Hi Karen,

Thanks for your question about Community Health Workers (CHW) in Rwanda. Here’s a partial response but hopefully other members of the community who are currently in Rwanda will pitch in and provide insights on their experience in the field.

CHW in Rwanda are called Animateurs de santé. As we explained in our GHD case study: HIV Care in Rwanda (not available online for now but check our blog for brief summaries: http://globalhealthdelivery.org/blog/?p=243), the Ministry of Health began recruiting Animateurs de santé to improve human resource capacity in 1995.

Animateurs are volunteers chosen by their communities who counsel community members and provide education about good health practices (family planning, HIV prevention, malaria prevention, antenatal care). They also monitor health and nutrition and report disease epidemics in their area of coverage.

Animateurs do not provide curative services (e.g., prescribing and dispensing medicines). Some animateurs specialize in one of the following: (1) home-based birth assistance and midwifery, (2) child growth monitoring and vaccination screening, or (3) home-based malaria prevention and case finding. By 2006, the MOH had trained approximately 12,000 animateurs nationwide.

According to the MOH Strategic Plan 2006-2010 on Human Resources for Health (http://www.rwandagateway.org/IMG/pdf/HRH_plan_2006-2010.pdf), CHWs work at the district level for health centers, either public or private: “The intermediary level is represented at the district by an administrative unit in the Mayor’s office. This unit is responsible for family health and gender, a district hospital and a network of health centres that are either public, government assisted not-for-profit, or private. The district is the operational level for the health system; it deals with the health problems of its population in the catchment area.”

In his foreword in the Ministry of Health newsletter #3 (http://www.moh.gov.rw/docs/URUBUGA_3_English.pdf), Minister of Health Dr. Jean Damascene says the following for his 2008 forecast: “Initiate disease prevention services and emergency treatment in villages through community health workers - Animateurs de santé.

In the same newsletter, Ms. Cathy Mugeni Murasa, head of the Community Health desk in the Ministry of Health, indicated during a 2007 seminar organized in Kigali that “pending the installation of a “healthcare station” (poste de santé) in each village as it is planned, four community health workers both males and females will be trained in each village. They will get necessary skills, enough basic drugs and other necessary materials to sensitize the population abut disease prevention, the need to decrease child mortality in children under five, the fight against malaria, diarrheal diseases and bronchitis, and to sensitize women about the benefits of delivering in a health facility.” So, as defined by the MOH, the focus for Accompagnateurs de santé is on disease prevention and family planning.

Partners In Health (PIH) in Rwanda provides salaries and training to its Community Health Workers. At PIH, CHWs serve as counselors, educators, treatment supervisors, and advocates experienced in identifying the needs of their communities. They:
1. Provide home-based care
2. Provide psychosocial support to patients undergoing treatment
3. Act as the link between the patient and the health center
4. Carry out active case finding
5. Educate the community on a variety of health topics

More information on training and implementation of a CHW program is available here: http://www.ghdonline.org/adherence/resource/partners-in-health-community-health-worker-pr/.

I know of the following groups in Rwanda:

* MTCT-Plus Initiative: International Center for AIDS Care and Treatment Programs, Mailman School of Public health, Columbia University: http://www.columbia-icap.org/wherewework/rwanda/index.html

* Family Health International: http://www.fhi.org/en/CountryProfiles/Rwanda/index.htm

* Elizabeth Glaser Pediatric AIDS Foundation: http://www.pedaids.org/OurWork/InternationalPrograms/Rwanda.aspx

* Médecins sans Frontières: http://www.msf.org/msfinternational/countries/africa/rwanda/index.cfm

The following organizations can provide you with more information on NGOs in Rwanda:

* The Treatment and Research AIDS Center (TRAC):
www.tracrwanda.org.rw
Located within the Ministry of Health, TRAC emphasizes HIV/AIDS surveillance, treatment of sexually transmitted infections, voluntary HIV counseling and testing, prevention of mother-to-child transmission of HIV, and clinical care and support.

* Rwanda TRACnet
www.tracnet.rw
TRACnet is an electronic information system that allows people involved in anti-retroviral treatment programs to electronically submit reports and have timely access to vital information. The system is playing a critical role in the implementation of Rwanda 's HIV/AIDS initiative
* The National Malaria Control Programme (PNILT):
www.pnlprwanda.org.rw
Working within the Ministry of Health, the National Malaria Control Programme (PNILT) coordinates all activities related to the fight against Malaria in the country.

* Protection and Care of Families Against HIV/AIDS initiative (PACFA):
www.pacfa.rw
A project led by the Rwandan First Lady to support People Living with HIV/AIDS (PLWHA), women and children.

* Organization of African First Ladies against HIV/AIDS (OAFLA):
www.opdas-oafla.org
The Organization of African First Ladies against HIV/AIDS (OAFLA) is a coalition of 40 African First Ladies who have joined forces to act as a voice for the voiceless in the fight against HIV/AIDS. The OPDAS executive secretariat is located in Kigali, Rwanda and led by the Rwandan First Lady.

