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Evaluation report

2010 Rwanda: Review of the family package project



Author: Dr David Kamugundu. Institution: Imbuto Foundation. Partners: Ministry of Health, UNICEF, CNLS, TRAC Plus

Executive summary

 

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Background:

PMTCT activities started in Rwanda in 1999 with a piloting phase in Kicukiro health centre in Kigali City. Results from this pilot were impressive and the MoH sought to expand PMTCT nationwide and to subsequently integrate it into existing health structures. In this regard, the MoH mobilized partners to support the roll out plan. A steering committee was set up with involvement of all potential partners and a steadfast rollout process was embarked on. Since then, scaling-up of PMTCT programme has been gradually taking place. By the end of 2009, 373 sites were offering comprehensive PMTCT services compared to the initial package.

Acknowledging the effects of poverty, gender inequality and food insecurity as key drivers in the spread of HIV and AIDS, the “Family Package”, was designed under the initiative of the First Lady, to promote socio-economic empowerment, male involvement in PMTCT services, psychosocial support using support groups, sensitization on Family planning use of services, support with “Mutuelles de Santé” (community health insurance) membership for families and nutritional promotion through Income Generating Activities (IGAs) in addition to standard clinical PMTCT services. After 8 years of implementation, there was a need to carry out a review in order to document project achievements; highlight best practices and lessons learned; and formulate recommendations for improvement and scale-up of the project. In this regard a review of the Family Package project was carried out between April and May, 2010.

Purpose/Objective:

 To assess the appropriateness of project’s model of care and support to address the PMTCT challenges
 To assess the overall performance of the project in delivering planned outputs and identify potential best practices for replication
 To determine the challenges faced during project implementation from program manager, care giver and beneficiary perspectives
 To formulate recommendations with regard to FP model of care and support, and programmatic interventions with potential for scale-up and sustainability

Methodology:

The review used both Qualitative and Quantitative approaches. Key evaluation questions were designed to assess if the model of care and support was appropriate, well implemented and sustainable. During the review process a literature and desk review was carried out and consultative meetings, Focus Group Discussions (FGDs) and interviews used as main methodologies to generate findings. Preliminary tools that allowed reviewers to gain insight into project intervention areas were developed and field visits were conducted in 7 sites. Key Informant Interviews were held with partners such as UNICEF, and UNIFEM, Clinton Foundation, World Vision, CNLS, a Head of PMTCT unit at TRACPlus and the Permanent Secretary of the Ministry of Health. In-depth interviews were conducted with Titulaires and head of the PMTCT department of each health facility where Family Package project was implemented. FGDs were conducted with two groups of beneficiaries, one group that comprised peer educators and another with beneficiaries drawn from associations/cooperatives at each facility. In total 14 FGDs in all seven FP sites.

Findings and Conclusions:

HIV test uptake among pregnant women attending ante natal care (ANC) in Family Package sites was higher as compared to the national average. In 2005, 98% in FP sites compared to national average of 89% of pregnant women attending ANC were tested. In 2008 and 2009, 100% of pregnant women were tested in FP sites compared with a national average of 97.9% in 2009.

The percentage of male partners attending ANC and testing for HIV in FP increased from 50% in 2005 to 82% in 2009. While this was much higher than the national average in 2005 and during the two years that followed, the national average caught up with FP sites average (82%) in 2009 (84%).

The proportion of HIV+ pregnant women in FP sites receiving ARV prophylaxis was consistently higher in FP sites compared to the national average. In 2009, this proportion in FP sites was 74% compared to 68% at the national level. 60% of infants born to HIV+ mothers get an HIV test at 6 weeks in FP sites compared to 54% nationally while 84% are tested at 18 months – a figure much comparable with the national average of 87%. The number of HIV+ mothers and infants lost to follow decreased respectively from 52 in 2007 to 26 in 2009 for the former and from 84 to 22 for the latter during the same period. In FP sites a total of 1,589 discordant couples are being followed up.

