rwanda health systems strengthening activity: quarterly

Rwanda Health Systems Strengthening Activity: Quarterly Report (April-June, 2017)

Alain Joyal

August 25, 2017

Rwanda Health Systems Strengthening Activity (RHSSA) will enhance the resiliency of the Rwandan health sector to address new challenges and will help build a country-owned sustainable health system capable of leading and managing change, through provision of extensive technical support.

[Health Systems Strengthening, Health Financing, Leadership, Management, Governance]

This report was made possible through support provided by the US Agency for International Development and Rwanda USAID, under the terms of Cooperative Agreement Number AID-696-A-15-00001 and Elisabeth Uwanyiligira. The opinions expressed herein are those of the author(s) and do not necessarily reflect the views of the US Agency for International Development.

Rwanda Health Systems Strengthening Project Management Sciences for Health, Headquarters 200 Rivers Edge Drive Medford, MA 02155 Telephone: (617) 250-9500 http://www.msh.org

http://www.msh.org/

1 | Page RHSS Quarterly Report, April–June 2017

Rwanda Health Systems Strengthening Activity (RHSSA) Cooperative agreement: AID-696-A-15-00001/MSH

Quarterly Report: Third Quarter, April – June 2017 Revised 25 August 2017

Cooperative Agreement No: AID-696-A-15-00001 MSH Rwanda

KK 341 St., Plot No. 22

Kigali, Kicukiro, RWANDA

Tel.: (+250)-788-308-081/82

MSH 200 Rivers Edge Drive

Medford, MA 02155

USA

www.msh.org

This report is made possible by the support of the American people through the United States Agency for International Development (USAID). The contents of this report are the sole responsibility of Management Sciences for Health (MSH) and do not necessarily reflect the views of USAID or the United States Government.


Table of Contents

Section 1: Overview 3

1.1. Acronym List 3

1.2. Activity Description 4

1.3. Major Achievements in Current Quarter 5

1.4. Major Challenges 5

Section 2: RHSS achievements in the Current Quarter 6

2.1. Executive summary 6

2.2. Progress on challenges identified in the last quarter 7

2.3. Accomplishments by results (IR) and sub-results areas 8

IR1. Institutionalized health systems thinking approaches and practices 8

IR2. Improved multi-level GOR policy, planning, and implementation capacity 9

IR3A. Increased revenue mobilization by the health sector 11

IR3B. Improved and expanded quality health services through more effective and efficient use of

existing resources in the health system, achieving better value for money 14

IR. 4. Improved M&E, culture of learning, and knowledge-based practices 19

Section 3: Cross-Cutting Interventions 22

Section 4: Collaboration, Learning and Adapting 22

Section 5: Public Events Planned 23

Section 6: Management and Administration 23

Annexes 25

Annex 1: Performance Monitoring Plan Indicators reportable this quarter 25

Annex 2: Financial Reporting (FY17, Third Quarter, April - June) 27

Annex 3: Success Story 30

Annex 4: RHSS Results Framework 31

Annex 5: Areas of RHSS collaboration with other projects, donors, and agencies 32


Section 1: Overview

1.1. Acronym List

CBHI Community-Based Health Insurance CHAIN Community Health and Nutrition Project CHWs Community Health Workers DCA Development Credit Authority DDS District Development Strategy DH District Hospital DHIS-2 District Health Information Software DHMTs District Health Management Teams DHUs District Health Units DP Development Partners eIDSR electronic Integrated Disease Surveillance and Response system FY Fiscal Year GIS Geographical Information System GoR Government of Rwanda HDP Health, Development and Performance HMIS Health Management Information System HRH Human Resources for Health HSS Health Systems Strengthening HSWG Health Sector Working Group IFMIS Integrated Financial Management Information System IR Intermediate Result JADF Joint Action Development Forum KM Knowledge Management L&G Leadership and Governance MAG Mutual Aid Group MCSP Maternal and Child Survival Project MOH Ministry of Health M&E Monitoring and Evaluation MINALOC Ministry of Local Government MINECOFIN Ministry of Finance and Economic Planning MSH Management Sciences for Health NGOs Non-Government Organizations PFM Public Financial Management PPP Public Private Partnership PSE Private Sector Engagement PTAs Provincial Technical Advisors QI Quality Improvement RALGA Rwanda Association of Local Government Authorities RBC Rwanda Biomedical Center RDB Rwanda Development Board R-HMIS Rwanda Health Management Information System RHSS Rwanda Health Systems Strengthening project GOR Government of Rwanda RSSB Rwanda Social Security Board SCHS USAID’s “Strengthening the Capacity of the Health Sector” project ToT Training of Trainers STTA Short Term Technical Assistance TWG Technical Working Group UR/SPH University of Rwanda/School of Public Health USAID United States Agency for International Development WHO World Health Organization WISN Workforce Indicators of Staffing Need


1.2. Activity Description

a) General description

Activity Title Rwanda Health Systems Strengthening Activity (RHSSA)

Agreement Number Cooperative Agreement No: AID-696-A-15-00001

Name of Prime Implementing Partner

Management Sciences for Health (MSH)

Names of Sub-awardees

Tulane University School of Public Health and Tropical Medicine Banyan Global UR/CMHS School of Public Health Jembi Health Systems, SA

Activity Start Date November 17, 2014

Activity End Date November 16, 2019

Reporting Period April - June, 2017

b) Activity goal, scope and results

Implemented by Management Sciences for Health (MSH) and its partners, the Rwanda Health Systems Strengthening project (RHSS) is a USAID-funded activity whose overall goal is to achieve “Strengthened and expanded performance of the Rwandan health system at the national, decentralized, and community levels.” The project works to enhance the resilience of the Rwandan health sector to address new challenges. The project helps build a country-owned sustainable health system capable of leading and managing change, through provision of extensive technical support across four strategic areas with five Intermediate Results (IRs):

● Leadership and Advocacy: institutionalized health systems thinking to increase advocacy, leadership, and stewardship (IR1);

● Governance, Policy and Planning: improved policy, planning, and implementation at the central and district levels (IR2);

● Management, Coordination, and Implementation: o increased revenue for the health sector through domestic and private sector sources to

achieve sustainability (IR3A); o improved quality of health services and greater efficiency in resource use (IR3B), and;

● M&E, Learning, and Knowledge-Based Practices: improved monitoring and evaluation (M&E), health systems research, learning, and knowledge-based practices (IR4).

The five IRs are interrelated and many activities are cross-cutting and implemented jointly to achieve overall results. Building on previous achievements, the RHSS Activity continues to support innovations and build the capacity of the Government of Rwanda (GOR) to deliver quality health services for all people and improve the health status of the Rwandan population (See Annex 4).


1.3. Major Achievements in Current Quarter

✓ Supported the ongoing process of health sector strategic planning, aligning the District Development Strategies (DDS), the Health Sector Strategic Plan (HSSP4), the Economic Development and Poverty Reduction Strategy (EDPRS3) and the Vision 2050;

✓ Supported the implementation of the CBHI M&E web-based system built on the DHIS-2 platform and trained users;

✓ Provided technical support to the newly-created Development Credit Authority (DCA) by streamlining its coordination and collaboration between USAID, Banque Populaire du Rwanda (BPR), and beneficiaries (Refer to the success story in Annex 3);

✓ Supported the development of extended service packages for health centers where services offered go beyond normal health center services package, frequently owing to the presence of medical doctors;

✓ Supported the development of private health care service standards, adapting Rwanda public hospital accreditation standards to the private health care facilities (private hospitals and polyclinics);

✓ Trained 16 staff from RBC and MOH on data use, display and interpretation of spatial data and basic principles in map-making using Geographic Information Systems (GIS);

1.4. Major Challenges

Problem/Challenge Solution Proposed Next Steps Timeline Responsible

Delays in launch of district operational research challenge fund due to lack of formal commitments from donors

Convene steering committee to confirm financial inputs and launch strategy and timing

Steering committee meeting, advocacy by new Research Coordinator

July-Aug Nadine Hitimana

Continuing inaction on the establishment of an Accreditation Body

Complete the business case for the Accreditation body as an advocacy tool

Complete the work started on the financial model for the body and develop a business case to entice potential investors and stakeholders

Aug-Sept Joy Atwine, Enrique Cabrera

Poor alignment of partners supporting CBHI interventions

Set up a CBHI TWG with RSSB and revisit the enterprise architecture roadmap

Work with RSSB Deputy DG Benefits (Dr. HAKIBA, Solange) to put together TOR for CBHI TWG and invite participants to a first meeting

Aug-Sept Randy Wilson, Therese Kunda

A low number of certified accreditation surveyors

Training of new cohort of surveyors and implementation of a retention strategy

Advocacy on training a new cohort of surveyors, development of a retention strategy and timely transfer of training capacity to the Accreditation Body.

