Goals & Objectives: IHSSP will strengthen Rwanda's health systems for information, finance (including performance-based financing, PBF), human capacity development, quality assurance, and decentralization (including community-based service delivery systems.) IHSSP will build on results of previous and current US Government investments in the health system in Rwanda. Strengthening the decentralized health system and workforce (with resulting positive impact on health) will reinforce good governance and improve productivity and economic opportunities, to help reach Rwanda's Vision 2020 national health goals. IHSSP will collaborate with USAID, CDC, the MOH, and other partners to build capacity in information and financial management systems at both the central and district levels; build on, refine and extend the utility of the national PBF program; and pursue with the MOH and district leadership the community PBF (c-PBF) initiative. IHSSP will partner with the MOH in analyzing and implementing innovative changes in MOH internal systems to improve functionality at the center and to strengthen

decentralized systems. With support to the national community-based health insurance (CBHI) system, health management information system and support systems, the USG will ensure an effective PBF database and open systems documentation which will enhance effective management and financing of services. IHSSP will assist to expand the successful Young Professionals Program in Rwanda and work to reinforce the existing multi-donor support to this program. The project will support capacity building in planning and team-based problem-solving for service providers and health managers through the MSH Virtual Leadership Development Program.

2) Partnership Framework: IHSSP will contribute directly to Strategic Goal 4: addressing 5 of the 6 objectives: 4.1, 4.2, 4.3, 4.4, and 4.6.

3) The geographic coverage and target population(s). Nationwide with targeted support interventions in specific districts.

4) Health systems strengthening: IHSSP will work with the MOH to strengthen health systems and provide support to sustain progress already made. Information systems must be refined, integrated, and used. Financial resources flowing from the central government (and donors) must be aligned with those coming from the communities through the CBHIS, allocated appropriately, used efficiently, and accounted for in a fully transparent way. Community health workers, as a key strategy in Rwanda to resolve the crisis in supply of human resources for health, must be recruited, trained, supervised, and supported. The process of QA must be built into all levels of service delivery; norms and standards must be updated as needed; and performance must be tracked and openly documented. Those tasked with organizing and providing health services at the district and local levels must have the authority, training, and resources to meet their obligations. (See narrative for Budget code 1, OHSS Health Systems Strengthening, for details)

5) Cross-cutting programs: Human resources for health is included as a component of Health System Strengthening.

6) Cost-efficiency strategy: IHHSP Project will help consolidate the Rwanda health financing system and continue USAID's support to the MOH PBF Unit (CAAC) and the CBHI system and the Mutuelles Unitto integrate and build equity, efficiency, and transparency into the financing mechanisms. Doing so will tie the flow of financial resources from communities (through the mutuelles) and the GOR (through the PBF system) to enable cost-effective allocation decisions by managers at all levels in the system. The overarching strategy will be to align with the GOR's HSSP II and Imihigo performance-based contracting approach with district mayors. This project will provide regular data exchange with the district authorities so that they can meet the overall performance goals for public management at the district level agreed to

and documented in performance management contracts they have signed with the Office of the President on behalf of their constituents. IHSSP will also support Rwanda's efforts for financial sustainability by helping MOH departments finance their strategic plans by developing proposals for direct or "basket- funding" opportunities.

7) M&E plan: IHSSP M&E data will be collected using both quantitative and qualitative methodologies. Improving efficiency and accountability are at the core of our strategy, routine monitoring and assessment are critical to the effective targeting of resources and effort to produce results. Data will derive from the national HMIS, and support will be provided to enhance the efficiency of the national system. Our M&E design recognizes five major data users: MOH, USAID and USG, the IHSSP and its management, the individual recipients of PBF funding (contracts) who are providing services to their communities, and the members of the communities themselves. The project will focus on using existing data and reinforcing MOH data collection system, avoiding parallel reporting systems for routinely collected data. IHSSP will include partners who are already collecting data, but may not have had much experience with donor funding and/or data analysis. IHSSP will extend data collection and tracking systems that are in use for PBF and CBHI to assure access and compatibility with data in the HIS already in use by the MOH. Furthermore, this partner will work collaboratively with data providers and data users to identify and address potential bottlenecks or incompatibilities.

At the national level the Integrated Health Systems Strengthening Project (IHSSP) will facilitate the clarification of the planning, monitoring and evaluation functions of the MOH Planning Department in relation to decentralization in the health sector. Building on the work of the GOR and USG partners, the project will help MOH design and implement a harmonized and simplified system that links data collection to planning.

