In COP12, with USG support, the MOH will provide direct support for comprehensive HIV service delivery as well as support for national programs including activities to strengthen health systems at all levels, provide training and mentorship for clinical services, injection safety, laboratory capacity, TB/HIV services, support health information systems and improving human resources for health (HRH). MOH will provide a comprehensive package of PMTCT, HTC, adult and pediatric C&T, and TB/HIV services at the 76 sites transitioned during COP11. MOH will ensure quality of care, continuum of care via effective linkages and referrals, and sustainability of services using performance-based financing (PBF). MOH will continue to support the revision and dissemination of FP/HIV integration guidelines and tools as well as training of district health teams (DHTs); coordinate the integration of SGBV and mental health services in HIV programs; support implementation of cervical cancer screening and treatment programs; organize training of health care workers and waste handlers on injection safety and waste management; implement construction of multipurpose waste pits and installation of appropriate incinerators; build human capacity for histopathology and diagnosis of cancers in HIV-positive patients, support the Medical Maintenance Division (MMD) to develop a central merchandizing of spare parts for laboratory equipment and establish a national quality system for laboratory tests as well as clinical services.The MoH is launching a program to train a critical number of HRH to be able to respond to the HIV epidemic in a sustainable way. Finally, the national disease surveillance system will be enhanced and the eHealth Enterprise Architecture will be implemented. No vehicles purchased.

Global Fund / Programmatic Engagement Questions

1. Is the Prime Partner of this mechanism also a Global Fund principal or sub-recipient, and/or does this mechanism support Global Fund grant implementation? Yes2. Is this partner also a Global Fund principal or sub-recipient? Principal Recipient3. What activities does this partner undertake to support global fund implementation or governance?(No data provided.)

The MOH will ensure provision of a comprehensive package of HIV clinical services at 76 transitioned sites. The package includes clinical staging & baseline CD4 count for all patients, follow-up CD4 every six months, management of OIs & other HIV-related illnesses including OI diagnosis & treatment, & routine provision of CTX prophylaxis for all eligible adults based on national guidelines, prevention with positive (PwP) interventions, nutritional counseling & support, positive living & risk reduction counseling & palliative care. Linkages from entry points for HIV testing & treatment will be supported . Pre-ART patients will be closely followed to maintain high retention rates & treatment initiation when eligible. Work with SCMS will ensure that sites have reliable forecasting & stock management systems & provide accurate reporting to RBC/MPPD/MPD on commodities for adult HIV care & support. The MOH will emphasize quality and continuum of care through effective linkages, & sustainability of services through PBF. MOH will support referrals for all PLHIV & their families, particularly children under 5 years of age & pregnant women, for malaria prevention services, including provision of LLINs & referral to community providers for water purification kits & health education on hygiene for reduction of diarrheal diseases. . Psychological support for PLHIV at clinic & community levels will be strengthened through training for all 76 health facilities & community-based providers. Moreover in collaboration with IHDPC and Ndera hospital, MOH will provide technical assistance to all district hospitals for HIV/mental health integration. in collaboration with the National Police, the MOH-MCH unit will coordinate the scale-up plan for the HIV/SGBV initiative at all district hospitals including capacity building of health care providers in SGBV client management & strengthening of SGBV M&E systems; In addition MOH will provide technical assistance to Gisenyi one stop center. The MOH will coordinate the implementation of the cervical cancer screening & treatment programs.