Aug- Sept

Joy Atwine, Dennis Akishuri


Section 2: RHSS achievements in the Current Quarter

2.1. Executive summary

This report presents the activities implemented and achievements realized in the areas of health systems strengthening by the USAID-funded RHSS project during the period of April to June, 2017. The main achievements in the project’s five components are:

Leadership and Governance:

● Organized an orientation session on health systems strengthening initiatives to the Ministry of Local Government (MINALOC) staff and held consultative meetings with the Rwanda Association of Local Government Authorities (RALGA) to advocate for District Health Unit staff recruitment;

● Reviewed the curriculum of College of Medicine and Health Sciences (CMHS) and proposed improvements on Leadership, Management and Governance (LMG) modules of the curriculum;

● Supported the organization of technical working groups as a means to strengthen multi-participation in planning and implementation;

● Continued support for improving functionality of District Health Management Teams (DHMTs) through DHMT meetings, district coordination meetings, and Joint Action Development Forums (JADFs);

● Supported the ongoing process of health sector strategic planning, aligning the national strategies under development: the DDS, the HSSP4, the EDPRS3 and the Vision 2050;

● Completed a desk review in preparation for development of Standard Operating Procedures (SOP) for the DHMTs.

Health Financing

● Supported the Rwanda Social Security Board (RSSB) to carry out analysis on primary health care (PHC) cost drivers and their implications for future CBHI sustainability;

● Supported the implementation of CBHI M&E web-based system built on the DHIS-2 platform and trained users (RSSB Branch managers, CBHI Officers from all 30 districts, CBHI verification officers and RSSB central level teams) on the use of the system;

● Trained 119 staff and managers at provincial and district level on Community Health Worker (CHW) cooperatives’ business planning and implementation. This focused on enhancing their Income Generating Activities (IGAs) using the documented best practices and business cases. The target for the CHW ToT planned for year three is 175 participants (35 participants from each of the 5 provinces).

● Provided coaching in five district hospitals for complying with Public Financial Management (PFM) guidelines, particularly the use of the Integrated Financial Management Information System (IFIMS). The target for PY3 is 22 District hospitals; representing 50% of all DH’s.

Private Sector Engagement

● Supported the development of a regulatory framework for private wings to be installed in public hospitals;

● Provided technical support for the implementation of the newly created USAID Development Credit Authority (DCA) portfolio guarantee with Banque Populaire du Rwanda (BPR) by streamlining its coordination and collaboration between USAID, BPR and beneficiaries (Refer to success story in Annex 3);

● Supported the update of Kiziguro hospital’s private wing business case, focusing on the business case for a private clinic, and assisted the hospital in the application of a loan to implement this initiative.


Quality Improvement

● Supported the development of extended service packages for health centers upgraded to a level beyond normal health center services package;

● Supported the development of private health care service standards, adapting Rwandan public hospital accreditation standards to the private health care facilities (private hospitals and polyclinics);

● Provided coaching and on the job support to 68 of 102 hospital staff from eight facilities (Masaka, Nyamata, Kibagabaga, Rwamagana, Muhororo, Gitwe, Bushenge and Kirehe) out of twelve targeted for PY3. This coaching aimed at improving compliance with specific accreditation standards on which the facilities scored low’

● Supported the MoH to conduct accreditation surveys in all hospitals for identification of quality gaps regarding standards compliance.

Monitoring and Evaluation and Knowledge Management

● Trained 16 central level staff from RBC and MOH on data use, display and interpretation of spatial data and basic principles in map-making using GIS. This training targeted 19 senior staff from RBC’s Planning, Monitoring & Evaluation and Business Strategy (PMEBS) division and MOH’s Planning Health Financing and Information Systems (PHFIS) Directorate. This central level course is the last round of GIS training planned, having started by training staff from all of the Districts in PY2;

● Supported an orientation training workshop for 70 RBC and MOH staff for conducting the integrated Supportive Supervision (ISS) and Data Quality Assessment (DQA) in all districts;

● Supported three MoH recently recruited database managers to attend a local DHIS-2 Academy, targeting the design and customization of the software;

● Continued support to the MOH and RBC for management of health information through DHIS-2, including analysis of Fortified Blended Food (FBF) data, enhancing the functionality of the Disease Surveillance System (eIDSR), and an upgrade of Health Management Information Systems (HMIS) servers to reduce costs and improve system performance;

● Created online resources and developed a capacity building plan for the research challenge fund.

Cross-cutting Technical Support

● Started the work on standardizing medical acts and procedures by selecting a local and an international consultant and working with the MOH to develop detailed plans for their work that begins in Q4.

● Continued support for the establishment of a Mutual Assistance Group (MAG) for health professionals to expand access to finance and improve health worker retention. During Q3, we completed a series of consultations with stakeholders, developed a financial model and prepared an policy options paper for the Minister

2.2. Progress on challenges identified in the last quarter

❏ Delays in staffing at MOH to support private sector engagement

The MoH continued to search for qualified staff to support private sector engagement activities. Although not responsible for private sector engagement activities at the MoH, the RHSS team has established effective collaboration with the Senior Health Financing Advisor, David Kamanda, in the development of the private wing regulatory framework.

❏ Advocating for implementation of the HSS Evaluation

Considerable effort went into managing this challenge during the quarter, including a short term technical assistance (STTA) visit from David Hotchkiss and meetings with stakeholders at MOH,


USAID and UR/SPH. It now seems clear that there is little interest from the MOH and that time is not on our side to implement the study using the proposed multi-round study design. We are therefore looking to integrate key components of the study into the project’s internal data collection work as part of the project Performance Management Plan (PMP). Some of the survey instruments that were developed will also be used by the local team to collect data for a series of case studies documenting lessons learned from some of the project’s key interventions.

❏ MOH has ambitious objectives for strengthening key institutions (e.g. CHW Cooperatives, District Health Units) in all districts but RHSS has limited resources for implementation

Support to district health coordination mechanisms has been provided by the project’s PTAs and staff to the key partners at district level (District Directors of health, Directors of hospitals, District planners, Vice-mayors) rather than organizing larger workshops/training sessions. We have also strengthened our collaboration with other USAID-funded projects: with Maternal and Child Survival Project (MCSP) for DHMT support and with Community Health and Improved Nutrition (CHAIN) project for strengthening JADFs and CHW cooperatives. Enhanced collaboration was also agreed upon with Belgian Technical Cooperation (BTC) and Swiss Development Cooperation (SDC) for support to the district level strategic planning process and for the upcoming district research challenge fund.

❏ Continuing delays in the establishment of national accreditation body

No progress was made on the creation of this body, partly because the last quarter the QI team was fully engaged in a round of progress surveys in all district hospitals. Moving forward, the RHSS team has planned to complete the financial model and business case in the next quarter.

