Facility supervision by the District Health Teams (DHTs) in Rwanda

Track1 MeetingMaputo, Mozambique, August 10th -12th

Dr. Ruben Sahabo

Background• ICAP-CU has supported GoR in implementing

HIV/AIDS activities since 2003, beginning with private funds and then PEPFAR in 2004.

• From 2005 direct sub agreement with DHs and HCs with distinct budgets and scope of work (SOW) for each health facility.

• Intensive technical support in clinical management, M&E, finance and administration .

• Establishment of 3 regional offices, in Kigali, Gisenyi and Kibuye, with multidisciplinary teams for DHT and site support and mentoring.

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ICAP support• By 31st March 2010, ICAP with PEPFAR funding

through CDC, supported:– 56 sites in 9 districts to provide HIV/AIDS services– Palliative care to 31,300 and ART to 19,321

patients• 31% of the PEPFAR support to GoR• 39% of patients on ART and 21% of PMTCT

clients at PEPFAR supported sites• Each quarter, ICAP supports testing for HIV of about

6000 pregnant women

ICAP-Rw : approach and perspectives for district and facility support

Shift from direct site support towards capacity building in services integration, services delivery, management and program M&E

ICAP-RW approach and perspectives

• Technical assistance beyond HIV• Build on the existing/accumulated expertise

in HIV programs management to strengthen national and district health team (DHT) capacity to manage health services:

– Integration and decentralization of services (TB, MH, SGBV, FP, MSM and other MARPs, etc)

– Epidemiological surveillance– Lab systems including accreditation– Administrative and finance management: procedures and tools,

capacity building in renovation management, etc

Strengthening the DHT capacity for facility supervision

• Integrated district planning and program review workshops

• Training and precepting of DHTs on national care and treatment guidelines

•Training and mentorship of DHTs on site support and supervision, Quality Improvement and assessment

• Joint facility supervision visits•MoH/ICAP to DHT•DHT/ICAP regional Team to Health Centers

Strengthening the DHT capacity for facility supervision (cont’d)

• Site supervision by DHT and sharing and review site supervision reports and recommendation with ICAP

•Joint follow up of recommendations and site improvement plans

•Supporting DHTs to organize outreach and community linkage activities and health care networking including Lab services.

Building Capacity

Site capacity development framework for sustainability

Site Start-up Time

Site

Mat

urity

Implementing the

HIV Model of Care

(MOC)

+

+

Site Support by Mentors

+STAGE 1: Start-up • Initial site assessment• Training of health providers• Evaluation by DHT•Site accreditation by TRAC+•Services initiation•Services coordination and follow-up

Enhancing quality of Care

(Standards of Care)

STAGE 2: Maintenance•Assessment of SOCs•Repeat SOCs assessment on a quarterly basis•Improvement of the quality of care

Mature and High Quality

program

Passing the Baton

to a National

Institution

STAGE 3: Maturation•Assessment of Capacity•Self assessment by site MDT

Rwanda PMTCT Standards of Care – additional SOCs for more mature programs

Standards of Care (SOC) for PMTCT Site: KIGUFI HC; District: Rubavu Period of Evaluation: January to March 2010 Date:19/05/2010 ICAP staff conducting evaluation: -- Epiphanie Kigufi staff: Berthild: PMTCT Nurse. Donatha : Ass. Soc.

Numerator Data Elements Needed Evaluation of Program Quality

Denominator

Source of information

Result of Quarterly measure of SOC Possible Actions

Intensive mentorship & capacity building to site

staff 1 All pregnant women should receive HIV

counseling and testing* and same day HIV test results at first ANC visit

Proportion of pregnant women who are tested and receive their HIV test results at first ANC visit

# of pregnant women who are tested and given their HIV result at first

ANC visit

o Date of 1st ANC o Date of HIV testing o Date of HIV test results o Date mother received results

>95%; 183/183 x 100= 100%

# of women attending first ANC PMTCT register Evaluate this month

Prioritize and evaluate next quarter On target

1a All partners of pregnant women should receive HIV counseling and testing services

