Rwandan MOH functional assessment Provisional results Briefing presentation

Rwandan MOH functional assessment Provisional results Briefing presentation 5 May 2007 MSH

Introduction Functional assessment of MOH carried out by Ousmane Faye, Kathy Kantengwa, Jean Kagubare, Tanou Diallo, Ida Grum, Maggie Partilla and David Collins Visit to Rwanda 22 April to 5 May 2007 MSH

Has the MOH been able to achieve its objectives & strategies since the restructuring in 2006? • MOH objectives by 2015 (MOH web site) – – – Human Resources Development Availability of drugs, vaccines & consumables Geographical accessibility of health services Financial accessibility of health services Quality of and demand for health services in the control of diseases – Strengthening national referral hospitals, treatment & research centres – Institutional capacity building 5 May 2007 MSH

Has the MOH been able to achieve its objectives & strategies since the restructuring in 2006? • MOH key strategies (MOH web site) – The decentralization of the health system using the health district as the basic operational unity of the system – The development of the primary health care system through its eight core components – The reinforcement of evidence based medicine: Integrated management of childhood illnesses, clinical care of obstetrical emergencies to decrease infant and maternal mortality rates – The reinforcement of community participation in the management and financing services 5 May 2007 MSH

Has the MOH been able to achieve its objectives & strategies since the restructuring in 2006? • The MOH has achieved good progress in some areas (eg PBF and mutuelles) but it is hard to assess objectively the overall impact of the restructuring on performance since only one year has past. • Also the current planning and reporting system does not make this type of performance assessment easy. 5 May 2007 MSH

Is the MOH’s mission appropriate for 2007? The main goal of the Ministry of Health is to provide and continually improve the health services of the Rwandan population through the provision of preventive, curative and rehabilitative health care thereby contributing to the reduction of poverty and enhancing the general wellbeing of the population. (MOH web site, 27. 4. 07). Recommendation: after the 2006 restructuring the mission of the MOH has changed and is not the same as that of the health sector as a whole. Consideration should be given to changing the wording to reflect the provision of only “leadership and coordination”. 5 May 2007 MSH

Do the roles of the MOH enable it to achieve its mission? Are there any gaps? Roles of the MOH per HSSP (roles are not shown on MOH web site): – – – defining policy, setting standards, regulating, resource mobilization and monitoring activities in the sector. Recommendation: include the roles of sector leadership, planning and coordination and clarify that all roles cover the whole health sector. 5 May 2007 MSH

Do the agencies form a cohesive and comprehensive network of organizations that complement the MOH’s work? • It is not clear that the network is cohesive and comprehensive • For example there may be some duplication of functions (eg IEC and BCC can be under the CRCS or other agencies and centres). • It is not clear if there are established areas and systems for communication among agencies and between agencies and the MOH. • Most agencies do not have MOUs with the MOH. Recommendations: • A more cohesive planning, coordination, communication and reporting system would make the network more functional. • To improve coordination and control, all autonomous agencies and centres should all have MOUs with the MOH and for autonomous agencies funding should be performance-based. 5 May 2007 MSH

Current MOH Network LNR Laboratory research and analysis CNTS CAMERWA National Blood Transfusion Centre Essential Drugs Procurement CCPS LABOPHAR Psychosocial Consultation Centre Drug production ACM CNLS Maintenance Centre National HIV/AIDS Centre Ministry of Health TRAC+ Research on HIV/AIDS, TB and Malaria CHUs Centre for University Hospitals CRCS Autonomous Executing Agencies Rwanda Centre for Health Communication Private providers 5 May 2007 District Health Services MSH NGO providers MOH executing agencies 9

Do the internal MOH structure and the roles of the internal MOH units allow it to fulfill its overall roles efficiently and effectively? • The current internal structure and roles of the units etc of the MOH does not appear to be as efficient and effective as it could be in terms of allowing it to fulfill its roles. • Example: the M&E and HIS functions should be together and the Policies unit includes too many diverse functions, such as technical programmes Recommendation: some restructuring of MOH and redefinition of the roles should improve its ability to fulfill its overall roles. See recommendation at the end of the presentation. 5 May 2007 MSH

Is the SG’s office able to play the leadership and management role required for the MOH to fulfill its roles? Yes but the workload is very high because too many organizations report to the SG’s office and there are too many tasks – eg the SG has to sign 4 times for each purchase. Recommendations: – the proposed restructuring would partially reduce this burden – carry out a review of the roles and functions of the SG’s office and see which can be delegated. 5 May 2007 MSH

