The Ministry of Health (MOH) vision of the Rwandan health sector is to continually improve the health of the people of Rwanda, through coordinated interventions by all stakeholders at all levels, thereby enhancing the general well-being of the population and contributing to the reduction of poverty. Ministry of Health is by far the largest provider of health services through its network of 416 health centers, 40 district hospitals and 4 national referral hospitals. In addition, it is responsible for coordinating services provided by NGOs and faith based organizations throughout the country.

The main responsibilities of the Ministry of Health are to develop policies, strategies and guidelines. It provides supervision to the district hospitals and is in charge of managing all human and financial resources for health in Rwanda. In FY 2009 with PEPFAR support, MOH/HIV integration task force is supporting the district level capacity building in HIV Prevention, care and treatment. This support includes support for district level in planning, implementation, coordination, supervision and district performance improvement meetings. In collaboration with TRAC Plus, MOH staff undertakes formative supervisory supervision related to HIV prevention, care and treatment integration activities within each district at least twice per year. MOH has enhanced information systems and a national web-based data warehouse platform to facilitate data analysis and information sharing. MOH has trained 302 data managers at the district level. In addition MOH has developed a community health information system through the development and dissemination of the reporting forms and registers for community health workers (CHW). MOH has rolled-out the CHW Information System with training of trainers at the health sector level and assisting with trainings by CHWs in their catchment areas.

FY 2010, MOH/UPDC will continue to support the district level capacity building in HIV prevention, care and treatment. This includes support for district level in planning, implementation, coordination, supervision and district performance improvement meetings. It will also support the HIV services integration into district health programs, as well as improved linkages between HIV programs. MOH in collaboration with USG implementing partners and Global fund, will continue to support the expansion of quality of HIV services to more decentralized sites of the health care system by providing continued mentoring to clinical staff. In addition, in collaboration with TRAC Plus, and PEPFAR implementing partners as well as Global Fund, MOH will undertake regular formative supervision to the district hospitals that in turn, will provide assistance to health centers in their catchment area. A supervision protocol and tools for district managers to improve both service delivery and data use for decision making at the district and health facility levels have been developed and will be implemented in FY 2010.

The Ministry of Health will continue to strengthen the capacity of district level managers to facilitate the search for the root causes of unsatisfactory performance of health facilities. In coordination with TRAC Plus the M&E Task Force of MOH will revitalize the national disease surveillance system to timely and completely reporting across the health information system. In addition MOH will develop a Standard Operating Procedure (SOP) for data management and feedback to provide clear guidance on data management at all levels of the health system. All data managers and information officers at district level will be trained in data management. A total of 922 will be trained with PEPFAR financial support.

During the course of PEPFAR I, health facilities were provided with the physical requirements to provide HIV services of -high quality. The majority of health facilities have been rehabilitated and provided with energy. A national strategy has been developed towards the Economic and Development Poverty Reduction Strategy goal of providing all health facilities with a source of power by 2012. In FY 2010 the remaining 45 facilities will be provided with a source of power and 10health centers and 8 district hospitals will be rehabilitated in order fulfill the TB infection control requirement.

Through PEPFAR equipment has been procured for laboratories and health facilities to allow HIV service delivery. In FY 2010, through this award, support for a sustainable maintenance system will be provided. At central level this will include; performance incentives against clear objectives for maintenance unit staff; training of six central level maintenance staff in biomedical engineering, and technical assistance for

the maintenance unit to provide training for technicians, develop contracts with the private sector and provide robust procedures for the procurement of spare parts and tools for maintenance and repair of medical and laboratory equipment.

Environmental Health Desk (EHD) of the Ministry of Health in collaboration with MMIS/JSI will develop the Terms of Reference in areas that require capacity building. EHD will identify areas that require capacity building and organize the training of healthcare workers and waste handlers on injection safety and healthcare wastes. Incinerator operators and their supervisors will also be trained on the use and maintenance of incinerators. A strategic plan for prevention of infections will be developed to enable healthcare workers and waste handlers to protect themselves against HIV and Hepatitis B. EHD will identify all of the required materials, consumables and equipment for injection safety and healthcare waste management and link them to the procurement organization SCMS which will in turn ensure the procurement of needed items in sufficient quantities and of the right quality. EHD in the Ministry of Health in collaboration with MMIS/JSI and key partners will implement the plan of constructing the multipurpose waste pits and installation of appropriate incinerators for the disposal of medical waste. Guidelines and specifications of waste pits and incinerators will be provided in collaboration with EHD, World Health Organization and John Snow, Inc. EHD will also organize training workshops in all Sectors for Community Health Workers and equip them with knowledge that will enable them to sensitize communities on injection safety and medical waste best practices. Monitoring and evaluation will be carried out to ensure smooth and successful implementation of activities as well as determining areas that need urgent problem solving and advice. MOH in collaboration with partners will define the indicators to measure performance.

