Supporting PHC through Performance Based Financing (PBF) in Rwanda

Background

Management Sciences for Health notes[1] that, “PBF is a powerful means for increasing the quantity and quality of health services by providing incentives to health providers to improve performance. A PBF program typically includes performance?based grants or contracts. Health clinics and their staff are rewarded for reaching or exceeding health indicators.” MSH cautioned that, “while PBF is expected to reduce unit costs in the long?term by increasing productivity, unit costs may actually increase in the short term when services have previously been underfunded???as salaries rise to appropriate levels, missing equipment and supplies are purchased, and facilities are upgraded.” In the long term they explained that PBF had a, “crucial impact on revenues received at health centers, motivated access to quality services for the people served, and allowed the Government of Rwanda to actively manage its investments in pursing national health goals.”

Performance Based Financing applies to health workers from CHWs to facility staff and beyond.

Between 2001 and the mid-2000s Rwanda introduced and began scaling up PBF. The focus of health care shifted from inputs to outputs to outcomes.  “Performance improvements that have been documented in Rwanda after the introduction of performance incentives for primary health care and HIV/AIDS service products have been impressive.”[2] In two pilot districts health care consultations per capita more than doubled. Institutional deliveries tripled. Child immunization, maternal immunization and contraceptive prevalence rates also increased.

There is national policy and political support for PBF as it fits into government desired for accountability. Financial support comes from government and specific programs within the Ministry of Health such as malaria elimination and TB control who have invested in specific performance indicators. Donors such as USAID, World Bank, and Global Fund, play a major role in providing the technical and financial support that pays for performance.

Community Level

PBF in Rwanda operates at all levels of the health system, but of interest to PHC are the front-line health centers and the local cooperatives and community health workers (CHWs). CHW support came about in 2008 as a strategy to sustain the CHWs system. PBF in Rwanda is based on two kinds of contracts, contracts on the performance of the health unit and contracts on the performance of individual health workers.

The PBF procedures manual[3] explains that, “Community PBF (C-PBF) is implemented at the village level through the trained community health workers (CHW) operational within each community. Health posts are located at the cell level and due to their private or faith-based organizations affiliation they are not integrated into the PBF system. Health Center PBF is implemented at the sector’s level health center while district and provincial hospitals are implementing the district hospital PBF model (recently linked with accreditation).”

Under the USAID MCHIP Project, Jhpiego conducted a malaria program implementation assessment in Rwanda that examined the health systems building blocks including financing. The report noted that, “Cooperatives have been set up for CHW; there are usually about 120 people (depending on the number of CHWs in the catchment area of the health center) per cooperative with a president, vice president, secretary, treasurer, and three advisors.[4] Cooperatives can engage in many different types of income-generating activities, based on the agreement among the members, and the executive committee makes final decisions and determines how income will be disbursed among members.”

The aspect of PBF contracting is undertaken with the CHW Cooperative. “Through the PBF, CHW cooperatives can earn ~250USD per quarter from the government. The total amount is based on the completeness of CHW reports and their performance on 20 set indicators. These indicators include elements such as timeliness and completeness of reports, number of pregnant women receiving consultation in the first trimester, number of women accepting family planning (new and continuing clients), and infant growth monitoring.”

Rwanda has also introduced a quality of services element known as Pay-4-Performance, and entities such as health centers and CHW cooperatives are also given a quality score arising from supervisory processes. The quality component has helped “cooperatives linked to the PBF address issues of attrition and motivation. The division of supervision among cell leaders also reduces the work burden for facility-based supervisors.” Practical service delivery problems such as stock-outs of commodities are less likely to occur at the community level when PBF is in place. The challenge moving forward may be the stress created by adding more responsibilities to the duties of the CHWs.

The MCHIP report concluded that, “PBF has set up a system of accountability so that not only is funding spent appropriately, but results are also expected and rewarded. PBF addresses the challenges of motivation that so often plague health care workers and managers in other countries who do not see rewards for working hard and doing a good job. The fact that the system of emphasis on quality services in sufficient quantities radiates from the national to the district to the community level (i.e., districts reporting to the President’s office, and CHWs reporting on indicators to health center supervisors) ensures that a culture of rewarding good performance is developing.” A systems challenge is dependence on donor support in terms of both continuity and donor focus, as many donors focus on particular interventions (malaria, family planning), leaving gaps among the service indicators.