Are policies, regulations and standards being developed to meet the requirements identified in the strategic plan? • It is hard to assess this since there is no MOH strategic plan that clearly sets out all the policies and procedures, regulations and standards required and states responsibilities and shows timelines. • Some policies have been developed but some of them are still in draft. Some other necessary policies do not yet exist • Some vertical programs have developed standards and guidelines – but it is not clear if, or how, these have been coordinated. Recommendation: A separate comprehensive strategic plan is needed for the development and implementation of policies and procedures, regulations and standards. This should identify priorities, responsibilities, timelines and budgets. 5 May 2007 MSH

Is the mobilization of resources done well enough to achieve the goals of the strategic plan (given funding constraints)? • The HSSP provide cost estimates but we have not seen a study of the financial commitments and the funding gap. Hopefully, the SWAP process will do this. • However, it is not clear how much strategic cost estimates have been used to advocate for additional resources from the MOF or donors. Recommendation: A funding gap study and an advocacy plan should be developed and used proactively to seek additional funding, especially for under-funded programmes or districts. 5 May 2007 MSH

Are the planning functions resulting in comprehensive, coordinated plans and budgets that, if implemented, will lead to achieving the goals of the strategic plan? • The MOH is working to improve linkages between different plans and between targets, activities and budgets within plans. The staffing of the planning function is, however, insufficient and some skills are lacking – particularly with increasingly complex planning demands (eg MTEF). Note that the planning work may not have decreased much since 2005 but the number of staff was reduced from 5 to 1 FT person. Recommendations: Improve the planning system, increase staff and provide training. 5 May 2007 MSH

Do the M&E and reporting systems result in managers and clients being well informed of performance in a timely manner? • The M&E function is new and a comprehensive system is not yet in place that results in MOH managers and clients being well informed of performance in a timely manner. Recommendations: – Create a new sub-unit under the Policy Unit with sufficient staff and appropriate skills (including HIS and GIS). – The system should cover the whole health sector and should take into account agency, district and central hospital M&E functions and needs. 5 May 2007 MSH

Are health services being coordinated in ways that result in a cohesive and comprehensive set of services • There does not appear to be a cohesive and comprehensive plan for technical coordination and support to district, private and NGO health care provider. Recommendation: a plan for technical coordination and support to district, private and NGO health care providers should be developed and used. 5 May 2007 MSH

Are the QC functions carried out in ways which enable the MOH to achieve its mission? • The QC programme as a whole is not comprehensive and integrated and tends to as separate systems under the cells, centres and agencies (eg the PBC QC system). Recommendation: a comprehensive and integrated QC system should be developed and the function strengthened and put under a new Health Service Delivery Unit. 5 May 2007 MSH

Do the support units (Operations, Finance, HR, Legal, ICT) provide adequate support to the technical units? • The technical units feel that they get support but some management systems are weak or lacking. • For example, staff feel need for clear job descriptions and PPR systems and supervision, and procedures are lacking for implementation of some management functions eg HR policies. Recommendations: Develop procedures for operational and management systems and strengthen skills (eg for HR). 5 May 2007 MSH

Current MOH structure • Reporting to SG: – 3 units: • Policy and Capacity Building • Finance and Internal Resource Management • Information and Communication Technology – 2 cells: • Performance Based Contracting Support Unit • Community Based Insurance Support Unit – Agencies 5 May 2007 MSH

CURRENT STRUCTURE – MOH Cabinet of Secretary of State in charge of the fights against HIV/AIDS Cabinet of MOH Office of Secretary General ICT Finance and Internal Resource Management Unit Agencies Policy and Capacity. Building Unit PBC Support Cell (CAAC) Community-Based Insurance Support Cell (CTAMS) COORDINATE Agencies Districts Private & NGO sectors MCH task force Pharmacy task force Nursing task force Blindness etc task force 5 May 2007 MSH 20

CURRENT STRUCTURE – DESKS UNDER UNITS ICT DESKS • Network Administration • Software Development • Health information system and statistics 5 May 2007 Finance and Internal Resource Management Unit DESKS • Communication and Public Relations, • Central Secretariat • Human Resources Management • Accounts • Logistics • Legal Affairs MSH Policy and Capacity. Building Unit DESKS • Planning, • Health care • Environmental health • Nutrition • Private medicine, • Community and traditional medicine • Human Resources Development • Monitoring and evaluation • Child health? • Maternal health? • Reproductive health? 21

