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 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 : 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: 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. Performance-based compensation (10-20 USD/month) for: • • • Monthly home visits, daily accompaniment & key maternal health activities; Timely completion of a monthly report form; Participation at monthly training. Additional support to Cooperatives: • • • 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: • • • • 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: • • Complements MoH PBF report Monitors and supports supervision of non-PBF CHW activities 6b. A household chart: • • • 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. 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 System works in close collaboration with existing societal structures: Local leaders; Traditional healers and birth attendants ; Church representatives; Local groups and associations, etc. CHWs use community forums to conduct sensitization and advocacy activities, promoting active participation of the community in decisions regarding their health. Builds solidarity and establishes a community link to the broader healthcare system. Costs of System: $3 US per capita Additional Components: 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 In the two districts: 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 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 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 .