USG will continue to support the laboratory by assisting the MOH to build human capacity for histopathology for the diagnosis of extra pulmonary tuberculosis and the diagnosis of cancers in HIV patients. It will support long term capacity needed in the laboratory of CHUK. Indeed, CHUK laboratory plan to organize training for one Microbiologist and one Histopathologist with a background of Medical Doctor and one technician for Histopathology. In addition, USG will support the purchase of equipment and reagents for the laboratory and the training of six physicians in anatomical pathology. Two physicians will be sent abroad for training in pathology while two physicians located at CHUK and two located at CHUB will be trained in country.

FY 2010 starts the first year of transition of Track 1.0 clinical partners' activities; therefore ICAP-CU and AIDS Relief will transition respectively 12 and12 HIV care and treatment sites to Ministry of Health (MOH). In FY 2010, MOH will insure continuum of provision of a comprehensive package of PMCT, CT, adult and pediatric care and treatment, TB/HIV services at 24 transitioned sites. Transition of the management and oversight of the activities formerly supported through the Track 1.0 clinical partners will require additional

financial management and reporting responsibilities. Therefore, during FY 2010 a second technical assistance position will be provided to ensure the necessary skills and experiences are available to fulfill these responsibilities.

At PMTCT sites, support groups of HIV-positive women will be strengthened in collaboration with community health workers through the organization of monthly meetings and home visits as needed. Early infant diagnosis (EID) will be strengthened by reducing the laboratory results turn-around time and linking identified HIV-positive infants to care and treatment services. EID will continue to be offered at six weeks of age and at any other ages for symptomatic infants less than 18 months post natal according to the national algorithm. MOH will continue support to the district health teams to ensure that samples collected at the sites are transferred efficiently to the processing lab at the National Reference Laboratory in Kigali.

The prevention of unintended pregnancy amongst HIV-positive women is one of the most cost-effective means of preventing mother to child transmission. In FY 2010, MOH will also support the revision, printing and dissemination of FP/HIV integration guidelines and tools. Moreover MOH will assist district team in training health providers on FP/HIV integration. In collaboration with national police and clinical partners, MOH will coordinate the national training of trainers on SGBV and roll-out SGBV in HIV programs considering the lessons learned from one year implementation program of the SGBV pilot phase.

To address the need to expand diagnosis of HIV in the pediatric population, MOH will continue to strengthen testing for targeted pediatric populations within the catchment area of its existing sites. Using each HIV adult patient enrolled in care and treatment as an index case, MOH will offer HIV-testing for their partners and children and enrolls the infected family members into care and treatment services.

In order to ensure continuum of HIV care and treatment, MOH through the Community Health desk will continue to support 24 health facilities in HIV patient follow-up, and organizing referrals to HIV care and treatment services for HIV patients. MOH will work with elected community health workers to develop effective referral systems between clinical care providers and psycho-social and livelihood support services, through the use of patient routing slips for referrals and counter referrals from community to facilities and vice versa. MOH will support Health facilities in assessing individual PLWHA needs, organize monthly clinic-wide case management meetings to minimize lost of follow up of patients in care and treatment and provide direct oversight of community health workers. Depending on the need of individuals and families, health facilities will refer PLWHA adherence counseling, stigma reducing activities, OVC supporting activities, legal support services, community-based pain management and end- of-life care in line with national palliative care guidelines. In FY 2010, MOH will work with ICAP and

Ndera Neuropsychiatric Hospital, TRAC Plus and the Mental Health unit to scale up mental health and HIV integration services to the 24 transitioned sites to MOH.

With the leadership of PBF unit within Ministry of Health and in collaboration with ICAP and AIDS Relief, MOH will continue to support the financing based on site performance in improving key national HIV services performance and quality indicators.

