Rwanda’s evolving community health worker system: a qualitative assessment of client and provider perspectives

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Abstract

Background

Community health workers (CHWs) can play important roles in primary health care delivery, particularly in settings of health workforce shortages. However, little is known about CHWs’ perceptions of barriers and motivations, as well as those of the beneficiaries of CHWs. In Rwanda, which faces a significant gap in human resources for health, the Ministry of Health expanded its community health programme beginning in 2007, eventually placing 4 trained CHWs in every village in the country by 2009. The aim of this study was to assess the capacity of CHWs and the factors affecting the efficiency and effectiveness of the CHW programme, as perceived by the CHWs and their beneficiaries.

Methods

As part of a larger report assessing CHWs in Rwanda, a cross-sectional descriptive study was conducted using focus group discussions (FGDs) to collect qualitative information regarding educational background, knowledge and practices of CHWs, and the benefits of community-based care as perceived by CHWs and household beneficiaries. A random sample of 108 CHWs and 36 beneficiaries was selected in 3 districts according to their food security level (low, middle and high). Qualitative and demographic data were analyzed.

Results

CHWs were found to be closely involved in the community, and widely respected by the beneficiaries. Rwanda’s community performance-based financing (cPBF) was an important incentive, but CHWs were also strongly motivated by community respect. The key challenges identified were an overwhelming workload, irregular trainings, and lack of sufficient supervision.

Conclusions

This study highlights the challenges and areas in need of improvement as perceived by CHWs and beneficiaries, in regards to a nationwide scale-up of CHW interventions in a resource-challenged country. Identifying and understanding these barriers, and addressing them accordingly, particularly within the context of performance-based financing, will serve to strengthen the current CHW system and provide key guidance for the continuing evolution of the CHW system in Rwanda.

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Most cited references 21

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Achieving child survival goals: potential contribution of community health workers.

Andy Haines, David Sanders, Uta Lehmann … (2007)

There is renewed interest in the potential contribution of community health workers to child survival. Community health workers can undertake various tasks, including case management of childhood illnesses (eg, pneumonia, malaria, and neonatal sepsis) and delivery of preventive interventions such as immunisation, promotion of healthy behaviour, and mobilisation of communities. Several trials show substantial reductions in child mortality, particularly through case management of ill children by these types of community interventions. However, community health workers are not a panacea for weak health systems and will need focussed tasks, adequate remuneration, training, supervision, and the active involvement of the communities in which they work. The introduction of large-scale programmes for community health workers requires evaluation to document the impact on child survival and cost effectiveness and to elucidate factors associated with success and sustainability.

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Effectiveness of community health workers delivering preventive interventions for maternal and child health in low- and middle-income countries: a systematic review

Brynne Gilmore, Eilish McAuliffe (2013)

Background Community Health Workers are widely utilised in low- and middle-income countries and may be an important tool in reducing maternal and child mortality; however, evidence is lacking on their effectiveness for specific types of programmes, specifically programmes of a preventive nature. This review reports findings on a systematic review analysing effectiveness of preventive interventions delivered by Community Health Workers for Maternal and Child Health in low- and middle-income countries. Methods A search strategy was developed according to the Evidence for Policy and Practice Information and Co-ordinating Centre’s (EPPI-Centre) guidelines and systematic searching of the following databases occurred between June 8 – 11th, 2012: CINAHL, Embase, Ovid Nursing Database, PubMed, Scopus, Web of Science and POPLINE. Google, Google Scholar and WHO search engines, as well as relevant systematic reviews and reference lists from included articles were also searched. Inclusion criteria were: i) Target beneficiaries should be pregnant or recently pregnant women and/or children under-5 and/or caregivers of children under-5; ii) Interventions were required to be preventive and delivered by Community Health Workers at the household level. No exclusion criteria were stipulated for comparisons/controls or outcomes. Study characteristics of included articles were extracted using a data sheet and a peer tested quality assessment. A narrative synthesis of included studies was compiled with articles being coded descriptively to synthesise results and draw conclusions. Results A total of 10,281 studies were initially identified and through the screening process a total of 17 articles detailing 19 studies were included in the review. Studies came from ten different countries and consisted of randomized controlled trials, cluster randomized controlled trials, before and after, case control and cross sectional studies. Overall quality of evidence was found to be moderate. Five main preventive intervention categories emerged: malaria prevention, health education, breastfeeding promotion, essential newborn care and psychosocial support. All categories showed some evidence for the effectiveness of Community Health Workers; however they were found to be especially effective in promoting mother-performed strategies (skin to skin care and exclusive breastfeeding). Conclusions Community Health Workers were shown to provide a range of preventive interventions for Maternal and Child Health in low- and middle-income countries with some evidence of effective strategies, though insufficient evidence is available to draw conclusions for most interventions and further research is needed.

