Community health worker administering medicine in Rwinkwavu. Photo courtesy of Partners in Health.

[Editor's note: In addition to Dr. Binagwaho, Dr. Fidele Ngabo, Cathy Mugeni, and Niloo Ratnayake also contributed writing to this post.]

Access to care in resource-constrained countries has three major barriers to overcome: finances, infrastructure, and geography. Community health workers (CHWs) are an unavoidable solution for both infrastructure and geography. The Government of Rwanda has recognized that CHWs are necessary in order to improve access to health in rural communities. By using CHWs, with their approach to health at the community level, Rwanda hopes to solve 80% of health problems in the country.

Rwanda has set up a system where each village (100 to 150 households) elects two volunteers to act as CHWs for the general population. Because each community votes on one woman and one man to serve the village in this capacity, becoming a CHW is now a position of respect, raising gender equity throughout Rwanda.

These two CHWs are then trained to monitor growth and development in children, to care for people living with HIV, and to refer sick patients to the nearest health facility. Their training is designed by the Ministry of Health, which enables them to provide services in a harmonized manner throughout the country. By sensitizing the local village and making themselves available, they improve access to care; because of CHWs, a greater number of previously unreachable Rwandan citizens now have access to care. The CHWs trained this year to provide services to their villages are trained to treat certain diseases using amoxicillin and to distribute family planning tools (condoms, contraceptive pills, and injectable contraception).

Taking lessons from the work done by the associations of persons living with HIV/AIDS at the community level, Rwanda dedicated two other village-elected CHWs, one woman and one man, to dealing solely with end-of-life issues. These CHWs are responsible for caring for people in the late stages of any disease, which helps ease the burden on family members. Their care also decreases the number of dying patients brought to the hospital.

CHW explaining how to feed children and the meaning of the growth chart outside a house. Photo by Cathy Mugeni.

As there continues to be a high maternal morality rate in Rwanda, the Government is also training traditional birth attendants as CHWs to promote birth delivery at health facilities. CHWs are paid for every delivery they transfer to the local health center.

All activities are included in the health reporting system through reports that CHWs give to the Executives Secretary of each Sector, who in turn report activities to the Director of Health at the District level. At present, CHWs are all volunteers, but the Government of Rwanda is working on compensating these workers with performance-based financing and helping them to create cooperatives.

In conclusion, the five CHWs per village create community ownership, since it is the community who elected them. They also improve access to care and decrease hospitalization through what they manage at the community level. The harmonized training of all CHWs throughout the country is key. Community health workers are a smart and unavoidable solution that enables effective health care to bypass a lack of infrastructure in a resource-constrained country.