PMI): Twubakane continues to assist the 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 integrated community

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health package. This quarter, the Twubakane team participated in the MOH-led evaluation of the Integrated Community Health Package in four districts (Kirehe, Ruhango, Gisagara and Nyamagabe). Both positive outcomes and constraints were noted, and areas for improvement include the use of the mid-upper arm circumference (MUAC) straps and data completion due to a lack of supervision by HC staff.

Integrated community health package: Twubakane continued to support trainings in integrated community health in Ruhango District this quarter. A total of 131 CHWs from Gishweru, Byimana and Ruhango health centers were trained in April. In May, the remaining 102 CHW from Gitwe, Byimana and Muyunzwe HCs were trained, thus completing the training of all 1070 CHWs in Ruhango on the integrated community health package.

Twubakane also supported and participated in the supervision of CHWs in Ruhango on the integrated community health package this quarter. In April, 205 CHWs based in Mukoma (50), Kinazi (43), Mbuye (58) and Kizibere (54) HCs participated in monthly monitoring meetings. In May, 300 CHWs participated in monthly monitoring meetings. These CHWs came from Muremure (29), Kigoma (87), Nyarurama (95) and Karambi (89) HCs. In June, 546 CHWs from Mbuye (68), Muyunzwe (50), Muremure (30), Gishweru (90), Gitwe (106), Mukoma (50), Kigoma (96), Kizibere (56) participated in monitoring meetings. New registers were provided to CHWs in Muyunzwe; 50 CHW registers are still needed and will be purchased with the Community Health Desk’s support. These supervision meetings supported improved data management by CHWs. During the supervision visits, stockouts of Primo (community available ACT) were noted. CHWs also raised issues of zinc tablet expiration dates and amoxicillin tablets which are not dividable. Corrective measures were discussed with the PNILP and local authorities.

Supervisions of CHWs responsible for HBM in Bugesera were conducted this quarter as well. A supervision meeting was conducted in May with 206 CHWs from Kamabuye (130) and Gakurazo (76) HCs and CHW registers were reviewed and discussed. A noteworthy issue addressed at the supervision meeting was the fact that some payments which the CHWs collect from patients at community level through CBD of Primo and which they are expected to transfer back to the health centers on a monthly basis are in fact not handed over to the health centers along with the CHW’s monthly report. Local leaders should address this issue and discuss ways for the CHWs to recover such missing funds.

In June, supervision meetings were conducted with 208 CHWs in Gashora, Mayange and Ruhuha HCs. The meetings revealed how CHWs are now confident in treating fever in children under five and how they regularly send their monthly reports to the HC. They were also an opportunity for CHWs to request expansion of their community health package in Bugesera and to note frequent stock out of Primo at the HC level. Twubakane will follow up on problem related to Primo and other commodities.

Capacity Development for Malaria Program Management: Through a special agreement with USAID and PMI finalized this quarter, the Twubakane Decentralization and Health Program has received and used funding to support Tulane University in implementing capacity- building activities for management and monitoring and evaluation of malaria programs in

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Rwanda. As a key component of this support, Twubakane used PMI funding to assist the head of sentinel surveillance for the Rwanda National Malaria Control Program in pursuing post- graduate studies with Tulane University’s School of Public Health & Tropical Medicine. This activity will ensure that Rwanda has the capacity to manage and monitor vector control programs, including indoor residual spraying (IRS). Twubakane’s financial support also permitted Tulane to provide Rwanda-based technical advice on Sentinel Surveillance, Epidemic Detection and Response, and the upcoming Rwanda Malaria Indicator Survey.

In addition, Twubakane provided financial support for Tulane and Rwanda’s National Malaria Control Program to deliver a nine-day training in Visual CE programming language to 11 Rwandans. Participants were drawn from a variety of central-level institutions, including TRAC- Plus/Centers for Infectious Disease Control, the National School of Public Health, and Kigali Institute of Science & Technology. The personnel who attended the training gained valuable skills in preparing Personal Digital Assistants (PDAs) for use in survey research. This increased capacity for PDA-based research will facilitate the implementation of Rwanda’s 2009 Malaria Indicator Survey.

To increase district-level capacity to manage and assess IRS and other malaria control interventions, Twubakane provided the necessary funding to deliver the intensive training in program management and M&E for malaria control officers to 16 district-level personnel (four women and 12 men). This five-week intensive training is the equivalent of three post-graduate university courses in malaria control and M&E at Tulane University. Instructors included faculty from the National University of Rwanda School of Public Health and Tulane along with expert lecturers from the World Health Organization, RTI, International, BASICS, and MINISANTE.

Clinical Integrated Management of Childhood Illness (IMCI): In April, supportive supervision of clinical IMCI activities was conducted in Kamonyi District by the Twubakane team in collaboration with the district health director, the Remera Rukoma hospital director and two supervisors. Out of the 11 HCs in the district, 10 have two providers trained in clinical IMCI, while Nyagihambo HC has only one. Only two HCs (Gihara and Kayenzi) provide daily IMCI services in a relevant setting while the remainder provide services once a week. A mjor constraint to the full implementation of clinical IMCI at the health center level, which has been raised by Twubakane at several national level meeting, is the lack of IMCI indicators in the MINISANTE’s PBF system, which inhibits the full implementation of IMCI at the HC level. Consequently, IMCI services and supervision are not seen as a priority to hospital and HC personnel. This issue was raised recently in a national workshop on PBF and the national PBF coordinator promised that it would soon be corrected.

In May 2009, IMCI supervision was conducted in Nyamagabe District. Of 13 HCs, nine are offering clinical IMCI services, some on a daily basis (Cyanika, Ngara, Rugege) with 80% of children treated according to IMCI standards. Lack of motivation to follow IMCI protocols was cited, linked to the non-inclusion of IMCI in PBF, trained staff turn-over, lack of ownership by health center managers and lack of supervision by hospitals. Corrective measures were discussed and recommended to district health authorities. Following these supervisions, Twubakane conducted a training in clinical IMCI to replace relocated trained staff in all HCs. Twenty nurses

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were trained from six districts: Kayonza (2), Rwamagana (3), Gasabo (4), Kamonyi (1), Ruhango (7) and Nyamagabe (3).

Community-based nutrition (PNBC) and HEARTH: Following the TOT conducted last quarter, a training on community-based nutrition was organized in April for 86 CHWs from all 13 HCs in Nyaruguru District and for 18 CHWs from Jenda and Kaduha HCs in Nyamagabe. Training modules included growth monitoring, nutritional education on breastfeeding and weaning, data collection and analysis, assessment of causes of malnutrition and corrective actions, and the HEARTH model. Relevant PNBC materials and equipment were also provided to all HCs in Nyaruguru and Nyamagabe. Each HC will launch three community nutrition sites with at least two trained CHWs per site. A refresher training was conducted and materials were distributed in April for 116 CHWs from all 13 HCs in .

Also this quarter, a TOT in PNBC and HEARTH was conducted in Nyarugenge and Kicukiro districts. 15 providers and two supervisors from Muhima and Kanombe hospitals were trained. The training of CHWs by these trainers was scheduled for this quarter but has been postponed at the Community Health Desk’s request.

Ongoing monthly monitoring of the 23 HEARTH sites in Rwamagana District continued to be conducted by CHWs, health center providers, and Twubakane staff. HEARTH data shows that the strategy was implemented in 6 villages around Muyumbu HC, with 85 malnourished children treated and monitored in 14 HEARTH sites. During the 21 day-period, 99% of those children gained weight, 62% were cured (that is, returned to a safe weight). Two HIV-positive children stayed severely malnourished and were referred for special care. Around Karenge HC, 94 malnourished children were treated in 16 HEARTH sites based in nine villages. Out of the 94, 54 were cured. All the children gained weight during the 21-day period.

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

Support to MINALOC Decentralization Joint Sector Review: Twubakane staff actively participated in the MINALOC Decentralization Joint Sector Review this quarter. The meeting was held on April 14 and assembled various stakeholders and MINALOC staff. This meeting reviewed the Citizen Empowerment, Participation, Transparency and Accountability (DCEPTA) report and the upcoming organizational and administrative changes at MINALOC and decentralized local government units. A MINALOC team prepared the 2008 Joint Sector Performance Report for the DCEPTA Sector. Key challenges noted included insufficient communication, inadequate financial resources, limited human resources and lack of data on key performance indicators. Recommendations were made regarding gathering accurate data, preparing reports, staffing of NDIS, and reviewing legislation on fiscal decentralization.

Collaboration and support to MINALOC: This quarter, the MINALOC NDIS office continued its search for recruiting personnel. Also this quarter, Twubakane staff continued collaboration with the Swiss Technical Cooperation PED project on the FORMADIS system of

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district capacity building with MINALOC and RALGA. The FORMADIS system was initiated to provide tools and mechanisms to the Districts for management of the administrative, organizational, technical and financial aspects of their capacity building programs. During this quarter, Twubakane staff participated in two workshops organized by the PED project that brought together all partners supporting district capacity-building to discuss the institutionalization of FORMADIS in all districts and to standardize training events at the district level. Twubakane is awaiting final approval from NDIS to roll out the FORMADIS system in our 12 districts.

Collaboration with MINISANTE: This quarter, Twubakane staff participated in an international technical review meeting on Performance and Resource-Based Financing (PBF and RBF) hosted by MINISANTE. The objective of the meeting was to review Rwanda’s and other countries’ experiences on PBF, discuss the implementation and scaling-up of PBF nationwide, and discuss key policy and programmatic challenges in implementing RBF in Rwanda.

MINISANTE Decentralization Technical Working Group: Twubakane staff continues to collaborate on operationalizing the Decentralization TWG. Assistance was provided on developing agendas and co-facilitating meetings. On April 15, Twubakane hosted a meeting that brought together stakeholders and development partners implementing and addressing decentralization and health activities and issues. During this meeting Twubakane staff presented the legal and administrative framework of the second phase of decentralization and decentralized health service delivery. A major recommendation of the meeting was to compile and publish a handbook of laws and regulations related to health services delivery and management which can be used by district and FOSA employees and development partners working at the local level. On June 12, another Decentralization TWG meeting was organized and held in . The meeting was attended by partners implementing health programs, the district executive secretary of Karongi, directors of district hospitals and directors of health units in the Districts of the Western Province supported by the Swiss Technical Cooperation. This meeting included a presentation of the purpose, objectives and ToR of the decentralization TWG, the positive and negative effects of decentralization on the functioning of district health system, a discussion of the district health budget and planning process (JAWP) underway for the 2009-2010 budget cycle, and a review of the upcoming administrative and organizational changes at the central and local levels.