[1] Management Sciences for Health. The Health Impact of Performance-Based Financing in Rwanda. Published: 2010?12?23 http://blog.msh.org/2010/12/23/the-health-impact-of-performance-based-financing-in-rwanda/

[2] Louis Rusa, (National PBF Coordinator-Ministry of Health Rwanda), and Gyuri Fritsche, (Health Care Financing Specialist-Management Sciences for Health). Rwanda: Performance-Based Financing in Health. Sourcebook: Second Edition. http://www.ccoms-imsuerj.org.br/capfts/2011/uploads/4-3RwandaPBF.pdf

[3] Ministry of Health, Rwanda. Performance Based Financing Procedures Manual for Health Facilities (Hospitals and Health Centers). April 2018.

[4] Maternal and Child Health Intergrated Program (USAID, Jhpiego). Analysis of the Status of Prevention and Control of Malaria in Rwanda: Best Practices and Challenges to Program Implementation. November 2013.

Community Participation for Primary Health Care in Burkina Faso

The history of community intervention in Burkina Faso dates back to immediately after the declaration of Alma Ata in 1978. The first community health experiments were carried out in 1979 with the support various development partners with an aim of reducing maternal and infant morbidity and mortality difficult to access health districts where village birth attendants where been trained, equipped and supervised. Today as a matter of policy, Burkina Faso aims at improving the quality of health services and increasing access to health services through community-based health workers (CBOs), civil society organizations (CSOs), non-governmental organizations (NGOs) and associations implements community intervention strategies. with the full participation of communities.[1]

Community Based Health Agent discusses community health needs with village leaders

Burkina Faso’s draft strategic plan for community health states that, “Community Health is a multi-sectoral and multi-disciplinary collaborative enterprise that uses public health science and some social science approaches to engage and work with communities. Its purpose is to optimize the health and quality of life of all people who live, work in a given community. It is based on community needs, understanding and community priorities for health.”1 Community participation is seen as central to achieving universal health care.

The Ministry of Health1 notes that there has been community participation as part of cost recovery (Bamako Initiative). Communities are part of the management committees set up at the level of the first-level health facilities so that the populations thus participate in the management of health facilities, through these committees. “In recent years, there has been renewed interest in community health with a strong mobilization of civil society through NGOs and associations. Community components are integrated into many health programs. This new dynamic has led to significant progress and positive results in the areas of the fight against HIV, tuberculosis, reproductive health (family planning, health of young people and adolescents), malaria, malnutrition, vaccination, etc.”

The Ministry reports that, “Indeed, the community actors have contributed to the achievement of the results obtained through the implementation of community-based health services, which however remain to be rethought not only in its vision but also to be in phase with that of the universal health coverage. For a better involvement of these actors in the achievement of the health objectives, the main challenges remain their motivation, the reinforcement of their capacities and the collaboration with the agents of health.”1 Systematic evaluation of such results remains to be done.

Community Based Health Agents review their service data each month

While there have not been systematic assessments of these participatory processes in community health, researchers did take a close look at the levels and types of community participation attained in water and sanitation projects in Burkina Faso. The following lessons have implications for involving Burkina Faso communities on PHC:[2]

  • Users and Neighborhood groups have a lower level of participation than city and government stakeholders
  • It is possible that the social structures and traditions in Burkina Faso do not encourage a more participative approach
  • Further study of power structures in Burkina Faso may determine why participation is lower than expected
  • There is a significant decrease in participation levels during the design and selection steps of planning as opposed to the earlier stages of problem identification and definiing objectives, and the later stages of option selection and action planning – a question of planning styles dominated by experts

These issues raise questions about the social and cultural aspects of the planning process and about leadership and governance. It would seem that ‘experts’ also need education about how to work with communities.  There are also concerns about the level of community education employed to help community members and CBOs make informed choices. The authors raise another important question concerning expectations that communities will take ownership in the running of projects when in fact these Users have only been asked about their problems and then been informed about a solution.

