Inside Rwanda’s army of community health workers

Health minister Dr Diane Gashumba vaccinates a child. / File

Mathias Nkiranya, 43, is one of the 58,445 Community Health Workers deployed at the community level across the country. His jurisdiction is Kareba Village, Nyarubuye Cell in Musanze Sector, Musanze District. He has been a community health worker for 20 years.

Nkiranya has volunteered to dedicate himself to saving the lives of Rwandans, including being behind eliminating severe malaria in Rwanda as of now, as well as reducing child mortality which was due to diarrhoea, among other factors.


According to statistics from the Ministry of Health, this community health initiative started with 12,000 CHWs as a pilot programme in 1995, but with the good results and impact, it was scaled up to 58,445 CHWs currently, of whom 65 percent are women.


Among other roles, Nkiranya monitors child’s growth, follows up on the life of the mother and new-born to tackle preventable deaths, as well as provides family planning services to people in his locality. He also registers information in RapidSMS system, a system mainly intended to tracking maternal and under 5 children health to prevent unnecessary deaths.


Dr Tedros Adhanom Ghebreyesus, the Director-General of the World Health Organisation (centre) poses with community health workers at Mayange Health Centre in Bugesera District last year. He said he was impressed by their passion and dedication in making health for all a reality in Rwanda. / File

Nkiranya dropped out of school when he was in second year of secondary school, which shattered his dream to be a doctor. However, in 1999, he received training from the Ministry of Health from which he acquired skills to work as a CHW.

“I wanted to be a medic, but I did not manage it through conventional schooling. However, what makes me very happy now is that since I became a CHW, I gained a lot of benefits both for myself and for others in terms of preventing diseases, preparing balanced diet. But, most importantly, children and the elders call me a medic,” he said.

“And we do that voluntarily without any regular salary,” he said.

About healthcare services that CHWs provide, Dr Diane Gashumba, Minister for Health, told The New Times that they include health promotion through community mobilisation around prevention, hygiene and sanitation, sensitisation around vaccination, delivery in hospitals, and early consultation.

“They screen/ test and treat moderate cases of malaria, diarrhoea, pneumonia, provide pills and injectable Family Planning (FP) methods, do growth monitoring to screen for malnutrition and refer to health centres [if need be],” Minister Gashumba said.

She explained that they also follow up on newborns, pregnant women and mothers after delivery to monitor any complications, alert health centres if [there] danger signs, and they use rapid SMS as they were all equipped with phones and required skills.

Impact on saving lives

Gashumba said that 83 percent of health conditions in Rwanda are treated at primary healthcare level, meaning at health centre and community health workers level, which she said is a big component of the CHWs’ contribution, but also they are behind successes in other health indicators.

“They are also the key players in sensitisation around vaccination, delivering at health facilities, the fact that we have 93 percent of the coverage in vaccine, and about 91 percent of women delivering at health facility level.

According to the Rwanda Demographic and Health Survey 2014-15 report released in 2016 by National Institute of Statistics of Rwanda, under-5 mortality declined during from 152 deaths per 1,000 live births in 2005 to 103 per 1,000 live births in 2007-08, 76 per 1,000 live births in 2010, and 50 per 1,000 live births in 2014-15.

The decreases in infant and under-5 mortality, the Survey said, are likely due to the implementation of integrated management of childhood illnesses in all health facilities and in community health services and the introduction of new vaccines among others.

Most importantly, Gashumba said, one typical example of CHWs’ role is to fight against malaria.

“Because they do home-based malaria management, today we don’t have any severe case of malaria, cerebral malaria was eradicated in Rwanda because people get treatment at community health workers’ level,” she said explaining that patients get timely consultation and treatment as most of them have community-based health insurance coverage.

“Being free from cerebral malaria, and children no longer dying from diarrhoea, is thanks to them [CHWs]. The prevention mechanisms, and awareness campaigns they carry out on a daily basis, but also enabling people to get timely treatment and access vaccines,’ she said.

How the idea of CHWs came about

The country was devastated by the Genocide, no preventive system, people dying from a simple diarrhoea, no trust in the health system after thousands of people were killed by those who were supposed to save lives (Doctors, nurses), patients including mental health ones killed while admitted, Minister Gashumba said.

“The Government of Rwanda had to think of an unconventional programme, system that may align with the vision the new leadership had to centre services on the people of Rwanda,” she observed.

“We had to have people who have the trust of the community and live close to them … geographic accessibility also was an issue to address: the few health centres and hospitals were demolished, equipment stolen, and health care workers killed or in exile after committing the genocide. President Kagame, at that time the Vice President, launched this programme in 1995,” she said.

About the level of education of CHWs, Minister Gashumba said that the basic criteria was primary school when the programme started, adding that today, there are even CHWs with bachelor degrees.

CHW programme foundation is patriotic people who started this programme during critical moments and vowed to volunteer, Gashumba remarked.

However, Gashumba said that “they get better than a salary,” pointing out that a survey conducted in 2016 showed that 97 percent of them responded that they would remain in the programme even if the incentives they receive from the government had to stop.

“The Government buys indicators from them and pay them an incentive through a scheme called performance-based financing (compared to Imihigo – performance-based contracts). They set indicators, targets and implement them, get evaluated and incentivized,” she said adding that the best performer gets more money.

She stated that the government sensitised them to be in cooperatives, and they were given a startup, adding that today, their cooperatives have grown and are very productive.

“They also get non-monetary incentives: The President offered to those with no electricity solar panels, all of them received a phone [each],” she said.

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