Community Health program in Rwanda:

from Policy to Action

Cathy Mugeni,

Community Health Desk, Ministry of Health

January 25, 2011

First International Community Health Conference

Kigali, Rwanda

Overview

To consolidate, expand and improve

services for the prevention of disease

and promotion of health

To consolidate, expand and improve

services for the treatment and

control of disease

To ensure financial accessibility to health services for all

To improve accessibility to, quality of and

demand for Maternal Health, Family Plan., Rep. Health, Nutrition

services

Levels of Intervention•Family-oriented community based services•Population oriented schedulable services

•Individual oriented clinical services

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To increase the availability and quality of human resources for Health

To strengthen the sector’s institutional capacity

To ensure the highest attainable quality of health services at all levels

To strengthen Specialised Services, National Referral Hospitals and research capacity

To ensure geographical accessibility to health services for all

To ensure (universal) availability & rational use at all levels of quality drugs, vaccines & consumables

To ensure financial accessibility to health services for all & sustainable & equitable financing of the health sector

Rwanda National Health Policy Rwanda National Health Policy (based on WHO’s seven building blocks health systems strengthening)(based on WHO’s seven building blocks health systems strengthening)

NATIONAL LEVELMiniSante

Community Health Desk

NATIONAL LEVELMiniSante

Community Health Desk

DISTRICT HOSPITAL•District Hygiene and Sanitation Officer •Community Health Coordinator

DISTRICT HOSPITAL•District Hygiene and Sanitation Officer •Community Health Coordinator

DISTRICT ADMINISTRATIONDistrict Health Supervisor

DISTRICT ADMINISTRATIONDistrict Health Supervisor

HEALTH CENTER/COOPERATIVEHygienist or Sociologue

Chargé of Community Health Activities

HEALTH CENTER/COOPERATIVEHygienist or Sociologue

Chargé of Community Health Activities

CELL LEVELBinome Supervisor

(1 per cell, elected from among the binomes)

CELL LEVELBinome Supervisor

(1 per cell, elected from among the binomes)

UMUDUGUDU (VILLAGE) LEVELCommunity Health Workers

•Binomes (male & female worker in each umudugudu)•CAS (1 per umudugudu)•ASM (1 per umudugudu)•Palliative Care (2 per umudugudu, not yet elected)

UMUDUGUDU (VILLAGE) LEVELCommunity Health Workers

•Binomes (male & female worker in each umudugudu)•CAS (1 per umudugudu)•ASM (1 per umudugudu)•Palliative Care (2 per umudugudu, not yet elected)

Community Health Structure Community Health Structure

T

+11% p.a.

201120051995

Evolution of CHWs

•Selection and training of CHWs countrywide

•Linkage to a diversification of strategies

• to reduce child and maternal mortality

•community case management

•Initiated : 1995 ( after Genocide ) Objective: first level of entry to the health system•Operates at smallest administrative unit of the country (villages)•Includes a minimum package of activities focusing on primary health care

BEGINNING OF CHW Evolution

Strengthening health systems through community Strengthening health systems through community healthhealth

Community Health WorkersCommunity Health Workers

1 Binome female & male

1 CHSA (in charge of social affairs)

4 CHWs/ village

Community Health Workers have a broad range of activities

Preventive Services

•Community sensitization on prevention of common: diseases: malaria, diarrhoea, ARI, etc.

• Education for prevention of sexual transmitted infections

•Community mobilization and sensitization, health campaign on hygiene and sanitation, immunization etc.

•Educate communities on use of water treatment solutions and distribute them

Curative Services

•Community Case Management of malaria, ARI, diarrhoea, vaccination, malnutrition (e.g. Community Integrated Management of Childhood Illnesses/Community IMCI)

•Provision of family planning services including FP products

•Engage in community DOTs for tuberculosis, HIV

Promotive Services

•Nutrition education to communities

•Growth monitoring particularly among children under five years old

•Nutrition surveillance

•Routine home visits for active case finding

Community Health Workers have a broad range of activities

Community Health Workers: a broad range of activitiesCommunity Health Workers: a broad range of activities

• Monthly growth monitoring & promotion

• Screening children for SAM using Middle Arm Circumference Measurement tape (MUAC)

• Treatment of SAM with RUTF (Plumpynut)

