Dr. Richard B. Munyaneza, MD, Rwanda Ministry of Health
ICCM Implementation
iCCM Rollout by District
Community Health in Rwanda
Currently 45,000 CHWs are in place
1 per village supporting maternal and newborn health as well asfamily planning
2 per village engaged in integrated community case management(iCCM) of childhood illness
Community participates, supports, encourages and recognizes CHWs
Community Health Desk (CHD), district hospitals, health facilities,and partners all involved in training of CHWs
CHWs are volunteers, but receive support from communityperformance based financing (c-PBF) via income generating activities(IGAs) of CHW cooperatives
1. Can read and write2. Are aged between 20-50 years
3. Willingto volunteer4. Lives in the local village
5. Is honest, reliable, and trusted by the community
6. Must be elected by the village members7. Two women, one man
Primary Care
• Community CaseManagement of malaria, ARI,diarrhoea, vaccinations,malnutrition, etc. (e.g.Community IntegratedManagement of ChildhoodIllnesses/iCCM)
• Engage in community DOTsfor tuberculosis and HIV
•Miso (in its pilot phase)
Promotion
• Education to communitieson nutrition
• Growth monitoring,particularly among childrenunder five years old
• Nutrition surveillance
• Routine home visits foractive case-finding
• Health campaigns onhygiene and sanitation,immunization, etc
Prevention
• Maternal and newborn healthpackage
• Provision of family planningservices and products likeinjectables, pills, and condoms
• NCDs packages
• Community sensitization onprevention of common diseaseslike malaria, diarrhoea, ARIs,etc.
• Education on the preventionof sexually transmitted diseasesand infections
Who is a CHW?
In Rwanda, community health workers are a formal part of the nationalhealth strategy and are coordinated by the Community Health Desk ofMinistry of Health
Qualifications
Specific Activities for CHWs foriCCM
Diagnostic and Curative Services
Diagnosis of malaria with rapid diagnostic tests
Treatment of confirmed malaria with artemether-lumefantrine
Treatment of acute respiratory infections with amoxicillin
Treatment of diarrhea with oral rehydration solution and zinc
Referral and Reporting Services
Report deaths to local health center and Ministry of Health
Refer children with moderate and severe acute malnutrition, severepneumonia, severe malaria, and severe dehydration to local health center
Under Five Mortality by District
Health Facility Utilization by District
Supervision
Monitoring and Evaluation of CHWs
1. A 5-day District hospital supervision by Central level: planningactivities and data analysis to sort out deficiencies in indicatorperformance (Quarterly)
2. A one-day Health Center supervision by District hospital (Monthly)
3. A one-day supervision of Community Health Workers by HealthCenters staffs (Quarterly)
4.Aone-day supervision of Community Health Workers by CellCoordinators (Monthly)
5. The iCCM program evaluation every 2 to 3 years
6.Individual assessment of CHWs, aim is strengthen the practicalskills of CHWs in the care of sick children according to iCCMCommunity protocol.
Supportive Supervision
1. The integrated supportive supervision is done in two ways.First rapid quality assessment using the integrated supervisionchecklist
2. This helps to identify areas that need improvement andtherefore the team able to prepare materials for the on-jobtraining.
3.Central level analyze reports and give feed backs to districtsduring coordination meeting held once every quarter withpresentation of weaknesses and recommendations
4. Districts respond by going to HC’s to do supportivesupervisions in certain districts that were seen with weakness
CHALLENGES
Huge number of CHWs who need training and supportive supervision;
Difficulty sustaining routine supervision visits to CHWs in the villageswhere they work.
Turn over of CHWs in some villages
Difficulties in overcoming some religious or cultural barriers to care andsustaining routine visits of rural populations to the villages where CHWswork
Due to decreased funding from the Global Fund, the financing of training,supervision, technical support, and the provision of medication, materials,and tools will be a major challenge in the coming years
Overall Conclusions
iCCM can be an effective means for reducing mortality childhooddiseases, Maternal Death and Newborn
iCCM requires intensive initial and follow-up trainings and qualitycontrol programs for the community health workers in each village
iCCM also requires well developed supply chains to ensure availabilityof supplies and medications
iCCM requires both strong local community support and nationalpolitical will to succeed
iCCM requires both strong local communitysupport and national political will to succeed
Questions?