IHSSP will support the roll-out of the new M&E and health information system policy and strategies. This will involve, among others, the development of norms and guidelines for data management and feedback; the revision of data collection and reporting tools; and the implementation of a centralized data warehouse and web portal that will enable managers at all levels to track trends in real time. The project will reinforce the capacity of the M&E Task Force and the eHealth Secretariat of the MOH to lead and provide oversight to the implementation of the national policy and strategies, to enhance the interoperability of computerized systems and to coordinate the periodic revision of the routine health indicator set.

While IHSSP will continue USG efforts to enhance the capacity of national policy-makers to use data to revise and update policies, norms, and guidelines, an equally important focus will be on promoting the local use of data in Districts, health facilities and communities. Through its district sub-offices, the project will assist the MOH in the development and roll-out of a plan for building the capacity of health managers and health care providers at district and peripheral levels to analyze routine health data, and to use the generated information effectively to identify the root causes of unsatisfactory performance and solutions to problems. Assistance will also be provided for the development of a module on the routine health management information system (HMIS)/M&E for incorporation into the pre-service training curricula of health professional training institutions (nursing, midwifery, and the medical school). This activity will be initiated during FY 2010.

The project will also endeavor to strengthen the linkages between the M&E Unit and the departments of the MOH that have the responsibility for the development of supervision and quality assurance. Moreover, the project will support the coordination function of the MOH to ensure that all partners involved in capacity building for data analysis and use are operating cohesively.

The IHSSP will also support various departments within the Ministry of Health to enhance and roll-out specific health information sub-systems. These include: • Community-based Health Insurance membership and indicator databases • Community Health Worker HMIS (SIScom) • Performance-Based Financing Systems for Hospitals, Health Centers, Community Health Worker Cooperatives

• Human Resource Information System (iHRIS)

Integrated Health Systems Strengthening: Recent health improvements in Rwanda are directly linked to the strong collaboration among implementing agencies, donors, and service delivery partners over the past several years. The Ministry of Health (MOH) has enjoyed the full support of the President and the Cabinet to roll out major policy initiatives. These efforts include PBF (which will focus action on desired results), establishment of CBHIS (to move toward universal access to health services with a clear community voice in quality), and integration of resources and services for AIDS, tuberculosis, and malaria in the primary health care package as services are scaled up. The IHSSP will work with the government, civil society, and communities to strengthen health systems, develop preventive interventions, and improve the quality of health services.

1) Systems barriers and strategies: To strengthen health systems, the IHSSP will reinforce the institutional capacity of the MOH and district managers through continued application of the Fully- Functional Services model used by the MOH in its functional analysis, adapted to target fully-functional districts, and other targeted performance improvement, leadership development, and training methodologies. The project will strengthen the ability of districts, facilities, and health workers to identify and develop creative solutions for priority health problems using the MSH Challenge Model. In addition, MSH will work at the central level to help align the QA mechanisms now being put into action with the already functioning PBF system. Through c-PBF and community-based policy work, IHSSP will collaborate with communities and civil society organizations to address barriers to the access and use of services and strengthen health workers' capacity to provide quality services which are integrated within the national health program. By refining health management information systems and processes, IHSSP will enable policymakers, managers, health workers, and communities to make informed decisions.

Health finance, governance/leadership: Selected Activities to be carried out with partial support in this budget code: • Coordinate the secretariat functions of the PBF and CTAMS extended team mechanism • Participate in the quarterly counter-verification mechanisms • Document development experience (through small-scale qualitative operational research) and publish experience in peer-reviewed journals • Conduct two-week Rwandan PBF short course in collaboration with the MOH and the School of Public