This a continuing activity under a new mechanism

FY 2010 is the first year of transition of Track 1.0 partners' activities. Under the transition frame work, ICAP and AIDS Relief will transition 12 and 11 HIV care and treatment sites respectively, to Ministry of Health (MOH). In FY 2010, MOH will ensure the continuum of a comprehensive package of HIV care and support services to patients at the 23 transitioned sites. The package of services includes: clinical staging and baseline CD4 count for all patients; follow-up CD4 every six months; management of OIs and other HIV-related illnesses; OI diagnosis and treatment; routine provision of CTX prophylaxis for all eligible adults based on national guidelines; prevention with positive intervention; basic nutritional counseling and support; positive living and risk reduction counseling; pain and symptom management; and end-of-life care. In addition, MOH will continue to provide psychosocial counseling and referrals for HIV-positive female victims of domestic violence. To ensure comprehensive services across a continuum, MOH, through a partnership with community health workers, will refer patients enrolled in care to community-based services based on their individual need. Such services may include adherence counseling, spiritual support, stigma-reducing activities, OVC support, IGA activities, and HBC services for end-of-life care.

Through SCMS, MOH will ensure the provision of OIs drugs, CD4 tests and other commodities and laboratory supplies for clinical monitoring of patients on care. Coordination with SCMS will ensure that sites have reliable forecasting and stock management systems and will provide accurate reporting to SCMS and CAMERWA on needed commodities for adult HIV care and support.

In FY 2010 MOH will emphasize on the quality of care, the continuum of care through effective linkages and referrals, and sustainability of services through PBF. Strengthened nutritional services through training and provision of nutritional care will include counseling, nutritional assessments using anthropometric indicators, and management of malnutrition through provision of micronutrient and multivitamin supplements, as well as links to CRS food support for clinically eligible PLWHA in line with national nutrition guidelines. MOH will also, in collaboration with GFATM and PMI, support referrals for all PLWHA and their families, particularly children under 5 years old and pregnant women, for malaria prevention services, including provision of LLINs.. MOH will also provide referrals for PLWHA and their families to community-service providers for distribution of water purification kits and health education on hygiene to reduce the incidence of diarrheal diseases. In addition, family planning education, counseling and methods will be provided to PLWHA and their spouses. Strengthened psychological support services for PLWHA at clinic and community levels will be done through expanded TRAC training in psychological support for all health facilities and community-based providers, including GBV counseling, positive living, counseling on Prevention for Positives, and follow up of discordant couples. Moreover, MOH in collaboration with ICAP will support the integration of mental health and HIV services at all MOH supported district hospitals. Health providers will be trained in mental health integration and roll out of mental health screening tools to all sites.

In FY08, MOH initiated a new community health policy which calls for the election of male and female leaders for every 100 households to deliver and lead community health activities. These community health workers (CHWs) will be organized in cooperatives motivated through community PBF, and reimbursements based on the number of patients they assist and quality of services provided. MOH will support facilities to train, equip, and supervise community health leads.

In order to ensure a continuum of HIV care and treatment, MOH, through the Community Health desk, will continue to support health facilities in HIV patient follow-up, and organizing referrals to care services for HIV patients. MOH will work with elected CHWs to develop effective referral systems between clinical care providers and psycho-social and livelihood support services, through the use of patient routing slips for referrals and counter referrals from community to facilities and vice versa. MOH will support health facilities in assessing individual PLWHA needs, organize monthly clinic-wide case management meetings to minimize lost of follow up, and provide direct oversight of CHWs. Depending on the need of individuals and families, health facilities will refer PLWHA to adherence counseling, stigma reducing activities, OVC supporting activities, legal support services, community-based pain management and end-of-life care, in line with national palliative care guidelines.

In collaboration with the Population Council, the National Police and USG clinical partners, the MOH- MCH unit piloted the Sexual Gender Based Violence Initiative at care and treatment sites in FY 2009. The pilot phase allowed the implementation of an SGBV client assessment tool and newly developed HIV/SGBV integration guidelines, as well as the documentation of the lessons learnt to guide the scale up plan for subsequent years. In FY 2010, MOH, in collaboration with TRAC Plus, the National Police and clinical partners will coordinate the scale up of the HIV/SGVB initiative at all district hospitals. These efforts will include developing the capacity of health care providers in SGBV client management as well as the strengthening of SGBV M&E systems.

The MOH will continue to strengthen and assume more oversight of output based financing for PBF, which has been a major component of the Rwandan strategy for ensuring long-term sustainability and maximizing performance and quality of services. With the leadership of MOH's PBF unit, the MOH will continue to support financing based on site performance as a means of improving national HIV performance and quality indicators. Lessons learned during the transition of Track 1.0 activities in FY 2010 will be used to improve the implementation of the Partnership Framework.

None

In FY 2010, starts the first year of transition of TRAC1.0 partners' activities; therefore ICAP-CU and AIDS Relief will transition respectively 12 and 11 HCT sites to Ministry of Health (MOH).