In another sector the World Food Program developed a diagnostic and planning approach based using community participation and conducted training and practical exercises on “Community-Based Participatory Planning.” The exercise brought many community actors together to identify food security issues such as land degradation, lack of economic activities for residents in the non-agricultural season and floods that block access to health and other services. participators discussions identified community resources to address these issues and demonstrate resilience.[3]

A recent Global Fund grant to Burkina Faso was entitled, “Strengthening health systems and scaling-up of integrated community case management interventions.”[4] Community-based organizations (CBOs) involved in control of the three diseases commonly addressed through integrated Community Case Management (iCCM) – malaria, diarrhea and pneumonia. The program was also expected to strengthen the community workforce be ensuring adequate numbers of functional CHWs. The project received a high level of regular reporting by CBOs (100%), but less than ideal from individual CHWs (83%). This was in spite of the fact that they achieved recruitment targets for ‘functional’ CHWs. Interestingly the biggest problem for the CHWs was the extremely low availability of essential supplies with which they could work (13%). The grant demonstrated the challenges of involving CHWs in more focused activities as opposed to a broader community agenda. Reorganization of the CHW program in the last few years has created a standardized curriculum so that there are two CHWs per village who respond to a variety of community needs ranging from reproductive health to disease control. The problem of adequate supplies and materials to do their work continues, though.

The Village Market provides a good opportunity for community education

While Burkina Faso has established the basic participatory structures in the form of committees and community agents, the Ministry of Health is concerned that Community participation is low.1 Lessons from other sectors show possible reasons and solutions and inter-sectoral collaboration, one of the hallmarks of PHC should be used to address the challenges. the MOH of course has its own ideas (listed below) about the root causes of this problem and having identified the following, it should be encouraged to continue efforts to strengthen the roll of the community in PHC:

  • lack of social capital (capacities of communities to work together effectively, to identify problems, to prioritize and take charge of them)
  • weak involvement of communities in the whole process of implementation.
  • greater focus on community diagnosis of needs, assets, and priorities, to develop appropriate intervention strategies, planning, implementation, evaluation
  • lack of capacity (skills, human resources, material and time) of community implementation actors,
  • lack of accountability of the stakeholders responsible for the implementation of community-based initiatives (CBIs)
  • lack of a multi-sectoral approach in the resolution of health problems

Insufficient strategies to combat social exclusion and to take into account specific groups also constitute a barrier to community participation

Partners worry that there is difficulty sustaining CBIs and demotivation of actors (CHWs, facilitators), which can allow morbidity and mortality to remain high in the community. Clearly, investment in strengthening community participation will go a long way in saving lives and promoting health.


[1] Ministere De La Sante. Draft Strategie Nationale De Sante Communautaire Au Burkina Faso 2019-2023. September 2018

[2] McConville J, Kain J, Kvarnstrom E, et al. (2014) “Participation in sanitation planning in Burkina Faso: theory and practice”. Journal of Water Sanitation and Hygiene for Development, vol. 4(2), pp. 304-312. http://dx.doi.org/10.2166/washdev.2014.125

[3] Ouedraogo, Celestine (2016). Promoting Community-Led Resilience and Development Solutions in Burkina Faso. World Food Program. https://www.wfp.org/stories/promoting-community-led-resilience-and-development-solutions-in-burkina-faso

[4] Global Fund (2017). Burkina Faso BFA-S-PADS Grand Performance Report. https://www.theglobalfund.org/en/portfolio/country/grant/?k=d8f34742-0d57-410c-b5ba-39615edc5785&grant=BFA-S-PADS

Community Data Systems for Primary Health Care in Rwanda

In Rwanda CHWs are male and female resident volunteers elected by members of the village and are accountable of the village they serve. They should have a Primary 6 education minimum. The system guarantees that CHWs are more accessible, acceptable by clients in their communities and less expensive. Each village has a team of three CHWs. Technical supervision is done by the Health Center staff and administrative supervision by the in-charge of social affairs (cell, sector, district). CHWs receive financial compensation through Performance Based Financing (PBF) based on a set of performance indicators from monthly reports. It is this reporting process from village onwards that is explored in this case study. Services include HIV support, integrated community case management of childhood illnesses, family planning and nutrition.

