THE ROLE OF PARTNERSHIP IN
STRENGTHENING THE COMMUNITY
HEALTH SYSTEM IN RWANDA:
THE MOH/PIH PARTNERSHIP AS AN EXAMPLE
Didi BERTRAND FARMER
Kigali, January 25-28, 2011
INTRODUCTION
The MOH/PIH community
health system
Background
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In 2006, in accordance with Rwanda’s MOH,
Partners In Health (PIH) began initiating a number
of health system strengthening (HSS) activities to
enhance the national Community Health Worker
(CHW) system.
MOH/PIH model is adapted from an established
international model of community health in PIH
Haiti.
Model is implemented in Burera and southern
Kayonza Districts (550,000 persons).
Principals of Community Health system
KEY principals to build a system of CHWs :
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Geographical distribution and Sufficient number of CHW (about
1 CHW per 40-50 households)
Standardized training with clear responsibilities (multidisciplinary
roles)
Staffing for systematic support for strong supervision and
coordination
Monitoring and Evaluation with feedback to the CHWs for
program improvement
Adequate Compensation
CHW system feeds into a well-functioning health center
Community involvement
Rwanda’s MOH Community Health System
Overview of MOH system started in 2008:
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Two CHWs per village (50 up to 250 households) for
IMCI community health;
One CHW per village for Neonatal and maternal
health;
One Health Center/sector based in charge of CHW
program;
One District Hospital level program supervisor;
Reporting through PBF Report;
Financing 100% through cooperatives.
Additional MOH Interventions
C-IMCI, Community Cooperatives, & PBF
MOH Intervention Achievements: 2009
 Implementation
of c-IMCI (community
integrated management of childhood
illnesses) through introduction of Binomes
Implementation of income-generating
CHW cooperatives to finance national CHW
system
Implementation of Performance-Based
Financing (PBF) Report to pair data
collection with financing and supervision
activities
PIH INTERVENTIONS
Key enhancement components to the
National Community Health Program
through a MOH/PIH Partnership
Activity 1:
Increase in number of multi-disciplinary
CHWs (binomes) in each village to one per
fifty households.
Average (umudugudu) size:
40 to 250 households
(or more)
Activity 2:
Monthly household visits by CHWs for early
case detection, treatment and referral.
Activity 3:
Additional training for CHWin primary
health specialties including
HIV to improve performance of CHWs.
Training for Health Center/sector based in
charge of CHW program and Hospital level
program supervisor on Program Management
and data quality Improvement
Activity 4:
Supplemental Performance-Based Financing
(PBF) to incentivize individual CHWs.
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Performance-based compensation
(10-20 USD/month) for:
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Monthly home visits, daily accompaniment & key maternal
health activities;
Timely completion of a monthly report form;
Participation at monthly training.
Additional support to Cooperatives:
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10% compensation directed to cooperatives;
Technical support for managing income-generating activities;
Added financial support to cooperatives based on number of
CHWs.
Activity 5-Staffing for systematic
support and supervision
5a. Community health nurse at each health center working in
collaboration with Charge of Community Health Program:
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Supervise the CHWs and CHW supervisors
Organize trainings and meetings
Collect and prepare monthly reports, organize sensitization
activities, and implement the PBF system.
Provide technical support for clinical components
5b. PIH funding CHW supervisor at cell level:
• With higher level of education
• Monitors all CHWs and their households
• Hosts monthly meetings with all CHWs
5c. Supervision tools provided at all levels
Activity 6-Monitoring, reporting and
evaluation
6a. A supplemental monthly report:
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Complements MoH PBF report
Monitors and supports supervision of non-PBF CHW
activities
6b. A household chart:
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Facilitates regular delivery of care
Captures socio-demographic data
Monitors target populations (pregnant women,
women on family planning, chronic care patients,
children under 5)
Activity 7:
Training of supervisors (cell and sector level) to
improve CHW performance.
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Daily accompaniment for chronic diseases to improve
treatment adherence and outcomes.
HIV patient on food
supplements and accompaniment
( 18 months later)
Activity 8:
Enhanced Community Involvement
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System works in close collaboration with existing societal structures:
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Local leaders;
Traditional healers and birth attendants ;
Church representatives;
Local groups and associations, etc.
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CHWs use community forums to conduct sensitization and advocacy
activities, promoting active participation of the community in decisions
regarding their health.
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Builds solidarity and establishes a community link to the broader
healthcare system.
Costs of System: $3 US per capita
Additional Components:
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Community Health Nurse salaries;
Supervisors salaries;
Compensation for CHWs;
Trainings and meetings for CHWs, supervisors , and
Community Health Nurses;
Training materials and tools;
Support training on MOH materials;
Sensitization activities with District collaboration;
Technical support and contributions to cooperatives.
Results and Conclusions
The role of partnership in strengthening
community health systems
Results
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In the two districts:
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2,067 multi-disciplinary CHWs follow 110,000
households performing IMCI community
protocols, family planning and maternal
health interventions;
1,741 CHWs accompany a total of 5,000
patients daily to aid in HIV, TB, and other
chronic disease treatment;
The CHW attrition rate in southern Kayonza is
< 3% and 98% of CHWs attend trainings and
monthly meetings and complete reports on
time.
Conclusion
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Nongovernmental partners can support and
strengthen important components of public CHW
programs through a number of different
interventions.
In two districts in Rwanda, an innovative CHW
model has been implemented quickly to reinforce
the overall health system.
More research is needed to evaluated the impact
of the added components
Acknowledgments
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MOH/CH DESK
Doris Duke Grant: Partnership for African Health
Systems Strengthening
Clinton Health Access Initiative (CHAI)
University of Rwanda School of Public Health.
National Institute of Statistics, Rwanda
THANK YOU
MURAKOZE
.