REPUBLIC OF RWANDA
MINISTRY OF HEALTH
DEPARTMENT OF MATERNAL AND CHILD
HEALTH
Community Health Desk
INTRODUCING COMMUNITY-BASED PROVISION OF FAMILY
PLANNING SERVICES IN RWANDA:
A PROCESS EVALUATION OF THE FIRST SIX MONTHS OF
IMPLEMENTATION
December 2011
With technical support from FHI 360
2 | P a g e
Acknowledgements
The authors would like to thank all of the community health workers and
supervisors who participated in the focus group discussions for this evaluation.
In addition, the authors are pleased to thank the members of the Family
Planning Technical Working Group, who helped to develop and implement the
CBP program in Rwanda.
This study was made possible by the generous support of the American people
through the United States Agency for International Development (USAID)
under the terms of FHI 360 Cooperative Agreement No. GPO-A-00-08-00001-
00, the Program Research for Strengthening Services (PROGRESS) project. The
opinions expressed herein are those of the authors and do not necessarily
reflect the views of USAID.
Prepared by:
Jennifer Wessona
, Emmanuel Munyambanzaa
, Herman Habarugirab
, Aline
Nyinawamahoroa
, Anastase Nzeyimanaa
, Cathy Mugenib
, Fidèle Ngabob
a) FHI 360 / Rwanda
b) Ministry of Health, Maternal Child Health Department
3 | P a g e
FOREWORD
The Government of Rwanda recognizes family planning (FP) as one of the key elements
contributing to the socio-economic development of our country and as a strategy to attain
the Millennium Development Goals (MDGs). Therefore, family planning is one of the top
national priorities. The Government of Rwanda’s goal is to achieve 70 % modern
contraceptive prevalence by 2012, as stated in the Rwandan Economic Development and
Poverty Reduction Strategy (EDPRS, 2008-2012).
Within this framework, the Ministry of Health is currently implementing Community-Based
Provision (CBP) of Family Planning Services by Community Health Workers (CHWs). CBP is
one of the key approaches implemented to increase the accessibility and uptake of family
planning services. As a component of the national community health policy and the family
planning policy, CBP of FP services were introduced in late 2010. The services provided
include not only counseling but also provision of contraceptive methods such as
contraceptive pills, injectables, cycle beads and condoms.
To execute this program, the Ministry of Health opted to implement it in phases. The first
phase covered three districts: Rusizi, Gatsibo and Kicukiro in Western, Eastern Provinces and
Kigali City respectively. To document the process and inform the scaling-up of this program,
an assessment was carried out in April 2011. The key findings are compiled in this report.
The Ministry of Health acknowledges its different partners, especially FHI360/Rwanda, who
contributed to conduct this assessment. Our gratitude is also addressed to the health
facilities and CHWs who willingly shared their experiences with us during the assessment.
Dr. Agnes BINAGWAHO
Minister of Health
4 | P a g e
Table of Contents
Background and intervention............................................................................. 5
Objectives of the process evaluation .............................................................. 5
Methodology...................................................................................................... 5
CBP Results ........................................................................................................ 6
Training .............................................................................................................. 7
Community acceptance...................................................................................... 9
Religious influences ...................................................................................... 10
Service Provision .............................................................................................. 10
Perceived competence ................................................................................. 10
Equipment and supplies................................................................................ 11
Supervision ................................................................................................... 12
Conclusions ...................................................................................................... 12
Barriers and Facilitators ................................................................................ 13
Recommendations........................................................................................ 14
5 | P a g e
Background and intervention
As Rwanda is Africa’s most densely populated country, the Government (GOR) has
recognized that facilitating rational population growth is key to its economic development.
The GOR has set a target of achieving 70% contraceptive prevalence by 2012. Among other
strategies, the GOR is working to increase access to modern contraceptive services by
bringing them closer to the population. To this end, the Ministry of Health (MOH) adopted a
strategy of using community health workers (CHWs) in the delivery of FP services at the
village level (Imidugudu).