2.3. Accomplishments by results (IR) and sub-results areas

IR1. Institutionalized health systems thinking approaches and practices

Sub-IR 1.1. Structural and process barriers to enhance leadership and stewardship identified and redressed

❏ Consultative meetings with stakeholders to advocate for and support removal of institutional barriers to leadership and stewardship in health system

During this quarter, the RHSS Leadership and Governance (L&G) component met with the MINALOC Permanent Secretary and technicians, providing them with the orientation on Rwanda Health Systems Strengthening Activity and its interventions to address policy, institutional, capacity and communication barriers to HSS, such as advocacy for clarifying the legal framework of the district health management team, support to local leaders for better resource allocation for health services, building the capacities of health facilities managers for financial and human resources management and improving the district health integrated planning process to promote participation of all district health stakeholders. It was agreed that such working sessions should be held on a regular basis to strengthen collaboration between the MOH and RHSS.

Among other interventions to address HSS barriers, regular meetings took place with the Rwanda Association of Local Government Authorities (RALGA) to monitor progress on the DHU staffing issue. Efforts by RALGA and district authorities to fill vacant positions have been slowed down by the recent establishment of e-recruitment, which is still in its initiation phase, but it is expected that most positions and particularly the missing Directors of Health (10 vacant positions out of 30 districts) will be filled during the next quarter. This is a critical condition for improvement of the functioning of DHUs and DHMTs.

Sub-IR 1.2. Increased understanding and practice of health systems strengthening at all levels

❏ LMG integration into the College of Medicine and Health Sciences (CMHS) curriculum


RHSS organized a one-day workshop (May 18th, 2017) with representatives from faculties of the CMHS to include Leadership, Management and Governance (LMG) content in the pre-service training of health care workers of all main health sciences faculties. Using the USAID-funded MSH led global Leadership, Management and Governance (LMG) Program’s LMG Faculty Facilitation Guide as a reference document, the previous curriculum was reviewed and additional topics proposed. Each faculty has to finalize its LMG content included in their updated curriculum, with implementation starting in the new academic year (September 2017). This will enhance CMHS’ students’ skills with greater exposure to the main concepts of LMG and practical application in their future professions.

Sub-IR 1.3. Attained multi-stakeholder, evidence-based decision making for efficient and equitable allocation of financial and human resources

❏ Rapid situation analysis of HRH staff turnover and proposal for retention strategies

Data collection for this study is almost completed and the results, including recommendations for possible HRH retention strategies, will be presented in the coming quarter. This issue of staff turnover is widely recognized by the MOH and other health stakeholders as a major challenge for the health sector, and interest in the results of this study is very high. The MOH has declared its interest to use the online survey developed in the framework of this study for a nationwide survey on staff turnover in all health facilities. Once the report is completed and submitted to MOH, the HRH TWG will explore how it can advise on implementation of approved retention strategies.

IR2. Improved multi-level GOR policy, planning, and implementation capacity

Sub-IR 2.1. Strengthened national and district-level capacity for planning and coordination

❏ Central level technical meetings for multi-level partnership in planning and implementation

The Planning, Health Financing and Information System (PHFIS) TWG, the Human Resources for Health (HRH) TWG, the Research and Knowledge Management TWG, the Health Sector Working Group and the Joint Health Sector Review (JHSR) have been active during this reporting quarter:

● The recently established Health Sector Working Group (HSWG) core team has focused on coordination and support to the ongoing strategic planning process (development of the fourth Health Sector Strategic Plan /HSSP4) carried out jointly with the PHFIS TWG;

● The HRH TWG focused on close follow up to the design and preparation of the HRH staff turnover rapid analysis;

● The Research TWG has made significant progress for the initiation of the district research challenge fund expected to be launched in the next quarter; The challenge fund was designed to incentivize operational research to answer implementation-related questions at the district/facility level using available data. In addition to offering a fixed amount of grant money ($3000 per study), the challenge fund program includes targeted training and mentoring of the selected grantees from districts across the country and support for dissemination of the best studies in a national research conference (see sub-IR 4.3, p.22).

● The Forward-Looking Joint Health Sector Review meeting was held on June 14th. The participants, including seven from RHSS, examined the priorities and indicators for the coming year (2017-18), reached consensus, and subsequently submitted them to the Ministry of Finance (MINECOFIN). The HSSP4 development process was also discussed with the consultants during this meeting.

In each of these TWGs, RHSS team members supported the TWG secretariat in organizing the meetings, agreeing on the agenda, preparing presentations and supporting documents, writing up the minutes of the meetings, and following up on the implementation of recommendations from the meetings. The secretarial function in these TWGs has been instrumental in the improvement of the dialogue and coordination of key health interventions between MOH and DPs.


❏ Support for organization of district level coordination meetings

As one of their primary responsibilities, the RHSS Provincial Technical Advisors (PTAs) continued to provide technical assistance to the DHMTs and Joint Action Development Forums (JADFs) to organize their quarterly meetings. Whereas in the recent past, only a few districts were consistently using the DHMT platform to discuss their health issues, now a majority (18/30) organize quarterly meetings facilitating exchanges and problem resolution around different topics such as unpaid or delayed CBHI bills and distribution of medical products to facilities. The increasing regularity of these meetings in many districts is evidence that these coordination mechanisms are progressively gaining institutional strength. Larger district health coordination meetings, involving health facility representatives (district hospitals and health centers) have also taken place in 11 districts during this quarter, improving the dialogue between district authorities and health facilities for better health services management.

Important topics discussed in these meetings during the last quarter include district health imihigo (performance indicators), evaluation and planning for the coming fiscal year (2017-18), finalization of district health annual action plans, and inputs from the health sector for development of the District Development Strategy (DDS) in terms of situation analysis (achievements and challenges) and in terms of priority for the next six years.

The JADF social commission/health sub-commissions have not yet reached the same level of functionality as DHMTs, but in an increasing number of districts (11 during this quarter), they are used as an important mechanism to ensure coordination of health interventions by development partners active in the district. This forum is used in particular for integrated planning and monitoring of health activities at the district level.

Sub-IR 2.2. Increased multi-sectoral participation in policy, strategy and implementation

❏ Development of fourth Health Sector Strategic Plan (HSSP4) and District Development Strategies (DDS)

According to MINECOFIN planning guidelines, the Sector Strategic Plans and District Development Strategies are expected to be developed simultaneously with the Economic EDPRS3 through an iterative process where each level feeds into and is guided by the others. This very ambitious process is expected to be completed in a very short timeline (from May to September 2017). During this quarter, the health sector held two participatory workshops to develop key strategies, indicators and interventions to be implemented for each programmatic area and health system during the timeframe of HSSP4 (2018-2024). The first draft of HSSP4 was submitted to MINECOFIN on July 14th. RHSS’s contribution to this exercise has been active participation in the core team for preparation of the entire process and involvement of project component teams during the workshops, providing inputs to inform the draft HSSP4, thus contributing significantly to the development of proposed strategies.

At district level, the RHSS PTAs were involved in collaboration with district health teams and provincial leaders in the integration process of health priorities in the situation analysis and priority setting for the development of the District Development Strategies (DDS, 2018-2024). The mechanism through which these priorities will be transmitted to the central level for inclusion in national documents (HSSP4, EDPRS3) still has to be reviewed and the RHSS team will advocate for the effective implementation of the bottom up consultative process. According to MINECOFIN roadmap, the second draft for all the strategic documents (EDPRS 3, Sector strategies and DDS) are expected to be submitted by August 31st

In conclusion, both at central and decentralized levels, RHSS played an important role in the identification of health sector’s strategic priorities for the coming years on the basis of evidence.