During FY 2010, MOH will insure continuity of counseling and testing service at 23 transitioned sites. MOH will provide counseling and testing services to clients including patients from TB service as well as those tested through PITC. The approach of PITC will target adult and pediatric patients presenting with HIV-related OIs such as TB symptoms, malnourished children, HIV-exposed infants, STI patients and all admitted patients. A system to ensure coordination between the different counseling and testing units has been developed and will be re-enforced to enhance adherence and minimize lost of follow up. This activity will be attained through integration of various approaches including community based mobilization for counseling and testing in collaboration with local authorities, an enhanced referral to health facilities and follow-up as well as maximization of all entry points with the health care facilities. These include ordinary HCT, ANC and general consultation rooms plus nutritional centers and admission wards using PITC and provided in a manner that respects human values, ensures confidentiality , and reduces stigma and discrimination.

In FY 2010, MOH will continue to support couples testing at the transitioned sites and reinforce the follow-up of discordant couples. In addition MOH will strengthen counseling and testing M&E system (documentation, utilization of tools, data analysis and reporting) in all services. In order to maintain quality assurance of the services, MOH will continue to support integrated formative supervision of district team. Health center staff will receive new and refresher in-service training on VCT and PITC guidelines.

MOH will continue to support counseling and testing indicators embedded in Performance Based Finance (PBF) as a way of improving both quality and quantity of service provision. MOH will continue to support the quality of data and its utilization for improving the quality of care through regular data quality audits, data analysis training and data sharing workshops and feedback.

In FY 2009, with PEPFAR support, the Ministry of Health (MOH)/HIV integration task force supports capacity building in pediatric HIV care and treatment at the district level. Support is provided in planning, implementation, coordination, and supervision of activities; in holding district performance improvement meetings; to enhance the integration of pediatric care and treatment activities in other district health programs; and to improve linkages between HIV programs. MOH, in collaboration with USG implementing partners and the Global Fund, also supports the expansion of quality pediatric services to

more decentralized sites within the health care system. Moreover, MOH and TRAC Plus staff undertake formative supervision of pediatric HIV care and treatment activities in each district at least biannually.

In FY 2010, MOH/UPDC will continue to strengthen the capacity of districts to plan, implement, supervise and to coordinate pediatric HIV care and treatment activities. The provision of support for the expansion of quality pediatric services at decentralized levels will also continue through mentoring of health care providers working in hospitals and health centers in pediatric clinical HIV care, basic care and support, patient record-keeping, data recording and use, and quality performance measurement and improvement. During biannual formative supervision visits to districts, a standard checklist will be used to assess the quality and integration of pediatric HIV services. Supervisors will provide regular feedback to sites and share with them best practices in pediatric care and treatment.

FY 2010 starts the first year of transition of TRAC 1.0 partners' activities to the MOH: ICAP-CU and AIDS Relief will transition 12 and 11 HIV care and treatment sites, respectively. MOH will insure the continued provision of a comprehensive package of pediatric HIV care and treatment services at23. This package of services is provided in collaboration with local community service providers and includes co- trimoxazole prophylaxis, nutrition counseling, food support, and safe water interventions. In addition, district supported sites provide follow-up services for HIV-exposed infants who are maintained on co- trimoxazole prophylaxis until their HIV status can be confirmed through the early infant diagnosis program. Sites will link with malnutrition and TB centers within their facilities or at specialized sites located in the vicinity to provide HIV testing to all pediatric in- and outpatients and enroll the infected children into care and treatment services. Districts will endeavor to establish and strengthen linkages with PLWHA cooperatives in the local network, and the administrative district authorities and health teams to support activities aiming at increasing awareness in communities on issues related to pediatric HIV with a view to increasing pediatric HIV testing and enrollment into care. At PMTCT sites, enhanced follow-up of mothers and exposed infants will be promoted through support groups of HIV-positive women based on the mother-to-mother model. In this model, women who demonstrate steady consultation attendance and good baby care are identified and used to coach new HIV-positive mothers during pregnancy and after delivery to ensure that both women and their infants access needed services. HIV-exposed infants identified at PMTCT sites will be followed in the context of existing MCH services offered at supported sites. Relevant HIV-related information on mothers and infants will be transferred from PMTCT to other MCH programs through the "carte de liaison" that is currently in use in Rwanda. MOH will also strengthen the capacity of district health teams to ensure that samples collected at the sites are transferred efficiently to the National Reference Laboratory in Kigali and to Butare University laboratory for processing. At MOH-supported sites, HIV-positive children will be staged clinically and using CD4 (counts or percentages as these become available), and eligible infants and children will be enrolled in ART. MOH will work with clinical implementing partners to train health care providers on newly updated

pediatric HIV treatment guidelines which include changes for new regimen, early treatment of HIV- positive infants, and in CD4 thresholds for treatment initiation in children between 36 and 59 months of age.