* SWAA-Rwanda “IHUMURE” (Society for Women and AIDS in Africa):
www.swaa.org.rw
SWAA-Rwanda aims at empowering women and girls in issues related to reproductive health in the struggle against the AIDS.

Hope this will help! All the best.

Dear Ailis,

Please find below answers to each of your questions as referenced by the **stars**. Please let us know if you have further questions. We look forward to hearing more on your project.

**I am trying to understand more about how the government system of community health workers functions and is organized. For example, are the CHWs paid? What do their responsibilities include? Do they sell or distribute health products?**

BACKGROUND OF THE RWANDAN MINISTRY OF HEALTH COMMUNITY HEALTH PROGRAM

To confront the dire health situation after the genocide, the Rwandan Ministry of Health (MOH) created the Programme des Animateurs de Santé in 1995. The overall effort of the initiative was to improve the population’s health status by ensuring access to preventative and curative health care services. These Animateurs de Santé were elected by their community and worked as volunteers. Their activities focused mostly on children’s health, vaccination, and malnutrition as well as community-based sensitization activities around hygiene and sanitation, for example. While the MOH provides policy directions, it is the local administration-- the District-- that is implementing these policies. The Rwandan health system’s decentralization process has resulted in a division of its’ various community-based care providers into three types of health workers:

1. Animateurs de Santé : in place since 1995; involved in activities such as vaccination, malnutrition and growth monitoring programs as well as other preventative health care interventions for children (ORS, vitamin A distribution) and community sensitization activities;

2. Home-Based Malaria (HBM) care providers for children under age five: program started in 2005; provides rapid access to malaria treatment at a cost of 100 Rwandan francs per child;

3. Traditional birth attendants (TBA): follow and monitor pregnant women.

In addition to these three categories, there are the accompagnateurs of the Partners In Health (PIH) model.

THE NEW RWANDAN MOH COMMUNITY HEALTH SYSTEM

Ten years later, in 2005, a new comprehensive and integrated system of Community Health Workers (CHWs) was designed by the MOH, in line with the present National Health Policy. This new system is composed of four people per umudugudu, or village. These Community Health Workers are the primary health agents in their community and work closely with their respective Health Centers and the Health Center leaders, the Titulaires. These four people are:

1. Binommes of Community Health Workers: two community-elected representatives (one male and one female) per umudugudu. The first binommes were elected in December 2007. Their responsibilities include helping to deliver an integrated health care package which mostly focuses on the IMCI (Integrated Management of Childhood Illnesses) program with strong emphasis on drug distribution. A comprehensive Community Health Worker training curriculum has recently been made available for use; trainings on the materials have started in four districts in Rwanda, with each training lasting 8 days. The drugs will be sold at the health center profit.

2. Animatrice de Sante Maternelle (ASM): previously referred to as TBAs. One person per umudugudu, recently elected by the communities in September 2008. Their tasks focus on maternal health, particularly accompanying pregnant women through their pregnancy and encouraging women to delivery their infants at health facilities (helping women to deliver in their homes is prohibited according to the National Health Policy). A training module and other tools are in preparation for the ASM Program.

3. Palliative care person: One per umudugudu, will work mostly in the HIV program. This role is not yet fully defined but is part of the overall plan.

COMPENSATION RATHER THAN REMUNERATION

The new CHW system proposed by the MOH did not provide a salary to the health care workers. In the MOH system, all CHW categories are organized in cooperatives, and it is the profits from these cooperatives that provide a salary to the CHWs. A system for further compensation for the CHWs will be based on a Performance-Based Financing (PBF) approach, monitored by primary health indicators. The community PBF model embedded in the National Health Policy was first conceived in 2005 and formally started in January 2006 in 23 districts. Some of the weaknesses observed in the model were a misuse of the funds that were meant to go to CHWs, delayed release of the funds, or delayed reporting on the indicators by the districts to the MOH. In 2008, the MOH requested assistance from the CAAC to develop a new community health worker model. At present, the strategic plan of this model is still in the conception phase; there is general agreement regarding the community PBF approach (purchaser-provider-controller), the community PBF indicators, the system of the payment flow, the reporting tools, etc. However, plans of implementing that approach are set for the beginning of 2009 in nine districts where the community IMCI program is already being implemented.

A package of 15 Million USD will be available for the Community PBF model over a 3-year period. The fund has been obtained from three sources:
1. The World Bank;
2. The Global Fund to fight AIDS, Tuberculosis and Malaria (GFATM);
3. Rwandan Ministry of Health.

DISADVANTAGES OF THE NEW CHW SYSTEM

Instead of harmonizing the various types of CHWs that were already in operation, the new CHW system multiplied the number of different types of CHWs, thus complicating the system. The new system also did not have a strategic plan in place of how to integrate the old CHWs training and experience with the new curriculum and newly-engaged CHWs. The new system is creating confusion within the Health Centers and with the Titulaires , who have continued their collaboration with the Animateurs de Santé and the former TBAs. It would be more realistic to concentrate training efforts and available funding to two or three CHWs per umudugudu, depending on the size of the umudugudu, and to focus on building their capacities and ensuring their performance with concrete motivation for their work (financial compensation). This model of well-trained and fairly-compensated CHWs is the one that PIH proposes. Responsibilities and activities included in the integrated health care package should be considered a full-time job.

