Contribution of Community-Health Workers in Reducing Maternal and Newborn Deaths in Rwanda

1. Contribution of Community-Health Workers in Reducing Maternal and Newborn Deaths in Rwanda

3. Coverage along the Continuum of Care Coverage % Opportunities for Africa 'mother and newborn DHS 10

4. Contributing Factors 3 Delays: 1. Delay in deciding to seek care (cultural beliefs and practices) 2. Delay in reaching appropriate care (transport, communication etc) * The first two delays deal with the community 3. Delay in receiving care at health facilities

5. Rwanda Health System and ASM

6. What is the Role of the ASM? • Identifies and registers all women of reproductive age in the community (encourage FP ) • Identifies pregnant women in the community and encourages ANC attendance and facility based deliveries • Promotes health behaviors during pregnancy and the postnatal period (nutrition, use of ITNS, EBF, use of FP, PPH etc) • Accompanies women in labor to health facility, • Provide misoprostol to women who deliver at home, • Make early home visits and identifies women and newborns with danger signs and refers to health facility for care • Encourages early postnatal facility checks for both newborn and the mother

7. Schedule of visits Delivery

8. Requirements • Female • At least a primary education • Ability to read and write • 20-50 years of age • Live in the village where they are work • Available to conduct home visits • Respected in the community

9. Motivation • Elected and trusted by community to address health issues in their communities (higher social status) • Receive capacity building to increase their knowledge and skills • Organized in cooperatives to ensure income generation and accountability of expected results • Community based indicators buy in into PBF system • Health center supervisions builds rapport and confidence

10. Support provided: ASM package • Training • ASM kit • Monitoring and Supervision • Motivation ( PBF) • Cooperative

11. Support provided: Training Package The set of materials is made up of the following: • Facilitator’s Guide for Trainers • Manual for Community Health Workers • Birth plan • Counseling Cards • Screening Cards for pregnancy and postnatal • Congratulations Parents (on newborn care at home) brochure

12. Support provided: ASM Kit • Registers • Counseling cards • Screening cards • Demonstration cloths for dry wrap and KMC • Thermometer to identify hypothermia • Timer to identify NB with breathing problems • Scale to identify low birth weight baby • Cellphones and solar torch . • Soap for hand-washing!!!

13. Monitoring and Supervision of ASMs • Monthly reports submitted to Health Center staff • Indicators have been defined and linked to HMIS • Monthly supervision by health center staff (Community Health Coordinator) • Monthly meetings at health center • Innovation: • e-ubuzima (e-health) • Ongoing training through radio

14. RapidSMS data flow

15. Results: Maternal Mortality Trend

16. Results: Contraceptive Prevalence Trends

17. Results: Trends in Use of LLINs Percent who slept under a LLIN the night before the survey

18. Results: Malaria situation in Rwanda Progress in the fight against malaria • Declining incidence • 70% decline between 2005 & 2010; • Declining morbidity • 60% decline, Out patient cases between 2005 & 2010; • Declining mortality • 54% decline, Inpatients deaths between 2005 & 2010; and • Declining Test Positivity Rate • 66% decline, between 2001 & 2010. 18

20. % of women accompanied by the CHWs for delivery to the HC to the women who are giving birth to the HC January-march 2012 Source: SISCO et HMIS Average: 68%

21. % of women accompanied by the CHWs for ANC to the HC to the New registration at HC January - march 2012 Source: SISCOM et HMIS Average: 40%

22. MESSAGES SENT BY CATEGORY

23. Number of women and NN (alive) pairs accompanied to postnatal visit within 24 hours of home delivery

24. Number of pregnant women with danger signs referred by ASM to ANC

25. Contributing Factors to Success • Strong political commitment from highest level to the grass roots • Performance-based contracts (imihigo) between all levels of government • Rwandan Parliamentarian Network for Population and Development (RPRPD) • Women empowerment • Innovative financing systems • Performance-based financing (health center and community) • Health Insurance coverage (95%) • Rwanda Public Expenditures in Health ( 16% > Abuja target)

26. Contributing Factors to Success Comprehensive and clear policies & strategies developed and implemented • Vision 2020 •  Health Sector Strategic Plan • Economic Development and Poverty Reduction Strategy (EDPRS) • Good Governance and Decentralisation • Health Sector Policy • Comprehensive and clear policies & strategies developed and implemented

27. Contributing Factors to Success 27 Good Health Sector Coordination: • JHSR: Joint HealthSectorReview (doneevery six months) • HealthSectorWorking Groups : to harmonizeimplementation of activities and avoid duplication • Maternal and Child HealthSub-groups

28. Challenges • CMNH activities have not yet been incorporated into routine district plans for local funding – since resources have been provided by development partners. • A number of barriers to referral remain, including lack of transportation, costs of transportation and geographic distance • No data on the costs of implementation –and a costed implementation plan for further expansion. • Difficulty sustaining routine supervision visits to ASMs in the villages where they work. • Post training follow up.

29. Lessons learned • Dedicated community coordinators and community supervisors have been essential for planning and training and support for ASMs. • Planning and coordination has been facilitated by having a dedicated Community Health Desk at the central level, and a Community Health Committee to coordinate partners • Equipment and supply kits are essential to enable ASMs to conduct home visit tasks according to standards. • High mobile phone coverage has made a SMS “rapid alert” system possible

30. Lessons learned • The PBF approach appears to work as an incentive mechanism for ASMs • Follow-up after training is rarely conducted. Some ASMs report that they would like refresher training and more regular updates. • Cascade training has worked well because of the presence of dedicated community health supervisors at districts and health centers – these staff have taken responsibility for training and have developed local training plans • ASMs are well liked and respected in communities. The selection process involves communities and has been well accepted. Because ASMs are required to live in the communities they serve they are effective communicators to local women.

31. Political, social, scientific and ideological influences on policies, practices and outcomes • A National Roadmap to Accelerate the Reduction of Maternal and Infant mortality was adopted in 2008. • Elaboration of the National Community Health Policy, • Program activities align with the Economic Development and Poverty Reduction Strategy of Rwanda (EDPRS 2008-2012) and the National Health Sector Strategic Plan (HSSPII 2009-2012). • A system of community-based health insurance in the form of mutual health insurance was established in 1996 and more than 90% of population covered. • Introduction of community-based maternal and newborn care built on a strong existing community-based structure.

32. Questions/issues for discussion/ research needs • A cost analysis of CMNH is needed, in order to quantify total resources required for implementation – at all levels. Future program activities should have costing built in up-front, to ensure that costing information is collected. • Mechanism to maintaining CMNH performance and motivation

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35. ASM practicing KMC

36. Some ASM training pictures

37. Murakoze! Thank you!