This activity relates to OHPS (7249) and HVSI (8175).

This activity is a public health evaluation, with methods described in further detail in an attached PHE backsheet. The overall goal of this evaluation is to improve palliative care services by determining what model of case management is best adapted to the Rwandan context. The USG has funded four distinct models of case management through Columbia, CRS, CARE, and IntraHealth Capacity in FY 2004, FY 2005 and FY 2006 to advance EP goals of creating a continuum of care. However, it is unclear which of these models will be both affordable and viable as an option for the national program. Within the Rwandan context, case management appears to be viewed as an initiative that is unsustainable in a resource-constrained setting, but no data exists to support this hypothesis. However, literature from other countries suggests that a case management model can both advance positive health outcomes for PLWHAs and be affordable. Consequently, this evaluation is necessary to advance data driven decisions for the USG Rwanda team and to advance the EP palliative care strategy on establishing a strong continuum of care from the point of diagnosis. The evaluation will assess the value added of a case management system in the care and treatment of PLWHAs using a prospective study at a defined number of sites with case management that will be matched with similar sites without case management. The evaluation will compare basic health outcomes and unmet needs between all sites and calculate per patient costs at sites where a case management system exists. In addition, as part of this evaluation, different models of case management will be costed out on a per patient basis. Overall, this activity will improve palliative care services and the direct output will be documentation on the effectiveness of case management in producing positive health outcomes and reducing unmet needs among HIV-positive persons.

This activity reflects the ideas presented in the Rwanda EP five-year strategy and the National Prevention Plan by advancing the quality of HIV services and strengthening the continuum of care for PLWHAs.

These activities relate to OHPS (7247).

There are three components to this activity with the goal to strengthen both organizational and human resource capacity in Rwanda and to ensure that the NUR/SPH will become a self-sustaining institution that can limit its reliance on external funding and support. One component is a continuation of a FY 2006 activity while the other two components are new.

In the first component, the EP will continue to support the Executive MPH program through Tulane at the NUR/SPH and, in FY 2007, expand the number of public health practitioners, especially those working at decentralized health facilities. The two-year Executive MPH program targets GOR staff and individuals who are actively involved in EP-supported HIV services implementation. The MPH program provides intensive, graduate-level training that emphasizes applied skills through a combination of classroom participation and field assignments, focusing on strategic, data driven decision making. In FY 2006, ten MPH candidates are completing four modules in year one of the program. In FY 2007, these ten will complete their degrees with support from the EP. In addition to the ten participants from FY 2006, an additional ten participants will begin the Executive MPH program in FY 2007. The anticipated funding level of this activity is $400,000.

In the second component, the EP will advance the quality of palliative care by training social workers. As more people are living healthily on ART, Rwanda has an increasing need for HIV service providers to be trained in client-centered social work concepts. The GOR TWG on palliative care identified social work training as a priority for FY 2007 since it will strengthen the continuum of care and services for PLWHA. Given its human capacity development experience with the RHPIF and its work at the NUR/SPH, Tulane is well positioned to build the palliative care capacity of service providers and develop a social work certificate training program.

In collaboration with NUR/SPH faculty, Tulane will adapt two graduate level courses from its School of Social Work. The courses will target 20 students who are graduates from the NUR program in social work or are from the Free University of Kigali's program in social sciences. The certificate program will provide intensive, in-class instruction, hands-on experience and practical experience with an emphasis on developing counseling skills and techniques.

In addition, Tulane will adapt social work modules and convert them into a distance education format that can be accessed on the NUR website. The modules will also be translated into both French and English for greater accessibility. This activity will contribute to EP goals by strengthening Rwandans who are essential for linking PLWHAs between the clinical and community level. The direct output of these two activities is the training of 20 social workers. This second activity is budgeted at $262,000.

For the third component, the EP will promote the sustainability of NUR/SPH. As the only public health program in Rwanda, the NUR/SPH serves a critical role in building the public health workforce that addresses HIV treatment, care and services. Currently, the NUR, like most universities worldwide, requires that all of its teachers hold doctoral degrees. However, after the 1994 genocide, Rwanda has an acute shortage of both trained service providers and academics. As a consequence, the EP will bolster its support in public health research, training and practice.

The GOR recently shifted the emphasis of EP support to pre-service training from in-service training. As a result, the EP will support five students from NUR/SPH to complete their doctorate degrees. These five graduate students, who are close to finishing their PhD, currently serve as faculty but are not allowed to teach because they do not hold doctoral degrees. This EP support in long-term training would allow these individuals to travel to Tulane University and defend their dissertation, which is the final step to result in their doctorate degrees. In accordance with EP guidelines and current MOH policies on educational training and human capacity development, these individuals will commit to working at NUR/SPH for three or more years of time in exchange for this support. This strategy will build sustainability at NUR/SPH because these individuals will assume full teaching responsibilities and significantly reduce both EP funding and Tulane's long-term TA to NUR/SPH. Over the next few years, the NUR/SPH will graduate additional

public health academics with doctorate degrees with the goal of becoming self-sustaining. The direct output of this activity is that five individuals will receive their terminal degrees, and the NUR will be staffed with locally qualified public health academics simultaneously advancing the EP human resources capacity development and organizational capacity development strategies. This third activity would be budgeted at $150,000.

These activities reflect the ideas presented in the Rwanda EP five-year strategy and support the GOR's national strategy of human resources and organizational capacity building.