Sub-IR 2.3. DHMTs strengthened and district health staff management skills improved, and clear roles and accountability structure in place at district level

❏ Development of DHU SOPs

This priority activity has been the subject of in-depth discussion with the MOH to determine the scope of the document to be produced and the methodology to be used. With the shift in the project’s resource utilization strategy, we have decided to conduct the desk review using RHSS staff rather than recruiting a consultant and we have proposed the outline and structure for these SOPs. The desk review is now complete and we plan to hold consultative sessions with district partners in the next quarter to develop the content of the SOPs. This document will be an important tool for building the capacity of the district teams, achieving clarity of understanding on their roles and responsibilities and agreeing on respective tasks each individual and institution is expected to perform for a more sustainable and operational health system at decentralized level.

IR3A. Increased revenue mobilization by the health sector

Sub-IR 3A.1: Improved functioning and sustainability of an integrated and equitable health insurance system

❏ Analysis of Primary Health Care (PHC) cost drivers and implications for CBHI sustainability

In the previous quarter, the project supported the Rwanda Social Security Board (RSSB) to conduct the annual performance analysis of the community-based health insurance scheme (CBHI) for fiscal year (FY) 2015/16. This was the first such analysis conducted since CBHI was transitioned to RSSB. According to the report, primary health care services received nearly half (41.36%) of the total FY 2015/16 expenditures. During quarter three, in response to those findings, RHSS staff helped RSSB carry out further analysis on primary health care (PHC) cost drivers and their implications for future CBHI sustainability and provided recommendations for effective planning and management of the scheme. The main findings from the analysis identified the following key cost drivers of PHC and their implications for CBHI sustainability:

● Increasing number of health posts: There were 60 health posts in 2012 which rose significantly to 252 in 2013 and reached 406 in 2015. Over the same period, claims reimbursement for PHC services had almost doubled, increasing from 7.2 to 13.9 billion Rwandan Francs per year (Refer to Table 1).

Table 1: Trend in CBHI reimbursement at primary care level in Rwanda

2011-2012 2012-2013 2013-2014 2014-2015 2015-2016

Claims paid for PHC

7,215,225,721 8,030,727,934

9,059,256,830

16,146,355,337

13,927,778,949

% change 11.3 12.81 78.23 -13.74

● Substantial increase in PHC service utilization: The utilization of primary health care services increased from 1.054 contacts per year per capita in FY 2011/12 to 1.7 in FY 2013/14 (Refer to Table 2).


Table 2: Trends of utilization rate of PHC services

2011/12 2012/13 2013/14 2014/15 2015/16

Utilization rate 1.054 1.101 1.787 N/A 1.72

Source: MOH annual report 2011/12, 2012/13, RSSB annual report 2015/16. (2014/15 data not available).

● High proportion of expenditure on medicines at private health posts compared to other PHC levels (HC, Government health posts, and FC): In 2015/16, the average cost per visit is balanced for the health posts (between 900 frw for Government health posts and 850 frw for OFH health posts), however reimbursements of private health posts (under OFH) went mainly to medicines representing 72% while procedures represented only 28%, compared to 52% on medicine and 48% on procedures for government health posts. These findings, although not conclusive, call for further investigations on potential over-prescription or over-utilization of services.

Based on the analysis and projections, the current CBHI financing gap (RWF 1,500 per capita/per

year) would continue and could even rise if there are no strategic changes initiated. Key

recommendations from the analysis include:

● Harmonize the benefit package, aligning it to the minimum package of activities and enforcing adherence to the standards of care. This should be strengthened by relevant authorities implementing stringent monitoring mechanisms on health providers at PHC service provision level through licensing of PHC services and monitoring the quality of services delivered (there is currently no licensing or accreditation system in place at the health center or health post levels).

● Enforce control mechanisms for the prescription of medicines at PHC service delivery level, as over prescription by some providers could be a motivation for revenue generation.

● Reinforce coordination of the patient referral system at PHC delivery level with clear and documented referral guidelines.

The evidence provided, raise the awareness about the CBHI system performance and serve for advocacy of more effective policies and quality assurance measures. During the next quarter, the project will be supporting RSSB to analyze the CBHI performance for FY 2016/17 once data collection through the new CBHI M&E system has been completed.

❏ Training of RSSB users on CBHI M&E and reporting framework

In the previous quarter, RHSS staff supported the establishment of a web- based CBHI monitoring and evaluation system built on the DHIS-2 platform. The system was developed to improve data collection and use, especially in planning and performance evaluation of the CBHI scheme including enrolment, health care service utilization, revenue and expenditure at central and decentralized levels. The system features user-defined dashboards that will enable RSSB staff at different levels to monitor their key performance indicators on a monthly basis (Refer to Figure 1 below).


Figure 1: Screenshot for the interface of the CBHI M&E System

In this quarter, RSSB end-users were trained, including all RSSB Branch managers, CBHI Officers from 30 districts, CBHI Verification officers and RSSB central level CBHI teams. A total of 104 end users (nine from central level and 95 from district level) were trained. Target for this activity was 112 RSSB staff; at central and decentralized levels. The RHSS team will continue to build capacity of RSSB to use the system and regularly analyze the data using dashboards and other analytical tools for decision making. During the training, data from all mutuelle sections for FY 2016/17 were entered in the system and this will ease data analysis for the current CBHI annual performance report.

Sub I.R 3A.3: Increased income generation capacity of CHW cooperatives toward CHW retention and self sufficiency

❏ Enhancing CHW financial capacity for sustainable service delivery in the community

During this quarter, the project team organized workshops to train a team of trainers at the decentralized level (Province and District) in business planning and implementation of income generating activities (IGA) and disseminated findings from the assessment of CHW Cooperatives conducted last year. In total, 119 district and provincial level staff were trained. The ToT target for PY3 was 175 participants (35 participants from each of the 5 provinces). City of Kigali ToT has not yet been conducted and is planned for next quarter (Q4 PY3). The persons trained will coach and mentor the CHW cooperatives by promoting peer-to-peer learning, nurturing their businesses and promoting an entrepreneurial culture amongst the CHW cooperatives. .

Sub-IR 3A.4: Greater private-sector participation in health is effectively supported and incentivized

❏ Strengthen leadership and policy environment for Public Sector Engagement (PSE)

MOH Private Wing Regulatory Framework: Following a high-level meeting in October 2016 with the MOH leadership, RHSS committed to support the development of the regulatory framework to implement private wings in public hospitals. To assist the MoH, the project developed a concept note to embody the private wing idea behind the regulatory framework. Based on comments provided by MOH, during this quarter, RHSS re-edited the concept note to include new sections: i) definitions, ii) perceived impacts of private wings, iii) private wing model pros and cons, and; iv) private wing regulatory framework. Currently, RHSS is awaiting the outcome of internal deliberations at the MOH concerning the recommendations provided in the concept note before we can begin more widespread promotion of the model.

❏ Investment and access to finance increased for the private health sector


RHSS provided training to BPR’s credit and risk management staff in operationalizing the DCA and reviewed BPR’s health sector loan applications in order to ensure compliance with the terms of the DCA guarantee agreement. This effort opened up funding opportunities with a recently-approved loan to the Medical Business Company (MBC).