1. As currently planned, the community health curriculum is being rolled-out nationally without pilot testing of the draft curriculum. Neither an ongoing training has been planned in order to strengthen the capacity of community health workers to provide effective services. The specifics of management, supervision, in-service training, and evaluation of services are not yet worked out.

2. The mechanism of compensation through the cooperatives is still unclear, specifically in the way that these cooperatives are not yet set up to develop micro-financing projects which could generate enough profit to motivate all members. The sustainability of these cooperatives is also an issue; one cannot rely on providing full compensation of the CHWs through this model. Furthermore, the performance of the CHWs and the provision of services could be negatively impacted. For example, a CHW who has been providing accompaniment and daily observed therapy (DOT) to a TB patient for eight months might find it unfair that both he and another CHW who has not been providing daily accompaniment have to contribute all of their compensation to the cooperative.

With the 15 million USD available for PBF over the next three years, the 30,000 binommes in Rwanda will be compensated through their cooperative a very small amount of 3000RWF monthly, roughly 6USD per month or 72USD yearly. A system of an eventual coordination or recognition of the private sources of funds (NGOs, other programs) is not considered.


**I'd like to understand how PIH's system of CHWs is a parallel system and if there is overlap between the two. What are the differences?**

The PIH CHW model is not a parallel system to the MOH CHW system. Rather, PIH works in collaboration with the MOH by providing technical, financial and programmatic support to the districts (Southern Kayonza, Kirhe, NGoma and Butaro) and Health Centers (Rwinkwavu, Kabarondo, Nyamirama, Ruramira, Ndego, Rutare, Cyarubare, Rurama) in which we work in order to facilitate the roll-out and strengthening of the MOH community health program. PIH does not do the work for the MOH; we support and collaborate with their representatives at District level.

When PIH came to Rwanda in 2005, we were faced with the urgent task of facilitating the access to HIV/AIDS treatment and care. PIH implemented the system of Accompagnateurs, a model of CHW developed over the past 17 years in Haiti. An accompagnateur is a type of CHW whose work focuses mostly on daily accompaniment of patients with chronic and infectious diseases, such as HIV/AIDS.

Unlike the MOH system of CHW integration, the PIH system harmonized the various types of CHWs that were already in operation and the new CHWs into a single model. For example, 70% of the previously-called accompagnateurs became CHWs or CHW Supervisors elected by the community. The integration of the CHWs into the formal health system was seen as imperative, with a standardized, integrated training scheme, as well as a common management, supervision and compensation structure.

This process of integration has started in Rwinkwavu Sector:
1. Reorganization of the Community Health system with the election of CHWs in each umudugudu. Each CHW is responsible for 40-50 households. Each umudugudu with 40 to 50 household will have three CHWs. The role of those CHWs is to create a link between the community and the health facilities through sensitization work for health prevention and promotion, active case finding, following specific target groups (children under five, pregnant women, women on family planning, follow-up of patients enrolled in particular programs and daily accompaniment of TB patients and people living with HIV/AIDS, chronic diseases etc...).

2. Creation of an harmonized system of CHWs with the implementation of a monthly trainings on primary health care and a monthly meeting where a report of activities is provided for monitoring and evaluation of the program and performance of the CHWs.

3. Execution of CHW activities including a monthly visit of each household in their catchment area (40-50 households) and follow-up of target groups, etc.

4. Execution of sensitization activities in close collaboration with existing civil structures (local leaders, associations, etc.) and forums. The CHWs and CHW Supervisors will conduct sensitization activities within the community by speaking at the monthly cellule meetings, umuganda (community service) day and other community events on the monthly health topic that they have been trained on.

5. Supervision of CHWs by the CHW Supervisor; each Supervisor is assigned 20-25 CHWs. CHW Supervisors conduct monthly meetings with their CHWs and also attend monthly CHW Supervisor meetings. Their responsibilities include monitoring the work of their CHWs and reporting on any specific problems they encounter in their work.

6. Compensation schemes based on the CHWs work performance. Each month, the CHW will receive X amount of which 10 percent will go towards the CHW cooperative. This amount will be provided only if certain performance indicators are met, including a monthly home visit for each patient and the completion of a monthly report.

PIH is also encourages the collaboration with other types of health care providers operating in the community, such as the Traditional Birth Attendants and Traditional Healers. We are doing the same thing but differently in supporting the existing structures.

**Also, are there other groups that organize and train large networks of CHWs in Rwanda? **

There are other NGOs which work in the prevention and care of HIV/AIDS who have organized networks of CHWs, but they are not necessarily called CHWs. The primary goal of the MOH CHW system is an integrated community-based approach to health care.

Thank you so much for this response. This information is very helpful! Best, Karen

Sorry for my slow reply Rebecca. This information was extremely useful for my research. I really appreciate the comprehensive reply! Best, Karen