Support to MINECOFIN for audit training manuals: In collaboration with MINECOFIN and DED, this quarter Twubakane finalized the training manual and training guide for district auditors. The MINECOFIN Chief Internal Auditor appreciated the documents and confirmed that the MINECOFIN will carry out the training in the districts where Twubakane does not intervene. Twubakane will carry out additional audit training for Kigali City participants and will collaborate with the Swiss Technical Cooperation PED project to support trainings in the Western Province districts next quarter.

Collaboration with RALGA for district capacity-building: VNG’s sub-contract with IntraHealth under the Twubakane Program to provide financial and technical support to RALGA came to an end in May. RALGA has agreed to take on direct responsibility to support the Capacity Development Officer and on-going capacity building activities. Twubakane continues

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to actively collaborate with and support RALGA. During the month of June, in collaboration with VNG, Twubakane participated in a functional and institutional review of RALGA and an evaluation of activities accomplished in its 2006-2009 strategic work plan. Key findings from this review reveal that RALGA continues to evolve as a viable local government association and is, for the most part, fulfilling its mandate. However, RALGA continues to be overextended and needs to strengthen its lobbying and advocacy work. The report from the review will be finalized next quarter and will be used for organizational and staffing changes within RALGA and for developing its 2009-2012 strategic work plan.

Twubakane staff participated in a two-day Local Finance Managers Network (LFMN) seminar held in Musanze in May 2009. Participants included members of the LFMN network, MINALOC, MINECOFIN, RALGA, the Rwanda Revenue Authority, GTZ and Twubakane. During the meeting, an overview of the Auditor General Office Report on Public Finance Management in Local Governments was presented on challenges faced by districts and local institutions in producing “clean, accurate and accountable” financial reports. Participants discussed the new structure of the finance departments and provided their input on how the finance department should be structured at district and sector levels. The representative of MINALOC urged the members of the LFMN network to follow the recommendations that are provided in the audit reports. Participants also examined the preliminary findings of the study on district financial absorption capacity.

Also this quarter, RALGA and the World Bank-supported Human Resources and Institutional Capacity Building Agency (HIDA) have continued collaboration on developing the framework for a training and trainers database for tracking capacity building activities at the district, sector, and cell levels. VNG International has been contracted to provide technical assistance on developing the software interface and data entry dashboard. Twubakane staff have provided input on the content and management of the database and provided examples of the training database that is used on the Twubakane project. In July, the database will be finalized with VNG’s assistance. Then, in August, RALGA will collect and enter data for each of the 30 districts.

Health Governance Assessment: This quarter, Twubakane disseminated the Health Governance Assessment to the Government of Rwanda (MINALOC, MINECOFIN, MINISANTE, and districts) and other relevant stakeholders. The assessment’s objective 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 as well as contributed to improved health outcomes. This report is being widely disseminated to the GOR and other development partners.

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: This quarter, Twubakane continued its support to district Joint Action Development Forums (JADF) in Nyarugenge, Gasabo, Kicukiro, Kirehe,

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Ruhango, Muhanga and Kamonyi districts and engaged in discussions with other development partners on how to better collaborate on supporting the JADFs. Twubakane technical staff and field coordinators provided regular technical and financial support, encouraging districts to use the JADFs effectively for coordinated development activities and planning. Twubakane staff and field coordinators carried out a small survey on the status and functioning of the JADFs in the Twubakane intervention zone. Information collected included the number of meetings organized and held, the existence of minutes for the JADFs meetings, ability of districts and JADF members to follow up on actions and recommendations, and important achievements at the district and sector levels. Information gathered shows that all the JADFs in Twubakane zone exist, but are operating at varying degrees of effectiveness, except for , which has not organized a meeting in the last six months. Next quarter, Twubakane will concentrate on Kayonza District to help reorganize and reactivate its JADF committee. Districts of the Southern Province have made good progress in establishing JADFs at the sector level.

Financial Management and Audit Training: Twubakane staff carried out two field visits to the Southern Province to assess training needs in audit and financial management. Information collected was useful to prepare the audit training for district authorities and members of district councils. During these visits, Twubakane staff interviewed districts’ vice mayors of economic affairs, district auditors and the Governor of the Southern Province to better understand the connections between the functions of district financial management, audit functions, internal controls and capacity gaps. Following this assessment, the Twubakane team and MINECOFIN trainers trained 58 participants from all districts in the Southern Province, including members of economic commissions of the District Councils, vice mayors of economic affairs, executive secretaries and auditors. The two-day training provided knowledge, techniques and best practices on internal financial controls and auditing. Participants were given the opportunity to review their roles and responsibilities as well as analyze and carry out the follow-up of audit recommendations. Participants provided recommendations that will be followed up on by District Council members within each district and best practices will continue to be shared by e- mail exchanges and local forums.

Training of Civil Society Memebers: In collaboration with GTZ/DED, a four-day training for civil society members of Gasabo District was carried out using the Plate Forme de la Société Civile and MINALOC training module. The objective of the training was to improve the knowledge and skills of members of civil service organizations and of the private sector on their role in development, in possible partnerships and in the legal situation of their structures at the local level. Participants discussed their role in planning and development activities of districts and sectors, service delivery to the community, and how to effectively collaborate with districts.

Training of Local Leaders on Decentralization Policies: In April, MINALOC organized a training of trainers for district authorities and members of CSOs on national and decentralization policies. Twubakane staff and field coordinators participated in this national TOT as active members of district JADFs. The trainers, including Twubakane field coordinators, will support the districts to organize training events for executive secretaries and other staff at sector and cell levels. Following the TOT, Twubakane provided technical assistance to Gasabo District’s training of 118 local leaders on decentralization policies. Participants included executive secretaries of sectors and cells, the staff in charge of social affairs at sector levels and the

- 13 - Twubakane Quarterly Report #18, April - June, 2009 president of CDC committees. Participants discussed these different policies and expressed the need for institutional support to understand, implement and apply these policies at the local level. As an outcome, MINALOC and districts will expect greater efficiency from the local leaders with continuous support, supervision and evaluation provided by the district.

Imihigo Contract Reviews and Support to District Budgeting and Planning: Extensive support was given to districts and sectors to revise 2009 work plans to align with the NEPAD budget cycle, now running from July 2009 to June 2010. The imihigo evaluations focused on the four pillars of the Government of Rwanda DIP program: good governance, economic development, justice and social affairs.

District Incentive Fund (DIF) Grants: Twubakane continues to support the 12 districts and Kigali City through its technical assistance and DIF grants implementation. The DIF grants program remains a valued and cherished program by the districts and by the beneficiaries of the activities it funds.

The Twubakane Health Governance Assessment, discussed above, highlights the importance of the DIF grants program as a valuable capacity-building system and a resource-mobilization tool that helps districts integrate governance activities into their health programs in a non-threatening way. The DIF grants program has resulted in a variety of health governance outcomes, including greater accountability, responsiveness to local needs and citizens’ input, and efficiency and effectiveness in health care service delivery. As stated in the health governance assessment, DIF grants reflect local health priorities and have been used to fund a wide range of activities. This quarter, the main activities for the Twubakane DIF grants staff, field coordinators, and accountants were the closeout of 2008 DIF grants activities and the contracting of 2009 DIF grants funds with the 12 districts and Kigali City.

Twubakane staff provided supervision and technical support to districts for the final review and closeout of 2008 DIF grants activities. This focused primarily on the completion of technical and financial reports (including cost share reports), and on-going support to district accountants in ensuring accurate and transparent reporting. Contract extensions up to May 31, 2009 were issued for three districts (Nyarugenge, Kayonza and Kirehe) to complete 2008 DIF grants activities. These districts’ delays were due to local contractors not being available to complete renovation work, and difficulties obtaining equipment and materials. The three districts were able to complete the work in May, submit reports in early June, and sign 2009 DIF grants contracts later in June. While delays and inaccuracies of financial and technical reporting are still a problem, overall, the Twubakane DIF grants team noticed significant improvements in the districts’ capacity to manage DIF grants funds and activities.

The Twubakane DIF team led the final review of 2009 DIF grants applications and the preparation of contractual documents for all 12 districts and the City of Kigali. The disbursement of the first tranche of payments for all 12 districts and the City of Kigali went out this quarter. Due to USAID funding constraints, there were some delays in contracting the 2009 DIF grants in a timely fashion until the Twubakane DIF grants team knew exactly what amount of FY 2009 funding would be available for the program this year. Once Twubakane received confirmation from USAID on this funding availability, the DIF grants team mobilized quickly to get all 2009

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DIF contracts signed and activities started. District and provincial officials and MINALOC and MINISANTE ministers were informed about the funding constraints and were understanding and patient.

This year, there are noteworthy positive improvements in the preparation of DIF grants 2009 proposals. The project descriptions and budgets were much more coherent and contained fewer errors that in previous years. This allowed the Twubakane staff and DIF Grants team to engage in a fast and efficient project proposal review and contracting process with the districts.

A detailed table of 2009 DIF grants activities appears in Annex 4 of this quarterly report.

Table 1 below illustrates the status of DIF grants funding for each district, showing remaining, unused funds from 2008 DIF grants activities to be deducted from 2009 grants funding, as well as the amount of funding available for 2009 activities as of June 30, 2009.