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Teaching mothers to provide home treatment of malaria in Tigray, Ethiopia: a randomised trial.

Gary R. Morrow, Asmeret G Kidane (2000)

No satisfactory strategy for reducing high child mortality from malaria has yet been established in tropical Africa. We compared the effect on under-5 mortality of teaching mothers to promptly provide antimalarials to their sick children at home, with the present community health worker approach. Of 37 tabias (cluster of villages) in two districts with hyperendemic to holoendemic malaria, tabias reported to have the highest malaria morbidity were selected. A census was done which included a maternity history to determine under-5 mortality. Tabias (population 70,506) were paired according to under-5 mortality rates. One tabia from each pair was allocated by random number to an intervention group and the other was allocated to the control group. In the intervention tabias, mother coordinators were trained to teach other local mothers to recognise symptoms of malaria in their children and to promptly give chloroquine. In both intervention and control tabias, all births and deaths of under-5s were recorded monthly. From January to December 1997, 190 of 6383 (29.8 per 1000) children under-5 died in the intervention tabias compared with 366 of 7294 (50.2 per 1000) in the control tabias. Under-5 mortality was reduced by 40% in the intervention localities (95% CI from 29.2-50.6; paired t test, p<0.003). For every third child who died, a structured verbal autopsy was undertaken to ascribe cause of mortality as consistent with malaria or possible malaria, or not consistent with malaria. Of the 190 verbal autopsies, 13 (19%) of 70 in the intervention tabias were consistent with possible malaria compared with 68 (57%) of 120 in the control tabias. A major reduction in under-5 mortality can be achieved in holoendemic malaria areas through training local mother coordinators to teach mothers to give under-5 children antimalarial drugs.

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Author and article information

Contributors

Jeanine Condo: jcondo@nursph.org

Catherine Mugeni: cmugeni@gmail.com

Brienna Naughton: bnaughton@pih.org

Kathleen Hall: kittyphall@gmail.com

Maria Antonia Tuazon: matuazon57@gmail.com

Abiud Omwega: aomwega@unicef.org

Friday Nwaigwe: fridaynwaigwe@yahoo.com

Peter Drobac: pdrobac@pih.org

Ziauddin Hyder: zhyder@worldbank.org

Fidele Ngabo: ngabog@yahoo.fr

Agnes Binagwaho: dr.agnes.binagwaho@gmail.com

Journal

Journal ID (nlm-ta): Hum Resour Health

Journal ID (iso-abbrev): Hum Resour Health

Title: Human Resources for Health

Publisher: BioMed Central (London )

ISSN (Electronic): 1478-4491

Publication date (Electronic): 13 December 2014

Publication date Collection: 2014

Volume: 12

Issue: 1

Electronic Location Identifier: 71

Affiliations

[ ]School of Public Health, University of Rwanda College of Medicine & Health Sciences, Kigali, Rwanda

[ ]Ministry of Health, Kigali, Rwanda

[ ]Partners In Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda

[ ]World Bank, Kigali, Rwanda

[ ]UNICEF, Kigali, Rwanda

[ ]Division of Global Health Equity, Brigham and Women’s Hospital, Boston, 02115 MA, USA

[ ]Department of Global Health and Social Medicine, Harvard Medical School, Boston, 02115 MA USA

[ ]Division of Global Health and Social Medicine, Ministry of Health, Kigali, Rwanda

[ ]Harvard Medical School, Boston, 02115 MA USA

[ ]Geisel School of Medicine, Dartmouth College, Hanover, 03755 NH USA

Article

Publisher ID: 469

DOI: 10.1186/1478-4491-12-71

PMC ID: 4320528

PubMed ID: 25495237

SO-VID: cc2c186d-5d81-4b1c-8fe3-150afb92316b

License:

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

History

Date received : 3 September 2014

Date accepted : 22 November 2014

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ScienceOpen disciplines: Health & Social care

Keywords: rwanda,chw,health system,provider and clients’ perspectives,qualitative assessment

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ScienceOpen disciplines: Health & Social care

Keywords: rwanda, chw, health system, provider and clients’ perspectives, qualitative assessment

Rwanda’s evolving community health worker system: a qualitative assessment of client and provider perspectives

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Emerald: Healthier Lives

Most cited references 21

Achieving child survival goals: potential contribution of community health workers.

Effectiveness of community health workers delivering preventive interventions for maternal and child health in low- and middle-income countries: a systematic review

Teaching mothers to provide home treatment of malaria in Tigray, Ethiopia: a randomised trial.

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