MCSP Community Health Contributions

Series: Rwanda
December 2019 www.mcsprogram.org

Background
The Maternal and Child Survival Program (MCSP)
was a global, $560 million, 5-year cooperative
agreement funded by the US Agency for
International Development (USAID) to introduce
and support scale-up of high-impact health
interventions among USAID’s 25 maternal and
child health priority countries, as well as other
countries. To support community health structures
in countries, MCSP advocated for institutionalizing
community health as part of national health
systems, strengthening the capacity of community
health workers (CHWs), and supporting
community infrastructure in partnership with Community health workers in Nyabihu District in Rwanda welcome
guests at a community event. Photo by Mamy Ingabire, MCSP.
country governments and civil society
organizations. This brief is one of an eight-part
series developed by MCSP to review and understand the processes of community engagement in MCSP-
supported countries and to identify how the community health approaches implemented by the project have
contributed to changes in health service uptake and behavioral outcomes.

Between 2014 and 2018, MCSP implemented reproductive, maternal, newborn, and child helath (RMNCH)
interventions in 10 districts in Rwanda.1 Specifically, MCSP worked in conjunction with the Rwandan
Ministry of Health (MOH), the Rwanda Biomedical Centre (RBC), and the Rwanda Health Communication
Center (RHCC) to increase coverage and utilization of high-impact, low-cost RMNCH interventions and to
strengthen the MOH’s capacity to manage and scale up select interventions. MCSP enhanced impact through
community engagement. Interventions were scaled up in stages. In the second year, MCSP initiated
implementation of community engagement in four districts while supporting the MOH at the national level to
update guidelines, tools, and implementation approaches. In the third year of the project, MCSP expanded to
six additional districts. For RMNCH activities, focus districts were chosen with the MOH and in
collaboration with USAID Rwanda using the following criteria: burden of disease based on key maternal,
newborn, and child health indicators (i.e., maternal, newborn, and child mortality) and high unmet need for
family planning; absence of a partner implementing key RMNCH and malaria programs; and high population
density. Additionally, in Nyaruguru District, MCSP collaborated with the RHCC to develop and implement

1 The 10 districts that MCSP Rwanda implemented RMNCH activities in were Huye, Gatsibo, Kamonyi, Musanze, Ngoma, Nyabihu, Nyagatare,
Nyamagabe, Nyaruguru, and Rwamagana. Activities targeted the entire population of the 10 districts with facility- and community-level
interventions.

MCSP Community Health Contributions Series: Rwanda 1

the National Community Mobilization Framework. The framework is guided by a number of objectives
aimed at creating demand for and improving access to equitable health services. MCSP supported the
implementation of the strategy primarily through implementation of the Community Action Cycle (CAC) in
Nyaruguru District (only).

Community Health Focused on Maternal and Newborn Health

MCSP’s community health approach in Rwanda combined community service delivery with community
capacity strengthening and social and behavior change, with an aim of institutionalizing and supporting
RMNCH services. Figure 1 outlines the project’s community health conceptual framework, while Table 1
categorizes activities implemented by MCSP in Rwanda by the type of approach at the community level. The
overall approach included meaningful community participation and ownership in planning, implementing,
monitoring, and evaluating community-based interventions. It was built off of national strategies, policies,
and tools 2 focused on community health workforce programs and community mobilization. Additionally,
MCSP collaborated with the RHCC to develop and validate a National Community Mobilization Framework
for mobilizing communities for social and behavior change. The framework is guided by a number of
objectives aimed at creating demand for and improving access to equitable health services, in alignment with
two objectives of the national Community Health Strategic Plan: to strengthen the capacity of decentralized
structures to allow community health service delivery and to strengthen the participation of community
members in community health activities.

Figure 1. MCSP Rwanda community health conceptual framework

Improved service
NATIONAL delivery at
(SOCIAL, POLICY) community and
Increased practice of
facility levels.
appropriate RMNCH
SERVICE/ Reduced
behaviors at the
HEALTH SYSTEM RMNCH
Improved community household level.
capacity to address morbidity
COMMUNITY RMNCH. and
mortality.
HOUSEHOLD
Increased social Increased RMNCH care
support for women seeking.
INDIVIDUAL
and families for
RMNCH.