Table 1: Status of 2008 and 2009 DIF Grants Funding in Rwandan Francs (Rwf) Province District Remaining Approved First tranche Amount to Amount yet unused 2008 funding amount be to be DIF funds amount of transferred accounted Transferred 2009 DIF for City of Kigali 276,894 16 500 000 7, 974,286 8, 251,180 8, 251,180

Nyarugenge 1, 209,027 41 250 000 19, 415,973 20, 625,000 20, 625,000 KIGALI Kicukiro 445,899 41 250 000 20, 179,101 20, 625,000 20, 625,000 Gasabo 2,900 41 250 000 20, 622,100 20, 625,000 20, 625,000

Ngoma 732,299 41 250 000 19, 892,711 20, 625,010 20, 625,010 Kayonza 756,823 41 250 000 19, 868,177 20, 625,000 20, 625,000 EAST Kirehe 1, 210,000 41 250 000 19, 415,000 20, 625,000 20, 625,000 Rwamagana 4, 179,269 41 250 000 16, 445,731 20, 625,000 20, 625,000

Kamonyi 2, 607,824 41 250 000 18, 017,176 20, 625,000 20, 625,000

Muhanga 16,445 41 250 000 20, 608,555 20, 625,000 20, 625,000 SOUTH Nyaruguru 35,494 41 250 000 20, 589,506 20, 625,000 20, 625,000

Nyamagabe 1, 123,152 41 250 000 19, 045,230 20, 168,382 20, 168,382 Ruhango 1,416 41 250 000 20, 623,584 20, 625,000 20, 625,000

TOTAL (Rwf) 12, 597,442 511, 500,000 242, 697,130 255, 294,572 255, 294,572

Also this quarter, a review of DIF-funded PAQ team activities in over the past three years was carried out to assess the impact of the use of grants to finance small scale revenue-generation projects to foster PAQ sustainability and operations. Likewise, Twubakane MIS and DIF staff have begun preparing for an ICT asset assessment of ICT equipment purchased with DIF grants funding and a questionnaire has been developed to collect information on how DIF grants funded ICT equipment have impacted capacity and ability of local government authorities to carry out their work. The assessment will cover equipment,

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databases, software, connectivity, alternative energy solutions, ICT financing, maintenance, and capacity building. The data will be collected in July and a report will be generated in August.

During this final year of the implementation of the Twubakane Program, special attention will be paid to documenting overall lessons learned, successes and challenges related to the DIF program.

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

Revision of Health Care Policies, Norms and Protocols/Standards (PNP): This quarter, the PNPs were posted to the MINISANTE’s website for review by districts, health facilities, development partners supporting health facilities and other stakeholders and final edits were compiled by the Quality Assurance Desk and local consultants and incorporated in a final set of draft documents, presented by topic. Decisions still need to be made about what levels and structures the information will be presented to and in what format. Then the documents will need to formatted and finalized. The MINISANTE is requesting that the documents be reformatted by level of intervention (referral hospital, district hospital, health center, health outpost, CHW), and then by topic.

Strengthening Health Facilities Management, Strategic Plans, Budgets, and Work Plans: At the request of the MINISANTE and other partners, the Twubakane staff provided sustained technical assistance to district and health facility staff in the preparation of their health strategic plans (July 2009—June 2012), and updating the 2009 health JAWP. Development partners teamed up at the local level to coordinate technical assistance; FHI and GTZ field coordinators worked in collaboration and coordination with Twubakane staff to divide the work at health center level and assure full coverage and support. Twubakane staff worked with health facility managers to prepare and conduct regional orientation sessions on the MINISANTE’s policies and guidelines concerning the preparation of the three-year health strategic plans, the updating of the 2009 JAWP to align with the new NEPAD budget and planning cycle, and best practices concerning health budgeting and planning. Twubakane staff provided explanations on the content and use of the MOH provided excel planning tools, reviewed the major objectives of the HSSP II, and ensured a participatory planning process. The following seven districts, hospitals and 87 health centers were supported by Twubakane staff:  Ruhango District: Gitwe Hospital and 13 health centers  Kamonyi District: Remera Rukoma Hospital and 12 health centers  Muhanga District: Kabgayi Hospital and 13 health centers  Nyamagabe District: Kigeme Hospital and 13 health centers  Nyaruguru District: Munini Hospital and 13 health centers  Ngoma District: Kibungo Hospital and 13 health centers  Gasabo District: Kibagabaga Hospital and 10 health centers

By the end of June 2009, all strategic plans were completed and sent to the MINISANTE with copies provided to the respective districts and provinces. Now that the strategic plans have been

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completed, districts and health facilities are finalizing the 2009 JAWP contributions which should be submitted by mid-July 2009. During the next quarter, Twubakane staff will continue to work with the districts and health facilities to begin operationalizing their strategic and 2009- 2010 annual work plans.

Twubakane staff continued to collaborate with hospital directors and accountants throughout the quarter to provide formative supervision on their accounting practices, focusing on closing the bookkeeping for FY 2008-2009 and preparing for FY 2009-2010. Guidance was given on carrying out accurate inventories and asset management. A best practices workshop, which included an evaluation of progress to date, was carried out in June 2009 and brought together all the district accountants and hospital directors. District accountants have made progress on their accounting and bookkeeping but are struggling with the inventory and asset management. During the next quarter, Twubakane staff will focus on providing additional guidance and support for inventory and asset management in the following six district hospitals: Kigeme (Nyamagabe), Kabgayi (Muhanga), Rwinkwavu (Kayonza), Muhima (Nyarugenge), Kanombe (Kicukiro), and Kibagabaga (Gasabo).

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 and mutuelles policy decisions. This quarter, the MINISANTE made two important ground breaking decisions: 1. The mutuelles subscription fee prepayment system was reevaluated and standardized, moving from a single subscription fee (1000 RWF per person) to a stratified payment system using a five-tiered classification method linked to the Ubudehe classification of indexing poverty and wealth. The exact stratified payment amounts per tier is still being discussed and will be reviewed with MINECOFIN and the mutuelles TWG next quarter. 2. A standardized billing and payment system called "capitation" was instituted, replacing the fee for service billing and payment system that is currently practiced in 75% of the districts and health facilities.

Twubakane staff members were asked by the MINISANTE and CTAMS to support a comparative analysis of the capitation system versus the fee for service billing system. During this quarter, Twubakane staff collected historical data (2006 through 2008) from health facilities, mutuelles offices and district offices in Muhanga, Kamonyi and Ruhango districts. These three Districts were chosen due to their experience with both systems of billing. It is anticipated that the comparative analysis will illustrate both the benefits and problems with each system of billing, but will also reveal that the capitation system has distinct advantages regarding management and financial viability. The challenge for the Twubakane comparative analysis team was to understand how Rwanda health facilities and mutuelles managers understand and apply the capitation system. In July 2009, a report will be finalized and presented for review by the CTAMS and the mutuelles TWG. The report will present recommendations on how the capitation system can be rolled out and implemented nationally, as well as precautions and next steps for the MoH, districts, mutuelles offices and health facilities.

Twubakane staff continue to participate actively to support the mutuelles database and support mutuelles managers and the district mutuelle officers to provide technical guidance and oversight

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on the quality of data entry, compilation and aggregation, and reporting. Data is gathered and verified at the health center mutuelles office and transferred to the district mutuelle office where it is then entered into the web-based database. Data is reverified and reports are generated and sent to the central Cellule d’Appui Technique aux Mutuelles de Santé (CTAMS) office. The CTAMS website, developed by MINISANTE and RITA with support from MSH, is located at www.cbhirwanda.org.rw.

Mutuelles in Twubakane-supported Districts: During this quarter, ongoing supervision and technical assistance was provided by Twubakane staff to the mutuelles managers of Ruhango District and the following observations were shared:  Completed and detailed mutuelles strategic plans and monthly work plans are absent, but have been replaced by a weekly district calendar of activities.  Monthly meetings are occurring between the district mutuelles officer and the mutuelles managers with mutuelles data being transferred and entered. There were delays and gaps in reporting for the first quarter of 2009, but reports are now up to date through the month of May 2009.  Data analysis is not carried out systematically and mutuelles indicators are not being adequately tracked.  Two of the 13 mutuelles offices within the district have outstanding debts with the health center; the district hospitals of Gitwe and Kabgayi are indebted and are drawing funds from the district health insurance risk pool to cover their gaps.  The 2010 subscription season will start in July 2009 and new books and accounting tools are being put in place.  The district mutuelle officers cite the lack of financial resources and transportation as obstacles to being more proactive in monitoring and supervising health center mutuelles

During the next quarter, Twubakane staff will continue to carry out spot checks and supervision of mutuelles offices within the Twubakane intervention zone. During the month of July 2009, Twubakane staff will carry out a training for all the new mutuelles managers that have been hired within the last 3 to 4 months.

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

National Community Health Strategy: This quarter, Twubakane’s Community Participation team supported the creation of an updated community health worker database at the request of the MINISANTE’s Community Health Desk. A consultant was recruited by the MINISANTE and Twubakane to technically facilitate data collection and data entry for the CHW database.

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Data collection was conducted in all 30 districts, and a draft version of the report and database was submitted to the Community Health Desk. After receiving feedback from the community health desk and the M&E unit at Twubakane, the consultant submitted a final report and an excel database with pivot tables to the Community Health Desk.

As discussed above, the Twubakane team participated in workshops organized by the MINISANTE to assess CHW skills and competencies in providing the integrated community health package before extending the strategy to the national level. A pretest of tools for the assessment was supported by Twubakane in Kirehe District. The workshops focused on indicators to be collected and tools used and discussions of CHW’s skills and competences. Finally, a rapid assessment was done by the Twubakane team in Gahara, Musaza, Kirehe, Nyamugari, Nyarubuye, Ntaruka, Mulindi and Kabuye health centers in Kirehe District. The main challenge revealed during the assessment was the need for more consistent technical support and supervision from the HC and hospital levesl.

Following preparations which took place last quarter for the roll-out of the community maternal and newborn health worker (ASM), this quarter a training of trainers (TOT) for 25 trainers of community maternal and newborn health worker was conducted in Rwamagana District in collaboration with the MINISANTE’s Community Health Desk. The trainers were all health workers from district hospital maternity wards and the training focused on the content of the training module and service package for the community maternal and newborn health workers.

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.

This quarter, Twubakane’s community participation team held quarterly coordination meetings with community health teams in 10 districts: Gasabo, Kayonza, Kamonyi, Kicukiro, Kirehe, Muhanga, Nyamagabe, Nyarugenge, Nyaruguru and Ruhango districts. The teams were made up of the social affairs vice mayors, hospital and district health directors, head of social affairs at the sector level, community health coordinators, supervisors of hospitals and PAQ committees. These meetings focused on coordination efforts between the community health teams and the PAQ teams and on planning for third quarterly PAQ activities. Integrated plans were developed to encourage sustainability and stakeholder engagement of the PAQ approach.