The structure of the health system is based on 4 Provincial hospitals that receive referrals from 35 district hospitals. Within these districts are 465 health centers whose catchment areas contain 2,148 cells and 14,837 villages. With a goal of 3 CHWs per village (1 female & 1 male pair in charge of iCCM and 1 Female in charge of Maternal Health), Rwanda has trained 44,511 CHWs. All CHWs are organized into cooperatives. Each health center oversees one CHW cooperative (which is the basis of performance-based funding as we discuss in Module 6).

Maternal Health CHW keeps track of pregnant women

The current system has evolved since 1995, when it was completely paper-based. The Community Health Information Systems, that is the M&E system for community interventions, is carried out through different national data collection and reporting tools ultimately managed by web-based interface[1]. Tools include national standard paper-based source document (registers), paper-based monthly summary form, DHIS-2 and the système d’information sanitaire des communautés/CHW information system (SISCOM), and Rapid SMS

Initially, separate systems existed to gather data on the country’s 45,000 community health workers, HIV services, human resources, and other special programs—these data streams were separate and though the systems were web-based, none of the databases could interact. The Rwandan health system was collecting immense amounts of data, and spending considerable time and money doing so, but it was unable to effectively use that information for strategic planning or immediate action. As reported by staff of the maternal and Child Survival Program (MCSP), since the successful launch of the Rwanda-HMIS[2], many new reporting modules have been integrated into the DHIS 2 platform which include weekly and monthly reporting of community-based health insurance indicators and the CHW information system.

The following community services are tracked: Treatment of sick children (iCCM), Community Based Nutrition Program (CBNP), Malaria Treatment Adults (HBM), RDTs carried out, Family Planning, Home based Follow up of pregnant women, mothers and newborns, Nutritional monitoring, Under-5 vaccination, Maternal and Newborn Death Surveillance, Drugs and supplies, IEC activities, and user payments. These are summarized into a CHW monthly report form and ultimately into the web-based SISCOM monthly summary form. The web-based R-HMIS data tools are accessible to health staff with passwords.[3]

The data flow system moves as follows:

  — Electronic – MOH

­­­  ^ Electronic – District Hospital

  ^ Electronic – Health Center

  ^ Paper-based – Cell Coordinator

  ^ Paper-based – CHW

The coordinator of CHW cooperative submits the monthly summary form to Health Center data manager who enters aggregated data into DHIS- 2/SISCOM. The data entry screen of DHIS-2-HMIS/SISCOM can be accessed at the health center.

According to MCSP, Rapid SMS text-messaging tool is used by the CHW assigned to maternal health to track pregnant women and track the first 1000 days of life up to 5 years. Examples of information submitted include 1) Woman’s pregnancy and delivery, 2) Children under five identified with danger sign, 3) Tracking referrals (track alert sent and responses) and 4) Maternal and under five deaths. Rapid SMS data are accessed at District Hospital and used at the primary level health facilities to respond to maternal and child health emergencies. Rapid SMS sends automated, actionable responses to CHWs when reported events indicate risk, or when antenatal care visits or deliveries are due. Health facilities are notified to prepare for an anticipated delivery and/or to provide ambulance transport.

DHIS/SISCOM from the CHW also report on drug and supply management. Primary level health facilities support community health workers within the catchment area to ensure they have timely and adequate supplies.

At the local administration level (village, cell, sector, district) CHWs data are used for planning, setting and monitoring health related performance contracts. At the Central level (RBC/MOH and development partners), these data inform policies, establish strategies, manage the supply chain management, aid in research, and perform PBF

MSCP explains that feedback mechanisms and data quality are promoted through quarterly community sub-technical working group meeting, Quarterly and annual analysis of community data, and biannual integrated supervision including community Data Quality Assurance (DQA). Quarterly analysis of Community Health data informs decisions by the Management Team. The biannual DQA of community data compares paper vs. electronic sources. Monthly meetings at Health Center level review reported data and link data to quality of service provision. Mentorship included community DQA

There are monthly CHWs meetings with cell coordinator to review reported data. This also aids in Community Performance-Based Financing. Incentives are given to CHW cooperatives in exchange of their performance based on two categories of indicators.  First, quarterly payment for reporting is based on the timely submission of quality data reports related to 29 indicators including –

  • Report Quality:  Timeliness, Accuracy and Completeness of Report
  • Cooperative   Quality: Legal status, Presence of President, Bank account, etc.