Proposed MOH structural changes – 3 options • • 3 options are presented Option 2 builds onto Option 1 Option 3 builds onto Option 2 The options are not mutually exclusive 5 May 2007 MSH

Proposed MOH structural changes – Option 1 • Split PPCD unit into: (1) Policy, Planning and Evaluation Unit and (2) Health Service Delivery Unit • Assign focal points for agencies in HSD • Move technical support cells to HSD • Move the Legal Advisor from FIR to PPE • Move HIS function from ICT to PPE unit • Move ICT to FIR • Should we move Communications and PR from FIR or expand/upgrade it since it seems be a key area for the 5 to May 2007 MSH PS?

Option 1 – create Health Service Delivery and QA Unit Cabinet of Secretary of State in charge of the fights against HIV/AIDS Cabinet of MOH Office of Secretary General Agencies Finance and Internal Resource Management Unit ICT Policy, Planning, and Evaluation Unit Mutuelles Support Cell PBC Support cell Health Service Delivery Unit COORDINATE Agencies Districts Private & NGO sectors MCH task force Pharmacy task force 5 May 2007 MSH Nursing task force Blindness etc task force 24

OPTION 1– DESKS UNDER UNITS Finance and Internal Resource Management Unit (Inc ICT) DESKS • Communication and Public Relations, • Central Secretariat • Human Resources Management • Accounts • Logistics • Network Administration • Software Development 5 May 2007 Policy, Planning and Evaluation Unit DESKS • Planning • Monitoring and evaluation • Health information system and statistics • Human Resources Development • Legal affairs MSH Health Service Delivery Unit DESKS • Health care • Environmental health • Nutrition • Private medicine, • Community and traditional medicine • Child health? • Maternal health? • Reproductive health? 25

Proposed MOH structural changes – Option 2 Same as Option 1 plus creation of a Health Financing Unit to which the Performance Based Contracting Support cell and Community Based Insurance Support cell would report The chart of desks under the units is the same as for Option 1 except for the desks that would be created for the Health Financing Unit which would be decided later. 5 May 2007 MSH

Option 2 – add Health Financing Unit Cabinet of Secretary of State in charge of the fights against HIV/AIDS Cabinet of MOH Office of Secretary General Agencies Finance and Internal Resource Management Unit Health Financing Unit Policy, Planning, and Evaluation Unit Health Service Delivery Unit COORDINATE ICT Agencies Districts Private & NGO sectors Mutuelles Support Cell PBC Support Cell MCH task force Pharmacy task force 5 May 2007 MSH Nursing task force Blindness etc task force 27

Proposed MOH structural changes – Option 3 Same as Option 2 plus creation of: • A Reproductive Health Cell under the HSD Unit • a Health Service Delivery Coordination Task Force under the HSD – members of relevant MOH units, agencies and also service providers • A Human Resource Planning and Coordination Task Force under the Policy, Planning and M&E Unit • Chart of desks not shown as not clear if additional desks would be created 5 May 2007 MSH

New Proposed Structure for MOH 5 May 2007 MSH

Option 3 – add HR and HSD task forces Cabinet of Secretary of State in charge of the fights against HIV/AIDS Cabinet of MOH Office of Secretary General Agencies Finance and Internal Resource Management Unit Health Financing Unit Policy, Planning, and Evaluation Unit Health Service Delivery Unit COORDINATE ICT Mutuelles Support Cell PBC Support Cell HR Planning and Coordination taskforce Agencies Districts Private & NGO sectors RH Support Cell MCH task force Pharmacy task force 5 May 2007 MSH Nursing task force Blindness etc task force Health Service Delivery Coordination task force 30

Option 1 - Proposed Policies, Planning and Evaluation Unit • coordinates the elaboration of policies, sector strategies and standards for the health sector • coordinates donor activities • coordinates and evaluate the application of the national policies within the Ministry; • coordinates the drafting of the legal and lawful texts as regards health care; • conducts health sector planning and M&E through desks (e. g. , Legal Affairs, HIS), working groups (HR), agencies and districts • plans human resource development and training • manages the Health Information System and designs data collection methodology 5 May 2007 MSH