Development Credit Authority (DCA): To improve the likelihood of success of the implementation of the USAID’s DCA credit guarantee agreement with “Banque Populaire du Rwanda” (BPR), RHSS conducted a rapid assessment of stakeholder needs in November 2016. Following this assessment, RHSS carried out in June 2017 the following activities: i) provided training and technical assistance to BPR team on implementing the DCA: BPR training participants included five Business Banking/ Relationship managers; one Institutional Banking staff, and four staff from Credit Evaluation/Credit Risk & Credit Analysis; ii) defined the value of DCA as a financial instrument to support provision of loans to the health sector beneficiaries; iii) reviewed BPR DCA existing loan applications from health sector borrowers, and; iv) supported brokering new relationships between the bank and health sector, including referrals and connections with suppliers. This work included leading a workshop for the bank to meet private health providers and yielded as a result the first approved qualifying loan by BPR under the DCA to Medical Business Company Ltd (Refer to the success story in Annex 3). The MBC will provide quality health services thus contributing to maternal and child health outcomes. To cement this result, the RHSS team introduced BPR staff to USAID Washington Credit Management System (CMS) Office team to ensure that DCA qualifying loan is registered in USAID CMS.

Private Wing Business Case Update: Moving forward with the implementation of the private wing at the Kiziguro District Hospital (KDH), RHSS updated the private wing business case developed in September last year. The KDH management was approached by Health, Development and Performance (HDP), a non-profit organization financing projects in Rwanda. As a result, staff of the KDH, HDP and RHSS met and agreed to update the private wing business case. The scope of the recommended update is to perform a financial analysis of a different business model - a private clinic. Both analyses (the private wing business case and the private clinic business case) are to be used by the KDH to obtain HDP financing. Further to this work, MSH provided a presentation to HDP concerning the results of the updated business case report. As a result of this work, HDP have decided to finance the KDH private clinic. Currently, HDP and KDH are finalizing the terms of the loan agreement for establishment of KDH private clinic.

IR3B. Improved and expanded quality health services through more effective and efficient use of existing resources in the health system, achieving better value for money

Sub-IR 3B.1. Strengthened financial and human resource management for improved program efficiency and outreach through increasing and effective use of e-Health systems

❏ Coaching selected district hospitals in financial management

In this quarter, RHSS staff provided coaching to 30 staff (DH managers, accountants and DH chief cashier) of five district hospitals (Kibagabaga, Nyamata, Masaka, Muhima and Kacyiru) on the implementation of Integrated Financial Management System (IFMIS) and how this tool can help in complying with Public Financial Management (PFM) guidelines. This intervention was jointly implemented with capacity building in other key components of PFM including:

● Supporting the development of business plans based on selected business opportunities and improvements that could yield tangible increases in hospital revenues.

● Review of financial management policy and procedures, standard operating procedures (SOPs) and guidelines. This review helped the hospitals to have clear policies and procedures for financial management and to meet standards required for Accreditation.

● Development of the cost centers analysis tool that aims at using existing hospital service data to improve planning and advocacy for resources.


RHSS will continue to provide coaching in financial management to the five district hospitals. Additionally, in the next quarter, the RHSS project will provide technical support through a peer-peer learning approach to 19 more district hospitals (Twelve in the Southern and eight in the Eastern province). The target for PY3 is to cover 22 District hospitals; representing 50% of all DH’s (Target PMP indicators).

Sub-IR 3B.2. Improved and updated service standards, quality assurance/accreditation, and improvement implemented and instituted

❏ Continuous quality improvement of services through strengthening of regulatory framework

Health Service Packages

In February 2017, a new revised version of the public service package was published and signed by the Minister of Health. During the process of developing the packages, it became apparent that five health centers, staffed by doctors and with greater infrastructure, were delivering services well beyond what is required in the new service package. MoH requested RHSS Quality Improvement (QI) component to support the development of a guiding document of expected medical interventions to be provided at this upgraded level of health facility. Plans for drafting extended medicalized service packages began in April 2017 and included visiting some of the health centers considered for upgrading. Three health centers (Bigogwe, Gikonko, Remera) were visited as a way of checking on the existing equipment, infrastructure and staff. A series of working sessions were thereafter held with different health care providers from this level of care. The final draft of extended medicalized service packages was developed and included packages related to dental, physiotherapy, ophthalmology, medical and surgical interventions that can be managed by skilled staff with equipment available in the health centers to be upgraded.

❏ Development of private health care service standards

RHSS QI component, at the request of the MOH, provided technical support in reviewing and adapting the Rwanda public hospital accreditation standards to the private health care facilities (private hospitals and polyclinics). RHSS QI staff supported a two-day working session to identify standards suitable at private hospitals and polyclinics in order to improve the quality of care provided to patients. Thirty-eight staff from polyclinics and private hospitals actively participated in different working groups tasked in different risk areas. Both hospital accreditation standards and the assessment tool kit were adapted to private hospitals and polyclinics. It was agreed that four standards out of 75 will not be adapted to private hospitals and polyclinics. These standards regarded mentorship of health centers, training students (oversight of students), privileging of clinical staff and supporting human research programs at health facilities, as they are not relevant to activities held at private health facilities and do not fall with the mandate of private facilities.

❏ Capacity building on compliance with the QI/accreditation standards

During this quarter, the RHSS QI staff supported QI/Accreditation committees from eight hospitals, inviting them to the RHSS office for working sessions and through on site visits at their hospitals. This support was in response to gaps which were identified during the December 2016 external progressive hospital accreditation assessment. The hospitals receiving facilitation support were Masaka, Nyamata, Kibagabaga, Rwamagana, Muhororo, Gitwe, Bushenge and Kirehe. A total of 68 participants took part in this facilitation process including members of hospitals’ accreditation steering committees, QI committees and health and safety committees

❏ Identification of system inefficiencies and performance quality gaps

External surveys to identify quality gaps regarding accreditation standards compliance

The RHSS team supported progressive accreditation assessments for 42 public hospitals, a process


that started in May and is expected to end in July 2017. Five certified RHSS staff surveyors provided technical support to this survey process. Draft reports of findings for 26 hospitals have been compiled and the whole assessment process will be completed in the next quarter. Graphs in Figures 2, 3 and 4 (below) indicate the accreditation performance scores for 39 hospitals (seven provincial/referral hospitals and 32 district Hospitals).

The provincial/referral hospitals are required by the MoH to achieve and maintain level one of the accreditation process. Six of those hospitals managed to meet the overall target of 85% (Rwamagana, Kibungo, Ruhengeri, Ruhango, Bushenge and Kinihira). Although Ruhango, Bushenge and Kinihira had an overall score above 85% they failed to meet requirements for critical standards, which is 100%. Kibuye hospital has failed to achieve level one with a score of 52%. An important factor that hinders the performance of these hospitals is instability of leadership and staff turnover. Kibuye has challenges of new hospital leadership as the hospital director and administrator were only recruited in November 2016. At present, the hospital does not have a human resource manager to support the area of competent workforce. In addition, Kibuye hospital is among those hospitals with the highest turnover of staff.

To achieve level two, district hospitals must obtain an overall score of 85% and 100% score on level 1 critical standards plus 75% on all level 2 standards and 80% on all critical level 2 standards. As indicated in Figure 2: Kibungo hospital has persistently maintained good progressive performance, where by it has achieved expected targets for level two, due stable and committed leadership and QI committees. Rwamagana made tremendous improvements in a period of six months achieving level two. Factors behind this success could a combination of the special facilitation arrangements made by the RHSSA team, committed leadership, and pressure from both MOH and provincial leadership. The four hospitals (Ruhengeri , Ruhago , Bushenge and Kinihira ) did not achieve level two due change of leadership and staff turnover . Kibuye hospital’s performance at level two has remained very low. This may be partially because it enrolled in the program later than other provincial hospitals, but it has not put in enough effort to address critical performance gaps.

Figure 2: Comparison of progressive performance assessment for provincial hospitals at level two

Over the next quarters, the RHSS QI component will work with MOH to organize special support for Kibuye hospital. Continuous hospital quality improvement committees will be supported through facilitations. At least two staff from Kibuye and all the district and provincial hospitals will be enrolled

90%

30%

63%

47%

74%

54%

18%

93%

76%

62%56%

51% 49%

11%0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

KIBUNGO RWAMAGANA KINIHIRA RUHANGO BUSHENGE RUHENGERI KIBUYE

Performance Results for Provincial Hospitals Level 2 for two consecutive

Surveys 2016&2017

L2 2016 L2 2017


in a facilitation certification course. This program will offer them skills that are essential for supporting quality improvement and the accreditation program at their hospitals by supporting their quality improvement committees.

