By: Harriet Napier, Catherine Mugeni, and Lauren Crigler
The Community Health Worker program in Rwanda emerged in 1995 after years of instability degraded health infrastructure and outcomes. Today, Rwanda maintains a workforce of nearly 45,000 workers who provide services such as maternal check-ins and age-appropriate health assessments. These workers are globally recognized as a key driver of Rwanda’s early achievement of Millennium Development Goals.
Rwanda’s renowned national Community Health Worker program was launched in 1995, shortly after the culmination of the Tutsi genocide. When the CHW Program was introduced, the country’s social fabric was particularly unstable, health infrastructure destroyed, and the reality of recent economic and productivity losses grim.
The program began in 1995 with a network of 12,000 CHWs endorsed by the MOH. Rwanda has three CHWs (one Animatrice de Santé Maternelle [ASM] and one male-female pair of CHWs called a Binôme) per village of approximately 50 to 150 households. These CHWs focused primarily on health promotion and referral activities. In the decade that followed, the CHW Program grew to 60,000 CHWs, before dropping to 45,000 following the elimination of the CHW In Charge of Social Affairs position.
The ASM identifies pregnant women, makes regular follow-up visits during and after pregnancy, and ensures that deliveries take place in health facilities in which skilled health workers are available. Binômes focus their activities on diagnosis and treatment of childhood illnesses, diagnosis and treatment of malaria for people of all ages, malnutrition screening and referral, provision of contraceptives, and tuberculosis treatment.
Although Rwanda’s Community Health Policy and Strategy states that CHWs should be appropriately trained in a standardized fashion, neither initial nor refresher trainings of either CHW cadre are standardized, and both are highly susceptible to change in duration and content based on available funding. On average, CHWs have approximately three months of initial training.
CHWs are supervised directly by the Health Center with the support of Volunteer Cell Coordinators.
Incentives and remuneration
Although CHWs in Rwanda are considered volunteers, they are incentivized through two methods of Community Performance Based Financing (C-PBF): the first is based on CHW Cooperative-level achievement of specified targets, and the second (more recently introduced) on individual event-based reporting through a RapidSMS program for cell phones. Anecdotally, CHWs take home around US$ 5 to US$ 10 on a quarterly basis.
Rwanda’s success in meeting many of the Millennium Development Goals (MDGs) for health – some far ahead of schedule – is important evidence of the strength of the country’s primary health care system. There is consensus internally (as well as externally) that Rwanda could not have achieved the MDGs for maternal and child health three years early without the support of the CHWs.