All pediatric patients will have regular anthropometric evaluations to identify early signs of malnutrition and to ensure prompt initiation of nutrition rehabilitation interventions. Newly identified patients will be screened at enrollment and at regular intervals for signs and symptoms of common opportunistic infections or other infectious complications of HIV in children, including: candidiasis, pneumonia, malaria, meningitis, and Pneumocystis jiroveci pneumonia (PCP). In addition, all pediatric patients will be screened for TB at enrolment and at each follow up visit using the set of 5 questions developed by the National TB Program (PNILT). Children suspected of having TB will be further investigated, and if infection or exposure is confirmed, they will be put on TB treatment or INH prophylaxis based on current national guidance. Additionally, infants and children on ART will be assessed at each visit for issues related to adverse events, toxicity and adherence to ART. Staff will be trained to ensure, as much as possible, the early detection of signs of immunologic and clinical failure, and the initiation of second-line treatment regimens based on national guidance.

In FY 2009, with the PEPFAR support, the Ministry of Health (MOH)/HIV integration task force supports capacity building in pediatric care and treatment at the district level. Support is provided in planning, implementation, coordination, and supervision of activities; in holding district performance improvement meetings; to enhance the integration of pediatric care and treatment activities into other district health programs; and to improve linkages between HIV programs. MOH, in collaboration of USG implementing partners and the Global Fund, also supports the expansion of quality pediatric services to more decentralized sites within the health care system. Moreover, MOH and TRAC Plus staff undertake formative supervision of pediatric HIV care and treatment activities in each district at least twice per year.

In FY 2010, MOH/UPDC will continue to strengthen the capacity of districts to plan, implement, supervise and to coordinate pediatric HIV care and treatment activities. The provision of support for the expansion of quality pediatric services at decentralized levels will also continue through mentoring of health care providers working in hospitals and health centers in pediatric clinical HIV care, basic care and support, patient record-keeping, data recording and use, and quality performance measurement and improvement. During biannual formative supervision visits to districts, a standard checklist will be used to assess the quality and integration of pediatric HIV services. Supervisors will provide regular feedback

to sites and share with them best practices in pediatric care and treatment.

FY 2010 starts the first year of transition of TRAC1.0 partners' activities to the MOH: ICAP-CU and AIDS Relief will transition 12and11HIV care and treatment sites, respectively. MOH will insure the continued provision of a comprehensive package of pediatric HIV treatment services at23 transitioned sites.. The package includes treatment with ARV drugs, routine CD4 follow-up according to the national guidelines, viral load testing, screening and management of ARV drug side effects, treatment adherence counseling and patient referral to community-based care.

MOH will work with health facilities on the implementation of updated pediatric HIV treatment guidelines which include changes for early treatment of HIV-positive infants and in CD4 thresholds for treatment initiation of children between 36 and 59 months of age. MOH will ensure that site-level providers are trained or receive refresher training sessions in pediatric HIV patient management. This training will include, among other topics related to pediatric HIV care, the new national pediatric treatment guidelines, identification and management of treatment failure cases, and psychosocial support to children, adolescents and their families. All pediatric patients will have regular anthropometric evaluations to identify early signs of malnutrition and to ensure prompt initiation of nutrition rehabilitation interventions.

Providers will receive regularly planned in-service trainings and coaching sessions. MOH supervisors will carry out monthly site visits for staff mentoring during which support will continue to be provided for the improvement of service provision, the strengthening of children support group activities, and for the active tracking of follow-up defaulters.

Through the Supply Chain Management Services (SCMS), MOH will ensure the provision of antiretroviral drugs, CD4 tests, and other commodities and laboratory supplies for the clinical monitoring of infants and children on ART. Work with SCMS will also ensure that sites have reliable forecasting and stock management systems in place and that they provide accurate reports to SCMS and CAMERWA on their commodity needs for pediatric care and treatment.

In addition, MOH in collaboration with AIDS Relief and ICAP, will continue to train managers and health service providers in the use of the IQChart software. With improved data on pediatric HIV care and treatment, MOH, in collaboration with TRAC Plus, the national performance-based financing program, and the HEALTHQUAL project, will support health facilities to build and sustain a system of quality performance measurement and improvement. Basic pediatric HIV care, support and treatment data will be used to regularly review program performance and to design/implement appropriate interventions to improve the quality of services provided to children and their families. MOH staff in charge of each district will ensure that meetings to review internal data take place on a regular basis and that the improvement

plans are implemented at individual sites.