Community-based provision (CBP) of family planning services (including commodities) is a
strategy for increasing access to family planning (FP) that has been adopted in many
countries, for example, Madagascar, Malawi, Zimbabwe and Ethiopia. Rwanda Ministry of
Health (MOH) policies authorize community health workers (CHW) to sensitize their
communities about the impact of population growth and provide: condoms, oral
contraceptive pills, injectables, and the Standard Days Method. However, CHWs are only
allowed to give resupplies to FP clients who have already been initiated on the method by a
health provider. CHWs are also trained to refer clients to the health center in the case of any
suspected side effects.
CHWs are elected by their communities in Rwanda. Each village has four CHWs including a
pair of CHWs (one male and one female) who were trained on CBP. The ten-day training
included both theoretical and practical elements. CHWs were required to be certified by
qualified trainers before they could officially begin providing counseling and methods. In
particular, CHWs were required to correctly provide at least five clients with injectables
before being certified. CHWs report monthly on the number of clients served by type of FP
method and consumption of stock.
Objectives of the process evaluation
The MOH introduced CBP in three districts in 2010 (Gatsibo, Rusizi, Kicukiro) as a first phase
to a national scale-up of these services. In order to document the process of implementing
CBP in the first three districts, we carried out a process evaluation with the following
objectives:
(1) Ascertain CHW and Community Health Supervisor satisfaction with the training they received
(2) Document barriers and facilitators of service provision
(3) Generate recommendations for scale-up of CBP of FP to other districts
Methodology
Focus groups were conducted with CHWs and their supervisors. We randomly selected two
facilities in each of the three districts and then requested supervisors to nominate CHWs
(with both large and small caseloads) who could provide a diversity of experiences. A group
of supervisors was also randomly selected from each of the three districts. In total, 80 CHWs
and 18 supervisors took part in the FGDs.
Trained facilitators and note-takers took detailed notes in Kinyarwanda, which were then
translated into French. Due to resource constraints, the content of the FGDs was not
transcribed and translated. During a three-day day workshop, the FGD facilitators worked
6 | P a g e
with MOH and FHI personnel to identify the major themes emerging from the focus group
discussions, as related to the objectives of the evaluation, based on the field notes.
CHW focus groups covered the following topics: (1) satisfaction with training, (2) self￾perceived competence in providing methods, (3) availability of supplies and commodities, (4)
satisfaction with supervision, (5) experience in client recruitment and perception of client
satisfaction, (6) religious objections encountered, (7) advice for future CBP CHWs.
Supervisors were guided in the same topics, with the addition of questions about community
reactions, side effects encountered, and any changes in FP workload at the health centers.
CBP Results
In July 2010, 3061 CHWs were trained in CBP in the three districts. Eighty-two percent of the
CHWs trained have been certified to provide injectable contraceptives. Service provision
began in December 2010. In the first seven months of service provision 70,308 clients were
served with a contraceptive method in the three districts. Over half of clients (57%) received
injectables, 27% received oral contraceptive pills, 16% received condoms, and 1% received
Standard Days Method (SDM). We would not expect to see many SDM clients, because it
does not generally require a follow-up appointment.
When asked whether the volume of clients coming to the health centers for FP had
decreased since the commencement of the CBP program, supervisors universally agreed
that they had seen a decrease in attendance for
FP.
On average, each CHW had 23 clients during the
seven-month period. However, this also varies
widely by district. In Gatsibo, CHWs had an
average of 42 clients, in Kicukiro the average is 13
and in Rusizi the average is nine clients.
“Although CHWs are
overburdened, here at the health
center it’s the opposite.”
– Supervisor
7 | P a g e
Figure 1: Evolution of FP service provision in three districts in Rwanda, December 2010-June 2011,
by method
When examining the data by district, Gatsibo District is clearly out-performing the other
districts. Although Gatsibo has 40% of the total number of trained CHWs, their share of the
number of clients served is 73 percent.
