Overview
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
Rwanda National Health Policy
(based on WHO’s seven building blocks health systems strengthening)
1
1
2
2
To improve accessibility
to, quality of and
demand for Maternal
Health, Family Plan.,
Rep. Health, Nutrition
services
3
To consolidate,
To consolidate,
expand and improve
expand and improve
services for the
services for the
prevention of disease
treatment and
and promotion of
control of disease
health
To strengthen the sector’s institutional capacity
To increase the availability and quality of human resources for Health
To ensure financial accessibility to health services for all
3
4
5
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To ensure financial accessibility to health services for all & sustainable & equitable financing of the health sector
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 the highest attainable quality of health services at all levels
7
To strengthen Specialised Services, National Referral Hospitals and research capacity
Levels of Intervention
•Family-oriented community based services
•Population oriented schedulable services
•Individual oriented clinical services
Community Health Structure
NATIONAL LEVEL
MiniSante
Community Health Desk
DISTRICT ADMINISTRATION
District Health Supervisor
•
•
DISTRICT HOSPITAL
District Hygiene and Sanitation Officer
Community Health Coordinator
HEALTH CENTER/COOPERATIVE
Hygienist or Sociologue
Chargé of Community Health Activities
CELL LEVEL
Binome Supervisor
(1 per cell, elected from among the binomes)
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•
•
•
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)
T
Strengthening
health systems through community
health
Evolution of CHWs
1995
BEGINNING OF CHW
•
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
+11% p.a.
2005
2011
Evolution
• Selection and training of CHWs
countrywide
• Linkage to a diversification of
strategies
• to reduce child and maternal
mortality
• community case management
Community Health Workers
1 Female
in charge of
maternal Health
1 CHSA (in charge of
social affairs)
1 Binome
female & male
4
CHWs/
village
Community
Health
Workers
have
broadof
of
Community
Health
Workers:
a abroad
ofrange
activities
Community
Health
Workers
have
broadarange
range
activities
activities
Preventive Services
Curative Services
•Community sensitization
•Community Case
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
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-based prevention, screening and
treatment of malnutrition
• 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
Integrated Management of Child Illness
(CB-IMCI)
• 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 maternal- neonatal care
• 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 provision of family planning
• 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 DOT HIV, TB and other chronic illnesses
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 behavior change and communication
• 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 Environmental Health Interventions:
Implementation of CBEHPP
• 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 health information systems and
innovative technologies (m’ubuzima: Rapid SMS & P4H )
• 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-based health insurance
• 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-PBF/www.pbfrwanda.org/siscom
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
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.
Incentives and motivation for CHWs
•
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
Monitoring and Evaluation
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
Way forward
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•
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Evaluate innovative interventions
Community participation
Promote and share best practices
Learn from other country experiences
Strengthen referral between community
and health facilities
• More…
THANKS