1. HHS/CDC Track 1.0 Transition in Rwanda Dr Ida Kankindi, Rwanda Ministry of Health Dr Felix Kayigamba, CDC-Rwanda August 2010 1

2. Rwanda and PEPFAR 9 million population, 3% HIV prevalence, ~178,680 PLHIV Major donors for HIV programs include PEPFAR and Global Fund – GF PR: $305 million since 2004 + $247 million for NSA recently awarded – 2010 PEPFAR Budget: $157 million 2 HHS Track 1.0 partners: ICAP and AIDS Relief Active, engaged government has led successful HIV program – 96% of pregnant women attending ANC received HIV results via PMTCT (2009) – ~75% of PLHIV in need of treatment with CD4 <350 receive ART (2009) – 1.5 million HIV tests through VCT in 2009 2

3. PEPFAR Contribution to Rwandan HIV Program, Oct 2008 – Sept 2009 HIV Program ResultPEPFAR- supported sites National results % support by PEPFAR Pregnant women who received HIV results in PMTCT 132,811307,24543% HIV+ pregnant women who received ARV prophylaxis in PMTCT 5,0198,59258% HIV+ clients receiving TB treatment2,2535,34242% People counseled and received HIV test results 861,7371,560,86355% HIV+ persons currently receiving ART46,34173,76963% 3

4. HHS Track 1.0 Supported HIV Clinical Services in Rwanda, December 2009 AIDS ReliefICAP TOTAL Health Facilities that provide HIV services 2056 (47 ART) 76 (60 ART) Health Workers financed through Track 1.0 166580746 Active Patients on ART3,06318,70821,771 Children on ART3962,0792,475 HIV Patients in Care8,46846,66455,132 Women enrolled in PMTCT3015,5395,840 People counseled and tested at VCT104,000158,992262,992 4

5. Principles Behind Track 1.0 Transition in Rwanda ICAP and AIDS Relief are transitioning programs to the Rwanda MOH as the local partner Emphasis on maintaining quality of care while increasing GOR ownership and management Quarterly site visits have been linked to already existing PBF quarterly evaluations Technical support and capacity building from Track 1.0 partners during the whole transition process Gradual transition approach – Transition one-third of sites during each year (2010, 2011, 2012) 5

6. MOH Agencies’ Distribution of Responsibilities for Transition Mentoring Supervision, M&E and Reporting Health Facilities Operations Salaries Performance Based Financing TRACPlus UPDC/MOH Decent Districts (via UPDC) CAAC (via UPDC) Implementing partner activity MOH Agency 6

7. Transition Planning & Implementation Timeframe 7 Mar 2009 – Feb 2010Mar 2010 – Feb 2012 TRANSITION Planning phase Establish Transition Task Force Conduct site readiness assessment Select 1 st 24 sites for transition Develop M&E plan Implementation phase Transition sites (~25/yr) Strengthen MOH capacity to manage and report according to USG requirements Monitor performance of transitioned sites in collaboration with GOR

8. Rapid assessment of site readiness, November, 2009 Joint MOH, CDC, ICAP, AIDS Relief visits to 65/76 sites Completed rapid assessment tool (RAT) – Administrative, managerial, financial aspects with score Reviewed routine HIV program performance indicators collected quarterly Reviewed sites for transition based on criteria: – Transition district hospital with associated health centers – Clinical performance indicators: >75% Discussions within TTF on site selection – 18 sites selected for transition March 2010 – 6 sites selected for transition October 2010 8

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10. Monitoring and Evaluation of Track 1.0 Transition in Rwanda Objectives: – Establish baseline level of performance of sites – Monitor any changes in overall performance of sites – Evaluate the quality of clinical services and management capacity of sites throughout the transition process Methods: – Conduct comprehensive assessment of sites at baseline and at 6, 12 months after transition – Quarterly site visits aim to be integrated with routine supervision through MOH, use routinely collected indicators – Two components: Capacity assessment survey to monitor overall management Performance indicators approved by MOH to monitor clinical performance 10

11. Baseline Assessment Management Results: Health Centers Partner Health Center District Hospital Financial MgtHR Clinical Mgt Supply ChainQISILab Overall Score (%) Color Code ICAP RugaramaMuhima 79 PCKMuhima 60 MwendoMuhima 71 KabusunzuMuhima 74 RubengeraKibuye 81 KiramboKibuye 73 MukunguKibuye 79 MunzangaKirinda 77 AIDS Relief GatareKibogora 73 RuheruKibogora 76 KarengeraKibogora 76 Kibogora 64 NyamashekeKibogora 74 Overall average76% Average Performance of Health Centers in the Muhima DH catchments area72% Average Performance of Health Centers in the Kibuye DH catchments area79% Average Performance of Health Centers in the Kibogora DH catchments area74% Above average Average Below average 11

12. Baseline Assessment, Clinical Performance Indicator Results: Health Centers Partner Health Center District Hospital New ART initiation Currently on ART ANC partner testing CTX initiation CD4 Control at 6 mo TB screen at enrollment ART retention Pharmacy pick-up LTFU tracing ICAP PCKMuhima DHN/A 1.000.801.000.80 N/A RugaramaMuhima DH81870.961.000.951.000.79 0.61 KabusunzuMuhima DH262770.940.950.891.000.94 0.67 MwendoMuhima DH5111080.990.761.000.970.80 0.29 RubengeraKibuye DH121510.621.000.941.000.97 0.96 KiramboKibuye DH416650.841.00 0.93 0.39 MukunguKibuye DH102250.981.00 0.81 0.88 MunzangaKirinda DH111410.730.571.00 0.91 0.59 AIDS Relief Kibogora HCKibogora DH21520.891.000.800.910.87 0.68 NyamashekeKibogora DH351430.780.900.620.970.91 0.50 KarengeraKibogora DH193850.951.000.750.911.000.710.60 GatareKibogora DH142620.971.000.500.880.930.470.50 RuheruKibogora DH172980.891.000.560.881.000.67N/A Above average Average Below average 12

13. Baseline Assessment Dissemination Workshop: Discussions with Districts and Health Facilities 13

14. Discussion: Impact of M&E for Track 1.0 transition Detailed review of site performance identified individual sites, clinical, and health systems issues in need of improvement – Supply chain management: ARV stock-outs noted – Financial planning and reporting – Staffing/HR: insufficient staff at some sites – CD4 control and ART retention need improvement in some sites ICAP, AIDS Relief, MOH, and CDC are now organizing intensive TA to improve these areas in these transitioned sites Transition M&E process will improve district-level supervision – Linked to performance-based financing for facilities 14

15. Conclusions Track 1.0 transition in Rwanda demonstrates country ownership, leadership, management – Inclusive planning involves GOR, USG, partners – M&E builds on existing MOH systems M&E with feedback to health facilities has led to site- specific action plans to address clinical and management deficits – MOH also investigating cross-cutting health systems issues: supply chain, personnel 15

16. Next Steps MOH, TRAC-Plus, IPs and CDC will collaborate to accomplish the following: Phase I: Continue to conduct quarterly assessments in 24 transitioned sites Phase II: Readiness assessment for the remaining 52 sites to be transitioned Conduct baseline assessment for the selected sites Transition the selected health facilities Overall: Address action points derived from dissemination workshop Strengthen MOH financial and administrative capabilities Continue monitoring the quality of services Define long-term plans for technical support 16

17. Acknowledgments Health facilities MOH UPDC TRAC Plus ICAP AIDS Relief CDC-Rwanda transition team 17

18. Thanks Questions/discussion 18