Figure 2: Evolution of FP service provision in three districts in Rwanda, December 2010-June 2011,
by district
Training
The CBP program was implemented through cascade training. National trainers first trained
community health supervisors and FP providers at health centers in a training of trainers
(TOT) workshop. This five-day workshop included the following topics:
0
2000
4000
6000
8000
10000
12000
14000
16000
18000
Cycle beads
Condoms
Pills
Depo provera
0
2000
4000
6000
8000
10000
12000
14000
16000
18000
Kicukiro
Rusizi
Gatsibo
8 | P a g e
1. Training methodology for adult learning, including group dynamics in adult training, how to
manage difficult situations in training, and a practical session
2. Designing session plans, including administrative elements
3. Teaching techniques, including the coaching of participants in clinical service
4. Technical preparation
5. Teaching aids
6. Evaluation and follow-up of a training activity
7. Review of family planning including anatomy and physiology and FP methods
8. Presentation and discussion the reference manual for CHWs in CBP / FP
9. Data collection tools
Some supervisors requested that the TOT be extended, but they still felt capable of
providing the training for CHWs. Supervisors were particularly appreciative of the sessions
on training skills and adult learning. CHW Supervisors recommended that they be the ones
trained to train the CHWs, rather than FP providers who do not have the time to supervise
the CHWs.
The theoretical CHW training was eight days and covered the following topics:
1. The current situation of family planning in Rwanda
2. Advantages of FP methods , rumors about FP methods, when to start using FP methods
3. Male and female reproductive system
4. Infection prevention while providing FP services
5. Health education techniques
6. Counseling in FP
7. Explanation of the existing FP methods in Rwanda, with a focus on the methods allowed to
the CHW
8. How to use data collection tools
Following the theoretical training, CHWs underwent practical training. The objective of this
training was to allow CHWs to sensitize, counsel and provide FP clients with methods under
the supervision of an FP provider. In addition, each CHW would have to provide five
injectables under supervision before they could be certified to provide them in the
community. Originally the practical training was planned for six hours: one hour of review of
information and five hours of service provision. However, many CHWs found that the time
allotted was insufficient to see the number of clients they needed to be certified for
injectables. This necessitated CHWs having to come back for further practice, which was
difficult logistically. Some CHWs and supervisors reported that due to these difficulties,
some CHWs did not continue with the process for certification.
Both CHWs and supervisors agreed that the selection of who will be trained is key. In
particular, the CHWs should be of reproductive age themselves. The CHW’s commitment to
providing FP should also be carefully assessed. In some isolated cases, CHWs who had
religious objections to FP attended the training and then never implemented the FP services.
FGD participants noted no differences between acceptance of male and female CHWs.
In general, the participants were satisfied with the training; however, they did have some
recommendations for improvement. Both CHWs and supervisors agreed that the number of
9 | P a g e
days was insufficient for them to master all the topics. In particular, some CHWs are at a
lower level of education and need more time to grasp the subjects.
The practical sessions of the CHW training were acknowledged to be the most important
(especially for injectables) and the most complicated to organize. Respondents also wanted
more time in supervised practice. Many felt that the practical trainings were disorganized
and they did not always feel supported by the FP
staff in the health centers. Furthermore, several
reported that it was difficult to find enough clients
(five are required) to practice on to receive their
certification for providing injectables (see above).
Nevertheless, most CHWs reported that they had
received enough training to effectively provide FP
methods. Some participants noted that the Standard
Days Method (SDM) is complicated and they did not
feel they understood it well enough. CHWs also noted that it was important that they are
trained to give counseling on all methods, not just
those they can provide. Some supervisors also
agreed that there was not enough in-depth
information provided about all of the FP methods.
Some CHWs said that they had not received
sufficient information on side effects. Finally, CHWs
said that they did not feel well enough prepared to
address the myths and misconceptions circulating in
their communities.