Figure 3 (below) shows performance at level one for the 7 provincial and referral hospitals which have been compared for December 2016 and June 2017

Figure 3: Provincial Hospitals maintaining and achieving level 1 (December 2016 and June 2017)

According to Figure 4 (below) there was a general improvement regarding all district hospitals during the first semester of 2017. The highest to lowest ranged from 91% to 50% for level one as indicated by the June 2017 progressive assessment results, while in December 2016 ranges were between 89% and 37%.

To achieve level one, hospitals are required to have an overall score of 85%, a minimum of 75% in each risk area and a minimum of 80% score for critical standards. Most hospitals were not able achieve level one due to failure to meet these high targets. Nine out of 35 district hospitals did not improve based upon their overall scores. However, there was a remarkable improvement among the other 24 hospitals. This was because of increased facilitation from the RHSSA QI team and the efforts of quality improvement committees within the facilities. These results suggest that continuous hospital facilitation needs to be maintained in order to sustain quality improvement and achieve accreditation.

99%

70%

96%

74%

97%

84%

60%

97% 96%

87% 85% 87% 86%

52%

0%

20%

40%

60%

80%

100%

KIBUNGO RWAMAGANA KINIHIRA RUHANGO BUSHENGE RUHENGERI KIBUYE

Performance Results for Provincial Hospitals Level1 for two consecutive

Surveys 2016&2017

L1 2016 L1 2017


Figure 4: Comparison of progressive performance assessment results for district hospitals carried out during periods of December 2016 and June 2017.


IR. 4. Improved M&E, culture of learning, and knowledge-based practices

Sub-IR 4.1. M&E frameworks developed, strengthened, and implemented at central and district levels

❏ Development of tools for knowledge exchange, capacity building, and M&E

Performance dashboards/GIS

RHSS M&E/Knowledge Management (KM) staff organized a meeting with staff from Maternal and Child Survival Program (MCSP) to harmonize approaches for introducing performance dashboards at the district level. These dashboards are a key part of the M&E framework developed by our team to monitor the implementation of the district annual action plans. The MCSP support will be focused on the district hospitals that they support, while RHSS staff will be supporting teams from the DHU/DHMT in all districts. The roll out of the new dashboards and district profiles is scheduled in the next quarter.

Session on GIS integration in program activities

Two M&E staff attended and made presentations on the use of GIS during the session on GIS integration in program activities organized by USAID Rwanda mission to its stakeholders. MSH staff made a presentation on how the project implemented and plans to use GIS in their activities. The session was an opportunity to further network, learn about the use of GIS as a tool to enhance evidence-based, results-oriented decision-making, and contribute to the USAID Rwanda Mission's ongoing efforts to strengthen use of GIS in its activities.

❏ GIS Capacity Building Workshop on data use for Central Level staff

The RHSS project facilitated a four-day workshop training for 16 central level staff (from RBC and MOH) on data use, display, interpretation of spatial data, and basic principles of map-making. In order to ensure that the participants use their newly-acquired skills for central level health data analysis and for evidence based decision making, the RHSSA team has begun two initiatives:

set up a GIS portal in as part of the data manager’s knowledge management site for sharing data and maps produced, and

scheduling regular mentoring sessions with participants from selected programs – especially in the areas of family planning, malaria and maternal and neonatal health..

❏ Capacity building for Integrated Supportive Supervision and DQA

At the request of RBC, MSH supported a week-long orientation training workshop for 70 RBC and MOH staff involved in conducting the Integrated Supportive Supervision (ISS) and Data Quality Audit (ISS/DQA) in all districts. A special focus of the RHSS support was on integrating a more comprehensive data quality assessment methodology into the supervisory checklists. The field ISS/DQA is scheduled to take place in the next quarter. In addition to RHSSA staff, some MCSP staff who participated in the workshop will participate in the ISS/DQA visits.

❏ RBC and MOH staff capacity building

In this quarter, RHSS staff supported three MOH database managers to attend a DHIS-2 Academy on system design and customization. These are staff who are managing PBF and routine health data systems on daily basis. Training them serves as a sustainability strategy and capacity transfer for future system maintenance.


Figure 4: Improvement in nutritional status

of children in FBF program

Sub-IR 4.2. 4. Data production streamlined, data converted to relevant information and knowledge products, and increased evidence-based decision making and practices at strategic and management levels

❏ Enhancement of data management systems built using the DHIS-2

The RHSS project team continued to support the MOH and RBC to maintain and enhance data management systems built around the DHIS-2.

Fortified Blended Food (FBF) M&E system:

In previous quarters, the RHSS team played a key role in designing a DHIS-2 system for monitoring a new fortified blended food distribution program (FBF) – together with partners from CHAI, the MOH/RBC and the private sector (a PPP has been established with a local company to produce, package and distribute the food). This program is one of several interventions designed to improve the nutritional status of pregnant women and children – and help to resolve the high levels of stunting in Rwanda that are a contributing cause to many maternal and child related health issues. Through this program, all pregnant women and children under-2 years in the lowest UBUDEHE categories (regardless of nutritional status) are provided with monthly packets of fortified blended food. The data collection for this program started in January 2017.

During Q3, the RHSS team supported the development of a series of queries to analyze the data from the FBF system. These enabled staff to track the growth trends of individuals who are part of the supplementary feeding program. Initial analyses of the results suggest that most program participants have improved, as over 68% of the first cohort of 10,326 children gained weight between their first and most recent visits. However, there is no control group, so it is not possible to determine if the children in the program grew any faster than children not participating in the FBF program. Fortunately, CHAI is implementing a multi-round household survey to help evaluate whether or not the program has achieved the desired impact.

Disease surveillance system (eIDSR):

RHSS continued to support the eIDSR development process - balancing the growing list of requirements with those that were initially included in the scope of work developed by Health Information System Program (HISP)/Uganda. New functionality built into the core of DHIS-2 version 2.27 may actually resolve some of the issues that were identified. The advantage of this will be that RBC staff can maintain the systems without relying on outside resources. RBC staff has suggested setting up a broader community of practice around disease surveillance that can support future evolution of the system. We will work with the RBC/Epidemic Surveillance and Response (ESR) Division team on that in the next quarter, leveraging funds from an MSH Board of Directors funded initiative to further enhance disease surveillance functionality of the DHIS-2 platform.

HMIS servers migration and upgrade

The RHSS team together with the consultant from HISP/Oslo (Bob Jolliffe) supported the process of migrating MOH servers from Platinum to Bronze packages to save thousands of dollars a month, upgrading the database and operating system software for better performance, improving server


security to A+, and supporting the first regional DHIS-2 Academy on Server Administration to build the capacity of MOH and RBC staff to sustain and maintain these systems.

Sub-IR 4.3. Operational health system research is strengthened and supported for sustainable HSS

❏ District Health Operational Research Challenge fund

This quarter saw a lot of progress on the establishment of the challenge fund, culminating in the recruitment of a new Research Assistant, Nadia Hitimana, at the end of the quarter. Nadia comes with sound applied research experience in the health sector and will oversee the day to day management of the challenge fund.

Other achievements included the finalization & approval of the grant-making procedures guidelines and commitments of resources from several donors (BTC & SDC, in addition to USAID – through RHSSA). The RHSS M&E/KM team also created a set of online resources for the research challenge fund on the existing knowledge management site (Refer to Figure 5): (http://pbf.moh.gov.rw/cop/districtme/district-health-operational-research-challenge-fund/). This is the site where candidates for the fund will obtain information about how the challenge fund operates and will post their study proposals.