Secondly, Pay-for-indicators are additional payment for improvement in five targeted areas (Nutrition, ANC, SBA, FP referrals and FP new users, LTPM). The average quarterly payment is $900 per cooperative for a 100% quality score.

MCSP notes as an example of success that all CHWs are using standard data collection tools (registers, flipcharts and summary forms). All CHWs are equipped with a mobile phone regularly loaded with airtime for Rapid SMS, communication with HC and other CHWs. The DHIS-2/SISCOM functional countrywide. A strong feedback and coordination mechanism is in place and functional. The PBF includes the CHW reporting rate. MCSP reports that the remaining challenges include turnover of trained CHWs, High workload for CHWs, inadequate response rate on alerts sent through Rapid SMS, disaggregation of data (e.g. FP not disaggregated by method), disparities in CHWs activity as per instructions for Rapid SMS, and sub-optimal use of data. Continued mentoring through CHW meetings addresses community level gaps.

CHWs keep records when providing integrated Community Case Management

[1] Jean de Dieu Gatete, Jovite Sinzahera, USAID Maternal and Child Survival Program (MCSP), Rwanda. Integrating community data into the health information system in Rwanda. Institutionalizing Community Health Conference, Johannesburg. 27-20 March 2017. www.mcsprogram.org

[2] US Agency for International Development (USAID). THE RWANDAN HEALTH MANAGEMENT INFORMATION SYSTEM: Improving Collection and Management of Health Service Data to Support Informed Decision Making. the Integrated Health Systems Strengthening Project. https://www.msh.org/sites/msh.org/files/ihssp_techbr2_final_webv.pdf

[3] Rwanda Integrated Health Management Information System. https://hmis.moh.gov.rw/

The Essential Health Service Package in Nigeria

When examining the service delivery building block of a health system we much ask what, how and where?  “What” addresses the package of services, “How” describes the mechanisms and personnel who do the delivery, and “Where” considers making services accessible in or very near the community. These are the issues explored in this case study on Nigeria. As USAID notes, “An Essential Package of Health Services (EPHS) can be defined as the package of services that the government is providing or is aspiring to provide to its citizens in an equitable manner. Essential packages are often expected to achieve multiple goals: improved efficiency, equity, political empowerment, accountability, and altogether more effective care.”[i]

Although Nigeria has held Primary Health Care as the official foundation of its national health policy since 1986, it took nearly 30 years to give legal backing to a standard service package with the legislative passage and presidential signing of the National Health Bill in 2014. The law says that “all citizens shall be entitled to a basic minimum package of health services…” defined as “the set of health services as may be prescribed from time to time by the Minister after consultation with the National Council on Health” (National Health Bill, 2014 (SB. 215)).1

Up until that time one could infer the existence of an essential medicines list for primary care through the “Standing Orders” service provision algorithms.[ii] These algorithms guide front line health staff known as community health extension workers (CHEWs) in providing quality and accurate treatment and prevention for common illnesses. The Standing Orders also form the basis for training for CHEWs. For each area, “there is a set of actions including health education, further investigation, treatment, and follow-up necessary for good client’s care.”

As an example of essential medicines, the section of an algorithm for fever management below indicates that Artemisinin-Based Combination Treatment (ACT) malaria medicines and Long-Lasting Insecticide-Treated Nets (LLINS) for malaria prevention should be part of the basic package found at the front line.

USAID describes the official service delivery system in Nigeria as organized in three tiers. Tertiary facilities operated by the Federal Ministry of Health are the highest level of health care and serve as referral centers for patients. State Ministries of Health manage secondary facilities, which provide some specialized health services. Local Government Area (LGA) PHC Departments manage primary facilities, which provide the most basic entry point to the health care system-health centers, clinics, and dispensaries. It is at the LGA level in frontline PHC clinics where the CHEWs mentioned above function and deliver the basic package. Volunteer CHW programs exist and are often run by NGOs and are poorly coordinated, although efforts in recent years have aimed at standardizing their training and activities.

