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

ICCM Implementation

iCCM Rollout by District

Community Health in Rwanda Currently 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 CHWs Community 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 write2. Are aged between years 3. Willingto volunteer4. Lives in the local village 5. Is honest, reliable, and trusted by the community 6. Must be elected by the village members7. 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

Specific Activities for CHWs for iCCM Diagnostic and Curative Services  Diagnosis of malaria with rapid diagnostic tests  Treatment of confirmed malaria with artemether-lumefantrine  Treatment of acute respiratory infections with amoxicillin  Treatment of diarrhea with oral rehydration solution and zinc Referral and Reporting Services  Report deaths to local health center and Ministry of Health  Refer children with moderate and severe acute malnutrition, severe pneumonia, severe malaria, and severe dehydration to local health center

Under Five Mortality by District

Health Facility Utilization by District

Supervision Monitoring and Evaluation of CHWs 1. 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.

Supportive Supervision 1. The integrated supportive supervision is done in two ways. First rapid quality assessment using the integrated supervision checklist 2. 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 recommendations 4. Districts respond by going to HC’s to do supportive supervisions in certain districts that were seen with weakness

CHALLENGES Huge 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 villages Difficulties 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

Questions?