Option 1 - Proposed Health Service Delivery Unit • Develop technical guidelines, standards and norms for health sector • Coordinate technical oversight (supervision, training and QA) of public and private services through desks, task forces, technical support cells and agencies: – Desks (Health care, Environmental health, Nutrition, Private medicine, Community and traditional medicine, MH, IMCI, RH) – Task Forces (MCH, Pharmacy, Nursing and Midwifery, Prevention of blindness and physical disability, Decentralization and HIV/AIDS integration) – Cells (PBF, Mutuelles, and Reproductive Health) If we have a RH cell then we would presumably not have an RH desk (we do not in the other cases) – Agencies (ACM, LNR, Camerwa, CHU, TRAC+, CCPS, CRCS, Labophar, EPI, CNTS) 5 May 2007 MSH

Option 1 Proposed Finance and Internal Resources unit • Supervises the management of human, material and financial resources of the MOH through the desks (Communication and Public Relations, Central Secretariat, Human Resources Management, Accounts, Logistics) • Coordinates central secretariat activities • Coordinates communication activities • Monitors and evaluates the performance of MOH staff • Coordinates the Ministry budget execution • Promotes ongoing modernization (eg. ICT) within the MOH in collaboration with other units 5 May 2007 MSH

Option 1 - proposed ICT cluster to include in FIR Unit • Coordinates ICT activities in the MOH through desks (Network Administration, Software Development) • Conducts Systems Engineering, Network Analysis/Engineering, IT Analysis, Equipment and Applications Specialty, Database and Security • Designs, develops, implements and monitors various information technology security systems • Proactive operational responsibility for incident, intrusion, prevention and detection 5 May 2007 MSH

Option 2 – proposed Health Financing Unit • Develop health financing policies and regulations • Coordinate and monitor and evaluate health financing mechanisms • Carry out health financing studies (eg National Health Accounts) • Coordinate and support Performance Based Financing and Community Based Health support units. 5 May 2007 MSH

Are there sufficient MOH staff to carry out the functions and do they have the required skills? • A comprehensive answer to this question will come from the completion of the analysis of role clarifications and a review of expanded functions. • However, there is already evidence that there are insufficient staff and in some areas and that some additional skills are required – eg planning and MTEF preparation. 5 May 2007 MSH

Needs identified by MOH staff during MOST exercise • Development of procedures manuals • Development of a new MOH mission and an MOH strategic plan • Plan and strengthen the M&E function and plan • Consider revising the organization chart • Develop clear job descriptions and assess work loads 5 May 2007 MSH

Weaknesses also identified in HSSP (before restructuring but probably still valid) • Planning, supervision and monitoring (also identified in HSSP) • Lack of results-oriented way of, such as MTEF monitoring of outputs and expenditures. • Under-utilization of health information and weak capacity to carry out meaningful analysis of data • Weak management and public health skills 5 May 2007 MSH

Fully Functional MOH Supply Demand MOH Role • Provide sector leadership • Sector planning and coordination • Develop, disseminate and monitor policies, standards and regulations • Organize and coordinate resource mobilization • Monitoring and evaluation Fully Functional Service Requirements: Clients: Service Providers • Sound structure • District health services • Good systems • Private and NGO providers • Public Hospitals • Clear dept and staff roles • Trained and motivated staff Clients: Population • Good communications • Individuals, families and communities • Administrative support • Parliament and civil society MOH Mission: Lead and coordinate strategies and activities to ensure and promote the health status of the Rwandese population by providing quality preventive, curative and rehabilitative services within a well-performing health system 5 May 2007 MSH Wording in italics was added by MSH team 39

Fully Functional MOH Supply Demand MOH Role • Provide sector leadership • Sector planning and coordination • Develop, disseminate and monitor policies, standards and regulations • Organize and coordinate resource mobilization • Monitoring and evaluation Fully Functional Service Requirements: Clients: Service Providers • Sound structure • District health services • Good systems • Private and NGO providers • Public Hospitals • Clear dept and staff roles • Trained and motivated staff Clients: Population • Good communications • Individuals, families and communities • Administrative support • Parliament and civil society MOH Mission: Lead and coordinate strategies and activities to ensure and promote the health status of the Rwandese population by providing quality preventive, curative and rehabilitative services within a well-performing health system 5 May 2007 MSH Wording in italics was added by MSH team 40

Functional Analysis Activity Calendar June 07 July Aug Sept Oct Nov Dec Jan 08 Feb Mar Apr May 1 MOH Role Clarification 2 MOU Negotiation (Performance Based Structure) and Documentation 3 HRM Capacity Review (MOH & Agencies) 4 M&E and Quality Assurance 5 Communication Plan 6 Health Sector strategy Review. MOH and Agency Plan Revision 5 May 2007 MSH 41