Community PBF in Rwanda CHD 2013

STRUCTURE MOH MCH DESK NUTRITION DESK COMMUNITY HEALTH DESK FP DESK EHDMNH MCH UNIT

Introduction  In 2005, MOH has reinforced 3 major stratagies to improve the health quality services: CBHI(Community Based Health Insurance) Performance based financing Quality assurance  The Community PBF started in January 2006, in all districts of Rwanda, with funding throught the local administration

Selected indicators  Number of members of CBHI(Community Based Health Insurance),  Mobilisation of assisted delivery,  Mobilisation in using LLIN(Long Lasting Insecticide Nets)  Treatment of dehydration of children under 5 years,  Hygiene  Report of Community Activities.

Challenges of this model of Community PBF  Use of funds for other priorities of the districts  Delay in reporting indicators  Delay in transfering funds by the districts  Lack of motivation to supervise the community activities  Lack of tools in data collaction  No reports from the districts to MOH  Lack of mechanisms for data verification

New model CPBF : 2009  Designed in 2009 to change the challenges of the old model: Trought the TWG of CPBF (MOH and parteners WB, USAID/MSH, HDP etc…) In december 2007: first draft of Community PBF The new model proposed in different Health Centers for review and considerations (MOH department of policies ; Senior Management; Health Financing Unit ; Technical Working Group of Community PBF etc)

Making decision  Results from the evaluation of selected HCs on the impact of CPBF show that MOH has reached : Increasing of utilization of health services – Assisted delivery, Preventive of Health care of children under 5 years Increasing health quality – Post natal care and immunization  Results also show that expanding of PBF at the Community level can reduce the difficult to realize the MCH indicators: Nutritional status Timely prenatal care utilization Institutional delivery Timely postnatal care utilization Modern contraceptive use

INDICATORS REMUNERATED :  Nutrition Monitoring: % of children monitored for nutritional status  ANC : Women accompanied/referred to Health Center for prenatal care within first 4 months of pregnancy  Deliveries: Women accompanied/referred to HC for assisted deliveries  Family Planning: new users referred by CHWs for modern family planning methods  Family Planning: % of regular users using long term methods (IUD, Norplant, Surgical/NSV contraception)  Number of TB suspects referred to the health center by the CHW’s  Number of TB patients receiving DOTS at home  Number of couples referred to a health center for PMTCT  Number of households referred to a health center for VCT  CHW’s Reports

Signing Contracts of Community PBF:  Improves performance  Payments made when proof of the agreed level of performance  The Sector Steering Committee signed the community contracts  Data entered at district level web-based database

 Mécanisme contractuel entre acteurs  Financement forfaitaire d’un seul résultat trimestriel: Rapport des ASC avec suivi spécifique de 5 indicateurs (Modèle national)

Community Health Information System Data Flow Chart

CHWs Motivation Trust and respect from community members, leaders etc… Support from Supervisors and implementation partners help improve work; Regular trainings, meetings supervision In-country study tours to learn from peers in other districts Distance learning Community performance-based financing (PBF); Membership in cooperatives for income generation

CHWs’ Cooperatives  - Community Health Workers’ (CHWs) cooperatives were initiated in late The model was introduced through a transformation process from CHWs non profit making associations - Previously, they had associations that were no more than a forum to receive and share funds from MOH, and after each member would do as they wished with that money - Up to-date, 449 cooperatives exist country wide - However, more are being formed as there are new health centers emerging 100% are operational with approximately 42% CHWs cooperatives legally registered at national level - Objective is to have all cooperatives with a legal certificate by end of first quarter 2012 because of the importance of registration - This shall be possible through close collaboration between MOH, district authorities and RCA

Achievements for CPBF Program  Implementation of Com PBF in all districts  CHW’S are remunerated by quarter(449 CHWs cooperatives)  Sector Steering Committee are trained on reporting and on all tools used in reporting and counter verification data  New revised CPBF Contracts in KINYARWANDA are signed between the SSC and HC;SSC and CHW’s Cooperatives  CHW’s cooperatives data reports are validated by Sector Steering Committees and submitted to the Community PBF  Health centers and SSC are the principal evaluators in data reported by the CHW’S and data entered by HC  District Steering Committee and DH are the second evaluators before sending the reports to the Central level  Central level make analysis on the data reported by the CHW’s before the payment

Achievements for CPBF Program  Monthly CPBF Subcommittee meeting  Monthly Extend Team PBF meeting  Community PBF Audit system is done and the report available  Community PBF Counter verification data, audit is done and the report is available  Results dissemination for Community PBF counter verification data presented in coordination meeting with the districts

Program Challenges  Training: CHWs need training in essential service delivery, data reporting, and income generation;  Robust verification mechanisms to ensure that minimum package of community health services has been delivered;  The logistics to deliver the minimum package of community health services;  Data verification mechanisms on reported indicators;  Communication issues: cell phones for reporting and sharing information regarding the community-based activities;  Issues related to the design and management of community health workers’ income generating activities (cooperatives)

PRIORITIES  Reinforce and increase the data reports provided by the CHW’s  Reinforce counter verification data at all levels  Reinforce the data analysis reports from CHW’s by the Sector Steering Committee and Districts Steering Committee  Reinforce keeping all reports from villages to cells and to be analysed by the Sector Steering Committees  Regular supervision by Central Level in data collection by Sector Steering Committee and District Steering Committee

HE Paul KAGAME with all CHWs

Merci