Health • Conduct capacity-building activities on PBF with the PBF Extended Team • Provide technical assistance for the new and evolving central MOH performance assessments • Organize district-level technical assistance to the sector steering committees that govern the c-PBF mechanism • Promote the transfer of technical capacity related to data use from the district to the sector level, contributing to a more targeted approach to community health activities • Assist the GOR in implementing the proposed four conditional cash transfer pilots at the community level in the areas of planning, training, and follow-up • Train districts to raise funds and improve the financial management of Mutuelles • Provide TA to improve the national PBF model for health centers and district hospitals • Provide technical assistance to the CAAC and the TWG subcommittees to share knowledge related to the management of the PBF administrative system • Reinforce contract management competencies within CAAC • Provide Virtual Business Planning for Health program to support health centers • Use the tool CORE Plus with CAAC for both facility PBF and c-PBF to build service costing capacity • Provide continuous capacity building and system strengthening assistance to CTAMS • Assist CAAC in establishing the standing peer evaluation committee and support the CTAMS in making its Mutuelle PBF system operational • Facilitate advanced strategies at the national level, to augment the productivity and quality of health services, including HIV services • Support the roll-out of community PBF model through trainings in collaboration with national Malaria, Community Health Desk, CAAC, TRAC Plus, CNLS, and USG partners, • Provide technical assistance to the Extended Team and district health teams in data analysis on all PBF matters, using existing USG resources from CAs nationwide • Incorporate QA mechanisms into PBF systems in collaboration with MOH • Create a new coordination platform that involves actors from community health, HMIS department, and c-PBF actors, under the leadership of the Community Health Desk • Build partnerships with educational institutions and existing mechanisms such as the Young Professionals Program • Support the MOH to develop quality and quantity indicators with costs for University Teaching Hospital • Conduct mentoring and targeted training to PBF steering committees at district level • Implement cost effectiveness, impact and sustainability analyses of health and social services • Contribute to the development of the national social protection policy in health

2) Linkages across functional areas, and leveraging: Recognizing and respecting the interdependence of the many actors and stakeholders in Rwanda's health system, IHSSP will seize the opportunity to

establish partnerships and align goals and priorities with those of other donors and agencies working in Rwanda. As an example, the Belgian Technical Cooperation (BTC) will provide substantial funding to the Young Professionals Program while IHSSP will provide the technical assistance and guidance.

3) Selected Activities to be carried out with partial support in this budget code for Human Capacity Development, Supportive Supervision, and Quality Assurance: • Support Human Resources (HR) Task Force to manage the implementation of HR capacity development initiatives • Conduct HR assessment studies to update the knowledge on the current health work force (in terms of qualification, gender, age, deployment etc) • Support the HRH technical working group strategic planning • Provide TA to the Community Health Desk in roll-out of CHW strategy • Coordinate with partners to harmonize community health worker training tools and support the desk to coordinate implementation of CHW strategy • Support health professional bodies to carry out continuous professional development (CPD) and licensing of health providers to improve the quality of health workers • Conduct the Blended Leadership Development Program for District managers and for Senior Management Team of MOH • Develop and implement capacity building plans for the CHWs cooperatives with other organizations (such as the Ministry of Commerce, MINALOC) • Review the HRMIS tool and upgrade the platform for an interactive and user-friendly software to facilitate the use of HRM norms and guidelines • Collaborate with the Capacity Development Pooled-Fund Secretariat to coordinate planning and in- service training of different levels of workers in the healthcare sector. • Use HRM Assessment Tool (with other tools) to assess the HRM system effectiveness to mitigate the impact of HIV &AIDS on the health workforce) • Work with the central level to identify HRM components needing strengthening ( HRM capacity, personnel policy and practice, HRM data, performance management and training) • Assist the MOH in introducing changes at district level (hospitals and health centers) in collaboration with Ministry of Labor and Ministry of Local Government and the district teams • Develop an action plan for interventions to facilitate a process of HRM improvement • Conduct an inventory of HRM tools and develop a human resources management manual with operational policies and Develop a performance assessment tool • Discuss with the MOH carrying out a health worker labor market study in the public and private sector to determine the demands and supply of labor • Review staff retention strategies based on the available labor market data • Support the MOH to develop measurable result oriented staff performance plans building on the staff

