Presented by Melene Kabadege MCH Regional Technical Advisor, World Relief December 9, 2010

Rwanda Health System Structure

Evolution of CHWs in Rwanda Beginning of CHW program The program was initiated in 1995 with the objective to be the first level of entry to the health system at to the smallest administrative unit of the country (villages) with a minimum package of activities focusing on primary health care Evolution The selection and training of CHWs countrywide was linked with a diversification of strategies to reduce child and maternal mortality and community case management

Present CHW Composition at village level 4 CHWs/ village 2 CHWs for CCM (binome: male- female pair) 1 CHW for Maternal Health 1 CHW for Health and Social Affairs

Plan to add two additional CHWs A fourth package of activities will be added soon and will focus on rehabilitative services (palliative care) A set of 2 CHWs might be added per village turning to 6 the number of CHWs per village and bringing the national number from 60,000 to about 88, , , CHWs per village Total CHWs Future activities

CHW election process Community is informed by MOH about the CCM program and the characteristics needed for CHWs. The community elects one man and one woman for CCM and one woman for Maternal health. CHW in charge of Health and social affairs is elected during local leader elections.

CCM Binome Community Health Worker Functions Preventive Services Community sensitization on prevention of common: Malaria, Diarrhoea, etc. Community mobilization towards healthy lifestyles especially during national health campaign: immunization, hygiene and sanitation Educate communities on use of water treatment solutions and distribute them Curative Services Community Case Management of malaria, pneumonia, diarrhoea, others (e.g. Community Integrated Management of Childhood Illnesses/Community IMCI) Provision of family planning services including FP products Engage in community DOTs for tuberculosis Promotive Services Nutrition education to communities Growth monitoring particularly among children under five years old Nutrition surveillance

CHW CCM training CCM Training is done by MOH/HC trainers after TOT Training lasts 4 days MOH relies on NGO partners to support implementation

CHW CCM Supervision and Follow-up Monthly meetings at the health center for data collection and medicine resupply. Some supervisors do mini trainings at this time. Each CHW should be visited by a Supervisor from the health center quarterly and by a Peer CHW Coordinator monthly.

CHW in charge of Community based Maternal & Newborn Care Identify in the community and register women of reproductive age, pregnant women Encourage ANC, birth preparedness, facility based deliveries, and FP Accompany women in labor to health facilities Encourage early postnatal facility checks for both newborns and the mothers. Identify women and newborns with danger signs and refer them to health facility for care

Community Health Information Management System A list of community health indicators has been established to feed into the national HMIS. Phones for CHWs have been distributed in some districts Some community health workers have been tested on use of mobile phones to capture and send health information by Rapid SMS.

CHW Incentives CHWs belong to a cooperative at the level of the health center. Funds from Community Performance Based Financing are used by the cooperative to fund income generating activities by the members. CHW make basket for sale

Policy environment National Community Health Policy has improved coordination of CHWs’ activities Community Health policy supports CCM for malaria, pneumonia and diarrhea. Community mobilization for behavior change is less developed.

RWANDA EXPANDED IMPACT CHILD SURVIVAL PROGRAM A Partnership of Concern Worldwide, International Rescue Committee and World Relief

6 Program Districts Nyamagabe Ngoma Map of Rwanda

Major EIP Strategies CCM: build capacity of MOH for training and supervision of CHWs doing integrated CCM of malaria, pneumonia, diarrhea and malnutrition.

EIP Strategies (cont.) BCC: community mobilization for behavior change using modified Care Groups comprised of CHWs and Community Health Volunteers. M&E: support CHWs and HCs to collect and analyze community health data.

DistrictPopulationCHWs Gisagara300,7361,048 Kirehe307,3911,250 Ngoma284, Nyamagabe334,0021,072 Nyamasheke357,0341,206 Nyaruguru280, TOTAL1,863,5716,186 CHWs trained on CCM by EIP

6,1186 CHWs Trained & Equipped by EIP

8 CHWs Volunteers for every 2 villages form one Care Group serving Total Households (fewer HH have children U5) Volunteers complement 13,000CHWs for BCC in 650 Modified Care Groups

Challenges Integration of Community Health data in National HIS Budget for replacement of CHW tools and materials Drug management

Challenges Ongoing Supervision of CHWs by Health center, transport & allowances Sustainability of CCM Quality of Care post project Inclusion of modified Care Groups into official CHW strategy Integration of Health Volunteers into CHW cooperatives

Lessons Learned Well-trained CHWs are capable of implementing integrated CCM. Peer Supervision for CHWs can help to compensate for HC staff limitations with supervision. Policy combined with strong political will for CHWs contributes to program success.

Lessons Learned (cont.) Increasing the number of CHWs & BCC volunteers per village helps to balance the workload. CHWs working as a team at the village level improves motivation and impact. Presently this only happens where EIP has incorporated the CHWs into modified Care Groups with complementary volunteers for BCC.

Murakoze cyane! THANK YOU!