The review found that project planning and introduction process encouraged a participatory approach whereby stakeholders were brought on board; that the project was fully owned by all its stakeholders, at the national the local level. Further, the review noted that stakeholders demonstrated profound understanding of the project with beneficiaries (peer educators and members of the associations) being at the forefront in this regard. The project also addressed local needs and brought about palpable benefits to the health facilities, the beneficiaries and collateral benefits in communities in which they live.

Regarding project organizational and institutional framework, the review observed that despite registering progress, the project was implemented with limited staffing (one project officer was available). This minimized the amount of supervision from central level towards the sites, lead to inadequate recording of project activities and likely contributed to the observed insufficiency in training of beneficiaries and implementers (tituliares and/or PMTCT heads). Although the review observed different areas in which target groups were trained in order to build their capacity, a lack of training material (such as curricula, training manuals) lead to inconsistency in the content of training delivered at different health centers.

The review noted that there was inadequate monitoring of the project previously and welcomed the fact that a monitoring officer has been hired to institute an effective monitoring system.

The review identified different aspects of the project it deemed to be sustainable. These include the way the project is well integrated within the existing health structures. In this regard, the project uses the same PMTCT national program, the same health infrastructure and same personnel. This potentially makes it for the project to be extended to new sites without having to incur heavy investments.

Also, the project implemented certain pioneering interventions which brought economic gains to beneficiaries which included providing loans for IGAs, loans to individuals who present sound project proposals. Loans once provided were used to start micro projects which generated income thus improving beneficiaries’ livelihoods as well as those of their families.

Lastly, the cost of implementing the project was found to be minimal as the project spent $5 per beneficiary per year over a five period – a powerful finding that pints to potential for sustainability and scale up.

Recommendations:

Imbuto Foundation
1. Strengthen and streamline the monitoring and evaluation system of the Family Package, through development of an M/E plan, definition of measurable indicators and data collection and reporting tools. Advocate for greater integration of family package approach within the overall MoH National HIV policy frameworks and implementation strategies.
2. Devise mechanisms to increase appropriation of FP additional components by health center staff through increasing their participation in training, refresher courses and encouraging them to provide site leadership.
Review existing and adapt or develop documents with clear and smart project objectives, targets, including strategies, IEC materials, training packages.
3. Strengthen partnerships with all stakeholders to increase support to Family Package project in areas of funding to allow for effective implementation of the project interventions.
4. Develop strategies specifically targeting discordant couples in order to avert new infections within this sub group – allowing for further reduction of stigma and gender violence within families.
5. Consolidate and strengthen community involvement in PMTCT activities by all organised community groups. Peer or Mentor Mothers; Community health workers and the community leaders and other peer support groups should be supported more and their capacities improved to support PMTCT services. Partnerships and networking between health facilities and community support groups should be promoted by establishing linkages for follow up of PMTCT clients within the community for improved effectiveness of the programme.
6. Strengthen project management capacity (HR, Training) of family package project staff.
7. Design and implement a quasi-experimental study comparing PMTCT outcomes in sites implementing FP and those not implementing it, to determine the real impact of FP interventions towards provision of PMTCT services.
8. The proportion of association members eligible to who received loans was 33 %. The review revealed that those who did not access loans had IGA proposals that did not meet the funding criteria. The review recommends that beneficiaries be trained in micro project plan development to help beneficiaries develop proposals that meet the funding criteria and increase their chances of receiving these much needed loans.

Health Facilitates
1. The review found many benefits of the project towards the health facilities, the staff and their clients. Tituliares should use findings of this review to increase awareness of benefits of FP among the staff thereby improving project appropriation by the staff.
2. Strengthen male championships and involvement of male partners to provide care and support to the mother and child, by extending male involvement beyond attending the first ANC visit and get involved in the whole cascade of the PMTCT services

TRACPlus
1. Adopt integration of family package project components (Loans for IGAs, discordant couple counseling and Peer Education) in the current PMTCT program
2. The Ministry of Health, through TRAC Plus should advocate for funding from national level and other sectoral plans to support cooperatives and associations members as well as families infected and affected by the HIV epidemic.



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