Dr. Richard B. Munyaneza, MD, Rwanda Ministry of Health

Community Health in RwandaCurrently 45,000 CHWs are in place

1 per village supporting maternal and newborn health as well as family planning

2 per village engaged in integrated community case management (iCCM) of childhood illness

Community participates, supports, encourages and recognizes CHWsCommunity Health Desk (CHD), district hospitals, health

facilities, and partners all involved in training of CHWs

CHWs are volunteers, but receive support from community performance based financing (c-PBF) via income generating activities (IGAs) of CHW cooperatives

1. Can read and write 2. Are aged between 20-50 years

3. Willing to volunteer 4. Lives in the local village5. Is honest, reliable, and trusted by the community 6. Must be elected by the village members 7. Two women, one man

Primary Care

• Community Case Management of malaria, ARI, diarrhoea, vaccinations, malnutrition, etc. (e.g. Community Integrated Management of Childhood Illnesses/iCCM)• Engage in community DOTs for tuberculosis and HIV•Miso (in its pilot phase)

Promotion

• Education to communities on nutrition• Growth monitoring, particularly among children under five years old• Nutrition surveillance• Routine home visits for active case-finding• Health campaigns on hygiene and sanitation, immunization, etc

Prevention

• Maternal and newborn health package• Provision of family planning services and products like injectables, pills, and condoms• NCDs packages • Community sensitization on prevention of common diseases like malaria, diarrhoea, ARIs, etc.• Education on the prevention of sexually transmitted diseases and infections

Who is a CHW?In Rwanda, community health workers are a formal part of the national health strategy and are coordinated by the Community

Health Desk of Ministry of Health

Qualifications

 Diagnostic and Curative ServicesDiagnosis of malaria with rapid diagnostic testsTreatment of confirmed malaria with artemether-lumefantrineTreatment of acute respiratory infections with amoxicillinTreatment of diarrhea with oral rehydration solution and zinc Referral and Reporting ServicesReport deaths to local health center and Ministry of HealthRefer children with moderate and severe acute malnutrition, severe pneumonia, severe malaria, and severe dehydration to local health center 

  Monitoring and Evaluation of CHWs1. A 5-day District hospital supervision by Central level: planning activities and data analysis to sort out deficiencies in indicator performance (Quarterly)2. A one-day Health Center supervision by District hospital (Monthly)3. A one-day supervision of Community Health Workers by Health Centers staffs (Quarterly) 4.Aone-day supervision of Community Health Workers by Cell Coordinators (Monthly)5. The iCCM program evaluation every 2 to 3 years 6.Individual assessment of CHWs, aim is strengthen the practical skills of CHWs in the care of sick children according to iCCM Community protocol.  

  1. The integrated supportive supervision is done in two ways. First rapid quality assessment using the integrated supervision checklist2. This helps to identify areas that need improvement and therefore the team able to prepare materials for the on-job training.3.Central level analyze reports and give feed backs to districts during coordination meeting held once every quarter with presentation of weaknesses and recommendations4. Districts respond by going to HC’s to do supportive supervisions in certain districts that were seen with weakness

  

CHALLENGESHuge number of CHWs who need training and supportive supervision;Difficulty sustaining routine supervision visits to CHWs in the villages

where they work.Turn over of CHWs in some villagesDifficulties in overcoming some religious or cultural barriers to care and

sustaining routine visits of rural populations to the villages where CHWs work

Due to decreased funding from the Global Fund, the financing of training, supervision, technical support, and the provision of medication, materials, and tools will be a major challenge in the coming years

Overall Conclusions iCCM can be an effective means for reducing mortality childhood

diseases, Maternal Death and Newborn iCCM requires intensive initial and follow-up trainings and quality

control programs for the community health workers in each village iCCM also requires well developed supply chains to ensure availability

of supplies and medications iCCM requires both strong local community support and national

political will to succeed

iCCM requires both strong local community support and national political will to succeed

Questions?