Community acceptance
FGD participants universally agreed that an official introduction (launch) of the program and
the trained CHWs is important to garner community support and confidence in the service.
CHWs also recommended that they receive their certificates in a public ceremony to
demonstrate directly to the community that they are qualified to provide FP services.
CHWs and supervisors both perceived that clients were generally satisfied with the services
they receive as part of the CBP program. Some clients even told the CHWs that they were
better at giving the injections than providers at the health center.
CHWs identified several positive factors that increased community acceptance and
satisfaction. Having the service available in the community saved clients time and money
because they did not have to travel regularly to the health centers. Furthermore, getting
methods from CHWs was more discrete than going to the health center. On the other hand,
some supervisors thought that community members might be more likely to go to another
village or the health center to obtain their method, since they perceived that as being more
discrete. Nevertheless, the CHWs served many clients in their communities. One CHW
reported that some clients came from other catchment areas to receive FP services.
The support of local authorities and providers at the health center was also perceived to be
essential in the community’s acceptance of the CBP program. Local authorities allow CHWs
“…even people living in other
districts who have not yet
benefited from this program and
are bordering with us come to get
their supplies from us.”
– CHW
“Many people, especially
educated people, do not want
CHWs to administer injections
because they know that they are
not medical professionals”
– Supervisor
10 | P a g e
to speak during community meetings, allowing them to make the community aware of the
program. The health centers also refer FP clients to the CHWs for their resupplies. CHWs
reported that if the local authorities do not support the program, that creates a strong
barrier against community acceptance. One means of gaining their support is to hold
community meetings before the commencement of the program to sensitize the population
about the CBP program. Another idea was to publicize the CBP program via the radio (e.g.,
Urunana).
Despite a general sense of acceptance by the community, CHWs were aware of some
community members who were not supportive of community-based provision of FP services.
In particular, some referred to CHWs as “charlatans” and claimed that without official
schooling they could not be qualified to provide methods, principally injectables. Some
CHWs reported that their inability to initiate clients on FP methods was perceived by some
community members as a negative reflection on their ability to provide methods.
Supervisors were more likely than CHWs to note hesitations among community members.
Religious influences
All the FGD participants acknowledged that there
are barriers to FP due to religious objections to
modern contraceptives. CHWs stress the
advantages of FP to those who object and have
seen some clients subsequently accept a modern
FP method. CHWs reported that some of their
colleagues were actively discouraged by their
religious leaders to not provide modern FP methods. In some cases, the CHWs then dropped
out of the CBP program.
Service Provision
Perceived competence
CHWs repeatedly stated that they were proud of the work that they are doing, and that for
the most part they feel well accepted by their communities. There was occasional opposition
by religious leaders, but CHWs believe that getting political leaders’ buy-in will help to
reduce the impact of this.
Several factors gave CHWs confidence that they were providing good services. First, they
reported having received no complaints from clients and having observed no method
failures (e.g. pregnancies). Supervisors also received no complaints from community
members or local authorities about the services being provided by CHWs. In addition, the
fact that clients returned to the CHWs in a timely manner for the resupply of their method
indicated that clients understood the counseling received and were satisfied with the
services they were receiving.
“At the beginning of the training
it was hard to understand, but
after the training I had confidence
in myself because among my 53
clients no one indicated any
problem.” – CHW
11 | P a g e
CHWs found some methods more difficult to provide than others. CHWs reported no
problems with respect to providing pills or condoms.
Supervisors agreed that the CHWs were providing these
methods well, but that CHWs did not put enough
emphasis in their condom counseling about the benefits
of dual protection. Also, some CHWs did not have a
penis model upon which to demonstrate correct use to
their clients. Supervisors thought that most clients who
ask CHWs for condoms are either sero-discordant or are
engaging in casual sex.