In reality, Nigerians at the community level face a mosaic of health service delivery mechanisms ranging from LGA clinics and dispensaries, patent medicine shops, private clinics often run by nurses and licensed to physicians living in the city, and a range of indigenous practitioners (herbalists, bone setters) and faith healers (based in all major religious groups).[iii]

CHEW providing Essential Services

The USAID report on Nigeria’s essential services shows major challenges in health equity.1

  • Coverage is low for reproductive health, maternal health, and immunization varies widely and is strongly associated with wealth, education level, and rural versus urban place of residence.
  • On some measures, health services coverage among populations with urban residence is more than double the coverage among populations with rural residence.
  • Only about 30% of women in the poorest households receive at least one antenatal care visit, compared to over 90 percent of woman in the wealthiest households, with service coverage steeply increasing along with wealth.
  • Coverage of most key preventive and curative health services is relatively low with large disparities in geopolitical zones, between rural and urban zones, and with regard to socioeconomic status; the poorest fifth of the population are much less likely to receive medical services than their counterparts in the wealthiest 20 percent of the population.

USAID’s Health Financing and Governance Project,1 helped group the Essential Package of Care into three “service delivery modes”:

  • family-oriented, community-based services that can be delivered on a daily basis by trained community health, nutrition or sanitation promoters with periodic supervision from skilled health staff;
  • population- oriented, schedulable services that require health workers with basic skills (e.g. auxiliary nurses/midwives and other paramedical staff) and that can be delivered either by outreach or in health facilities in a scheduled way; and
  • individually oriented clinical services that require health workers with advanced skills (such as registered nurses, midwives or physicians) available on a permanent basis.

These modes come along with recommended actions which could be interventions like safe water for the family or drugs like antibiotics for child pneumonia. Therefore, at present the package focuses more on essential interventions (than essential medicines) for groups such as adolescents, pregnant women, women in childbirth, and infants and children among other populations to be reached with of RMNCH services (reproductive, maternal, neonatal, and child health). In conclusion, Nigeria has articulated its PHC service delivery in terms of what, how and where, but has some ways to go in articulating a clear essential package across the life span and ensuring equitable access to and provision of these services across the country and among all income groups.


[i] Wright, Jenna (2016), ESSENTIAL PACKAGE OF HEALTH SERVICES COUNTRY SNAPSHOT: NIGERIA. United States Agency for International Development (USAID), Health Finance and Governance Project (Abt Associates). https://www.hfgproject.org/essential-package-of-health-services-country-snapshot-nigeria/

[ii] National Primary Health Care Development Agency (2015) NATIONAL STANDING ORDERS FOR COMMUNITY HEALTH OFFICERS/COMMUNITY HEALTH EXTENSION WORKERS, Revised By CHPRBN IN COLLABORATION WITH NPHCDA. Nigeria Federal Ministry of Health, Abuja.

[iii] Brieger WR. PHC: in search of a system that works. Africa Health 1987; 10: 30 31,26.

Community Health Officers Extend Primary Health Care in Ghana

In the 1990s the Navrongo research center started the Community-based Health Planning and Services (CHPS) initiative 3 pilot districts. The CHPS Initiative has now become the national strategy for implementing community-based service delivery by reorienting and relocating primary health care from sub-district health centers to convenient community locations.[1] CHPS is even seen as crucial to Ghana’s broader poverty reduction agenda and policy.

CHPS Compound, Upper East region
CHPS Compound, Western region

The CHPS Operational Policy notes that, CHPS was designed to operate at the third tier of the district health system that encompassed a district hospital, sub-district health centers and community-based services by addressing the needs of zones of 3000-4,500 residents “where primary health care services will be provided to the population by a resident Community Health Officer (CHO) assisted by the Community structures and volunteer systems. The deployment of all elements necessary for the CHO to provide house-to house service shall make that zone a fully functional CHPS zone within the sub-district,” thus creating CHPS compounds. It is the CHO who represents the human resource innovation in the Ghana system

A CHO engages each Community within the zone in micro planning of health activities termed “community decision making systems,” building on the following key elements: Community (as social capital); Households and individuals (as target); Planning with the community (community participation); and Service delivery with the community (client focused).

