Kirehe, Rwanda – On a sunny morning in October, Christine Umuhoza stood outside her brick house chatting with a neighbour – a young mother holding her infant by the hips. For most women in this small village of fewer than 200 people in Rwanda’s eastern province, Umuhoza is both neighbour and maternal guide.
Dressed in a long brown skirt, black polka-dotted top, and a printed scarf tied to her neck, she was fresh and chirpy for a long day of work. Beyond the banana plants that surround her house, scatterings of mud and brick buildings – some with accompanying sheds for livestock – peppered the landscape of unpaved red clay roads in the traditional farming community.
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Umuhoza used to be a subsistence farmer. But for the last decade, the 38-year-old single mother of two teenagers has worked voluntarily, seeing on average at least two pregnant women a day, for 1-2 hours each. Her clients are all from the village, which in 2009 elected Umuhoza as a community health worker (CHW) known as Animatrice de Santé Maternelle or ASM.
In villages across Rwanda, their role is critical.
“Earlier a woman would go from pregnancy to childbirth without a single visit to a health facility, putting their lives and that of their children at risk. There were so many deaths,” Umuhoza recalled. “Now I ensure that a woman goes through pregnancy and delivery equipped with everything … all the information about check-ups, family planning … dangerous symptoms. It has changed a lot of lives.”
Back in 2005, when she was pregnant with her youngest child, Umuhoza remembers there being no CHW in the village. She went for a few prenatal check-ups but eventually gave birth at home. Immediately after, she experienced severe pain and bleeding and had to be taken to the health centre as a result.
“So much has changed since then,” she said. “The main change is that we now educate and mobilise women to take care of their health during pregnancy and go to the health centres.”
As part of her work, Umuhoza had scheduled a session the following day to teach new mothers how to prepare a balanced diet for their young children. That weekend, she would do regular home visits with her three pregnant clients, all of whom were a quick mobile phone call away in case she needed to rush to their side for an emergency.
Today, there are about 60,000 CHWs across the country, almost four in each village, including an ASM like Umuhoza who is responsible for infant and pre and postnatal maternal care. About 66 percent of CHWs are women, according to Diane Gashumba, the minister of health.
Rwanda’s community health programme was started in 1995. The year before, a genocide against the Tutsis left nearly a million people dead. It also devastated health infrastructure: facilities were destroyed, health workers fled or were killed, and public services broke down.
It is the first contact the communities have with the health sector ... These are strong leaders of our health system because they live in the community ... They know the people they are taking care of. And they have their trust.
With low immunisation rates, high child mortality, and a widespread epidemic of infectious diseases, the new programme hoped to help address the fallout and attempt to rebuild the health system using community interventions. Its specific aim was also to increase the uptake of essential maternal and child care services among communities.
Today, government officials and health staff at all levels are quick to acknowledge the role that CHWs have played in reducing maternal deaths. “It is the first contact the communities have with the health sector … These are strong leaders of our health system because they live in the community … They know the people they are taking care of. And they have their trust,” said Gashumba.
Rwanda’s maternal mortality rate drastically decreased from 1,020 deaths per 100,000 live births in 2000 to 290 in 2015. By achieving this, it became one of the few countries to meet the United Nations millennium development goal 5A, to reduce maternal mortality by at least 75 percent over the 25-year period.
In referral and district hospitals, which were packed with pregnant women during daylight hours, staff acknowledged the contribution CHWs make.
“The decentralised health system means that a woman can go to a community health worker who is her neighbour, instead of coming all the way to the health centre,” said Patient Ngamije, the director general of Kirehe district hospital. “We are not worried because they are trained and they practise it.”
Care on the move
At home, Umuhoza sat in her sun-lit living room with yellow-washed walls that doubles as a consulting space. Next to a brown floral printed sofa-set was an old 12-inch TV and, above it, a framed photo of her deceased husband. On a table in the centre of the room, a vase of pink and white plastic flowers sat next to booklets she uses during sessions with clients.
Umuhoza scrolled through the overflowing message folder on her phone with one hand, while referring to a code guide book held in the other. She has been working with a mobile phone since 2010, when the Rapid SMS system began to be extended countrywide. Using mobile technology for work is now second nature to her, she said. The system is meant to record real-time information on key maternal and neonatal health indicators with an aim of preventing undue loss of life.
“It’s like creating a file for each client over texts,” she explained.
From the start of a woman’s pregnancy for up to 1,000 days – until her child is two years old – Umuhoza is responsible for following up on her health and recording details related to check-ups, treatments and immunisations, among other things. She is aware and intrigued by the fact that the SMS reaches all the way to officials at the topmost level of the government.
“If for some reason I get busy with something and forget to follow up on a client, I receive an SMS with reminders and asking for updates. It gets me up and running on my feet immediately,” she said, laughing.
Like Umuhoza, Concessa Mukeshimana also sees clients at home, in her living room that has been informally designated as a consultation space. On a table next to her sofa, the 42-year-old stores thick registers with details of all her clients, government-issued guidebooks, several rapid diagnostic test kits used to detect malaria, a batch of medicines and contraceptive injections, among other things.
Mukeshimana was elected a CHW over a decade ago. Her responsibilities began with only malaria care for children below the age of five without the use of any equipment, and have since grown to include other diseases and age groups.
Now, on average, she sees at least five clients a day. The number goes up to 10-15 when it is busy. People arrive at their convenience, she says; there is no fixed appointment time and they sometimes overlap. This can be challenging for the CHWs who strive to give each client privacy. But they make do with what they have because they see value in the work they do.
“Just imagine, I only have primary education but the kind of diseases I can provide care for, because of the training I have received, are the same as someone who has passed the university,” Mukeshimana said. “It makes me proud of this work.”