Also this quarter, the Twubakane team provided support to the supervision of a total of 68 PAQ teams: 10 PAQ in Muhanga, 2 PAQ in Ngoma, 10 PAQ in Rwamagana, 4 PAQ in Kirehe, 3 PAQ in Kayonza, 13 PAQ in Nyamagabe, 13 PAQ in Nyaruguru and 13 PAQ in Ruhango districts. The supervisions showed that the majority of PAQ teams are working and are actively providing feedback to the health centers and encouraging their communities to use the health services available to them. Observations by district and by PAQ teams can be found in Annex 5.

A workshop was held in Gasabo District to support the reorganization and relaunch of the PAQ team at Kacyiru health center. The purpose and objectives of the PAQ approach were redefined and the roles and responsibilities of the PAQ team to improve quality of health services were

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presented. A new PAQ committee and board will be elected in the last week of July after selecting active stakeholders. Finally, in collaboration with the DIF Grant team, the community participation team conducted a review of PAQ projects financed through DIF grants in Kirehe District. Preliminary results show that successful projects are underway in Gahara, Nyarubuye, Nasho, Gashongora (Nasho), and Ntaruka (Bukora) HCs. The rest of the projects need management reinforcement though support and monitoring of the sector and the district.

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, implementation of refined data quality strategies, and dissemination of quarterly data. The M&E team also facilitates and coordinates the regular planning, coordination, and integration of activities for the Twubakane Program. This quarter, the M&E team has been working on a mapping document that contains Twubakane Program results from the 2008 annual facility assessment to map Twubakane interventions across the 12 districts. During the past quarter, the team collected GIS coordinates from district hospitals, health centers and family planning secondary posts. These coordinates were added to a worksheet containing information such as target population, services offered, human resource information, trainings received, community activities, and number of sectors, cells and villages per district. This spreadsheet will be converted into a GIS map.

The Twubakane team continued to work on IntraHealth’s web-based results database. IntraHealth International developed a web accessible database to make project data globally accessible. The Twubakane Program was chosen among IntraHealth projects around the world to pilot this initiative.

Also this quarter, the M&E team collaborated with the FP/RH team to visit FP secondary posts in Ngoma District as some had proved to be having data collection problems last quarter. The four FP secondary posts visited were Zaza, Rukoma-Sake, Nyinya and Jarama. Jarama and Zaza were functioning well and serving many clients. However, the other two were not functional. Meetings were held with local administrative and health officials and they promised to take ownership of the secondary posts and found solutions to make them more useful for the population and to ensure regular data collection.

The Twubakane M&E team provided support to special projects implemented primarily by technical program staff, including collecting data for the baby basket initiative which awards mothers delivering at health facilities and adhering to the 4 ANC standard visits. The M&E team also provided support in the development of the CHW database for all 30 . Members of the M&E team participated in all steps of the creation of the database including data collection activities, providing feedback on the draft report and creating a useful spreadsheet that presents the data in excel pivot tables and is easy to maintain and to update. See Annex 6 for the updated performance monitoring plan with quarterly indicator data.

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5. CHALLENGES AND OPPORTUNITIES

Challenges and opportunities this quarter included:

Unexpected Shortfall in Funding: In February 2009, Twubakane learned that the full anticipated funding for this final year of the project would not be available. Shortfalls in funding have had a particularly strong impact in delaying our community health activities, but it is hoped that the final planned community health trainings will be able to take place in July/August. Funding available for the creation of the CHW database was limited; the decision was made to deploy Twubakane staff to this activity to reduce data collection costs.

Changes in Per Diem Rates: This quarter, the USG proposed that its partners follow the ne recently increased GOR national perdiem rates for all levels of personnel. Because Twubakane’s activity budgets during this last year of implementation had been based on previously approved perdiem rates, this quarter the Twubakane Program had to shorten the length of some trainings or the number of people trained in order to stay within budget and abide by these new per diem rates.

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 dependent on partner organizations, and health centers have, in general, not provided consistent support and supervision of CHWs. It is hoped that the community PBF system will soon become functional and will contribution to the resolution of this and other challenges related to community health in Rwanda.

District Incentive Fund Grant Execution: There are systematic delays in the districts in providing timely and accurate financial and technical reports. Financial reports get completed more regularly than the technical reports which tend to lag behind, but financial reports often contain errors which require extra time and effort to resolve or are delayed because supporting receipts and documents are missing. This quarter, there were problems with the financial reports of Kamonyi and Rwamagana districts that caused delays in the close out of their 2008 DIF grants activities and progress on their 2009 contracts, but these issues were resolved by the end of the quarter.

National HMIS Data and Twubakane Reporting: The Twubakane Program collects data to monitor performance indicators and uses data collected routinely by health facilities and submitted to the districts through the national health management information system (HMIS). The Twubakane M&E staff continues to face challenges and delays in data collection at the facility, district and central level. This quarter, itorero activities have made it difficult to find staff at health facilities that can provide the data. At the central level, HMIS staff have not been able to provide all required information, which has further compounded challenges in data collection and analysis. These constraints were particularly difficult in the district of Kicukiro. Thus, there is significant missing or incomplete data in this report for Kicukiro including: June data for all 7 HCs; health education data for family planning; data on deliveries for June in all facilities, for April in Busanza HC, and for all 3 months in Kanombe Hospital; data on # of

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diarrhea cases treated; data on # of children who received DPT3; data on # of children who received Vitamin A in health facilities and the community; data on the # of children reached by nutrition program; and data on # of children < 5 years diagnosed with simple malaria.

6. PERSPECTIVES FOR NEXT QUARTER

During the third quarter of 2009, Twubakane will continue to support key activities that were delayed during revision of the workplan and budget earlier this year, and Twubakane will continue to collaborate with other partners, including those funded by USAID, to leverage costs and ensure that key activities are carried out. Also this quarter, Twubakane will collaborate with USAID and othe partners to organize the dissemination of the PAQ evaluation carried out earlier this year. Finally, this quarter Twubakane will finalize plans for its final program review and closeout activities.

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ANNEX 1: TWUBAKANE PROGRAM RESULTS FRAMEWORK

Twubakane Decentralization and Health Program Goal Components/ Results Objectives

Component 1:  Norms and protocols (MPA and CPA) for FP and RH FP/RH revised to expand package of services offered at health centers Increase access to and  Increased use of modern FP the quality and  Improved quality of FP services in health utilization of FP and facilities To increase access to RH services in health  Quality of RH services, including safe and the quality and facilities and delivery and management of obstetrical utilization of family communities emergencies, improved in health facilities health services in  Health care providers following norms for health facilities and referral/counter-referral for FP/RH communities by  Functional rapid response system for strengthening the obstetrical emergencies exists at community capacity of local level governments and  Increased utilization of antenatal services communities to ensure improved health service Component 2: delivery at  Norms and protocols for IMCI, malaria and Child Survival, nutrition to expand package of services decentralized levels Malaria and Nutrition offered at health centers package of family  Quality of child survival/malaria/nutrition Increase access to and health services services improved in health facilities the quality and includes FP/ RH and  Improved community-based nutritional utilization of child child survival/malaria surveillance and community-based case health, malaria and and nutrition services 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 #18, April - June, 2009 Annex 1

Twubakane Decentralization and Health Program Goal Components/ Results Objectives

Component 3:  Increased capacity of central level Decentralization (MINALOC and MINISANTE) to support Policy, Planning and local governments to plan, finance and Management monitor health service delivery  Improved policies for effective Strengthen central-level implementation of decentralization, capacity to develop, especially fiscal decentralization, developed support and monitor  NHA institutionalized and used as planning To increase access to decentralization and monitoring tools and the quality and policies and programs,  National HMIS assessment conducted utilization of family with an emphasis on  RALGA’s capacity for supporting good health services in health services governance at local levels improved health facilities and communities by strengthening the capacity of local governments and communities to ensure improved health service Component 4:  Local government capacity for integrated delivery at District Level planning strengthened, including health decentralized levels Capacity Building sector planning

 Local government capacity for mobilizing package of family Strengthen capacity of and managing resources strengthened health services districts to plan,  Community participation strengthened in includes FP/ RH and budget, mobilize planning and budget decisions, including child survival/malaria resources and manage ongoing review of service delivery and other and nutrition services services, with an expenditures and attention to building citizen

emphasis on health oversight to mitigate corruption services

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Twubakane Quarterly Report #18, April - June, 2009 Annex 1

Twubakane Decentralization and Health Program Goal Components/ Results Objectives

Component 5:  Capacity of health facilities (district hospitals Health Facilities and health centers) to effectively mobilize Management and manage diverse resources strengthened  Improved HMIS data collection, analysis and Strengthen capacity of use (in Twubakane-supported zones) To increase access to health facilities,  Health committees effectively functioning to and the quality and including health centers strengthen health facility management utilization of family and hospitals, to better  Increased rate of membership in mutuelles health services in manage resources and  Capacity of mutuelles to manage and ensure health facilities and promote and improve quality of services strengthened communities by the functioning of  Participation of mutuelles in the prevention strengthening the mutuelles and promotion increased capacity of local governments and communities to Component 6:  Community-based health agents capable of ensure improved Community providing information and advice related to health service Engagement and FP/RH and child survival/malaria/nutrition delivery at Oversight  Community-based services delivery system, decentralized levels supported by districts/sectors, effectively

Increase community functional and providing a variety of package of family access to, participation commodities and services health services in, and ownership of  Community-provider partnership committees includes FP/ RH and health services child survival/malaria active in evaluating and solving problems and nutrition services 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 #18, April-June, 2009 Annex 2

ANNEX 2: TWUBAKANE’S INTERVENTION ZONE

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Twubakane Quarterly Report #18, April-June, 2009 Annex 3

ANNEX 3: SHORT-TERM TECHNICAL ASSISTANCE PROVIDED AND OTHER TRAVEL

There has been no Twubakane program-funded travel nor any travel funded by IntraHealth International (non- Twubakane program funds) this quarter.