Figure 5: Screenshot for the interface of the KM Platform with Research fund information

At the end of the quarter, Nancy Mock from the Tulane School of Public Health and Tropical Medicine came to Rwanda for two weeks to help with the recruitment effort and develop a capacity building plan for the challenge fund. The plan builds on the results of the district capacity building survey conducted last quarter and identifies specific content that will be built into the initial orientation workshop for selected candidates, and outlines the mentorship of researchers by academic staff from University of Rwanda/School of Public Health (UR/SPH) and development partners.

❏ HSS program evaluation

During his two week visit in June, David Hotchkiss from Tulane met with USAID and UR/SPH staff to discuss how best to advance the work of HSS program evaluation. It seems that the MOH is not keen to push ahead with this comprehensive evaluation protocol for a variety of reasons, both methodological and financial. In discussions with MOH & USAID the current proposal is to re-shape the evaluation into a set of case studies prepared using local resources to identify shareable lessons learned from the Rwanda experience, without conducting a major multi-round data collection exercise.

http://pbf.moh.gov.rw/cop/districtme/district-health-operational-research-challenge-fund/


❏ Planning of Policy Brief training for MOH staff

The Planning Directorate at MOH requested RHSS support for organizing capacity building on developing policy briefs - an intervention that can help to close the gap between research and action. David Hotchkiss from Tulane met with the UR/SPH team to discuss how this training could be organized. RHSS has proposed to finalize the methodology for the training during the fourth quarter (July-September) and conduct training at the beginning of PY4 (since the activity was not included in the current year work plan). Certain elements of this training will also be included in the capacity building planned for the first cohort of District Research Challenge fund recipients.

Section 3: Cross-Cutting Interventions

❏ Support standardizing medical acts and procedures through adoption of an international nomenclature classification system

RHSS concluded recruitment of two consultants to lead the standardization of medical acts and procedures. Initial detailed planning began this quarter with the local consultant and Pascal Birindabagabo from the Ministry of Health and the bulk of the work is scheduled to take place during the three weeks from July 10th. We have selected two complementary consultants: Dr. Emile Rwamasirabo (former director of King Faisal Hospital and a well-known clinician) and Jaci Johnson (with the American Academy of Professional Coders with many years of experience using medical coding systems). Their work will include site visits to public and private health facilities and insurance providers, analysis of the existing procedure lists to map them against the available classification systems and facilitating a stakeholder workshop to reach consensus on the most appropriate systems for use in Rwanda.

❏ Technical assistance for establishing a Mutual Assistance Group (MAG) for health professionals

RHSS continued to lead the analysis work for the implementation of a mutual aid group (MAG) or saving group scheme (Tontine) for the health sector staff. This is a high priority for the Ministry of Health because it is seen as a mechanism to promote staff retention by offering employees access to credit at well below market rates. During this quarter, the team focused on preparation for the workshop to finalize the guiding documents required to set up the scheme: by-laws, communication products, and standard operating procedures (SOP) for managing savings and loans; and on assessing the information technology platform that is currently in use by a similar scheme implemented by the University of Rwanda, the “Caisse d’Entraide de Butare or CEB” to determine if it can be adapted for use by the MOH for the MAG.

Section 4: Collaboration, Learning and Adapting

During quarter three, the RHSS team worked closely through the USAID SCHS team to reach out to other implementing partners to promote collaboration and leverage support for a number of priority initiatives. The RHSS L&G team met on several occasions with the Community Health and Nutrition Project (CHAIN) team to discuss how to better engage district authorities to promote health, nutrition and WASH activities. The QI team worked closely with Maternal and Child Survival Program (MCSP/JHPIEGO) team to develop the primary health care standards that will be used in the design of the health center level accreditation system, while the M&E/Research/Data use team has developed a detailed plan for working together on rolling out district dashboards. The RHSS team has reviewed the work plan priorities for the remaining two quarters of the year with our technical counterparts at MOH, RBC and MINALOC, and will reach out to other implementing partners in the next quarter to work more closely on other initiatives including accreditation, technical support to the


CHW cooperatives, and data demand and use. Annex 5 provides details for specific areas where such collaboration has taken place during the quarter.

Section 5: Public Events Planned

The RHSS project will be working with the Ministry on the following public event related to our work:

● Launch of the MOH Mutual Assistance Group (MAG) by the Minister of Health: RHSS staff will help to prepare communications strategy and talking points to assist the MOH team with this launch. The MOH will become the first Rwandan Ministry to establish such a savings and loan scheme for all of its employees.

Section 6: Management and Administration

❏ USAID communication technical working group

In June 2017, the RHSS communication team participated in a technical working group which was hosted by USAID. During the detailed and practical session, the USAID Development and Outreach Communication Specialist discussed the essential pre- and post-production skills every photographer should acquire in order to produce high quality and impactful images.

❏ Communication coverage on Dissemination of CHW Cooperatives Evaluation Findings, Best practices and Training of Trainers (ToT) on Business Cases in South Province

During this quarter, the RHSS Health Finance team organized a training of trainer workshops at the decentralized level (Province and District) on business planning and implementation for IGAs. The team also disseminated findings from the assessment of CHW Cooperatives conducted last year. As part of these initiatives, the RHSS communication team provided coverage for these events in all four provinces and the City of Kigali. Photos and interviews with participants were collected for the project archives, as well as for future publications which are to be developed to raise awareness around the support that RHSS provides for CHWs.

❏ Communication support on JADF Open Day

The second phase of “Nk’Uwikorera”, a service delivery campaign by the Rwanda Governance Board, was launched in June 2017 and the ceremony was held in Gatsibo and Gasabo districts. The launch coincided with Gatsibo and Gasabo Joint Action Development Forum (JADF) Open Day, an exhibition of services, products and achievements by partners of the districts. The RHSS Communication team facilitated a duo of videographers and journalists for a documentary commissioned by the District authorities. Moreover, during the three days of the exhibition, an RHSS stand was installed with materials that explain RHSS district interventions.

❏ Project Management

Key highlights of project management activities during this quarter included:

▪ As part of MSH ongoing project management strengthening process, this past quarter, recruitment and hiring were completed for all remaining management and operations positions. Staffing changes included USAID approvals of RHSSA new Chief of Party (Alain Joyal) and Director of Operations and Finance (Dorothy Kiburi) who joined the project on April 25th and May 15th respectively. RHSSA new Accounting Manager (Placide Rutsintwarane) was hired and joined the project in May. At this time, all management and operations positions are staffed;

▪ With support of a staff from MSH Headquarter (Natalie Gaul), RHSS project organized a training session for its staff on operations and procurement regulations. This training was


carried out to further reinforce compliance with USAID and MSH regulations by project employees;

▪ In May, the newly assigned COP and Director of Finance and Administration led a detailed review of PY3 work plan remaining activities with program teams aimed at further rationalizing use of budget resources. The project finance team prepared for the internal and external audits planned to be conducted in succession during the next quarter.

▪ The project team started the FY18 planning process. Individual program teams met with key stakeholders to identify top priorities and the senior leadership prepared the project for the planning workshop that will be conducted early in the next quarter to produce the first draft of the PY4 work plan.

Please see Annex 2 for a comprehensive financial analysis of this quarter

❏ Short-Term Technical Assistance

During next quarter, the following short-term technical assistance visits are planned (all subject to review and approval by USAID).

