GOAL: The ultimate long-term goal of the TRACnet project is to improve quality of care through effective and efficient use of health data by health care providers, program managers and political leaders in Rwanda under the PEPFAR program over five years of implementation.

LINKS TO PARTNERSHIP FRAMEWORK: The overall goal and each of the specific objectives and activities of this project will contribute to the accomplishment to Partnership Framework Goals in Strategic Information. 1. Working with the Government of Rwanda, Voxiva's efforts to Improve data quality in TRACNet will extend automated data quality checks for new modules, support for a data audit and expand the data quality tool developed in FY 2009 with ICAP in order to support the development and implementation of data quality assurance mechanisms. 2. Activities to promote data use will focus on the use of data for monitoring, evaluation, supervision and contribute to the national plan for the promotion of data use. In FY 2010, data use activities will focus on modules introduced in FY 2009, specifically TB and IDSR with courses held by the School of Public Health to build the capacity of health managers to analyze and use these data to enhance program management and response. It should be noted that TRACnet users will be able to leverage GOR and USG efforts to improve IT infrastructure at MOH, TRAC Plus, CNLS and health facilities, making increasing use of more robust infrastructure and connectivity to increase a focus on data analysis and

use, especially at the facility level. 3. Voxiva will also work with TRAC Plus to maintain and upgrade TRACnet, adding a malaria module in FY 2010 and contributing to the implementation of the National e-Health strategy by assuring that data collected by new modules can be exported to the performance-based financing system, integrating with IQ charts and continuing to implement the national and international standards that are adopted by the Ministry of Health. 4. Through all activities, Voxiva will seek to build local human capacity to sustain and expand TRACnet; developing a program of mentorship and in-service and pre-service training based in the School of Public Health and other local institutions, assuring that Rwanda can sustain and build on TRACnet to meet the ongoing needs of the health sector.

GEOGRAPHIC COVERAGE: TRACnet is national in scope. During FY 2010, data will be collected from and feedback provided to all health facilities across the country. It is anticipated that by the end of 2010, there will be more than 2000 trained users routinely accessing the system to monitor and report on HIV/AIDS, TB and Integrated Disease Surveillance and Response (IDSR) Programs.

CONTRIBUTIONS TO HEALTH SYSTEMS STRENGTHENING: TRACnet contributes to strengthening of health systems in several ways: 1. The project supports health systems strengthening in a variety of ways: building a national information system for evidence-based decision making in key areas; human resource capacity building for HIS, use of NIT to improve health care delivery and health data management. 2. The data collected will be availed for enhanced monitoring and supervision of health programs, facilitating the identification of under-performing sites, analysis of performance issues and feedback to sites. 3. Standard reports and dashboards will foster evidence-based management and decision-making at all levels. 4. Training of district level managers will strengthen a key level in Rwanda's decentralized health system.

CROSS-CUTTING PROGRAMS/KEY ISSUES: Human resource capacity building is a critical dimension of the TRACnet program in FY 2010, with the implementation of in-service training programs in the maintenance and use of TRACnet directed at national and district level officials and data managers and the establishment of pre-service training at the School of Public Health. As a complementary activity, Voxiva will continue to work with the GOR to build capacity in the local private sector.

TRACnet will also expand its health-related wraparounds to provide more comprehensive program support by expanding TRACnet to incorporate malaria reporting in FY 2010.

COST EFFICIENCY: In FY 2010, three new modules - IDSR, TB and Malaria - will be making use of the same platform, infrastructure and cost basis of TRACnet, increasing the value and cost-efficiency of the investment in developing the base system.

MONITORING AND EVALUATION: FY 2010 activities and work plan may well be modified to reflect the findings of the external evaluation planned for second quarter in FY 2009. The Technical Support Unit will continue to monitor system usage (number of users, power users, sessions); human capacity development (trainees, skill development); data use (number and distribution of standard reports); and data quality (timeliness and completeness, data audit findings).

In FY 2010, Voxiva will work in support of TRAC Plus and contribute to three areas of Strategic Information: HMIS, Monitoring and Evaluation, and disease surveillance, complementing TRAC Plus and Ministry of Health activities under this program area.

The collaborative TRACnet program will pursue an active program with the following objectives: • Improving data quality: Led by sub-grantee ICAP Columbia, the TRACnet program will support an annual data audit, incorporate automated data quality checks in new modules, and work to achieve >90% completeness and timeliness for the reporting of VCT/PMTCT, TB and IDSR data by the end of FY 2010.

