CHAPTER ONE
INTRODUCTION
Background of the Study
Globally community based intervention true CHWs is in urgent
need to improve health of women and children, particularly in areas of Africa,
where Millennium Development Goals (MDGs) 4 and 5 are most lagging. This
requires strong community engagement and formal investments in national health
systems, especially for those least likely to be reached through current
national health strategies, such as those in rural communities. Community
Health Workers (CHWs) have been internationally recognized for their notable
success in reducing morbidity and averting mortality in mothers, newborns and
children. CHWs are most effective when supported by a clinically skilled health
workforce, particularly for maternal care, and deployed within the context of
an appropriately financed primary health care system. However, CHWs have also
notably proven crucial in settings where the overall primary health care system
is weak, particularly in improving child and neonatal health. They also
represent a strategic solution to address the growing realization that
shortages of highly skilled health workers will not meet the growing demand of
the rural population. As a result, the need to systematically and
professionally train lay community members to be a part of the health workforce
has emerged not simply as a stop-gap measure, but as a core component of
primary health care systems in low resource settings, Prabhjot Singh (2011).
A National Roadmap to Accelerate the Reduction of Maternal and
Infant Mortality was adopted by the Rwandan Ministry of Health in 2008. The
roadmap outlines approaches to reducing maternal and newborn mortality, and
includes strategies for improving the quality of the facility based primary and
referral care, the availability of Kangaroo mother care (KMC) and the
availability of community-based services for women during pregnancy and in the
post-natal period.
According to the Roadmap builds on the National Reproductive
Health Policy and the National Child Health Policy (2008), and the Strategic
Plan for Acceleration of Child Survival (2008-2012), all program activities are
implemented in the context of the Economic Development and Poverty Reduction
Strategy of Rwanda (EDPRS 2008-2012) and the National Health Sector Strategic
Plan (Rwanda HSSPII 2009-2012).
General approaches to implementing community-based
activities are outlined in the National Community Health Policy of Rwanda
(2007). The health system in Rwanda is decentralized to the district level.
The country is divided into 4 provinces and the City of Kigali, 30 districts,
416 sectors, around 9,000 cells and 15,000 Imidugudu (villages). A system of
community-based health insurance in the form of mutual health insurance was
established in 1996. Since 2006 Rwanda has implemented a Performance Based
Financing (PBF) model to provide incentives to facility-and community-based
health workers. The PBF approach provides quarterly remuneration to health
workers based on performance measured by defined indicators (MOH Rwanda,
2012).
In order to improve the performance of CHWs and
obtain good results on agreed upon indicators especially the maternal and
infant mortality, payments are made when proof of an agreed level of
performance is attained. Every month at the Health Center level data is
collected from reports on indicators and entered into a web-based database
(SisCom). The Sector Steering Committee oversees the evaluation of different
indicators during a quarterly meeting and approves the payment to the CHW
Cooperatives. This quarterly C-PBF accompanied with monthly top ups and
trainings are the major and in some cases the sole incentives provided to CHWs
as a motivation to achieve their different and important tasks (MOH, Rwanda
2009).
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