Facility supervision by the District Health Teams (DHTs) in Rwanda Track1 Meeting
description
Transcript of Facility supervision by the District Health Teams (DHTs) in Rwanda Track1 Meeting
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.
2
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?
13
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