TRAC Plus will be supported to provide supervision to enforce the implementation of standard operating procedures (SOP) and Data Quality Assurance and Improvement tools. Maintenance and updating the master registries (users, health and administrative hierarchies) will continue as an ongoing activity of the Technical Support Unit. • Promoting data use at health facilities, districts, at national level, and by implementing partners. Users will be trained to create and transmit automated feedback and standard reports for all levels (facility, district, central) for all modules in the system. District data use workshops will be held by the School of Public Health, and the effectiveness of health programs associated with TRACnet will be documented. • Maintaining and upgrading TRACnet: Within the limits of available resources, Voxiva will continue to maintain and upgrade the TRACnet system in line with the needs and priorities of the Government of Rwanda (GOR) and in support of the TRACnet Sustainability Strategy. The implementation of the 5-year technology road map will continue, enhancing support for HMIS and integrating with priority areas of the national e-Health strategy, with the following as examples of the kind of activities to be supported: Integration of TRACnet with two systems will be operational: PBF (exchanging relevant reports) and OpenMRS (submission of aggregate HIV data). The integration with PBF will be upgraded from a semi- automatic process of reports interchange to automated data exchange using web services. The design of the interface for the integration with IQChart will be developed and implemented in sites where IQChart is used. The requirements for alignment with national ID standards will be specified in collaboration with the National ID Program and under the guidance of the National e-Health Task Force. In subsequent COPs, integration will be carried out to support patient authentication for patient-level interventions. The plan for integration with the National Data Warehouse will be developed with a focus on needs assessment for the interoperability and definition of data interchange standards and interfaces. High level requirements for integration with GESIS will be collected, in line with the plan for strengthening this system. By end of FY 2010, TRACnet will share the same facility and administrative hierarchies and codes with the Community Information System (SIScom). • Building local human capacity in Rwanda's institutions to collect, manage and use good quality data and to build on and maintain TRACnet to meet the ongoing strategic information needs of the health sector. In FY 2010, Voxiva will undertake SI activities that support specific objectives related to capacity building. During FY 2010, TRAC Plus staff members are expected to be able to handle advanced TRACnet system implementation activities such as development and configuration, business analysis, and infrastructure maintenance. Voxiva will provide the necessary technical assistance for this purpose, while making every effort to ensure that all technical assistance is designed with capacity building components such as a mentoring activity, workshops or some other type of training. In addition, the School of Public Health will build on its successful data analysis and use initiatives focused on hospital officials and district data managers and offer ongoing workshops in analysis and use of Strategic Information.

HMIS

In its first years, TRACnet was operated somewhat independently from the national HMIS. Given that TRACnet was initially introduced in a small number of health facilities offering ART and was only used to collect data for ART indicators that was a justifiable approach. However, it was always clear for the GOR that TRACnet would merge over time with other systems constituting the national HMIS. As the HIV/AIDS program has grown, so has TRACnet to the point where it has achieved a national footprint with coverage of all districts and an active reporting currently from more than half of health facilities that offer ART. In FY 2009, with the national implementation of PMTCT/VCT, virtually all health facilities will be actively reporting into TRACnet. In FY 2009, TRACnet is expected to expand to incorporate Integrated Disease Surveillance and Response (IDSR). In FY 2010, TB and Malaria programs will be added. With this growth, even if harmonization and integration of information systems were not a national policy, it would be imperative to integrate TRACnet with other HMIS systems.

In FY 2009, a technology roadmap is being prepared that will lay out the technical integration of TRACnet and HMIS. Also, in FY 2010, Rwanda is expected to be connected to the submarine high-speed internet cables and will have completed the fiber optic ring linking all districts. As USG and other support for health infrastructure is expanding, all district hospitals and many health centers will enjoy high speed internet connectivity across the wireless communications infrastructure. Higher bandwidths, and more access options and packages for end users will reduce costs and allow many more health officials to use a variety of analytic and other tools available in TRACnet. Therefore, we expect in FY 2010 to be able to put increasing emphasis on on-line training tools and support for power users across the country, while continuing workshops for districts led by the SPH with increasing participation from facility-level users.