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Twubakane Quarterly Report #18, April-June, 2009 Annex 4

ANNEX 4: ACTIVITIES SUPPORTED BY 2009 DISTRICT INCENTIVE FUNDS

Metropolitan KIGALI (MVK) Activités Activities Budget RwFr

1 Renforcement de la coordination des Strengthening the capacity of the City of 4,360,000 activités de santé dans la ville de Kigali par Kigali LGAs and technicians to coordinate les autorités et techniciens des District et health sector activities amongst the Ville de Kigali; vérifiable par la tenue de various stakeholders; as verified by deux réunions trimestrielles du forum des implementing two forums / meetings partenaires de la ville de Kigali dans le between stakeholders and Kigali City domaine de la santé ; le partenariat efficace officials; assessing and documenting the entre la Ville de Kigali et les partenaires effectiveness of the partnerships, and the ainsi que les comptes rendus des réunions minutes of quarterly meetings and forums. trimestrielles du forum. 2 La sensibilisation des autorités et des Orientation sessions for community and 4,001,000 leaders communautaires a la prévention et LGA leaders of the 3 Districts of Kigali on a la prise en charge de la violence basée sur the management of gender based le genre dans la Ville de Kigali; vérifiable par violence; as verified by carrying out, la tenue et la diffusion des informations, documenting and disseminating the résultats et recommandations d’un proceeds of a one day workshop of 150 séminaire d’une journée pour 150 leaders community leaders and authorities in the communautaires des trois districts de la ville three districts of Kigali City. de Kigali. 3 Renforcement des capacités en Capacity building of the City of Kigali LGAs 8,139,000 planification des autorités et techniciens de and technicians for the 2009‐2012 budget la Ville de Kigali ; vérifiable par la tenue de 2 & planning cycle; as verified by ateliers de planification et budgétisation, et implementing 2 planning & budgeting la production du document de MTEF 2009‐ workshops; the production of the City’s 2012 (le cadre des dépenses à moyen Medium Term Expenditure Framework terme) et l’établissement du contrat de (MTEF 2009‐2012) and preparation and performances‐ Imihigo 2010. documentation of the performance contract – Imihigo 2010. TOTAL 16,500,000 Gasabo Activités Activities Budget RwFr

1 Renforcement des capacités en Capacity building of the District of Gasabo 3,955,000 planification et budgétisation des autorités LGAs and technicians for the 2009‐2010 et techniciens du District de Gasabo, pour le budget & planning cycle; as verified by the cycle 2009‐2010 ; vérifiable par la production of the annual work plan and production du plan d’action et budget budget ‐ July 2009‐ June 2010; revision of annuel ‐ Juillet 2009‐Juin 2010 ; le cadre the Medium Term Expenditure Framework des dépenses à moyen terme (CDMT), le (MTEF); reporting on and evaluation of the contrat de performances annuel – Imihigo 2009 Imihigo performance contracts and 2010 ; évaluation des contrats de indicators; the preparation of the 2010 performance ‐ Imihigo 2009 ; et le plan Imihigo performance contracts; and

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d’action et réunions du Joint Action preparation of the Joint Action Development Forum (JADF). Development Forum (JADF) work plan. 2 Renforcement de capacité des agents de Capacity building of Community Health 2,097,000 santé communautaire, les membres du Workers, National Women Council and conseil national des femmes et des jeunes National Youth Council members of 7 de 7 secteurs administratifs en planification administrative sectors of Gasabo District familiale ; vérifiable par la tenu de la in Family Planning ; as verified by the formation et le rapport de formation training and training session report 3 Achat du materiel et équipements Purchase and distribution of medical 31,498,000 médicaux pour les centres de santé de supplies and equipment for Nduba and Nduba et Gikomero du District de Gasabo ; Gikomero health centers of the District of vérifiable par l’achat, la livraison et Gasabo; as verified by the purchase, l’utilisation des équipements. delivery and use of the supplies & equipment. 4 Achat du matériel et équipements du Purchase and distribution of materials and 3,700,000 bureau de la police du District responsable equipment for the District police office in de la prise en charge de la violence basée charge of the management of gender sur le genre dans le District de Gasabo; based violence in Gasabo District; as vérifiable par l’achat, la livraison et verified by the purchase, delivery and use l’utilisation des équipements. of the supplies & equipment.

TOTAL 41,250,000 Kicukiro Activités Activities Budget RwFr

1 Achat du matériel et équipements Purchase and distribution of medical 6,382,828 médicaux pour le nouveau centre de santé supplies and equipment for the new Betsaida du District de Kicukiro ; vérifiable health center of Betsaida of Kicukiro par l’achat, la livraison et l’utilisation des District; as verified by the purchase, équipements. delivery and use of the supplies & equipment. 2 Renforcement des capacités des agents des Capacity building of District of Kicukiro 17,841,150 services du District de Kicukiro et ses 10 and Sector staff in planning, production of secteurs en planification, élaboration des Sector profiles; monitoring and evaluation monographies des secteurs, suivi‐ of performance contracts – Imihigo, and évaluation des contrats de performance ‐ operationalisation of 10 Sectors’ JADFs; as Imihigo et l‘opérationnalisation des Joint verified by carrying out one training Action Development Forums (JADF) des 10 session, production of 2009‐2010 action Secteurs ; vérifiable par la conduite d’une plan and MTEF for the District and 10 séance de formation, la production des sectors, Imihigo contract reporting, and plans d’action 2009 – 2021 et MTEF (le the minutes of JADF meetings. cadre des dépenses à moyen terme) pour le District et 10 Secteurs, et les rapports des réunions du JADF. 3 Lutte contre les maladies féco‐orales Improved hygiene and reduction of oral‐ 3,512,200 (Programme « Plus ») par la dotation de fecal illnesses (“Plus” Program) in 22 canacris d’eau a 22 écoles primaires du primary schools of ; as

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District de Kicukiro ; vérifiable par l’achat, verified by the purchase, delivery and la livraison et l’installation des canacris ainsi installation of small water tanks and their que leur utilisation. use at the schools. 4 Extension des sites communautaires de Expansion of the advanced community‐ 9,396,322 stratégies avancées en planification based family planning strategies and familiales dans 15 nouveau sites dans les activities at 15 new sites of Kicukiro Secteurs du District de Kicukiro «P.F. Bis» ; District; as verified by the purchase of vérifiable par l’achat de matériel pour ces supplies and materials and the technical sites et les rapports d’activités de reports of activities carried out at the 15 démarrage dans les 15 nouveaux sites. new sites. 5 Renforcement des capacités de 55 Capacity building of 55 private health 4,117,500 formations sanitaires privées dans la clinics of Kicukiro District in health data gestion et l’utilisation des données GESIS ; management ‐ HMIS ; as verified by the vérifiable par la formation des agents des training of the staff of private health formations sanitaires privées en GESIS et clinics in the use of the MoH GSIS software l’installation du programme GESIS dans les and the installation of the software ordinateurs des gestionnaires des données program on their computers. au niveau des formations sanitaires privées. TOTAL 41,250,000 Nyarugenge Activités Activities Budget RwFr

1 Achat du matériel et équipements Purchase and delivery of medical and 41.250.000 médicaux pour les centres de santé de office supplies and equipment for the Nzove, Kabusunzu, Gitega, Mwendo et health facility of Nzove, Kabusunzu, Butamwa du District de Nyarugenge ; Gitega, Mwendo and Butamwa in vérifiable par l’achat, la livraison et Nyarugenge District; as verified by the l’utilisation des équipements. purchase, delivery and use of the supplies & equipment. TOTAL 41,250,000 Ngoma Activités Activities Budget RwFr

1 Appui au renforcement des capacités des 7 Capacity building of 7 admin Sectors of 13,650,000 cellules administratives du District Ngoma Ngoma through their management of the par la réhabilitation de leurs bâtiments et renovations of their public buildings and bureaux ; vérifiable par la passation de offices ; as verified by the management of marche pour l’achat, la livraison et la the tender bid process of the purchase, distribution des moellons, du ciment et du delivery and distribution of stones, cement sable, et la gestion du projet de and sand, and management of the réhabilitation des bureaux. construction work. 2 Achat et installation du matériel d’énergie Purchase and installation of a solar panel 14,929,500 solaire au centre de sante de Kirwa du system and material at Kirwa Health District de Ngoma ; vérifiable par l’achat, Center in Ngoma District; as verified by l’installation, et l’utilisation des panneaux the purchase, installation and use of the solaires, batteries et autres accessoires. solar panels, batteries and accessories.

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3 Achat du matériel et équipements Purchase and delivery of medical supplies 3,470,500 médicaux pour le poste de sante de and equipment for the secondary health Rujaramba du secteur Ruramba du District facility of Rujaramba, Ruramba sector, de Ngoma, vérifiable par l’achat, livraison et District of Ngoma; as verified by the l’utilisation de ce matériel. purchase, delivery and the use of the supplies & equipment 4 Refinancement d’un abonnement annuel a Renewal of the contract for broadcasting 4,000,000 la radio IZUBA pour une émission weekly radio shows at the IZUBA hebdomadaire sur la sante et la community radio station on décentralisation ; vérifiable par la decentralization and health issues of documentation des « scripts » et le passage Ngoma District; as verified by the et l’enregistrement des messages passés documentation of the scripts of the weekly par différentes autorités du District a la messages recorded and broadcast by radio IZUBA. Ngoma District authorities on the radio station. 5 Amélioration des conditions d’hygiène par Improved hygiene through the purchase of 5,200,000 l’achat de 4 citernes d’eau pour la collecte 4 plastic water tanks for rain water des eaux de pluie dans les centres de santé harvesting and storage for the health de Kirwa et Nyange du district de Ngoma ; centers of Nyange and Kirwa of Ngoma vérifiable par l’achat, la livraison, district; as verified by the purchase, l’installation et l’utilisation des citernes. delivery, installation and use of the tanks. TOTAL 41,250,000 Kayonza Activités Activities Budget RwFr

1 Achat du matériel et équipements Purchase and delivery of medical supplies 32,750,000 médicaux pour les formations sanitaires du and equipment for the health centers of district de Kayonza ; vérifiable par l’achat, the District of Kayonza; as verified by: their la livraison et l’utilisation des équipements. purchase, delivery, and the usee of th supplies & equipment. 2 Appui aux équipes PAQ dans les 6 centres Support to 6 PAQ teams of the 6 health 3,000,000 de santé du district de Kayonza en centers of Kayonza district in the préparation et gestion des projets conception, planning and execution of générateurs des revenus ; vérifiables par la income generating activities; as verified signature des protocoles de financement by the signed and executed agreements pour des projets générateurs de revenus et and MoUs for the income generating leur mise en œuvre. projects; the appropriate use of the financing, and the implementation of activities. 3 Renforcement des capacités des autorités Increased capacity building of local 5,000,000 et techniciens du District par l’achat des government authorities and technicians équipements informatiques pour les through the dpurchase an use of IT cellules et les unités du District de Kayonza; equipment for Cells and technical units of vérifiable par l’achat, la livraison et Kayonza District; as verified by the l’utilisation des ordinateurs (lap top) par le purchase, delivery, distribution and use of staff. lap top computers by the staff. TOTAL 41,250,000