Proportion of pregnant women’s partners who were tested in ANC

# total number of partners tested for HIV

o Date of mother HIV testing o Date of HIV test results o Date of partner HIV testing o Partner HIV test results

179/ 183 x 100 = 97,8%

Total # of women tested in ANC PMTCT register Evaluate this month

Prioritize and evaluate next quarter On target

2

In areas of malaria risk all HIV-infected pregnant women should receive insecticide treated bednets for malaria prevention

Proportion of HIV infected pregnant women receiving bednets

# of positive pregnant women receiving bednets

o Date of 1st ANC o HIV positive women < 75% 75 - 94% > 95%

Total number of positive pregnant women

ANC register

Evaluate this month

Prioritize and evaluate next quarter

On target

4 All HIV positive pregnant women with CD4 <350 should initiate HAART for their own health during pregnancy

Proportion of HIV+ pregnant women with CD4<350 initiating HAART during pregnancy

# of HIV positive pregnant women initiating HAART

o Women with CD4 test o Test results of CD4<350 o ART Number o ART regimen

>95%; 1/1 x 100 = 100%

# pregnant women with CD4<350 PMTCT register / ART clinic register/ CD4 log book

Evaluate this month

Prioritize and evaluate next quarter On target

5 All HIV-positive pregnant women should receive PMTCT prophylaxis according to national guidelines***

Proportion of HIV positive pregnant women >28weeks who received appropriate PMTCT prophylactic regimen according to national guidelines***

# of HIV-positive pregnant women >28weeks who received appropriate

PMTCT prophylactic regimen according to national guidelines***

o HIV status o Gestational age o Type of prophylactic regimen

provided o Hemoglobin

>90%; 4/4 x 100 =100%

# of HIV positive pregnant women >28weeks whose records have been

reviewed

PMTCT register/maternity register

Evaluate this month

Prioritize and evaluate next quarter On target

13

All HIV exposed infants should be started on cotrimoxazole preventive therapy (CPT) by 4-6 weeks of age

Proportion of HIV-exposed infants started on CTX at 4-6 weeks of age

# of HIV exposed infants started on CTX at 4-6 wks age

o Sample of 10% HIV exposed infants

o Date of birth o Date of CTX initiation

<75; 2/3 X 100 = 66,6%

# of HIV exposed infants > 6weeks of age o Exposed infant follow-up registers or dossier

Un enfant s’est presenté après 6semaines

On target

14a All HIV exposed infants identified through PMTCT program should have a final

Proportion of HIV exposed infants identified through

# HIV exposed infants, identified through PMTCT program, with a

o Sample of 10% HIV exposed infants

o Date of birth

60-94%

Trends in ART prophylaxis regimen for HIV pregnant women at ICAP supported sites:

decrease in SD-NVP & increase in multi drug and HAART for pregnant women

77%

94% 94%100% 100% 100%

0%

20%

40%

60%

80%

100%

120%

Mar 07 Jul-07 Dec-07 Jan-09 Jul-09 Jan-10

Percentage

Period

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

Lessons learned• Decentralization is an effective way to improve

efficiency of services and to sustain quality of care• Integrated /joint planning is key to increase access to

HIV services (eg. PEPFAR & Global Funds)• Community participation and Involvement of PLWAs

in care is an effective way to improve retention and adherence

• Direct SubAg with national institutions enhances ownership and culture of accountability

• Involvement, oversight and supervision by local leadership is a guarantee to the partnership and transparency

Some challenges

• High staff turnover at all levels: – How to address at both central and district levels?

• Available resources versus need and demand for broader health system strengthening: – How to use the available limited resources,

mainly streamlined to HIV to meet broader health sector needs (HSS issues) ?

• How to transform vision into implementation in a rapidly and continuously changing environment?

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Acknowledgment• Government of Rwanda• Site Staff• PLWAs• CDC and other USG agencies• Partner organizations• Support by PEPFAR

"Teamwork is the ability to work together toward a common vision; the ability to direct individual accomplishment toward organizational objectives. It is the fuel that allows common people to attain uncommon results.” Andrew Carnegie