In COP12, the MOH will continue to support the 76 transition sites in the delivery of quality TB/HIV services, while supporting the national TB/HIV program. The priority in COP12 will be to expand HIV testing to all TB suspects and enroll those who test positive in HIV care and treatment, expand implementation of regular TB screening for all PLHIV, ensuring adequate diagnosis of TB and completion of TB treatment with DOTS programs. In COP12, the MOH will continue to support sites to increase case detection rates, as well as provide quality case management and follow-up. In addition, the MOH will support scale-up of the implementation of the TB infection control policy as well as the national PIT policy at the MOH- supported ART sites. MOH will ensure high quality recording of individual patient information, collect high quality data, and report and review these data. Efforts will be made to progressively transition the supervision and mentoring of the TB/HIV activities at site level to the district teams. This will be done through a collaborative approach based on evaluation of TB/HIV standards of care, district evaluation meetings and supportive supervision and mentorship of the district team. Infrastructure improvement is crucial in TB prevention and management. As outlined in the Partnership Framework, in COP12, the MOH in collaboration with the TB Division will continue to implement TB infection control guidelines in order to reduce TB transmission in health care facilities. These activities will include rehabilitating three health facilities according to national TB infection control requirements, including rehabilitating patient waiting areas and TB wards. In addition, the MOH will improve and expand its current District-level supervision activities to include activities relating to the quality of diagnosis of TB suspects.

In COP12, the MOH will continue to strengthen the capacity of districts to plan, implement, supervise and coordinate pediatric HIV care and support activities. The provision of support for the expansion of quality pediatric services at decentralized levels will also continue through mentoring and supervision of health care providers working in hospitals and health centers in pediatric clinical HIV care and support. MOH will support the provision of a comprehensive package of pediatric HIV care and support services at the 67 Track 1.0 HIV care and treatment sites, This package of services includes Co-trimoxazole prophylaxis, nutrition counseling, food support, and safe water interventions. In addition, all pediatric patients will be screened for TB at enrolment and at each follow-up visit. 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. At the MOH-supported sites, HIV-positive children will be staged clinically and using CD4 (counts or percentages as appropriate), and eligible infants and children will be enrolled in ART. 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. Moreover, sites will establish and strengthen linkages with PLHIV cooperatives in the local network, administrative district authorities and health teams to support activities aimed at increasing awareness in communities on issues related to pediatric HIV with a view of increasing pediatric HIV testing and enrollment into care. The MOH will also strengthen the EID program at health facilities and reinforce capacity of district health teams to ensure that samples collected at the sites are transferred in time to the NRL. All pediatric patients will have regular anthropometric evaluations to identify early signs of malnutrition and to ensure prompt initiation of nutrition rehabilitation interventions.

In COP12, PEPFAR will continue to support the MOH to strengthen its histopathology program in extrapulmonary tuberculosis and cancers in HIV patients by developing a histopathology laboratory at the University Teaching Hospital of Kigali (CHUK) and by sending four medical doctors abroad for specialty training in pathology. The USG is providing a pathologist to facilitate the functional development of the laboratory at CHUK and to train histotechnicians working in the laboratory. In addition, the USG pathologist will mentor the four medical doctors as they complete their training program and work with other pathologists at King Faisal Hospital and the University Teaching Hospital of Butare to develop a laboratory network in histopathology. The SCMS will work with the MOH to provide needed laboratory reagents and equipment for a functional histopathology laboratory

The Ministry of Health has a five-year eHealth strategic plan which encompasses all activities related to Strategic Information systems. In addition, a large part of the HMIS strategic plan deals with the development and roll out of the electronic system and these activities are subsets of the eHealth strategic plan. The Ministry of Health will continue the implementation of various components of the eHealth Enterprise Architecture and a selected number of end-user applications such as the roll out of the electronic medical records. The Ministry of Health will also continue to strengthen the capacity of district level managers to increase the performance of health facilities in data management. Capacity building of about 800 data managers at both national and district levels is a cornerstone of human resource capacity enhancement. The MOH will develop guidelines on data production and dissemination as well as training curricula for data management and feedback. These documents will be widely distributed to provide clear guidance on data management at all levels of the health system. These will also be useful for district authorities given their roles in the decentralization process. Data managers and information officers at district levels will be trained in data management with USG financial support. In COP12, steps will be taken to conduct regular formative supervision to district hospitals that in turn will provide assistance to health centers in their respective catchment areas. 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 COP12, the MOH will harmonize reporting at all levels-community, facility and national, and across the various programs of the Ministry in an attempt to have a harmonized HMIS. The health sector cannot deploy the various technologies without appropriate infrastructure to support this deployment. In addition to the funds from the Ministrys ordinary budget, the COP12 funds will also be used to make capital investment in IT infrastructure especially at decentralized levels.