INTERVENTIONS Normative change Individual-level change

RMNCH = reproductive, maternal, newborn, and child health

2Rwanda Ministry of Health’s Health Sector Strategic Plan, July 2014–June 2018; National Community Health Policy, 2015; Community Health
Program Handbook, 2015; Government of Rwanda’s Vision 2020; Economic Development and Poverty Reduction Strategy, 2013–2018;
National Community Health Strategic Plan, 2013–2018.

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Table 1. Three pillars of MCSP’s community health approaches and activities in Rwanda
Service Delivery Capacity Strengthening Social and Behavior Change
• Worked with Rwanda Biomedical • Facilitated the Community Action • Supported the Rwanda Health
Centre (RBC) staff to analyze Cycle 4 process (only in Nyaruguru Communication Center (RHCC)
community health worker (CHW) District, in all 332 villages). and Health Promotion Technical
workload in Rwanda using MCSP’s • Assessed home-based PNC and updated Working Group to strengthen
CHW Coverage and Capacity existing capacity-building materials, district- and sector-level capacities
tool.3 including job aids. to implement and coordinate
• Assisted the Ministry of Health • Supported training, equipment provision,
community engagement and social
(MOH) to establish protocol and and behavior change activities.
and supervision of CHWs.
specifications on what needs to be
• Provided mentoring and built district
• Facilitated sensitization sessions
done and when at health facility with stakeholders and partners
and health center capacity to plan for
and community levels to ensure about the provision of fistula
and coordinate integrated service
improved postnatal care (PNC) services and other reproductive,
delivery by CHWs.
and attendance. maternal, newborn, and child
• Worked with the RBC to
• Strengthened capacity of health health (RMNCH) interventions.
providers through training for increased
integrate postpartum hemorrhage
community awareness of and response
• Supported the RBC and RHCC in
protocols and follow-up developing documents for
to gender-based violence.
procedures into training provided community mobilization and social
to animatrices de santé maternelle. • Supported the MOH to review and and behavior change materials for
update the community-based maternal
• Supported quarterly CHW
and newborn health modules and tools
RMNCH.
technical coordination meetings • Assisted with the development
for CHWs for consistency with the
organized at each health center. and implementation of district
2013 World Health Organization
communication plans in 10
recommendations on PNC of the
districts.
mother and newborn.
• Strengthened capacity of MOH-
• Engaged community leaders,
CHWs, and women’s groups to
supported CHWs to use the RapidSMS
improve home-based care of
system and DHIS2 dashboards (both
newborns and mothers.
digital data collection tools) to improve
data quality and use in decision-making. • Strengthened linkages between
facilities and homes with improved
• Trained CHWs on the prevention of
referral systems.
fistula and how to implement verbal
autopsies.

Achievements
Overall, MCSP’s community health interventions reduced barriers to accessing health services and
contributed to changes in RMNCH behaviors. In particular, the project improved planning and coordination
of integrated services delivered by CHWs, reinforced community mobilization, and strengthened the capacity
of the community to plan and fashion its own solutions. In total, MCSP supported 4,780 animatrices de santé
maternelle (ASMs)5 and 9,560 binômes 6 in all villages of the 10 targeted districts to offer maternal, newborn, and
child health services, and reached 516,090 people through home visits, community dialog, and community
radio. The binôme facilitated integrated community case management and community-based family planning
activities. These efforts and MCSP’s ongoing mentorship approach (see below) contributed to improved
management of childhood illness, provision of family planning services, and quality of maternal and newborn
health care services, along with increased demand for health services by the community and data use for
continuous quality improvement at both facility and community level.