‘You seek a worker out’
Mother-of-four Marsarena ‘Muzaka’ Muzakamargwanice, was Mukeshimana’s first adult client after the government extended the community-based malaria treatment programme in 2016 to include children over the age of five and adults. She remembers being constantly unwell and making regular runs to the health centre. After each of her pregnancies, and almost every other year, the 36 year old was bed-ridden for days, sick with malaria and scared for her life.
As a subsistence farmer, there was no time for or knowledge about malaria prevention at that time, she said: “The health centres focused on treatment but they did not have the time and resources to teach so many of us about prevention.” In 2016, following her last pregnancy, she fell ill again.
“When I heard she’s unwell, I visited her as a friend and neighbour, but also as a client,” said Mukeshimana, explaining that women who have given birth are “our topmost priority” to be followed up with at home.
On seeing Muzaka bid-ridden with high fever, Mukeshimana asked for the villagers’ assistance to get her home where she tested her for malaria with a rapid diagnostic test that detects the presence of a malarial parasite through a blood sample. On testing positive, she administered Muzaka medicines for the next three days. Once she was well and able to care for her children again, Mukeshimana also taught her some malaria prevention methods.
Some 11 million pregnant women were infected with malaria in sub-Saharan Africa last year, according to the recently released World Malaria Report 2019. As a result, more than 900,000 children were born with low birth weight. Mukeshimana and other CHWs in Rwanda understand the risk of malaria for pregnant women fairly well. And thanks to the focus on malaria eradication in the country, they say, women are alert about symptoms and promptly seek help.
“I have health insurance but I’ll be honest, I never need to use it because I’ve been healthy in the last few years,” Muzaka said. According to her, the CHWs have completely transformed the way she and others take care of their health. “Even those who can’t read or write can now know the dangers of diseases and the importance of treatment. Earlier if you felt feverish, you would just go to sleep. But now you seek a worker out.”
Muzaka appreciates that there are several such workers, especially during emergencies. “If one of them is unavailable, there will always be someone else you can reach out or trust.” Now, when she hears about the importance of checkups, treatments and insurance during village meetings, she says she chooses not to turn a deaf ear to it.
Dedication and trust
Muzaka says one of the main reasons she trusts Mukeshimana with her health is because of her years observing the health worker care for children under five as a part of this programme. “As mothers, we talk about these things. We have seen her dedication,” she said. “The other thing is, I voted for her (to be a CHW) because I trusted her to begin with.”
Muzaka is not alone in the trust she places in CHWs.
A short distance away in one of the maternity wards in Kirehe district hospital, 29-year-old Olive Kamaliza cradled her new-born. It was her third pregnancy and dressed in a green hospital gown, she was recovering after a caesarean delivery. Her village lay about 8km away, but the road to institutional delivery was smooth: she visited the nearest health centre and was referred to the hospital by an ambulance on her due date.
“I saw the CHW throughout my pregnancy and knew what to do,” she said. “I attended all my ante-natal checkups as well because I understood they were important for me and my child.” Kamaliza has delivered all three of her children in health facilities.
While health indicators have significantly improved, for the community health workers on the front lines, their work continues to be largely volunteer-based and unsalaried.
‘Everybody needs money’
A challenge that Umuhoza often faces is receiving pregnant clients who are still unable to afford health insurance or do not have the funds to visit health centres. “I am ill-equipped to support them myself. I try to find means to help them but sometimes, there are none,” she said.
To support her own family, Umuhoza works as domestic help for a few doctors who, she said, are understanding of the nature of her role as a CHW and thus, often flexible with work timings. “Everybody needs money but this is voluntary work so I don’t like to think about money while doing it. If I were to receive a salary, I would demand a real salary,” she said, shyly refusing to talk about it further.
Both Umuhoza and Mukeshimana are members of the same CHW cooperative in their district, which includes 327 others all working in communities in the vicinity of three main health centres.
Rwanda uses a system of performance-based financing, encouraging CHWs to form cooperatives and providing these groups with quarterly financial incentives based on the output of their work. Success is measured on several maternal and neonatal health indicators, and 70 percent of the incentives are required to be invested in financial projects of their choice. The rest is disbursed among members based on the discretion of the cooperative.
In Kirehe, their cooperative has built a hostel for 20 (salaried) outstation staff of the district hospital who paid regular rent. The large brick structure was complete with an office, backyard, fencing, and outdoor toilets.
Through cooperatives, CHWs across Rwanda have accumulated about 11.2 billion Rwandan francs ($12 million) worth of immovable assets and over 3.5 billion Rwandan francs ($3.7 million) in cash deposited in banks. Mukeshimana believed the small amounts of money they received through the cooperative allowed her family to pay for their health insurance without any problems and also seek low-interest loans during emergencies. But many like Umohoza felt like this did not really count and another job was essential to make a living.
Some others were more candid about this: “We understand that the programme has a constrained budget. There are so many of us and the government is unable to pay us all,” said Ethiene Semwiza, another member of the same cooperative. “But at the same time, we feel like we put in a lot of time and energy and deserve to take home money for the work. Perhaps in the future.”
A district-level official in eastern province, who spoke on the condition of anonymity, thought the CHWs were overburdened and the incentive budget provided for them was limited and irregular.
Meanwhile, the programme continues to serve Rwanda’s gender equity goals of ensuring healthy lives for women and encouraging women to be leaders in society. Many, like Umuhoza, have now embraced the messages being shared. At village meetings, she straightforwardly raises the issue of sex education for adolescents, in spite of objections by parents.
“Pregnancy is not only for women. I speak to families,” she says, confidently.
Later in the conversation, she laughs at the topic of home births, which brought her both her children. “That doesn’t happen here in our community any more,” she says. “It’s history.”
This reporting was supported by the International Women’s Media Foundation in partnership with Malaria No More.