PEPFAR II strategic thinking is built around host country ownership and participation during the program life-cycle. This is strongly reflected in the full and active involvement of the Ministry of Health (MOH) in the identification, design and implementation of activities in the strategic information technical area. Support provided to the MOH embraces two of the three SI technical areas, namely HMIS and Monitoring and Evaluation. PEPFAR will continue to support ongoing interventions funded through the Cooperative agreement established with the US Centers for Disease Control and Prevention (CDC).

Through PEPFAR's technical and financial support, key strategic documents have been developed during FY 2008 and FY 2009. They include the national Monitoring and Evaluation policy, the Monitoring and Evaluation strategic plan, the Health Information System strategic plan and the e-Health strategic plan. These strategic plans are at different levels of implementation, and PEPFAR will support these efforts during FY 2010.

The Ministry of Health will continue to strengthen the capacity of district level managers to facilitate the search for the root causes of unsatisfactory performance of health facilities. In coordination with TRAC Plus, the M&E Task Force of the MOH will revitalize the national disease surveillance system to achieve timely and complete reporting across the levels of the health system. PEPFAR funding will support the recruitment of 4 staff for the e-Health Secretariat within the Ministry of Health.

In addition to these on-going interventions, the SI TWG has identified new activities to be carried out during FY 2010. These interventions will contribute to the strengthening of the current health information system and provide quality data to PEPFAR and the health sector in general.

MOH will develop standard operating procedures (SOP) for data management and feedback. This document will be widely distributed to provide clear guidance on data management at all levels of the health system. It will be also useful for the district authorities given their roles in the decentralization process. Data managers and information officers at district level will be trained in data management with PEPFAR financial support.

The MOH is engaged in an effort to increase its technical assistance to its decentralized bodies at the district level. In FY 2010, steps will be taken to conduct regular formative supervision to the district

hospitals that in turn will provide assistance to health centers in their catchment area. A supervision protocol and tools will be developed for district managers to improve both service delivery and data use for decision making at the district and health facility levels.

During FY 2009 the Ministry of Health published its first annual health statistics bulletin that was compiled from various data sources. This document has proved to be a useful compendium of health statistics. The second bulletin will be developed during FY 2010 with technical and financial support of PEPFAR. The document will be widely disseminated through different channels including workshops and websites.

During the course of PEPFAR I health facilities were provided with the physical resources necessary to provide high quality HIV services. Through this initiative, the majority of health facilities have been provided with a power source. A national strategy has been developed to achieve the Economic and Development Poverty Reduction Strategy's goal of providing all health facilities with a source of power by 2012. In FY 2010, with PF funds, the remaining facilities will be provided with a source of power.

Through PEPFAR, equipment has been procured for laboratories and health facilities to allow HIV service delivery. In FY 2010, through this award, support for a sustainable maintenance system will be provided. At central level this will include: performance incentives against clear objectives for maintenance unit staff; training of six central level maintenance staff in biomedical engineering; technical assistance for the maintenance unit to provide training for technicians; development of contracts with the private sector; and creation of procedures for the procurement of spare parts and tools for maintenance and repair of medical and laboratory equipment. The funds will allow emergency procurement of spare parts, tools, equipment and materials for reparations and maintenance. At the district level this will include provision of training and logistics to district level technicians to allow them to provide preventative maintenance and reparations of health facility equipment (including energy equipment) in collaboration with the private sector and health facility staff. Supply of logistics (including motorbikes) to district level technicians will be in tandem with other donors that offer this support. USG supported facilities will be the primary recipients of USG procured equipment. In FY2010 five new positions will be supported at the Ministry of Health to support and coordinate transition activities and reinforce capacity building in M&E. The new coordinator, financial administrator, two M&E officers, and one data manager will work together to improve the quality of HIV services at the 23 sites being transitioned to the MoH in FY10. In FY 2010 awareness-raising campaign will begin on maintenance of equipment, targeted at district level

managers and supervisors at health facilities. These personnel will receive training on planning and budgeting for equipment maintenance and replacement, while staff will be trained on the correct use and care of equipment, thus preventing an estimated 50% of equipment failures. All appropriate communication strategies will be use to achieve this goal.

In FY 2010 the award will allow senior maintenance staff to participate in international conferences, helping them stay current in their knowledge of cost saving and environmentally friendly technologies, as well as innovative maintenance strategies.