Community health nurses (CHN) trained in the nation’s various schools of nursing would be designated a CHO once they were posted to a CHPS compound. The CHPS compound, often a building donated by the community or a philanthropist served as a health post and accommodation for the CHO. There could be two CHOs and a trained midwife, since CHNs are not trained to conduct delivery. The CHOs are expected to deliver a package of essential primary health care and promotion services at the community level that revolves around home visiting. The idea is to take services to the clients.

While the curriculum of a CHN addresses some basic issues of the CHPS program, CHNs do not exit school as ready-made CHOs. Those who opt to become CHOs must receive orientation from the regions and districts where they work in a CSPS. Depth and quality of orientation varies. CHOs could be assisted by community health volunteers who are supervised by a community health committee.

Sacks et al. report that CHNs obtain a Certificate in Community Health Nursing as part of pre-service training after completing a 2-year curriculum post-secondary school.[2] After 3-5 years of service, CHNs can enroll for higher education to become a midwife or public health nurse (PHN). Sacks and colleagues found that CHN/CHO satisfaction was often determined by professional isolation and lack of basic resources and materials to perform their jobs.

By 2002, 95 out of 110 districts had launched the CHPS program, though not every potential zone was covered. The rapid national expansion of the CHPS program may have contributed to some of the CHNs’ frustrations, as the time was not taken to recruit and train health workers from the target communities who would have spoken the same language. Facilities were not upgraded prior to the increase of health workers and communities were not prepared to provide free housing to CHNs, as originally planned, say Sacks and co-researchers. Although the original goal was for CHPS to achieve complete national coverage by 2015 through the establishment of 6,000 CHPS zones, challenges led to completion of only 3,000 CHPS zones by then.  Now, more than 20 years after the initial trial, Ghana is re-launching the CHPS policy to elevate PHC as a priority and to expand the CHPS model to parts of the country that are not yet covered.[3]

The three broad areas of work by the CHO include basic primary health care issues such as promotion and prevention, management of minor or common ailment and their referrals and case detection, mobilization and referrals. Ghana Web reports that,[4] CHPS compounds cover all 8 essential PHC services and aim at helping ensure improved access to primary health care in these communities. For proper functioning of the various CHPS compounds, there is very strong community participation in the implementation.

The article reports that, “Where there is strong community participation, traditional leaders and community members provide resources, both financial and non-financial incentives, to support implementation of the program. A CHO is expected to work in partnership with the community, households and district assemblies to ensure that, citizens are able to access services and health information as and when they need them whereas the communities are expected to also exert some levels of answerability to health providers.”

The Upper West Region serves as an example of CHPS and CHOs implementation as reported by the Ghana News Agency.[5] There are 308 functional CPHS zones out of 361 planned which cover 62% of the population. The region had 364 CHOs in the 308 functioning zones and 305 active community committees, with 1,669 volunteers. Unfortunately, only 155 of the functioning CHPS zones were fully equipped to standard. A relaunch of CHPS will focus on performance guidelines, systems strengthening and quality of services


[1] Community-Based Health Planning and Services (CHPS): The Operational Policy, Ghana Health Service, Policy Document No.20, May 2005.

[2] Emma Sacks, Soumya Alva, Sophia Magalona and Linda Vesel. Examining domains of community health nurse satisfaction and motivation: results from a mixed-methods baseline evaluation in rural Ghana. Sacks et al. Human Resources for Health (2015) 13:81, DOI 10.1186/s12960-015-0082-7

[3] John Koku Awoonor-Williams, Elisabeth Tadiri, and Hannah Ratcliffe . Translating research into practice to ensure community engagement for successful primary health care service delivery: The case of CHPS in Ghana. https://improvingphc.org/translating-research-practice-ensure-community-engagement-successful-primary-health-care-service-delivery-case-chps-ghana

[4] Gabriel Frimpong. The Community-Based Health Planning and Service (CHPS) concept in Ghana, Ghana Web. Tuesday, 24 April 2018. https://www.ghanaweb.com/GhanaHomePage/features/The-Community-Based-Health-Planning-and-Service-CHPS-concept-in-Ghana-646058