Some CHWs indicated a lack of understanding of the
Standard Days Method. Supervisors also noted this
weakness and recommended that the training spend
more time on this complex method.
Some CHWs and supervisors reported that they had
difficulty drawing all of the content of the injectable
suspension, which may have caused them to under￾medicate the clients.
Supervisors recommended that CHWs be provided with calendars to help them keep track of
client appointments.
Equipment and supplies
One of the major barriers mentioned by CHWs and supervisors was the difficulty of keeping
all the required materials in stock. CHWs reported that since they receive only 2-3 units of
each method that they sometimes quickly ran out of stock. A particular problem noted was
an insufficient quantity of disinfectant supplied. In rare instances, this even resulted in a
client not receiving her resupply on time. As an interim solution, CHWs lacking materials or
products often refer the client to another CHW in the same area. However, in some cases
the neighboring CHW was also experiencing stock-outs.
CHWs often live far from the health center that resupplies them. CHWs are required to go to
the health center to retrieve commodities and consumables, but they are not given a means
of transport. Respondents variously suggested that CHWs receive a transport allowance,
that they be provided with bicycles, or that they receive a regular salary in order to facilitate
travel to and from the health centers. Supervisors also suggested that they could resupply
the CHWs during supervision visits, thus avoiding multiple trips for the CHW to the health
center.
In most cases, CHWs did not receive their equipment and stock of methods immediately
following the training. They reported that this was not a good practice, as much information
could be forgotten in the interim period when they are not practicing. Supervisors echoed
this sentiment. In addition, CHWs and supervisors both noted that CHWs should be provided
“This problem happened to me.
One time, two clients came for
their injections and I didn’t have
any Chlorhexidine. I asked my
colleague but he didn’t have any
either. It touched my heart – these
clients left without receiving the
methods…”
– CHW
“I also had this problem for
clients who use pills. At the clinic,
usually we are only given pills for
two people. Recently I had a third
unexpected client and I managed
the situation by contacting my
neighboring colleague…” – CHW
12 | P a g e
with a separate storage container for the FP
consumables and commodities. Some were storing
them with their IMCI materials, while one supervisor
noted a CHW was storing the FP methods in
envelopes.
CHWs reported no difficulties in completing the stock
management forms. However, some had not received
these forms yet.
Supervision
Nearly all of the CHWs reported having received at
least one supervisory visit. (The exception was among
some CHWs in Rusizi. CHW supervisors reported that
they could not yet supervise the CHWs since they
hadn’t been trained themselves. Instead, FP nurses
received the CBP training.) The policy states that
CHWs should be supervised once a quarter; however,
CHWs reported that supervision visits took place irregularly. Supervisors variously reported
that supervision should happen once a month, once a quarter, or upon request from the
CHW. Thus, supervision visits were often prompted by a request from the CHW. CHWs also
reported occasionally phoning their supervisors with specific questions. Supervisors
reported that it was sometimes difficult for them to conduct the supervision visits, since
they lacked transport.
CHWs and supervisors stressed the importance of supervision visits taking place in the
CHW’s home/village. Not only does this strengthen the CHW’s skills, but it also reinforces
the credibility of the CHW in the eyes of his/her community. CHWs requested more regular
and frequent supervision visits, particularly in their first months of providing services.
Conclusions
CBP appears to be well-accepted by the community, judging by the number of clients who
agreed to receive a method from CHWs, although there are still some challenges. The
training curriculum appears to be well designed, judging by the lack of adverse events
reported by the three districts. However, CHWs and supervisors were nearly unanimous in
requesting that days be added to the training. In particular, the practical training was
challenging to organize, which appeared to frustrate some of the CHWs.
Although this evaluation was only able to assess competence in terms of supervisors’ and
CHWs’ perceptions, nearly all the participants of the FGDs reported confidence in the CHWs’
abilities to provide these contraceptive methods effectively and correctly. As mentioned
above, the fact that there were no adverse events reported also implies that the FP methods
are being provided correctly. This evaluation was unable to assess if CHWs are referring their
clients when appropriate, although supervisors reported receiving at least some referrals for
side effects.
