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

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

NATIONAL LEVEL MiniSante Community Health Desk NATIONAL LEVEL MiniSante Community Health Desk DISTRICT HOSPITAL District Hygiene and Sanitation Officer Community Health Coordinator DISTRICT HOSPITAL District Hygiene and Sanitation Officer Community Health Coordinator DISTRICT ADMINISTRATION District Health Supervisor DISTRICT ADMINISTRATION District Health Supervisor HEALTH CENTER/COOPERATIVE Hygienist or Sociologue Chargé of Community Health Activities HEALTH CENTER/COOPERATIVE Hygienist or Sociologue Chargé of Community Health Activities CELL LEVEL Binome Supervisor (1 per cell, elected from among the binomes) CELL LEVEL Binome Supervisor (1 per cell, elected from among the binomes) UMUDUGUDU (VILLAGE) LEVEL Community 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) LEVEL Community 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 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 health

Community Health Workers 1 Binome female & male 1 CHSA (in charge of social affairs) 1 Female in charge of maternal Health 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 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 treatment 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 Integrated 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 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 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 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 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: Implementation 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 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/

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 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