Rwanda’s Community Health Workers: Meeting People Where They Are

In the 25 years since Rwanda’s genocide, the country’s government has made expanding access to reproductive health care a core component of its development strategy, and Rwanda has consequently experienced striking improvements in health outcomes. From 2000 to 2015, modern contraceptive prevalence among married women rose from 5.7 to 47.5 percent, and the fertility rate decreased from 5.8 to 4.2 births per woman. In addition, maternal mortality dropped by 84 percent, from 1,558 to 253 maternal deaths per 100,000 live births; infant mortality decreased by 64 percent, from 117 to 42 infant deaths per 100,000 live births; and life expectancy at birth increased by nearly 20 years, from 48 to 67 (during the years immediately before, during, and after the genocide, life expectancy hovered around 30 years).

To explain Rwanda’s dramatic improvements, many point to the country’s network of community health workers (CHWs) and mobile outreach programs to reach the most isolated rural people.

First implemented in 1995, the Rwandan government crafted its CHW program to provide local community members with the training and tools necessary to educate their peers on crucial reproductive health topics. By 2005, Rwanda had over 45,000 CHWs working within communities, with much of their work focused on providing evidence-based information about modern forms of contraception and breaking down the stigma against contraceptive use.

Rwamagana’s family planning register and a sampling of methods offered.

Today, each village of approximately 100-150 households elects two women and one man who cater to the health needs of their communities. These CHWs counsel, treat, and provide referrals to their peers on a broad range of health interventions, including modern contraception, nutrition services, HIV and infectious disease prevention, integrated community case management, and maternal and child health.

CHWs work in tandem with over 500 health centers in hard-to-reach communities across Rwanda. The health centers provide the same range of services as CHWs, as well as consultation with nurses, hospitalization, pharmacy services, HIV testing and treatment, and gender-based violence care.

Esther is a community health worker whose health center hub is Rwamagana

Participants of the 2018 International Conference on Family Planning (ICFP) had the opportunity to visit one of these health centers in Rwamagana, a district about 30 miles east of Kigali, and to speak with health center staff and CHWs working out of the facility. The Rwamagana Health Center was founded in 1997 and now serves a community of 51,592 people, spanning 52 villages in the region.

In 2018, the Rwamagana Health Center trained six providers on modern methods of family planning, two providers on postpartum family planning, two providers on gender-based violence care, and 156 new CHWs on community-based family planning provision.

Rwamagana health center reproductive health nurse, also named Esther.

Of course, there is still more work to be done. While the country has made major strides in increasing access to family planning, Rwanda’s adolescent pregnancy rate increased slightly, from 6.1 percent to 7.3 percent in recent years, health center staff and CHWs face challenges in bringing men into conversations about family planning, and nearly one-fifth of Rwandan women who want to avoid pregnancy still aren’t using modern contraception. As a whole, the health sector faces financial instability that could undermine the success of the country’s many efforts, made even worse by U.S. policies that threaten the reliability of development aid.

However, the Rwamagana Health Center’s staff and CHWs working throughout the region clearly demonstrate that Rwanda’s innovative approach of integrating comprehensive reproductive health services into its development strategy is essential to ensuring the fundamental right to a healthy life for all of the country’s people, regardless of where they live. By meeting people where they are and working to provide contraception and destigmatize its use, Rwanda has set itself as an example, for both the East African region and developing countries across the world.

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