Another driver for integration and harmonization is Rwanda's vision for health information and related technologies. Rwanda has articulated a national e-Health strategy that lays out a framework to achieve a national, integrated architecture that serves its citizens and strengthens the health care system. Several advances are underway including a National ID system; the development of an enterprise architecture based on an approach adopted by the Health Metrics Network and comprising key systems such as the national ID infrastructure; centralized data warehouse systems; facility-based HMIS systems; community- based information systems; laboratory and pharmaceutical information systems; hospital systems; financial incentive systems, etc. The facility-based electronic medical record system (EMR) will connect through an integration architecture that can work on multiple channels (Web/internet, phone, mobile phone, PC clients and hand-held smart phones) and become accessible to all participating and authorized systems. By this timeframe, each citizen could access health services anywhere in the country where information about them is readily obtainable by authorized health professionals and made available to systems that need to use it in order to advance service quality.

TRACnet already incorporates several standards likely to be adopted by Rwanda. The first is data

standards. At the moment, Rwanda's health IT systems are focused on key program areas and offer limited but growing support for common data registries, vocabularies and standards. TRACnet will support a core set of data vocabularies and standards, and an extended, program specific set geared towards achieving a target vision of a fully interconnected ecosystem of health IT functionalities. As of the end of FY 2010, the following will be incorporated in TRACnet: disease codes and listing; national ID, shared facility registry and geographic references.

TRACnet will be integrated with other systems. In FY 2009, basic integration with OpenMRS will be available and will allow the exchange of aggregate data and reduce the burden of reporting from sites using this electronic medical record. In FY 2010, we will expand integration with another system - such as IQChart - following the priorities established by CDC and GOR.

Monitoring and Evaluation (M&E) TRACnet will continue to be used to collect the core facility-based data for TRAC Plus for the monitoring and evaluation of Rwanda's national HIV/AIDS. In FY 2009, the TRACnet Support Unit is forging closer relationships with the M&E group in TRAC Plus. This will continue in FY 2010 with a concerted training and support effort so that the M&E group can make full use of the standard analytic tools in TRACnet and prepare its own reports and charts.

Disease Surveillance In FY 2010, the roll-out of the electronic Integrated Disease Surveillance and Response (eIDSR) system will be available for all health facilities, providing nationwide electronic surveillance and response capacity. Building on the pre-existing paper system, this will allow Rwanda to leapfrog many of the known problems of implementing and maintaining paper-based IDSR systems and rapidly introduce a number of specific tools and benefits in FY 2010, for example: • automated tools to enhance data quality (e.g. validation checks, standardized disease list and access to online case definitions via Web and IVR, monitoring timeliness and completeness of weekly reports, reminders for report submission); • opportunity to review and confirm reports and automated confirmation of report submission; • automated real time submission and notification of immediately notifiable diseases and other events (such as a maternal death); • support for supervision and feedback to submitting facility; • automated aggregation and analytic tools to reduce burden, increase data quality, and facilitate analysis at all levels; and • significantly reduced cost.

CDC and TRAC Plus may also wish to consider incorporation in FY 2010 of algorithms that Voxiva has

implemented in other settings where they have been proven to be extremely effective for the early detection of disease (for example, CUSUM, X-Bar, and Moving Range). As IDSR moves into widespread use in FY 2010, data quality, analysis and use of IDSR will become a major focus of the project team with the objective of achieving and maintaining > 95% reporting rates for weekly reporting. The School of Public Health will support IDSR in-service training and incorporate pre-service training on this module into its program in epidemiology.

Other By the end of FY 2010, TRACnet will be supporting routine data collection from every health facility in Rwanda and provide the tools to store and analyze data on all aspects of the HIV/AIDS, TB and malaria programs and IDSR. As recommended in the Notice of Award, in order to achieve these ambitious goals, Voxiva will provide the increasing level of effort needed in three key areas: • Increased participation of local partners (SPH and KIST) in building local capacity to sustain TRACnet. This shall include international technical assistance and an internship program with such topics as health informatics, system administration, business analysis, configuration and basic development as well as other initiatives to implement the sustainability strategy and human capacity development plan completed in FY 2009. Voxiva will specifically collaborate with KIST to integrate into existing KIST training curricula for the development and maintenance of the TRACnet technology. • Implementation of the technology roadmap; incorporation of standards and integration/ harmonization of systems in keeping with the national e-Health strategy; and other enhancements prioritized in the roadmap. • Increased support needed for national implementation of four program areas cutting across all our interventions to assure data quality, data analysis and use, and decentralization of ongoing support to districts and national programs.