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Rwamagana Activités Activities Budget RwFr

1 Financement d’un abonnement annuel a la Financing of the contract for broadcasting 4,597,320 radio IZUBA pour une émission bimensuelle bi‐monthly radio shows at the IZUBA sur la sante et la décentralisation pour le community radio station on District de Rwamagana ; vérifiable par la decentralization and health issues of documentation des « scripts » et le passage Rwamagana District; as verified by the et l’enregistrement des messages passés documentation of the scripts of the weekly par différentes autorités du District a la messages recorded and broadcast by radio IZUBA. Rwamagana District authorities on the radio station. 2 Achat du matériel et équipements Purchase and delivery of medical supplies 29,160,400 médicaux et non médical pour le centre de and equipment and non‐medical sante de Gahengeri du district de consumables for Gahengeri health center Rwamagana ; vérifiable par l’achat, la of Rwamagana District; as verified by the livraison et l’utilisation de l’équipement et purchase, delivery and use of the supplies matériel. & equipment. 3 Appui aux équipes PAQ dans les 4 centres Support to 4 PAQ teams of the District 4,000,000 de santé du district de Rwamagana en health centers in the conception, planning préparation et gestion des projets and execution of income generating générateurs des revenus ; vérifiable par la activities; ; as verified by the signed and signature des protocoles de financement executed agreements and MoUs for the pour des projets générateurs de revenus, et income generating projects; the leurs mis‐en‐œuvre. appropriate use of the financing, and the implementation of activities. 4 Renforcement des capacités en Capacity building of the District of 3,492,280 planification et budgétisation des autorités Rwamagana LGAs and technicians for the et techniciens du District de Rwamagana, 2009‐2010 budget & planning cycle; as pour le cycle 2009‐2010 ; vérifiables par verified by carrying out and documenting a l’exécution et documentation d’un atelier de 2 day workshop for the revision and 2 jours de révision et de validation du validation of the 2009 budget, and 6 budget 2009 ainsi que 6 ateliers workshops for the quarterly evaluation of d’évaluation trimestrielle des contrats de District performance contracts (Imihigo). performance (Imihigo) du District. TOTAL 41,250,000 Kirehe Activités Activities Budget RwFr

1 Renforcement des capacités des autorités Capacity building of the District of Kirehe 3,092,000 et techniciens du District de Kirehe par la local government officials and technicians formation des unités décentralisées en in improving their performance on livraison des services, système de services delivery, reporting systems, reportage, gestion des ressources human resources management, planning humaines, planification et budgétisation ; and budgeting; as verified by vérifiable par une session de formation de 3 implementing a 3‐day training workshop jours et missions de supervision. and follow‐up supervision reports.

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2 Renforcement des capacités des autorités Capacity building of the District of Kirehe 3,000,000 et techniciens du District de Kirehe a travers local government officials and technicians l’organisation des compétitions sur les by organizing a best practices competition bonnes pratiques de gestion des projets, on project management, good bonne gouvernance et livraison des services governance, and service delivery at the au niveau des cellule ; vérifiable par la Cell level; as verified by the documentation documentations sur les résultats d’un of the results of the evaluation committee, comite d’évaluation, le rapport des ethe sit visit reports at the Cells and descentes dans les cellules et l’atelier de carrying out a workshop to publicly présentation des résultats. present the results. 3 Appuyer les équipes PAQ des centres de Support to PAQ teams operating at 2,570,000 santé de Kabuye et Nyabitare dans les Kabuye and Nyabitare health centers, to activités génératrices de revenus pour put in place income generating activities appuyer les indigents de leur zone de for the indigent population; as verified by rayonnement ; vérifiable par la signature the twp signed agreements and MoUs for de deux protocoles de financement des providing financing and establishing activités génératrices de revenus et leur income generating projects, and the mise en œuvre. implementation of activities. 4 Amélioration des conditions de travail dans Improved working conditions for the staff 15,403,800 les bureaux du Secteur de Nyarubuye par la at the Sector office of Nyarubuye, through réhabilitation de la toiture du bâtiment des the repair and renovation of the roof of bureaux ; vérifiable par le remplacement de the building; as verified by repairs and la toiture du bureau et la réception des replacement of the roof and the site travaux par le Secteur. inspection report of the final work. 5 Amélioration des conditions d’hygiène par Improved hygiene through the purchase of 1,200,000 l’achat d’une citerne d’eau pour la collecte one water tank for rain water harvesting des eaux de pluie dans le centre de santé de and storage at Ntaruka health Center; as Ntaruka ; vérifiable par l’achat, la livraison, verified by the purchase, delivery, l’installation, et l’utilisation d’une citerne installation and use of one large plastic d’eau a grande capacité en plastic. water storage tank. 6 Renforcement des capacités en Capacity building of Kirehe District staff in 3,788,000 planification et budgétisation des autorités local government budgeting & planning et techniciens du District de Kirehe, pour le processes; as verified by the production of cycle 2009‐2010 ; vérifiable par la the Imihigo performance contract, the préparation des contrats de performance 2009‐2010 budgeted work plan, and the Imihigo, le MTEF (le cadre des dépenses à Medium Term Expenditure Framework moyen terme 2009‐2012) et le plan d’action (MTEF 2009‐2012) budgétisé pour 2009‐2010. TOTAL 29,053,800 Note: the district is in a process of submitting another project for the amount of 12,196,200 FR in order to complete its budget of 41,250,000 FR Muhanga Activités Activities Budget RwFr

1 Renforcement des capacités du staff Capacity building of the District of 3,870,000 technique du District de Muhanga dans la Muhanga technical staff in planning, planification, budgétisation et utilisation budgeting, and use of ICT equipment; as

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des équipements informatique ; vérifiable verified by: the production of the Medium par la production du : le cadre des dépenses Term Expenditure Framework ‐ MTEF à moyen terme – MTEF 2010‐2012 ; le plan 2010‐2012; the annual budgeted work d’action annuel budgétisé pour 2010 ; plan for 2010; the evaluation of 2009 l’évaluation du plan d’action et contrat de performance on work plans and the performance Imihigo 2009; l’achat et la Imihigo performance contract; the distribution de 2 ordinateurs desktop et 2 purchase and distribution of 2 desktop imprimantes à 2 bureaux secteurs. computers, 2 printers at 2 Sector offices. 2 Achat du matériel et équipements Purchase and delivery of medical supplies 23,617,520 médicaux pour le centre de santé de and equipment for Gasagara health center Gasagara, Muhanga District; vérifiable par of Muhanga District; as verified by the l’achat, la livraison, la distribution et purchase, delivery and use of the supplies l’utilisation des équipements et matériel. & equipment. 3 Finalisation des activités de rénovation du Finalization of the renovation of Gasagara 13,792,764 centre de santé de Gasagara; vérifiable par Health Center, as verified by Electric la mise en place des installations électriques installation Water pipes Installation, toilet et de l’eau, toilettes et autres équipements and sanitation equipments installation and sanitaires ainsi que d’autres salles the completion of other services wards TOTAL 41,250,000 Ruhango Activités Activities Budget RwFr

1 Achat du matériel et équipements Purchase and delivery of medical supplies 18,514,000 médicaux pour l’hôpital et les centres de and equipment for the hospital and health santé du District de Ruhango; vérifiable par centers of the District of Ruhango; as l’achat, la livraison, la distribution et verified by the purchase, delivery and use l’utilisation des équipements et matériel. of the supplies & equipment. 2 Renforcement des capacités en Capacity building of the District of 4,510,000 planification et budgétisation des autorités Ruhango LGAs and technicians for the et techniciens du District de Ruhango, pour 2009‐2012 budget & planning cycle; as le cycle 2009‐2010 ; vérifiable par la verified by the production of the annual production du plan d’action et budget work plan and budget ‐ July 2009‐ June annuel ‐ Juillet 2009‐Juin 2010 ; le cadre 2010; revision of the Medium Term des dépenses à moyen terme (MTEF), le Expenditure Framework (MTEF); reporting contrat de performances annuel – Imihigo on and evaluation of the 2009 Imihigo 2010 ; évaluation des contrats de performance contracts and indicators; performance ‐ Imihigo 2009. the preparation of the 2010 Imihigo performance contracts. 3 Support aux ménages pauvres dans trois Support to vulnerable households in three 12,026,000 Secteurs VUP (Mwendo, Kinihira et VUP Sectors (Mwendo, Kinihira and Ntongwe) du District de Ruhango et Ntongwe) of Ruhango District, and amélioration de leur conditions de vie et improvement of their living conditions and état nutritionnelle; vérifiable par l’achat, la nutritional intake; as verified by the livraison et la distribution des vaches à 37 purchase, delivery and distribution of cows ménages pauvres. to 37 vulnerable & poor households. 4 Appui aux autorités du District de Ruhango Support provided to the District 6,200,000 à mettre en place une initiative du program authorities and technicians to implement

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Itorero, pour la mobilisation des comités de an Itorero program, focused on base sur la politique gouvernementale en decentralized service delivery, health matière de santé et décentralisation et services and civic education / responsabilités civique; vérifiable par la participation; as verified by the training of formation des formateurs au niveau du trainers at District – Sector ‐ Imudugudu District, des Secteurs, des Imudugudu, qui levels, followed by these trainers orienting par la suite vas orienter la population dans the local population on their civic duties leurs responsabilités civiques. and responsibilities. TOTAL 41,250,000 Kamonyi Activités Activities Budget RwFr