productivity evaluations of the different cadres of health workers Support the establishment of a culture of ongoing learning and performance improvement, • Work with the CDPF coordination organ to develop a strategic plan for institutionalization of the Young Professionals Program, identifying the unit home, hiring staff to manage and oversee program and make the program sustainable • Help the MOH finalize the supervision tool by facilitating a workshop to get final feedback • Create an integrated training on the supervisory framework • Roll out supervision training in a cascade approach (starting with a central level training of trainers) for health management teams at the health center, district hospital, and referral hospital levels. • Reinforce the implementation of the supervision system through mentoring • Help develop/adapt tools for data use and assure that the data flows from the HMIS, QI, Mutuelles, and PBF databases and aligned and are used to reinforce the quality of the all the data • Explore the idea of using the PBF and Mutuelle web-based database as a model for the QI database • Help formalize the ad hoc M&E TWG to help in these processes • In collaboration with the Ministry of Education and the MOH, work with schools of medicine nursing and public health to see that the QI framework is incorporated into pre-service training modules for health providers • Train Health Management Committees at the district level so they can provide strong, transparent, and effective leadership for managing quality performance. • Support and mentor HMC on a regular basis • Support district management teams to bring facilities together to problem solve and learn from their experiences in QI • Support and facilitate forums for sharing of best practices • Support research on best practices • Review norms and indicators to help the MOH develop accreditation standards and rankings for district hospitals and health centers • Conduct an accreditation baseline survey to selected facilities • Ensure that districts effectively disseminate the patient charter of rights, and introduce tools successfully used by MSH in other countries

Indicator targets related to the budget code (if the optional indicator data is used). To be determined in consultation with USAID.

New activities for FY 2010, and plans for transition. IHSSP is a new project.

Selected Capacity building activities funded in FY 2010 to be carried out with partial support in this

budget code: • Conduct training of COGE and HMT in facility management, oversight of CHWs, validation of results, team building, and role clarification • Facilitate facility- and community-based sessions to reinforce skills and adherence to protocols, standards, and guidelines • Help coordinate meetings among the District Health Directors, pharmacists, and Mutuelle directors with mayors and vice-mayors for social affairs to foster integration of activities, common planning, and exchange of information • Encourage the formation and strengthening of CHW cooperatives • Link to the Mutuelle insurance system through the Imihigo contracts with district mayors by assuring that the financial and service data are available to these district managers. • Support conversion of the MOH website to a content management system platform • Establish an MOH website editorial committee • Train departmental staff on site maintenance • Train extended teams for PBF, Mutuelles, and eHealth/M&E (using e-learning courses and in-person trainings) in data use and data analysis. • Help MOH institutionalize the District Health System Strengthening Framework by generating most data through the annual HMIS reports rather than as a parallel facility survey • Work with the HIV Integration Task Force to establish standard planning procedures and guidelines at health facility as well as district levels • Develop HMIS data use guidelines for community-based HMIS as well as for hospital and health center HMIS. • Develop HMIS data use guidelines into curricula for interactive e-learning or blended courses • Conduct trainings on data use • Link with the QI initiative to strengthen use of qualitative indicator data gathered through supervision and accreditation • Help develop personalized web-based dashboards that will enable the tracking of key indicators • Continue support for implementation of the data warehouse and internet/intranet dashboard • Configure MOH-wide Exchange email server, shared calendars, etc., and train staff on use • Develop automated methods for data exchange between HIS subsystems Introduce Voice over IP (VOIP) services in district hospitals and selected health centers (VPN) • Support development of modules for the OpenMRS (electronic medical records system), in particular a module to support Mutuelles in tracking members, processing claims, and generating data for M&E • Design (or enhance) and test tools for collecting and compiling quality of care data from supervisory checklists and health facility PBF quality assessments • Facilitate a process to select a minimum package of indicators for the MOH, and develop and publish a metadata dictionary linked to the national data warehouse

• Revise existing data recording and reporting instruments for the HMIS Train M&E staff responsible for the data warehouse in database management • Continue to advocate for strong links between HMIS subsystems and demonstrate the feasibility of integrating data from separate systems through the national data warehouse • Support phased implementation of CTAMS databases, particularly for membership tracking and integration with EMR • Support computerization of Community Health Information System (SISCom), eventually moving it from the PBF server to a new module of the HMIS • Adapt and institutionalize data audit and data quality mechanisms control at all levels • Develop an MOU with the Rwanda Development Board to complement internal functions with services provided by RDB, i.e., remote help desk support, hosting of web servers, data warehouse, and email server • Provide continuing technical assistance for the upgrade, configuration, and management of the MOH Data Center • Support the development of policies for data security and email and internet use • Develop M&E management functions and structures, central MOH M&E unit, and M&E teams within departments and districts • Conduct trainings for M&E teams on planning, coordination, routine- and non-routine data collection approaches, and data use • Work with M&E teams and the Planning Division to develop standardized work planning formats and procedures for all MOH departments • Lead local teams to develop learning modules for HMIS, M&E, and disease surveillance