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Community Health Workers

In Delivery on September 19, 2009 at 11:53 am

The key to effective care in rural Rwanda

Alison Kraemer, Staff Writer

55 Rwinkwavu , Rwanda 6 029

The primarily rural population of Rwanda faces seemingly overwhelming barriers to obtaining quality healthcare where there is only one doctor for every 20,000 people.  The government of one of the world’s poorest nations has sought for over a decade to revitalize the shattered post-genocide health system.  To strengthen public healthcare for the impoverished and underserved people of Rwanda, the non-governmental organization Partners In Health (PIH) partnered with the Clinton Foundation and the Rwandan Ministry of Health (MOH) in April 2005 to bring its model of comprehensive community-based care, developed over several decades in rural Haiti, to Rwanda.1 In fact, PIH boldly instituted resources often overlooked in global health delivery – Community Health Workers, or CHWs.  As members of their local villages, the CHWs are employed, trained, and compensated by PIH and the Rwandan MOH to invest in personal home-based care.

“This program is giving value, recognition, and training to these community health workers,” says Melissa Gillooly, the Project Manager for PIH in Rwanda.  “They are given the training needed to carry out these important jobs, allowing them to play an important role in the public health system as educators and providers and serving as a vital link to the health centers.”

When PIH arrived in 2005, community based-care providers already existed and comprised three types of health workers.  The Animateurs de Santé (“Health Facilitators”) had been in place since 1995 and were involved in activities such as vaccination, malnutrition, and growth monitoring programs as well as other preventative healthcare interventions for children and community sensitization activities.  The Home-Based Malaria (HBM) program started in 2005 and instituted community health workers who provided children under five with rapid access to malaria treatment at a cost of 100 Rwandan francs (approximately $0.20) per child.  The third group, traditional birth attendants (TBAs), followed and monitored pregnant women.  Most of these CHWs had no organized training and often worked without compensation.2

Community Health Worker PIH Rwanda 046Thus, Inshuti Mu Buzima (“Partners In Health” in Kinyarwanda, the Rwandan national language) began to recruit a network of trained and paid CHWs to deliver high-quality primary care to two districts in southeastern Rwanda, which were without a doctor or district hospital.3

For years, PIH has utilized accompagnateurs, CHWs that originated from PIH’s work in Haiti to provide locals with medical and socioeconomic aid.  Following the positive results in the first two years of recruiting and training CHWs in Rwanda, in 2007 PIH began to work with the MOH on plans to harmonize the national community health worker system.  Together, the Rwandan MOH and PIH have developed plans to expand a new, comprehensive system of CHWs that includes efforts to serve every umudugudu (village).  This plan incorporates the successful approaches used in PIH’s work, which influenced the development of the Ten Principles of Rwanda Scale-Up and the Rwandan District Health System Strengthening Framework. This plan anticipates full scale up in five to seven years across the country’s 27 districts with ten goals, including the delivery of high-quality universal healthcare services, access to drugs and nutrition services, and socioeconomic aid to remove barriers to treatment.4

The success of the “Scale-Up” will rely upon the work of skilled and educated CHWs.  As respected members of their local communities, CHWs are elected by community members and supported by local leaders.  Most CHWs are unemployed or working as subsistence farmers before being elected to these positions.  Yet, they are not without experience as a few are former Animateurs de Santé and some are even former patients with first-hand experience relating to HIV and/or TB.5

With the more comprehensive model that PIH began to carry out in 2008, “training [of CHWs] occurs in primary healthcare, including malnutrition, reproductive health, family planning, hygiene, and childhood illnesses,” says Jill Hackett, the Director of Training for PIH.  “The content of training is decided and prioritized according to the Ministry of Health’s priorities.”

The new system ensures that each CHW visits 40-50 houses at least once a month.6 Due to the specialized training they receive in the treatment of HIV and TB and primary healthcare topics such as malaria, the CHWs administer medications to ensure that patients take the proper dose and avoid drug-resistance.  Additionally, CHWs provide psychosocial support by educating patients about strategies for following their often complex drug treatments.  They work to dispel stereotypes and misunderstandings about HIV, TB, or other diseases through education and the encouragement of preventative options.7

“Community involvement and the harmonized system of CHWs will ensure the delivery of effective Primary Health Care services by bringing health services, social needs and institutional support closer to the community,” says Didi Bertrand Farmer, the PIH Director of Community Health Programs in Rwanda.