1 Réhabilitation du centre de santé de Renovations of the Remera Rukoma 22,005,400 Remera Rukoma ; vérifiable par la passation Health Center building; as verified by the de marche, achèvement et réception des contracting and completion of the travaux de construction et renovation works, the modification and transformation/extension de l’intérieure du improved use of the rooms of the health centre de santé. facility. 2 Appui aux activités des équipes PAQ du Support for improved functioningQ of PA 10,000,000 District de Kamonyi; vérifiable par les teams of the District of Kamonyi; as comptes rendus des réunions d’échange verified by the documentation of minutes entre les FOSA, équipes PAQ et autorités of PAQ meetings between the public and politico‐ administratives; les protocoles administrative authorities; the signed d’appui financier pour les activités agreements and MoUs for income génératrices de revenus et les rapports de generating projects; and monitoring and supervision d’activités des équipes PAQ. supervision reports of PAQ activities. 3 Achat du matériel et équipements Purchase and delivery of medical supplies 9,245,472 médicaux pour les postes de santé de & equipment for Karama, Kayumbu and Karama, Kayumbu et Nyamiyaga du District Nyamiyaga secondary health facilities of de Kamonyi; vérifiable par l’achat, la the District of Kamonyi; as verified by the livraison et l’utilisation des équipements et purchase, delivery, and the use of the matériel. supplies and equipment. TOTAL 41,250,000 Nyamagabe Activités Activities Budget RwFr

1 Renforcement des capacités du staff Capacity building of the District of 25,689,800 technique du District de Nyamagabe dans la Nyamagabe technical staff in planning, planification, budgétisation, utilisation des budgeting, use of ICT equipment, and équipements informatique, et system de improved communications; as verified by: communications ; vérifiable par le du cadre the production of the Medium Term des dépenses à moyen terme CDMT 2009‐ Expenditure Framework ‐ MTEF 2010‐ 2012 révisé, les comptes rendus des séances 2012; the annual budgeted work plan for d’évaluation des contrats de performances 2010; the evaluation of 2009 performance Imihigo, la productionn du pla d’action on work plans and the Imihigo 2009‐2010 ainsi que l’achat des performance contract; the purchase ICT

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Twubakane Quarterly Report #18, April-June, 2009 Annex 4

équipements informatiques et la equipement and distribution of eight distribution de huit modems à huit modems to eight executive secretaries of secrétaires exécutifs des secteurs du the administrative sectors of the District. District. 2 Support aux ménages pauvres dans deux Support to vulnerable & poor households 7,850,000 Secteurs VUP (Kamegeli et Mbazi) du in two VUP Sectors (Kamegeli and Mbazi ) District de Nyamagabe et amélioration de of Nyamagabe District, and improvement leur conditions de vie et état nutritionnelle of their living conditions and nutritional avec un projet de cuniculture; vérifiable par intake through a rabbit breeding project; l’achat et la distribution des lapins aux as verified by the purchase and the ménages des deux secteurs. distribution of rabbits to the households of the two sectors. 3 Appui aux activités des équipes PAQ du Support to PAQ teams of the District of 7,710,200 District de Nyamagabe à travers les activités Nyamagabe in conception, planning and génératrices de revenus ; vérifiable par la implementation of income generating signature des protocoles de financement à activities; as verified by the signed 11 équipes PAQ pour les activités agreements and MoUs for income génératrices de revenus et les rapports de generating projects and the monitoring suivi et de supervision des activités des and supervision report of PAQ activities. équipes PAQ. TOTAL 41,250,000 Nyaruguru Activités Activities Budget RwFr

1 Appui au staff technique du District de Technical assistance and support to the 10,505,000 Nyaruguru à la politique de l’habitat technical staff of the District of Nyaruguru regroupé par l’extension de la seconde to implement the GoR urban habitat and phase d’exécution d’un schéma directeur zoning policy of the district through the du chef lieu du District (Kibeho) ; vérifiable production of a master plan of the Kibeho par le montage et document du plan zoning area; as verified by production of d’aménagement du site de Kibeho finalisé et the final zoning plan of Kibeho and the le bornage des parcelles. cadastral surveys of the land plots. 2 Appui au staff technique du District de Technical assistance and support to the 21,460,000 Nyaruguru à la politique de l’habitat technical staff of the District of Nyaruguru regroupé du gouvernement central, par la to implement the GoR urban habitat and mise en place d’un programme de zoning policy within the district by putting génératrice de revenue et le montage d’un in place a revenue generation project; the projet de production des matériaux de construction of an improved and construction géré par le District ; la ecological furnace for the production of construction d’un four amélioré et bricks and tiles; as verified by construction écologique pour la production des briques and management of a firing furnace with et tuiles; vérifiable par le montage d’un four a capacity of manufacturing one hundred amélioré avec une capacité de fabrication thousand to a hundred and twenty de cent mille à cent vingt mille thousand tiles and bricks per trimester. tuiles/briques par trimestre.

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Twubakane Quarterly Report #18, April-June, 2009 Annex 4

4 Renforcement des capacités en Capacity building of the District of 9,285,000 planification et budgétisation des autorités Nyaruguru LGAs and technicians for the et techniciens du District de Nyaruguru, 2009‐2010 budget & planning cycle and pour le cycle 2009‐2010 et utilisation des use of ICT equipment; as verified by the équipements informatique; vérifiable par la production of the annual work plan and production du plan d’action et budget budget ‐ July 2009‐ June 2010; revision of annuel ‐ Juillet 2009‐Juin 2010 ; le cadre the Medium Term Expenditure Framework des dépenses à moyen terme (CDMT), le (MTEF); reporting on and evaluation of contrat de performances annuel – Imihigo the 2009 Imihigo performance contracts 2010 ; évaluation des contrats de and indicators; the preparation of the performance ‐ Imihigo 2009 ; et le plan 2010 Imihigo performance contracts; d’action et réunions du Joint Action meetings and preparation of the Joint Development Forum (JADF) ; l’achat et la Action Development Forum (JADF) work distribution de 10 ordinateurs portables et 6 plan and the purchase and distribution of imprimantes au staff du district et 6 écrans 10 laptop computers and 6 printers for the téléviseurs pour la mobilisation. district staff and 2 television set for the sensitization. TOTAL 41,250,000

GRAND TOTAL of all DIF grants for 2009 511,500,000 RwFr NB ‐ Pending District performance on this first set of DIF Grants activities, and availability of USAID funding, an additional $ 25,000 per District may be made available for additional activities. All Districts have received 50% funding for the activities listed above; second disbursements are anticipated in July and August 2009.

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Twubakane Quarterly Report #17, January-March, 2009 Annex 5

ANNEX 5: SAMPLING OF PAQ TEAM ACTIVITIES AND ACHIEVEMENTS

Region District # HCs and # Achievements PAQs The Kimironko HC’s PAQ team improved hygiene in the HC and promoted good scheduling and good respect for clients. The team also advocated for the Gasabo 10 10 procurement of a plot of land on which to build the Remera HC. The Kayanga HC’s PAQ team advocated for the construction of latrines and of a septic tank at the HC – both of which are now functional. The Gikongo HC’s PAQ team improved hygiene in the HC by advocating for the construction of latrines Kigali Kicukiro 7 7 and water cisterns. The Betsaida and Masaka HCs’ PAQ teams continuously ensure the effectiveness of service delivery at the HCs. The Mwendo and Butamwa HCs’ PAQ teams successfully improved the quality and scheduling of Nyarugenge 8 8 services by coordinating the rental of a taxi bus for the two HCs. The teams also advocated for the fencing in of the HCs. The Kabarondo HC’s PAQ team launched the initiative to procure an ambulance through personal contributions of 5,000 RWF/person and successfully managed an income-generating project financed with DIF grant funds. The Gahnini HC’s PAQ team organized a “hygiene Kayonza 13 13 association” whose mandate is to monitor hygiene activities at the commercial center. The team also launched an income-generating project funded by the Eastern DIF grant funds to finance a moto taxi. Province * Overall in Kayonza District, to address PAQ teams that are less active than others, a sector commitment was made to improve the functioning of those teams with the support of the District Health Unit and hospital supervisors. The Ruhunda HC’s PAQ team successfully improved the overall quality of service delivery at the HC and lobbied for the conversion of former HC personnel’s Rwamagana 11 10 living quarters into public quarters that can be used directly by the HC. The team also received funds for an income-generating project which it developed into a marketing business of beans and sorghum. The Muyumbu HC’s PAQ team continued its support to orient traditional practitioners towards collaborating with the HC and thereby contributed to higher rates of delivery at the HC. The PAQ team has also continued

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Twubakane Quarterly Report #17, January-March, 2009 Annex 5

Region District # HCs and # Achievements PAQs its awareness raising and dialogue with the Church. The team assures its sustainability through an agricultural income-generating project that produces fruit trees seeds. * Particularly noteworthy in Rwamagana District is the sustainability of its HC’s PAQ teams which collaborate by regularly coming together to share experiences, difficulties, and opportunities. Eastern The Gahara HC’s PAQ team continues to effectively Province fight malnutrition through subcommittees responsible Kirehe 12 12 for identifying cases of malnutrition in each umudugudu and reporting them to the HC. The Kabuye HC’s PAQ team has supported the construction of toilets and a kitchen for patients. The Nyamirama HC’s PAQ team focused on revitalizing itself with elections for a new committee Ngoma 12 12 and with the creation of four specialized subcommittees. The Ndego HC’s PAQ team showed progress with its income-generating project which consisted of installing 146 beehives, 62 of which are now occupied. The Kigese HC’s PAQ team focused on revitalizing itself with elections for a new committee, identification of the new priorities, and with the formation of thematic awareness-raising subcommittees. The team supported the promotion of better overall hygiene around the HC by encouraging the clearing of the bush. It also advocated for the hiring of a new lab specialist to strengthen the human resources of the lab. Kamonyi 11 11 The Kamonyi HC’s PAQ team is ensuring awareness-raising of the population on family planning, VCT, hygiene, and malnutrition. * Even though a recent annual review of PAQ activities showed that Kamonyi District was facing the most challenges, this quarter revealed noteworthy progress thanks to a coordination meeting and to the open support of the Director of the Health Unit of Kamonyi Southern District. Province The Nyabinoni HC’s PAQ team formed five Muhanga 13 13 awareness-raising subcommittees and worked to ensure better relations between service providers and clients as well as higher hygiene standards at the HC. The team also launched the initiative to provide CHWs with registers in which to record pregnancies in their umudugudu and to encourage women come for their four standard ANC visits.

