Meeting Minutes Meeting Subject: Seventeenth Extended Team Meeting Meeting Organizer: Location: MSH Conference Room Kigali Start Date: 9/25/2008 End Date: 9/25/2008 Start Time: 9:00 AM End Time: 12:00 PM Objective To bridge the gap between policy and implementation; to coordinate PBF activities nationwide, to provide TA to the districts/district PBF Steering Committees and to follow up on 3Q08 control and validation activities. Meeting A large part of this meeting was briefing the Extended Team members on the two national counter verification protocols which are being rolled out throughout Rwanda. Agenda Items 1 La revue des recommandations des réunions précédentes 1. Kacyiru CS. Problem has been put to the National PBF Coordinator, the HC wanted to be evaluated as a hospital. This is not possible. Because of its status, and also its catchment population. 2. Review of certain elements in the DH checklist. The meeting will be held 26 Sept, 9 am at the CAAC to solve these issues. 3. Review of the DH InfoPath tool. Done. 4. DH PBF Guide, draft has been circulated, we await feedback. This feedback should be in before Oct 7, 2008. 5. Standard patient admission folders/files in Hospitals: The tools have been created and sent to DH directors, but no feedback received yet. 6. Funding Byumba, Kibogora and Bushenge DH: problem has been transmitted to the National PBF Coordinator. Problem is still pending. Funding has not been available since July 1, 2008. 7. SONU: CAAC/MOH coordinator has been briefed, and this will be discussed in the Health Taskforce, under Bonaventure. 8. HDP contract discussed and negotiated between MSH, HDP and CAAC/MOH will be signed 25 Sept. The meeting minutes from the last ET meeting have been discussed and accepted. 2 Le calendrier des évaluations des
HD et le suivi (appui) des évaluations des CS Issue 1: 3Q08 evaluation calendar for DH's has been presented. This will take between 7 and 24 October. Teams of peer evaluators have been mixed, and approved by the central MOH. Issue 2: some complaints about the tools being too heavy (some DH do their controls late and mix quantity/volume and quality supervisory activities). This was also observed during last week's quality counter verification exercise in five districts. It seems that this typically is an occurrence in those districts in which the PBF district steering committees does not work. Issue 3: controls are being done late in the fourth month in most cases. Issue 4: Review status of control/verification activities in various districts, by PBF district focal points. Nyagatare and Kirehe districts are singled out for intense support. CAAC/MOH and MSH to discuss how to intensify efforts. Request for having one MSH focal point based in Nyagatare, and one BTC focal point based in Kirehe to accomplish more intense support. Both districts are new, former phase 2 districts. Quality of FOSACOM (community managed health facilities, especially in Ngororero and Nyamasheke) remains weak. These FOSACOM pass on their results to official health facilities, who claim performance payments on their behalf from the MOH. District PBF focal points to bring up these issues in the respective PBF district steering committees. And RM to bring up this issue in the CAAC/MOH. Nyamagabe district HC, Kaduha CS, has not yet signed its contract. The responsible nurse has not yet signed. FHI to follow up through the district PBF steering committee. New Health Centers: those who have been recently created (two examples from Nyanza district provided by Sylvestre/MSH): Rigobert explains the procedure to follow, the HC needs an official accreditation by the MOH (SIS code; defined catchment population and the district Mayor needs to submit a written request to the Minister of Health, there will be a visit from the CAAC/MOH to check the level of services). 3 La restitution des résultats de l'activité de Contre-évaluation effectuée durant la semaine du 15-19 septembre dans les districts de Nyarugenge, Nyaruguru, Nyamasheke, Burera CN/MSH
et Nyagatare Two national protocols have been drawn up: one for the quarterly counter verification of the reported health center quality performance, the second, a protocol for community client surveys. The first will be organized by the CAAC/MOH in collaboration with agencies in the Extended Team, the second will be contracted out to a third party agency (See item 4 below). The national protocol for counter verification of reported quality performance of health centers, has been applied for the first time, for 2Q08 data. A team national technical experts, drawn from various agencies participating in the Extended Team mechanism, has assessed four randomly selected districts and one purposely selected district, on the data reported for the quality performance of health centers. Overall, the results were encouraging: the results found in 16 randomly selected health centers (multi stage random sampling: 5 districts chosen from 30 (one per province); 25% of health facilities in those districts; 25% of 13 services in each health facility), were broadly consistent with those reported by the district Hospital teams. In a few instances some scores deviated, however, plausible explanations were identified in all instances. As an example: an HIV services score of 75% in one HC could be explained as the HIV fridge was broken during the counter verification, but functioning during the 2Q08 evaluation by the Hospital. These evaluations were done in close collaboration with the district health authorities and the hospital director and his supervisory team (participation in the counter verification exercises). The CAAC shows the results of one health center, Tabagwe HC, Nyagatare district, using a specially designated reporting template to illustrate typical findings. Some evaluation teams (there were five parallel evaluation) used a comparative methodology: the hospital teams and the evaluators applied the same tool to the services, and compared results afterwards. This to be able to understand inter-observer variability. Other teams did the assessments conjointly and discussed differing interpretations, if any, during the process. Conclusions on Tabagwe HC (as an illustration of a sample of findings0: 1. Most evaluators had the same understanding of the indicators 2. The overall majority of indicators were scored similarly 3. Evaluations were done in a cooperative ambient 4. Close and participatory collaboration by district health staff with evaluators Also general conclusions on the Nyagatare District PBF system were listed: 1. Poorly functioning PBF Steering committee: leaving all control functions to the hospital team 2. Insufficient quality and quantity of staff with high staff turn over (newly PBF-ed phase 2 district), however, most say that this will probably be remedied by the recently introduced PBF system