No SOW Proposed TA Planned Dates

1 Internal Audit Joseph Ngando, MSH July 2017

2 Safe health design QI standards development Joanne Ashton August 2017

3 Project supervision visit Ken Heise, MSH August 2017


Annexes

Annex 1: Performance Monitoring Plan Indicators reportable this quarter

# Indicator Title Disaggregation

Target FY17

Achieved in FY17 Comments

Q1 Q2 Q3

Sub-Component 1 : IR 1 Institutionalized health systems thinking approaches and practices to strengthen structural and process attributes towards increased advocacy, leadership and stewardship

1 Number of staff/managers trained in leadership and management related skills (short term trainings/workshops and mentorship)

Gender 1996 630 ( (80+550)

No training conducted during Q3. 550 that had not been reported were added in the Q1 (165 were trained through CPD trainers on CPD programs, 385 leaders/managers from districts were trained on governance, management, planning and accountability of health system strengthening activities.

Sub-Component 3A : IR 3A Increased revenue mobilized by the health sector through domestic and private sector sources to achieve sustainability

2 Number of staff/managers trained in health financing related skills

Gender 841 168 254 - 105 RSSB end-users were trained, including Branch managers, CBHI Officers from all districts, CBHI Verification officers and RSSB central level teams. - A team of 119 trainers was trained in CHWs business planning and implementation. - 30 staff from five hospitals were mentored on IFMS implementation and compliance with PFM guidelines. - 10 staff from BPR were trained on DCA implementation for effective loan provision in the health sector


Sub-Component 3B : IR 3B Improved and expanded quality health services through more effective and efficient use of existing resources in the health system, achieving better value for money

3 Number of staff/managers trained in quality improvement (QI), Infection Prevention and Control (IPC), and accreditation surveys and facilitation/supervision

Gender 202 160 68 68 staff from eight hospitals were mentored and facilitated on Accreditation standards compliance.

Sub-Component 3 : IR 4 Improved M&E, health systems research agenda, learning, and knowledge-based practices

4 Number of staff/managers trained in MIS, data management and use related skills

Gender 327 - 86 - Conducted orientation training workshop for 70 staff (RBC, MOH, MCSP) involved in conducting the ISS/DQA in all districts. - Conducted a workshop training on data use, display and interpretation of spatial data and basic principles in map-making for 16 central level staff.

5 Percent of health facilities and districts that have created dynamic data dashboards for the key indicators in DHIS-2

- 70 74 80 88 PTAs continued mentorship in district on the creation of dynamic dashboards.


Pictured: A BPR loan officer stands with the MBC leadership team and at the main entrance of their new

hospital.

“During the Labor Day celebration of

2014, we asked ourselves how we

could use our skills to contribute to

the wellbeing of Rwandans for years

to come, and it was on that day that

we decided to begin a savings fund

with the hope of opening a full service

hospital in the center of Kigali” said

Jean Baptiste Impamugamahanga –

President of MBC

Annex 3: Success Story

Increasing access to finance for private healthcare businesses in Rwanda The private health sector in Rwanda is underfunded. Financial institutions are often reluctant to lend to healthcare businesses because of their perceived high risk concerns about collateral. Moreover, financial institutions have little experience in providing tailored financing solutions to the health sector. These limitations, in practice, mean that the private health sector struggles to add new or expand existing services or make quality improvements.

To address these limitations, in 2016 USAID/Rwanda structured a Development Credit Authority (DCA) Portfolio Guarantee with Banque Populaire du Rwanda (BPR). The DCA Guarantee shares risk with the bank and incentivizes the bank to lend to private providers in health, water treatment,

purification, and sanitation services. The private sector reaps the benefit of easy to access capital to support services (e.g., working capital for holding inventory or support operations)

and expand services (e.g., investing in facilities or equipment).

Through the Rwanda Health Systems Strengthening (RHSS) project, USAID is providing technical assistance to Banque Populaire du Rwanda (BPR) to support the effective utilization of the DCA loan guarantee and expand health and WASH services through the private sector.

In June 2017, RHSS designed and delivered training to BPR’s credit and risk management staff in operationalizing the guarantee and in lending to the health sector. RHSS also reviewed BPR’s health sector loan applications in order to ensure compliance with the terms of the DCA guarantee agreement and to provide support in credit analysis. This effort increased BPR’s ability to build its health sector portfolio and opened up funding opportunities for private health sector projects, including a recently-approved loan to the Medical Business Company (MBC).

MBC is a new healthcare business whose owners/investors comprise 476 doctors and nurses. With the backing of the DCA guarantee, MBC was approved for a loan of over USD 180,000 which, paired with their own savings, has enabled them to invest in a comprehensive transformation of a former hotel into a new private hospital, located in Kigali. MBC Hospital will be a 70-bed, acute care facility that will serve patients for a broad range of health issues and will employ 62 staff including specialists in gynecology, pediatrics, and surgery. The facility, which includes both maternal and neonatal wards, will increase access to maternal & child health services within the densely populated Kigali area.

Increasing health care access and financing avenues for healthcare businesses is one of the ways RHSS is supporting the overall vision of the Rwandan Government to enhance the sustainability of the health system.


Annex 4: RHSS Results Framework


Annex 5: Areas of RHSS collaboration with other projects, donors, and agencies

No. Collaboration area/Event

Partner(s) RHSS Teams Content/Purpose Results of these collaborations

1. Technical working groups and Joint Health Sector Review meetings

Planning, Health Financing and Information System (PHFIS), HRH and Research and Knowledge Management TWG members and Health sector stakeholders for JHSR

All components teams

Preparation of meeting (agenda, invitations), reporting and follow up of recommendations and joint action plans

Working documents shared ahead of meeting for DPs inputs and improved quality policy dialogue and implementation of joint interventions between MOH and DPs

2. Continuing technical support for JADF in districts

Local partners, NGOs, JADF staff

RHSS technical team

Support to the formation of JADF Social Commissions and Health sub-commissions gathering health stakeholders at district level, including NGOs and civil society organizations (CSOs)

11/30 districts now have active and productive JADF Health sub-commissions where district health integrated action plans are implemented, with coordinated interventions by health partners

3 Advocacy for recruitment of missing DHU staff in all districts

Rwanda Association of Local Government Authorities (RALGA)

L&G team Intensive communication by RALGA with district authorities to speed up recruitment of many missing DHU staff

During the past quarter, the total number of vacant positions has been reduced by half (from 32 to 14 positions) and the remaining should be filled in the next quarter.

4 Provincial TOT workshops for CHW cooperatives strengthening

CHAIN implementing partners, District cooperative agents, CHW coordinators

Health Financing team

4 TOT workshops for various district agents supporting CHW cooperatives to strengthen their financial management and governance

Increased awareness and commitment by district agents to support the CHW cooperatives for better financial and institutional viability

5 Coordination meeting with SCHS projects

SCHS members (MCSP, Supply Chain management, IRS)

RHSS Team leaders

Meeting with representatives of SCHS projects to agree on enhanced collaboration between USAID funded health projects

Several collaboration mechanisms have been agreed upon, particularly with MCSP for DHMT support, Quality improvement and Information system joint interventions

6 Development of Health Sector Strategic Plan (HSSP4)

Health Sector Working Group (HSWG) Core team and other

All components teams

Involvement in organization and participation in meetings and workshops for

Strong participation of DPs as well as MOH and other GOR representatives in the development of first draft of


members identification of key strategies, interventions and indicators to be included in HSSP4

HSSP4 (to be submitted to MOH and MINECOFIN by July 15th)

7 Support for CBHI information systems

Access to Finance Rwanda (AFR)

M&E/Research/Data Use

Met with Access to Finance Rwanda Chief of Party and technical staff to discuss coordination of technical assistance for CBHI claims management system

AFR has been asked to finance the same task that RHSS completed last November - develop requirements for an electronic claims management system. We met with AFR and JEMBI staff to share the outputs of our work and agree on a coordinated approach to supporting RSSB.

rwanda health systems strengthening activity: quarterly

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