Despite recent worries that CHWs might not be compensated enough, Ishuti Mu Buzima can assure that it sets a high priority to compensating its CHWs fairly for their work.  PIH believes that such compensation of these community members in settings of poverty and unemployment boosts local economies and stabilizes CHW commitment.8

Some may refute that, as members of the communities they serve, the CHWs may be tempted to reveal information about their patients to other locals and, thereby, exacerbate stigma concerns.  However, CHWs are trained to respect the privacy and confidentiality of their patients.  CHWs must also build the patient’s trust as they often grant sensitive emotional support and counseling.9

Indeed, CHWs are required to serve as the community’s link to the health facilities. The CHWs constantly feed back to their CHW leaders at the clinics who are responsible for supervising between 20 and 25 CHWs.10 If patients have non-medical problems – housing, nutritional, educational, or economic hardships – that could complicate care, the CHWs notify the clinical staff immediately to request aid.11Community Health Worker PIH Rwanda 050-1

“Community health workers strengthen health systems overall,” says Hackett.  “As the eyes and ears of the clinic, their role is very important in helping to strengthen the public health structure that they are referring to – not just in the community but in their ties to the clinic that is so vital, as well.”

Unlike health workers from certain non-governmental or aid organizations who set up shop temporarily in a rural village and leave after their work is ‘done,’ the Rwandan CHWs are established members of their local communities and are there to stay.  As such, Rwandan patients will not rely on foreign doctors and health workers for their well-being, but rather will be more self-sufficient and innovative in their health systems.  The Community Health Worker model of the MOH-PIH partnership in Rwanda will continue to deliver these long-term, sustainable medical and social services to locals not only now but long into the future.

Based on the main principles of a sufficient number of CHWs per umudugudu, reception of standardized training, systematic supervision, fair compensation, and community involvement, the harmonized system of CHWs will ensure the delivery of effective Primary Health Care services by bringing health services as well as social needs and institutional support closer to the community.  These principals have integrated the CHWs into the formal health system and are securing the sustainability of the community health program in Rwanda.  This approach will create enduring partnerships that will engage the community in their own development while improving equity of access to healthcare and helping the Rwandan MOH to meet the Millennium Development Goals.10

1Gillooly, Melissa. Partners In Health. E-mail to the author. “Strengthening Health Systems with Community Health Workers; Rwanda’s Comprehensive Community Health Program.” Primary Reference: “The Rwandan District Health System Strengthening Framework, MOH July 2008.” 20 March 2009.

2Didi Bertrand Farmer. Partners In Health. E-mail to the author. 4 April 2009.

3Partners In Health. “Rwanda/Inshuti Mu Buzima.” Where We Work. 2006. <http://www.pih.org/where/Rwanda/Rwanda.html&gt;.

4Partners In Health. “Rwanda scales up PIH model as national rural health system.” PIH News. October 2007. < http://www.pih.org/inforesources/news/Rwanda_Scale-up.html&gt;.

5Partners In Health. “Community Health Workers.” Accessed Online on 27 February 2009. <http://model.pih.org/book/export/html/4&gt;.

6Didi Bertrand Farmer. Partners In Health. E-mail to the author. 4 April 2009.

7Partners In Health. <http://model.pih.org/book/export/html/4&gt;.

8Gillooly, Melissa. Partners In Health. E-mail to the author. 20 March 2009.

9Gillooly, Melissa. Partners In Health. E-mail to the author. 20 March 2009.

10Didi Bertrand Farmer. Partners In Health. E-mail to the author. 4 April 2009.

11Partners In Health. <http://model.pih.org/book/export/html/4&gt;.

12Didi Bertrand Farmer. Partners In Health. E-mail to the author. 4 April 2009.

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