• Community demonstration kitchens to prevent malnutrition and reoccurrence

• Community level follow-up for treatment effectiveness

Community-based prevention, screening and Community-based prevention, screening and treatment of malnutritiontreatment of malnutrition

• Targets children less than 5 years for following health problems • fever • diarrhea • acute respiratory infections • malnutrition

• Medications provided include;• coartem • amoxicillin (pneumonia)• oral rehydration solution +

zinc

Community based Community based Integrated Management of Child IllnessIntegrated Management of Child Illness

(CB-IMCI)(CB-IMCI)

• Identify and register women of reproductive age (encourage family planning)

• Identify pregnant women and encourage ANC, birth preparedness and facility based deliveries

• Identify women and newborns with danger signs and refer them to health facility for care

• Accompany women in labor to health facilities

• Encourage early postnatal facility checks for both newborns and the mothers

• Use RapidSMS to support activities

Community-based maternal- neonatal care Community-based maternal- neonatal care

• Community health workers (CHW) provide:

• condoms,

• oral contraceptive pills,

• injectables,

• Standard Days Method

• Pilot In March and April, 2010,

• 3068 CHWs were trained as trainers in CBP.

Community based provision of family planning Community based provision of family planning

Community DOTs for treatment and care of TB; •implemented in 30 districts •100% of the Rwandan population

Community DOTs for treatment and care •HIV •NCD implemented by partners in 3 districts since 2005

Community DOT HIV, TB and other chronic illnessesCommunity DOT HIV, TB and other chronic illnesses

• Sensitizing communities on disease preventive measures

• proper hygiene and sanitation,

• use of Insecticide treated mosquito nets,

• early health care seeking behaviors,

• breast feeding, infant and young child feeding/nutrition

• Disease surveillance

• Contact tracing

Community behavior change and communicationCommunity behavior change and communication

• CHWs will be responsible for mobilizing the community to join CHC

• CHWs will facilitate for the CHC during dialogue sessions

• The CHWs will list all CHC members in a registration book

• CHW signs membership cards for those attending sessions

• CHWs make household visits to check improved hygiene practices

Community Environmental Health Interventions: Community Environmental Health Interventions: Implementation of CBEHPPImplementation of CBEHPP

• All CHWs received mobile phones;

• Phone4He being piloted for CHWs to report on HMIS indicators

• CHW binome enters list of community health indicators that feeds into national HMIS;

• 22 indicators

• include CCM, MCH, deaths,

• Rapid SMS transmits information into computerized recording and response system

• Improves referral system

• Contact tracing, etc

• Facilitates emergency services /

Community health information systems and Community health information systems and innovative technologies (m’ubuzima: Rapid SMS & P4H )

• Health mutuelle:• Covers 85% of population• 1000Rwf annual fee, • payment per service

• Increases access to health facility services

• Reduction in illnesses• Most vulnerable are covered

by basket fund (risk-pooling)

Community-based health insurance

Improves performance of CHWs by motivating them to raise agreed upon performance indicators

Payments made when proof of the agreed level of performance

Community PBF guide details management at different levels

The Sector Steering Committee oversees the implementation and approves payment to the CHW Cooperative.

Indicators entered at district level into web-based database after quarterly approval by committee with feedback

Community-PBF/www.pbfrwanda.org/siscom

CHWs COOPERATIVEs

All CHWs organized in cooperatives to ensure income generation and accountability of expected results

Community PBF payments used for cooperative income generating projects including:

poultry, cattle/goat/pig rearing, crop farming, basket making, etc.

• Trust and respect from community members, leaders etc…

• Support from Supervisors and implementation partners help improve work;

• Regular trainings, meetings supervision

• In-country study tours to learn from peers in other districts

• Distance learning

• Community performance-based financing (PBF);

• Membership in cooperatives for income generation

Incentives and motivation for CHWsIncentives and motivation for CHWs

National• M&E desk at MoH: supervisors• M&E technical work group with partners

District• 41 & 5 NGOs Community health and M&E

supervisors

Health center• 380 In-charge of community health• 416 Sector-level comité de pilotage

Cell• CHW supervisors

Monitoring and Evaluation

• Evaluate innovative interventions• Community participation • Promote and share best practices• Learn from other country experiences• Strengthen referral between community

and health facilities• More…

Way forward

THANKS