Introduction It is anticipated that hospital-acquired infections contribute to morbidity and mortality of patients that seek healthcare services in Rwanda. Mismanagement of injections and use of other sharps may result in the transmission of infectious diseases, such as HIV/AIDS, Hepatitis "B" and Hepatitis "C" to the consumers and the health care providers.

Background According to the national cross-sectional survey conducted in July-August 2004 in Rwanda, about 28% of the injections observed were about to be given with un-sterile needles and/or syringes. Following inception of JSI/R&T project, the situation has greatly improved although a lot needs to be addressed as 38% of the health facilities visited had sharps and other wastes in the compound, thus exposing the community to needle-stick injuries (MOH data). Health facilities were not equipped with knowledge in injection safety and healthcare waste management and did not have proper waste disposal facilities.

More than 36%of the service providers interviewed reported at least one needle stick injury during the same survey. Recapping with two hands was observed in 47% of preventive injections and in 59% of therapeutic injections. The community is also exposed to hazardous sharp waste. In order to minimize risks of transmission of HIV/AIDS and other blood borne pathogens through unsafe injections, the Ministry of Health (MOH) has phased out the use of sterilizable injection instruments (syringes and needles). Furthermore, a National Injection Safety and Health Care Waste Management sub-policy has been developed and approved by the MOH Senior Management in 2009. The healthcare waste management strategic plan is currently being developed and guidelines will soon be updated, printed and distributed to health facilities.

INJECTION SAFETY AND HEALTH CARE WASTE MANAGEMENT IN FY 2010

Reduction of blood-borne HIV transmission in clinical environments The Environmental Health Desk (EHD) of the Ministry of Health in collaboration with JSI/R&T will develop the terms of reference in areas that require capacity building. EHD will identify areas that require capacity building and organize the training of healthcare workers and waste handlers on injection safety and healthcare waste. Incinerator operators and their supervisors will also be trained on the use and maintenance of incinerators. All beneficiaries of this training program will be those who have never been exposed to these training before, especially newly employed staff. A strategic plan for prevention of infections will be developed to enable healthcare workers and waste handlers to protect themselves against HIV and Hepatitis B.

EHD will identify all of the required materials, consumables and equipment for injection safety and healthcare waste management and link them to the procurement organization SCSM which will in turn ensure the procurement of needed items in sufficient quantities and of the right quality.

Reduce blood-borne HIV transmission outside clinical environments EHD in the MOH in collaboration with JSI/R&T and key partners will implement the plan of constructing the multipurpose waste pits and installation of appropriate incinerators for the disposal of medical waste. Guidelines and specifications of waste pits and incinerators will be provided in collaboration with EHD, World Health Organization and John Snow, Inc. EHD will also organize training workshops in all sectors for community health workers and equip them with knowledge that will enable them to sensitize communities on injection safety and medical waste best practices.

EHD in collaboration with JSI/R&T and USG will conduct joint supervisory visits on injection safety and healthcare waste management practices in health facilities and district administration. A monitoring and evaluation specialist will be hired to ensure smooth and successful implementation of activities as well as determining areas that need urgent problem solving and advice. Collection of data for analysis of the program for appreciation or re-planning will be organized and preparation of reports for program management officers will also be organized.

EHD is keen to follow up all steps of the implementation of the program so that when JSI/R&T completes the transition exercise with MOH/EHD through transferring of competences, roles and responsibilities, the MOH/EHD will have enough experience to run the program effectively and efficiently.

PMTCT services uptake in Rwanda is high as indicated by ANC attendance and HIV counseling and testing. However mother and infant follow-up is weak due to high rates of home delivery and infants lost to follow-up. ICAP-CU and AIDSRelief have provided ongoing site level implementation support to the district hospital multidisciplinary teams to improve uptake of PMTCT. The PMTCT package includes CT, screening for STIs, infant feeding counseling, implementation of more efficacious PMTCT regimen, prompt CD4 count and clinical staging for HIV-positive pregnant women, combination ARV prophylaxis for non-eligible women and rapid initiation of HAART for eligible women, and delivery following safer practices, infants and mother follow-up, CTX for OI prevention and infant HIV testing; and supporting human resources by providing high-quality training and clinical mentoring.

In FY 2010, under the first year of transition of Track 1.0 partners' activities, ICAP-CU and AIDSRelief will transition PMTCT supported sites to MOH.