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Twubakane Quarterly Report #17, January-March, 2009 Annex 5

Region District # HCs and # Achievements PAQs The Birehe HC’s PAQ team worked on improving the overall quality of service delivery at the HC and advocated for the creation of two health posts which are now operational. The team also organized into a cooperative which it is financed through with DIF grants funds and personal contributions of 1,000 RWF/month. * In Muhanga, the PAQ teams are doubling efforts towards a better partnership with the HC and the sector in order to improve their approach and impact. Southern The Ruhango HC’s PAQ team has organized itself Province into five subcommittees and supported awareness-

raising among the population on hygiene, nutrition, Ruhango 13 13 VCT, and delivery at the HC. It also worked on improving service delivery at the HC and organized

joint field visits with representatives of the HC to

determine what issues to address in priority. The PAQ team purchased a milk cow and a bull as an income- generating project. The Gituku HC’s PAQ team established a monitoring committee to improve the quality of its work. It Nyamagabe 13 12 reported that its income-generating project has generated a revenue of 500,000 RWF. The Maraba HC’s PAQ team reported high use of services for FP, delivery, and vaccination as well as Nyaruguru 13 13 mutuelle enrollment. The team also reported producing a coffee plantation as its income-generating project. * Some PAQ teams from Nyaruguru District are innovatively integrating executive secretaries from the cell level into their initiatives in order to ensure their understanding of and support for solving the health problems of the community.

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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 ‐ Results for Quarter (April ‐ June 2009) Gasabo Kicukiro Nyarugenge Kayonza Rwamagana Ngoma Kirehe Muhanga Kamonyi Ruhango Nyaruguru Nyamagabe Other

Indicator Total

FAMILY PLANNING Couple years of protection offered by 52,372 4,812 5,507 6,942 4,851 4,656 3,918 5,393 5,208 4,222 ‐ 3,080 3,783 public facilities in USG‐supported programs1 # People that have seen or heard a 299,076 17,958 10,535 17,778 17,611 22,444 17,160 18,263 51,232 59,711 15,438 20,985 29,961 specific USG‐supported FP message # People trained in family planning/ 171 13 6 65 87 reproductive health2 Female 58 Male 113 # new FP users at health centers 33,467 2,802 2,467 1,958 2,457 2,209 2,748 2,790 2,841 2,114 2,580 6,531 1,970 Pills 5,750 616 745 374 393 348 514 445 459 409 633 349 465 Injectables 23,585 2,026 1,307 1,413 1,863 1,670 2,015 2,060 1,963 1,439 1,590 4,946 1,293 Implants 3,471 65 336 118 167 148 176 210 323 221 314 1,219 174 IUDs3 101 52 0 5 2 3 0 0 28 0 11 0 0 Standard Days Method 174 11 18 44 4 11 10 12 33 1 14 10 6 Condoms 306 32 11 4 28 29 31 61 12 42 18 7 31 Periodic abstinence 80 0 50 0 0 0 2 2 23 2 0 0 1

1 Twubakane collects CYP data from the USAID|DELIVER Project which is collected from district pharmacies. 2 Training events carried out this past quarter in family planning and reproductive health are: o Training of 7 Doctors in “Non‐scalpel vasectomy” in the districts of Ngoma (3), and Muhanga (4) o Training of 6 nurses in “Non‐scalpel vasectomy” in the districts of Ngoma (3), and Muhanga (3) o Training of 87 students from the school of journalism and secondary school teachers in FP/RH in the southern province o Training of 58 students, from the school of journalism of Kabgayi, in FP/RH – District of Muhanga o Refresher training of the San Francisco Project staff, on the insertion of eIUD in th District of Nyarugenge (13) 3 The District of Gasabo along with the Twubakane FP/RH team validated health providers in the use of IUD and carried out sensitization during the month of June. This might explain the increase of IUD use in Gasabo District compared to previous months. -41-

Twubakane Quarterly Report #17, January-March, 2009 Annex 6

Gasabo Kicukiro Nyarugenge Kayonza Rwamagana Ngoma Kirehe Muhanga Kamonyi Ruhango Nyaruguru Nyamagabe Other

Indicator Total

SAFE MOTHERHOOD AND REPRODUCTIVE HEALTH # ANC visits by skilled providers 59,768 6,211 3,840 6,904 5,448 3,800 4,988 4,599 5,301 4,205 4,418 3,729 6,325 # women with four standard ANC 2,480 132 56 217 272 266 186 407 335 65 217 29 298 visits # Deliveries with Skilled Birth 24,865 2,277 1,735 2,392 2,360 2,107 2,456 2,003 2,971 1,744 1,474 1,520 1,826 Attendants (SBA) # Postpartum/newborn visits 24,865 2,277 1,735 2,392 2,360 2,107 2,456 2,003 2,971 1,744 1,474 1,520 1,826 within 3 days of birth4 # People trained in maternal / 51 2 2 2 2 28 15 newborn health5 Female 23 Male 28 # pregnant women diagnosed 4,206 256 104 77 723 496 1,278 507 201 51 390 59 64 with malaria

4 # 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 three days at home. 5 Training in maternal / newborn health consisted of: ‐ A refresher training in Focused Antenatal Care given to health providers from the district of Ruhango (26) ‐ National training of trainers in the Maternal and Newborn Community Package for ASM, in the district of Kicukiro (2), Nyarugenge (2), Ngoma (2), Kamonyi), (2 Ruhango (2). The other 15 trainers were from non‐Twubakane intervention zones.

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Twubakane Quarterly Report #17, January-March, 2009 Annex 6

COMPONENT TWO: CHILD SURVIVAL, MALARIA AND NUTRITION ACCESS AND QUALITY OF SERVICES ‐ Results for Quarter (April‐June 2009) Bugesera Gasabo Kicukiro Nyarugenge Kayonza Rwamagana Ngoma Kirehe Muhanga Kamonyi Ruhango Nyaruguru Nyamagabe

Indicator Total

CHILD SURVIVAL # Diarrhea cases treated 23,501 1,196 701 2,144 2,359 1,222 3,214 3,994 1,001 810 1,445 1,639 3,776 # Children less than 12 months 28,462 2,920 1,890 1,706 2,696 2,402 2,741 2,515 2,269 2,265 2,511 2,132 2,415 who received DPT3 MALARIA # People trained in treatment or 1,718 414 4 2 3 1 1,291 3 prevention of malaria 6 Female 874 Male 844 # children < 5 years diagnosed 81,457 12,810 4,509 1,893 5,902 10,330 6,303 11,831 8,994 3,765 2,518 6,910 3,150 2,542 with simple malaria at health centers # children < 5 treated for malaria 59,831 12,924 2,711 2,190 689 5,480 4,509 8,527 7,782 2,990 6,127 5,887 15 0 through HBM7

6 Trainings conducted in treatment and/or prevention of malaria were: - Training of CHWs on the integrated community health package in the district of Ruhango (233) - Training of 20 health providers of Gasabo (4), Kayonza (2), Rwamagana (3), Kamonyi (1), Ruhango (7), Nyamagabe (3) districts in clinical IMCI - Supervision of4 41 CHWs in HBM in the district of Bugesera - Supervision of CHWs trained in integrated community health interventions in Ruhango (1051) 7 There are still issues with data completeness on community indicators. Only three districts – Ruhango, Ngoma and Nyarugenge – 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: Kicukiro, Gasabo - 3 HC monthly reports missing from: Bugesera, Kirehe, Muhanga - 4 HC monthly reports missing from: Kayonza - 5 HC monthly reports missing from: Kamonyi - 6 HC monthly reports missing from: Rwamagana

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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 71,300 7,228 4,491 2,688 3,959 3,147 5,335 4,639 32,856 1,940 3,275 1,044 698 Vitamin A in the health facilities & community # Children reached by 242,403 9,079 11,340 5,825 26,741 16,764 18,692 13,378 63,571 15,730 26,294 12,465 22,524 nutrition programs # People trained in child 1,541 4 10 7 2 3 116 1 1291 86 21 health and nutrition8 Female 793 Male 748

8 Trainings conducted in child health and nutrition were: - Refresher course of 116 CHWs on CBNP and HEARTH in the district of Muhanga - Training of 104 CHWs on CBNP and HEARTH in the districts of Nyamagabe (18) and Nyaruguru (86) - Training of 17 trainers of CHWs on CBNP andRTH HEA in the districts of Kicukiro (10), and Nyarugenge (7) - Training of CHWs on the integrated community health package in the district of Ruhango (233) - Training of 20 health providers of Gasabo (4), Kayonza (2), Rwamagana (3), Kamonyi (1), Ruhango (7), Nyamagabe (3) districts in clinical IMCI - Supervision of CHWs trained in integrated community health interventions in Ruhango (1051) -44-

Twubakane Quarterly Report #17, January-March, 2009 Annex 6

COMPONENT FOUR: DISTRICT LEVEL PLANNING, BUDGETING AND MANAGING ‐ Results for Quarter (April‐June 2009) Gasabo Kicukiro Nyarugenge Kayonza Rwamagana Ngoma Kirehe Muhanga Kamonyi Ruhango Nyaruguru Nyamagabe City Other

of

Kigali

Indicator Total

USG ASSISTANCE FOR CAPACITY BUILDING IN PUBLIC SECTOR # Sub‐national government entities receiving 12             USG assistance to improve their performance # Sub‐national governments receiving USG assistance to increase their annual own‐ 13              source revenues # Individuals who received USG‐assisted 90 32 9 7 5 7 10 20 training, including management skills and fiscal management, to strengthen local government and/or decentralization9 Female 35 Male 55

9 Capacity building activities in fiscal management and local governance which were carried out this past quarter were: - National Audit training of political and administrative authorities and District Officials (58 participants) - Training of members of civil society and private sector on Civil Society and Local Governance in Gasabo (32 participants) -45-

Twubakane Quarterly Report #17, January-March, 2009 Annex 6

COMPONENT FIVE: HEALTH FACILITIES MANAGEMENT AND MUTUELLES ‐ Results for Quarter (April‐June 2009) Gasabo Kicukiro Nyarugenge Kayonza Rwamagana Ngoma Kirehe Muhanga Kamonyi Ruhango Nyaruguru Nyamagabe

Indicator Total

# Service Delivery Points (SDP) with USG 215 17 12 10 17 17 19 16 33 13 17 25 19 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 34 6 0 0 1 4 2 3 11 0 1 5 1 FP Secondary Posts 31 0 4 1 1 1 4 0 8 1 2 6 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; it does not include however private clinics, dispensaries or prison health facilities.

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