The Rwanda Biomedical Center/Medical Maintenance Division (MMD) is the institution within the MOH in charge of healthcare technology, infrastructure management and equipment maintenance. In previous years USG supported the MMD in terms of personnel and technical assistance; the purchase of toolkits, equipment for maintenance, generators and spare parts; and training of MMD staff on new medical technology and maintenance techniques. In COP12 USG funds will be used to support MMD to develop a central mechanism for procurement of spare parts and to establish a national control quality system. Specific activities will include the purchase of spare parts and quality control tools and equipment; training of staff on quality control measures; and the revision of key policies and procedures.

The MoH is launching a program to establish a critical number of Human Resources of Health (HRH) to be able to respond to the HIV epidemic in a sustainable way. Rwanda wants to ensure good access to quality health services for HIV patients at all levels of the health system, from the referral hospitals to the community level.

Rwandas health system is decentralized which means that most of the health care takes place in health center and district hospital level. Therefore the only way to ensure access of essential services for all patients, included HIV-infected patients, is to train a sufficient number of qualified health providers in order to be able to deploy them across all 30 districts. With support from the USG, the MoH will equip some district hospitals to function as teaching sites and to upgrade the available services and clinical mentors at five Provincial Hospitals.

In the HRH Program the focus is on building the capacity of Rwandas health professionals in the following areas: Surgical Care (including associated services); Pediatric and Peri-natal Care; Womens Health; Anesthesia Care; General, Internal Medicine and Specialty Care (including community/public health care); Radiology Care; and Health Management.

Warehousing support.

With USG support, Rwanda will continue its safe injection activities by reducing blood-borne HIV transmission both inside and outside clinical environments. In COP12, the Ministry of Health Environmental Health Desk (MOH-EHD) will organize the training of healthcare workers and waste handlers on injection safety and healthcare waste management. Incinerator operators and their supervisors will also be trained on the use and maintenance of the equipment. A strategic plan for prevention of infections will be implemented to enable healthcare workers and waste handlers to protect themselves against HIV and Hepatitis B. EHD will identify 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 appropriate quality. The USG and MOH-EHD will conduct joint supervisory visits to assess injection safety and medical waste management practices in health facilities. Monitoring and evaluation will be carried out to ensure the smooth and successful implementation of activities as well as determining areas which require immediate action. Data collected will be used for an analysis of program performance as well as preparation of management documents for program officers.

During COP12, the MOH will ensure continuity of counseling and testing services at all 76 transitioned sites. The MOH will provide counseling and testing services to clients including patients from TB services as well as those tested through PITC. The approach of PITC will target adult and pediatric patients with HIV-related OIs such as TB, malnourishment for children, known 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 reinforced to enhance adherence and minimize loss-to-follow-up. This will be achieved 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 within health care facilities. These include ordinary HTC, 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 COP12, the MOH will continue to support couples testing at transitioned sites and reinforce the follow-up of discordant couples. In addition, the MOH will strengthen counseling and testing M&E systems (documentation, utilization of tools, data analysis and reporting) in all services. In order to maintain the quality of services, the MOH will continue to support integrated formative supervision of district teams. Health center staff will receive new and refresher in-service training on VCT and PITC guidelines. The MOH will continue to support counseling and testing indicators embedded in Performance-Based -Financing (PBF) as a way to improve both the quality and quantity of service provision. The MOH will 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. Procurement of rapid test kits.

Note: 1,563,625 added from the USAID TBD Commodities and Warehous proposed mechanism.