MOH will ensure continuity of provision of a comprehensive PMTCT package at the transitioned sites, including CT, screening for STIs, infant feeding counseling, implementation of more efficacious PMTCT regimen, prompt CD4 count and clinical staging for HIV-positive pregnant women, combination ARV prophylaxis for non-eligible women and rapid initiation of HAART for eligible women, and delivery following safer practices, infants and mother follow-up, CTX for OI prevention and infant HIV testing including early infant diagnosis. In additional MOH will support human resources by providing high- quality training of PMTCT providers. Task-shifting instruction is being implemented at PMTCT sites (which will in the future also provide ART) in order to decrease loss to follow up, which must be avoid during pregnancy in particular. Supportive supervision and mentorship will further be reinforced. MOH will also promote integration with other MCH (including malaria interventions, nutrition support, IMCI) and linkages with OVC services. MOH will also identify and refer victims of gender-based violence (GBV) to appropriate care.

In FY 2010, MOH will use community health workers to increase health facility delivery for HIV-positive women thus ensuring completion of the more efficacious PMTCT regimen. In addition, MOH will reinforce district's outreach team workers in order to track PMTCT defaulters and conduct home visits if needed.

Ministry of Health will ensure access to a comprehensive network of services for PMTCT clients and their families, link PMTCT services with other HIV and MCH interventions, and assure an effective continuum of care by increasing male partner involvement and community participation in PMTCT services. Health center staff will receive new and refresher in-service training on new PMTCT protocol, including use of site-level algorithms and checklists, as well as laboratory monitoring. MOH will sustain the PMTCT

follow-up system through support to sites for formal meetings and referrals to ensure that mothers and exposed children are followed regularly in PMTCT ward but also from vaccination, TB and nutrition wards to care and treatment.

To ensure the FP/HIV integration, in FY 2010 MOH will also support the revision, printing and dissemination of FP/HIV integration guidelines and tools. Moreover MOH will assist district team in training health providers on FP//HIV integration. In addition MOH will support salary of FP/HIV technical advisor and will develop and disseminate the GBV guidelines and tools.

MOH will collaborate with Catholic Relief Service (CRS) which is the principle PEPFAR sub-awardee for the purchase and distribution of nutritional supplements to people infected and affected by HIV and AIDS including weaning food supplements in PMTCT as well as nutrition support to eligible pregnant and lactating mothers.

To improve HIV exposed infant follow-up, MOH will facilitate the implementation of the updated immunization card containing HIV information by printing and disseminating this card nation-wide.

With the leadership of PBF unit within Ministry of Health and in collaboration with ICAP and AIDSRelief, MOH will continue to support the financing based on site performance in improving key national PMTCT performance and quality indicators.

In FY08, the USG supported the renovation of the laboratory at CHUK for microbiology, tuberculosis and histopathology. In FY 2009, the USG will continue to support the laboratory by assisting the Ministry of Health (MOH) to build human capacity for histopathology for the diagnosis of extrapulmonary tuberculosis and for the diagnosis of cancers in HIV patients

In FY 2010, the USG will support long term capacity building needed in the laboratory of CHUK. Indeed, the CHUK laboratory plans to organize training for one microbiologist and one histotechnician. The CHUK lab will need also to strengthen the management of routine activities in the purchase of equipment, consumables and reagents.

The USG will support the purchase of equipment and reagents for the laboratory and the training of six physicians in anatomical pathology. Several physicians will be sent abroad for specialized training in

pathology while two physicians supported by GOR located at CHUK and two supported by GOR located at CHUB will be trained in country. The two physicians at CHUK will be trained by the CDC-hired histopathologist seconded to the MOH and the two physicians at CHUB will be trained by the pathologist on staff at that location. Once the pathologists abroad have completed their training and returned to Rwanda, GOR will seek to send several other physicians for training. This cycle will continue until all are trained. By identifying local physicians to be trained as pathologists in country and abroad, a pool of Rwandan pathologists will be developed to sustain the program.

The objective of TB-HIV collaborative activities is the establishment and expansion of "one stop services" where patients have access to a complete package of services for both HIV/AIDS and TB diagnosis and treatment. Support includes initial infrastructure development (labs and referral systems), mentoring and supervision to clinical staff, expansion and improvement in screening and diagnosis of TB for HIV- positive adults and children, improved and integrated monitoring and evaluation, and improved TB case detection rates. Infrastructure improvements are crucial in TB prevention.

As outlined in the Partnership Framework, in FY 2010 MOH in collaboration with PNILT will implement key policy areas for TB infection control activities in Rwanda in order to reduce the likelihood of TB transmission in health care facilities. These activities will include rehabilitating health centers (n=TBD) and 8 districts hospitals according to national TB infection control requirements. Patient waiting areas and TB admission patient wards will be rehabilitated at specified health facilities. In addition, MOH will improve and expand its current District-level supervision activities to include activities relating to the quality of diagnosis of TB suspects.