“When the supervisor comes, he
observes the storage of methods,
the registry and the appointments
that I made for clients. He
simulates a client to see how
clients are greeted and if you
correctly fix the resupply
appointment.” – CHW
“The importance of supervision is
that it compares perhaps to a new
training because the supervisor
reminds me what I had forgotten.
Another important element is that
it increases the people’s trust
towards me; there is assurance
that I am implementing a
government program.” – CHW
13 | P a g e
The FGDs also could not evaluate client satisfaction beyond the perceptions of supervisors
and CHWs; however, the fact that CHWs said that their clients were returning on-time for
resupplies of their methods implies some measure of client satisfaction. While religious
barriers were acknowledged by the FGD participants, the sheer volume of clients served
indicates that it is not a significant issue. However, CHWs recommended that local
authorities and health providers make an effort to sensitize and solicit support from religious
leaders.
Support of local authorities and the health center personnel emerged as the most important
element for gaining community acceptance of this program. The credibility of CHWs was
bolstered by community sensitization, CHW participation in community meetings, provider
referrals of clients to CHWs, and supervision visits to the community by supervisors. It is also
likely that the confidence that CHWs report having encourages the community to have
confidence as well.
Nearly all CHWs reported having received a supervision visit and they were perceived as
being important for both credibility and reinforcement of skills. In the case where
supervision visits did not take place, supervisors reported that it was because FP providers
were trained in the CBP program, rather than those people who are charged with
supervision of CHWs. FP providers apparently do not feel that CHW supervision is in their
mandate, nor do they have the time or the resources to provide this support to CHWs. While
most CHWs did receive a supervision visit, they complained that they were often irregular
and sometimes unannounced. A regular calendar of supervision should be established and
maintained.
The most significant barrier to successful execution of CBP appears to be regular provision of
commodities, consumables and equipment to the CHWs. The lack of equipment and supplies
directly following training delayed implementation of the program and CHWs reported that
this could result in a degradation of CHW skills in the interim. In addition, CHWs regularly
reported stock-outs of materials, which hampered their ability to provide services. With such
a large number of CHWs, this will remain a serious challenge. The provision of start-up
materials and the supply chain for resupply need to be strengthened in the future to
maintain CHW effectiveness and community confidence in the robustness of the program.
Barriers and Facilitators
Barriers
Delayed start of program after training due to lack of equipment
Insufficient time during practical training; difficulty in finding enough injectable clients
to achieve certification
Stock-outs because they receive a small quantity of supplies and have to go to the
health center to resupply, but they are not given transport funds
Facilitators
Local authority buy-in, including allowing CHWs to sensitize the community during
community meetings (e.g., umuganda)
Referrals from health centers to CHWs
Supervision not only improves skills, but also reinforces CHW reputation in the
community
14 | P a g e
Recommendations
Below are the strongest recommendations that emerged from the focus group discussions.
 Provide CHWs with equipment and supplies immediately after the training to ensure that
they do not lose any of their skills in the interim.
 The program should consider compensating CHWs in the cases where they must use their
own resources to perform their jobs (transport to/from training, transport to health centers
for resupply, cell phone units for telephone calls to supervisors).
 Provide CHWs with calendars to facilitate managing client appointments.
 Supply CHWs with an adequate stock of supplies to reduce the burden of traveling to health
centers for resupply.
 Ensure that the people trained to train the CHWs and implement the CBP program are the
people who are responsible for the supervision of CHWs (e.g., Community Health
Supervisors).
 Establish a realistic and regular supervision schedule and ensure that supervisors have the
resources to carry it out (including being trained and allocated the time and transportation
necessary).
 Organize a refresher training for CHWs, since some reported that they have trouble with
drawing the entire amount of the solution for the injectable, which could possibly lead to
method failure.