3. Supervisors and health centers found the counter verification quite stimulating and requested continued such exercises 4 Contracting of a national civil society organization for carrying out the national protocol for community client surveys. CN & GF/MSH MSH and the MOH/CAAC have negotiated with a local civil society organization, Health Development & Performance (HDP), to carry out the national protocol for community client surveys. The contract will be signed 25 September 2008, for four quarterly surveys. Performance-Based Financing (PBF) has been rolled out nationwide in Rwanda, in phases, from January 1, 2006 to April 1, 2008. Various PBF models exist; for the District Hospitals; for the Health Centers and for MOH Head Quarter Staff. A model for Community PBF is being designed, and a model for Tertiary Hospitals will also be created. The Health Center PBF model is based on decentralized governance at the district level, a separation of functions, and a system of internal controls by the district for the volume of services and the quality of services, which together determine the final performance of each health center. The system of internal controls is reinforced by specifically designated technical assistants, drawn from a pool of Ministry of Health, bilateral partners, and implementing agency technical staff. This is the so-called extended team. On top of the internal controls and existing checks and balances, a system of external controls, i.e., from outside the district has been piloted. National protocols for external counter-verification of the volume of services using community client surveys and for counterverifying the quality of services have been drawn up. For the counterverification of the quality of services, extended team members will be used. For the counter-verification of the volume of services, a third party agency will be engaged. This third party agency, Health Development & Performance asbl (HDP) [1] was formed by former staff and managers of the Rwandan Branch of the Dutch PVO CORDAID after the ending of CORDAID Rwanda operations in 2007. CORDAID had been instrumental in introducing PBF in the western province of Rwanda since 2002 in what was, at the time, a pilot initiative. The results that were achieved later on proved to be critical in the MOH decision to make PBF a national policy. The CORDAID experience has been published in the international peer-reviewed literature. [2] CORDAID Rwanda converted, through technical assistance of CORDAID/Netherlands, into the local NGO HDP, capturing the entire former CORDAID Rwanda team.
HDP has been selected by MSH, in close collaboration with the CAAC/MOH, to act as the operational agency for carrying out the national quantity counter-verification protocol. By involving the CAAC/MOH closely, in particular related to the budget assumptions underlying the negotiated fixed price, a degree of sustainability has been built into this exercise; it is foreseen that the CAAC/MOH, after the end of this current contract, will take over the financing of this activity. The national quantity counter-verification protocol is based on a multi-stage random sampling of health centers, services and clients, once per quarter. [1] http://www.hdp-rw.org/ asbl stands for association sans but lucratif or Not for Profit Organization [2] Soeters, R., Habineza, C., Peerenboom, P.B., (2006), Performancebased financing and changing the district health system: experience from Rwanda. Bulletin of the World Health Organization, 84, 6 5 Divers 1. The issue of GF purchase of HIV services, nationwide. It was remarked that those health facilities in which no USG CA was present, but was offering HIV services (predominantly through GF but also through other partners), would need intense support in the initial months. Experience has shown that errors are mostly in the beginning/start up phase of PBF, and mostly due to poor register keeping and wrong understanding of the indicators. 2. Recap on DH PBF InfoPath forms outstanding for 2Q08 evaluations. They need to be submitted to Cedric/MSH or Rigobert/CAAC. 9 hospitals are missing. 3. Excel Pivot Training/Retreat early November 2008. Those interested need to indicate this to Cedric/Rigobert or Gyuri. Action Items Action Title Action Owner Priority Progress Due Date Those interested in participating in the one week Excel Pivot/training should send an email to Gyuri Feedback on the JP GF/CN/RM High Normal Not Started 10/13/2008 10/7/2008
first draft of the DH PBF Guide DH patient folders/files pending feedback from end users (DH directors) AU Normal 10/30/2008 Byumba, Kibogora and Bushenge DH PBF funds LR High 9/30/2008 Related Meetings Subject Link Organizer Date Next ET meeting will be at FHI office in Kigali 10/30/2008 Attendee Information Name E-mail Address Present Cedric NDIZEYE cndizeye@msh.org Joseph NTIBIRINGRWA ntibijos@yahoo.fr Octavien NDAKENGERWA ondakengerwa@msh.org Mathias MUREKEZI mathiasm@fhirw.org Thomas BUDUREGE buduthom@yahoo.fr Theogene GATETE gatetetheo@yahoo.fr Eugene INGABIRE eingabire@msh.org Michel MATUNGWA mat_mic2001@yahoo.fr Josephine MUKAMUGANGA jmukamuganga@crsrwanda.org Jacques MUHIGIRWA jmuhigirwa@msh.org Sylvestre HATEGEKIMANA shategekimana@msh.org Anja FISCHER anja.fischer@gtz.de Christine MUKANTWALI cmukantwali@msh.org Tatiana UZAMUKUNDA uzamukuta2001@yahoo.fr Njeri MICHEU nm2313@columbia.edu Adorata UKUNDAGUSABA au2118@columbia.edu Janvier GASHORI jg2712@columbia.edu Joy ATWINE jatwine@msh.org
Laetitia KAKANA lkakana@msh.org Odette MUKANDANGA odette@pedaids.org Apolline UWAYITU auwayitu@msh.org Theophile NTEZIRYAYO tnteziryayo@pedaids.org Moses MUNYAMAHORO mmunyamahoro@msh.org Emmanuel KAMANA kamanaem@yahoo.fr Georges NTABASHWA georgesntabashwa@yahoo.fr Marie Rose KAYIRANGWA mkayirangwa@intrahealth.org Gyuri FRITSCHE gfritsche@msh.org Rigobert MPENDWANZI rigobertnzi@yahoo.fr