3
This is an Excel-based tool that models options for CHW allocation and engagement. More at:
https://www.mcsprogram.org/resource/community-health-worker-coverage-and-capacity-tool.
4 The CAC model reinforces the capacity of communities to resolve their own health-related challenges, particularly around uptake of high-
quality health services and healthy behaviors at household and community levels. The CAC process comprises seven phases: prepare to
mobilize, organize communities for action, explore and set priorities, plan together, act together, evaluate together, and prepare to scale up.
5 ASMs are CHWs who are identified by the communities and trained, equipped, and supervised by health center-level providers. They are
volunteers and not part of the MOH payroll. However, they do receive some monetary incentives following the performance-based financing
mechanism in place in Rwanda, and they benefit from membership in CHW cooperatives.
6 A binôme is a male and female pair of CHWs who are multidisciplinary, polivalent health agents.

MCSP Community Health Contributions Series: Rwanda 3

Demand Creation and Quality Improvement
To increase demand for RMNCH services, MCSP worked closely with the MOH and RBC to strengthen the
capacity of frontline health workers to improve diagnosis and referral for the management of sick and small
babies using the newborn protocol. Additionally, MCSP supported the RBC in initiating community health
mentorship by developing mentorship guidelines and tools, facilitating training of the mentors, and following
up with the mentees (CHW) at community level. The community health mentorship component strengthened
the knowledge and skills of the CHWs. Working in the community and with CHWs, MCSP helped mobilize
participation and create demand for health services.

Community Action
As part of the National Community Mobilization Framework, the MOH, with MCSP, adapted and
contextualized the CAC process to mobilize the community in improving RMNCH indicators in Rwanda.
The CAC is a community mobilization approach that fosters individual and collective action to address key
health program goals and improve health outcomes. In Rwanda, the CAC process was used to reinforce the
capacity of communities to resolve their own health-related challenges, particularly around utilization of high-
quality health services and healthy behaviors at household and community levels. Using a phased approach,
the CAC process was scaled up to all villages in Nyaruguru District (only) under the leadership of
multisectoral, subdistrict teams. Community action plans were developed in all 332 villages within Nyaruguru
District and implemented using different strategies, such as household visits and/or meeting with existing
community platforms. The findings suggest the CAC approach contributed to the uptake of health services,
including postnatal care (PNC) services, and strengthened the capacity of communities to identify health
issues, prioritize health activities, and plan and monitor health interventions independently in
Nyaruguru District.

Contributions to Maternal Health

MCSP prioritized fistula screening and repair through household visits and linking women to socioeconomic
support and screening for surgical repair eligibility. Within the 10 selected RMNCH districts, CHWs
conducted household visits to identify fistula cases, resulting in more than 500 women being referred for
screening and repair.

Contributions to Newborn Health

The project also emphasized integration of newborn care with maternal care while strengthening health
services through the household-to-hospital continuum of care. In particular, the project emphasized facility
births and predischarge PNC, followed by PNC provided by ASMs. Overall, available data indicate an
improvement in the utilization of the PNC services by women and newborns in all MCSP RMNCH districts
from January 2017 to March 2018. See the MCSP brief, Strengthening the capacity of communities to increase
utilization of postnatal care services at scale in Nyaruguru District, Rwanda, for more information.

Conclusion
Rwanda has been hailed as among the few sub-Saharan nations on track to reducing child and maternal
mortality according to the Sustainable Development Goals. The country achieved the fourth and fifth United
Nations Millennium Development Goals in 2015. Such a spectacular change was made possible by the
government’s commitment to and prioritization of RMNCH. The key achievements of the community health
component of MCSP in Rwanda included increasing capacity-building of the MOH staff at central and
decentralized levels, planning and coordinating integrated services delivered by CHWs, and reinforcing
community mobilization and the capacity of the community to plan and find solutions for its health issues.

This brief is made possible by the generous support of the American people through the United States Agency
for International Development (USAID) under the terms of the Cooperative Agreement AID-OAA-A-14-
00028. The contents are the responsibility of the Maternal and Child Survival Project and do not necessarily
reflect the views of USAID or the United States Government.

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