Rwanda Community Health Workers in frontline drive to cut maternal and child mortality

By Jeanne d’Arc Munezero

8th March 2023

After the 1994 war, a percentage of mothers in rural communities of Rwanda gave birth at home because access to health care facilities was a challenge.

Expectant mothers were assisted to deliver by traditional birth attendants who were not medically trained.

Josephine Mukakalisa, a mother of four in Mwiri Sector, Kayonza District says that gave birth at home because she would not race to the nearest health facility located 5-kilometers away from the village.

After some days, she got exposed to a high risk of pregnancy related infections, because her wounds were not tied up properly by the traditional birth attendant.

According to the World Health Organization (WHO) estimates, almost 800 women died from preventable causes related to pregnancy and childbirth in 2020.

Beatrice Nyirarukundo, a resident of Mukarange Sector, Kayonza District lost her baby in 2006. The baby passed away after five months, leaving a hole in the mother’s heart.

She says that they had no idea there was a problem until when the doctors, revealed that ‘the baby suffered from lungs illness but the baby’s chronic malnutrition made it worse” 

In response to these challenges, the Ministry of Health (MoH) initiated the Community Health Worker (CHW) program.

The program began in 1995 with a network of 12,000 CHWs as a cost-effective way to bridge the gap between communities and health facilities. 

The initiative which constitutes Rwanda’s Home Grown Solutions (RHS) empowers communities to take care of their lives besides addressing the shortage of health workers.

For instance, in the district of Rwamagana, in each village of approximately 100–150 households, there are two maternal health CHW (ASM) and one multidisciplinary CHWs (Binômes). 

All CHW’s must come from the villages in which they live. They must be able to read and write preferably, be honest, trustworthy and aged between 20 and 50 years.

In addition, they’re elected by village members in a process that takes place on the last Saturday of the month- community service day.

After being selected, they’re given approximately 3- month of training before being allocated to their respective communities.

Binômes are trained in community-based Integrated Management of Childhood Illness (IMCI) to prepare them to be first responders to common childhood illnesses, including diarrhea, and malaria while ASM’s are trained on when and how to refer severe cases to the facility.

CHW’s are supervised directly by the Health Centers which are in turn supervised by district hospitals on a quarterly basis to assess implementation of community health activities; identify gaps and discuss solutions.

CHW’s are also supervised by Cell coordinators who make house visits to see how the [CHWs] are performing their activities and to verify reports that have been sent using mobile phone text messaging (SMS) to the health centers.

Alphonse Maniraguha a health counselor in Bitega Village, Murehe Cell, Muyumbu Sector says that they counsel expectants to eat energy-boosts, body-building foods with immunity, as well as fruits and how to cook a balanced diet for the baby and the mother.

In the Rwamagana district, more than 97 per cent of the CHW’s trained in family planning (FP) remain active.

The CHW role is appreciated, Esperance Mukamanzi is a trained ASM working in the village of Samuramba, Ntebe Cell; Muyumbo Sector points out that people now bring children to her home for treatment, and some still call her when their children are sick.

“Having free medicines and mosquito nets for malaria has eased our work. Mothers are happy about the support they receive because some cannot afford to buy the medicines” She narrates.

According to data collected between 2019-2020, a total of 1,920 citizens in five districts of Kicukiro, Muhanga, Rubavu, Musanze and Gatsibo were satisfied with the program.

In the other district of Gatsibo, CHW’s role continues to save lives in communities.

Claudine Uwimana, a resident in Kiramuruzi Sector says, “CHW’s sensitize us about FP, malnutrition, how and when to breast feed our babies which is good for baby’s growth after birth”

“They have increased our knowledge and awareness of prevention and treatment of childhood diseases,” Uwimana notes.

Theopista Kabuteni, the Technical Officer for Reproductive Maternal New-Born and Child Health at the World Health Organization says that CHWs globally are frontline public health workers who are well-liked in their communities

 “They influence several mother and child health outcomes, including newborn birth weight.” she adds

CHW’s have contributed to diminishing the burden on the nurses and doctors who are still few in the country in rural communities.

Dr. François Regis, Director of Health Facility Program Unit at Rwanda Biomedical Center –RBC, acknowledges that based on the numbers, it is clear that there is a big step forward.

“Since 2005, CHW’s have helped parents to change their attitudes, which hasten the child’s birth.” Regis points out.

According to RBC, in 2020, Rwanda’s maternal mortality ratio for the 5-year period before the 2019-20 (RDHS) is estimated at 203 maternal deaths per 100,000 live births.

Even though there some improvement since the CHW’ program was introduced, respiratory infections, diarrhea, and malaria remain important causes of under-5 mortalities after the first month of life.

Medical experts say that some of the primary postpartum hemorrhage (PPH) services are extremely low and are not provided by CHWs.

CHW intervention also comes with costs, related for instance to training; to the risk of expiry of medicines given the very rare use.

This story was first published in Panorama