In COP12, MOH will ensure continuity in the provision of the comprehensive PMTCT package at 52 transitioned PMTCT sites. MOH will support human resources by providing high-quality training of PMTCT providers. Task-shifting instruction is being implemented at PMTCT sites in order to decrease loss to follow up, which must be avoided during pregnancy in particular. Supportive supervision and mentorship will further be reinforced. The MOH will also promote integration with other MCH services (including malaria interventions, nutrition support, IMCI) and linkages with OVC services. MOH will reinforce the district outreach teams in order to track PMTCT defaulters and conduct home visits as needed. The MOH will also identify and refer victims of gender-based violence (GBV) to appropriate care. MOH 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. MOH will sustain the PMTCT follow-up systems through PMTCT integration with other services. To ensure the FP/HIV integration, in COP12 MOH will support the update of guidelines and tools as needed. Moreover, the MOH will assist district teams in training health providers on FP//HIV integration. MOH will collaborate with Ibyringiro to distribute 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 the PBF Unit within the Ministry of Health, MOH will continue to support the financing based on site performance with the aim of improving key national PMTCT performance and quality indicators.

In COP12, the MOH will support the provision of ART at the 67 Track 1.0 transitioned care and treatment sites. The package of services will include treatment with ARV drugs, routine CD4 follow-up, viral load testing, management of ARV drug side effects, and adherence support. In COP12 the MOH will emphasize quality of clinical services, continue support to district health teams, increase sustainability through quality assurance and capacity building of district and health center teams through supervision and mentorship. The MOH will also continue to support district hospitals and health centers to initiate treatment in HIV positive patients based on national guidelines and current eligibility criteria. In collaboration with district hospital teams, adherence support will be provided to prevent loss-to-follow-up. To support a high quality of service, clinicians from the district team will review complicated cases with providers at health centers. District Hospital team will mentor the health center providers on provider-initiated testing, follow-up of patients, and the detection and referral of complicated cases to district hospitals. The MOH will continue to promote quality improvement through reviews of indicators, medical dossiers and viral load measurements. The results of these reviews will be used to develop and strengthen clinical capacity for more efficient and high-quality patient management. In addition, the MOH will also work to improve reporting linkages with RBC/MPPD/MPD and to mentor health center staff on strategies to effectively receive, manage, and forecast the need for ARVs. PBF is a major component in the PEPFAR Rwandas strategy for ensuring long-term sustainability and maximizing performance and quality of treatment services. MOH will support PBF by participating in health facility performance evaluations. Staff will also be trained to recognize the early signs of immunologic and clinical failure, and to initiate second-line treatment regimens based on national guidelines.

In COP12, the MOH/DI will continue to strengthen the capacity of districts to plan, implement, supervise and 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 and supervision of health care providers working in hospitals and health centers in pediatric clinical HIV care and treatment. During COP12, the MOH will ensure provision of a comprehensive package of pediatric HIV treatment services at 67 transitioned sites. The package includes treatment with ARV drugs, routine CD4 follow-up according to national guidelines, viral load testing, screening and management of ARV drug side effects, treatment adherence counseling, and patient referral to community-based care. The MOH will also work with health facilities on the implementation of updated pediatric HIV treatment guidelines. Providers will receive regularly planned in-service training and coaching. The MOH supervisors will carry-out monthly site visits for staff mentoring during which support will be provided in improving service provision, strengthening children support group activities, and for active tracking of follow-up defaulters. Through the Supply Chain Management Services (SCMS), MOH will ensure the provision of ARVs, CD4 tests, and other commodities and laboratory supplies for 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. In addition, the MOH will continue to train and mentor managers and health service providers in the use of the IQChart software as well as open MRS. With improved management of data on pediatric HIV care and treatment, the MOH, in collaboration with RBC, the PBF program, and quality management program will support health facilities to build and sustain a system of quality performance measurement and improvement.