[5] Prosper K. Kuorsoh, Upper West Region has 62 per cent CHPS coverage. Ghana News Agency. Thursday 9th August, 2018. http://www.ghananewsagency.org/health/upper-west-region-has-62-per-cent-chps-coverage-136932

Burkina Faso Ensures Essential Medicines Reach the Front Line

Meike Schleiff of the Department of International Health, The JHU Bloomberg School of Public Health has explored how Burkina Faso manages to get essential medicines, including those for malaria, to the front line health services. She explains that the World Health Organization (WHO) has determined essential medicines to be, “those that satisfy the priority health care needs of the population. They are selected with due regard to public health relevance, evidence on efficacy and safety, and comparative cost-effectiveness.”(WHO, 2018) These medicines should be available as part of health systems functioning to all persons at appropriate amounts, affordable costs, quality standards and sufficient information assured to consumers. Every country develops an essential drug list,

In Burkina Faso, approval of modern medicines (specialty and generic), traditional pharmacopoeial drugs, medical consumables and medical biology reagents is assigned to the Drug Regulatory Directorate (DRP).

Essential Medicines in Burkina Faso are purchased and distributed primarily through the Centrale d’Achats des Médicaments Essentiels (CAMEG), or Central Purchasing of Essential Drugs system.(CAMEG, 2018) This CAMEG system operates with two agencies in Ouagadougou, and then has seven additional agencies in other zones of the country (see map). From the zonal agencies, the CAMEG supplies 67 District Dispatching Depots (DRDs), and also supplies University Hospital Centers, regional hospitals, and additional services provided by the Ministry of Health. For the private sector, the CAMEG manages supplies for NGOs, faith-based organizations, medical laboratories, pharmaceutical companies, and the Global Fund for HIV, tuberculosis, and malaria.(CAMEG, 2018)

Before the CAMEG was created, access to essential medicines and supplies was very difficult, particularly for rural and other hard to reach populations. This was due to geographical access as well as high prices for specialty drugs, limited availability of generic drugs, and prohibitive regulations against the introduction of generic medicines. In response to this situation, the CAMEG was created under a presidential decree in 1992 and commenced activities in 1994. In 1997, an evaluation was carried out to determine the impact of the CAMEG and decide whether to continue the activities through a long-term structure; the results of this evaluation proposed establishing a legally and financially autonomous non-profit entity to carry forward the work of the CAMEG.(CAMEG, 2018) Today, the CAMEG manages the selection of drug suppliers for the country, ensures compliance with WHO and national regulations on price and quality, and facilitates distribution and storage of drugs across the country. A full product list of the drugs managed by the CAMEG can be found on their website (www.cameg.com).

Medicines Reach Front-Line Health Facility

Community Level

The availability of essential generic medicines at health and social welfare centres in Burkina Faso is 74.5%, compared with an average of 40% across the African region and less than 60% globally.(World Health, 2016, Ministry of Health, 2010) For hospitals, rates are slightly lower with 61% of generics available and regional hospital centers and 39% at university hospital centers (Saouadogo and Compaore, 2010), but only 1.2% of branded medicines; this situation results in patients who are referred to hospitals from lower level facilities often being forced to purchase medicines from more expensive private pharmacies in order to receive the necessary care at higher levels of the health system.(Vervoort, 2012)

While immense progress has been made in ensuring affordability and accessibility of essential medicines in Burkina Faso, mark-ups at different points along the supply chain still result in prohibitively high prices at final points of sale; patients still pay for 37% of the cost of essential medicines and remain the single greatest healthcare cost for households in Burkina and a burden for the majority of the population who still live on less than $1.25 per day.(Vervoort, 2012)

References

CAMEG 2018. Centrale d’Achats des Médicaments Essentiels. Ouagadougou, Burkina Faso.

Ministry of Health 2010. Measuring the Price, Availability, Financial Accessibility, and Price Composition of Medicines in Burkina Faso. Ouagadougou, Burkina Faso: Ministry of Health of Burkina Faso.

Saouadogo, H. and Compaore, M. (2010) ‘Essential Medicines Access Survey in Public Hospitals in Burkina Faso’, 4(6), pp. 373-380.

Vervoort, K. 2012. Ensuring the Availability of Essential Medicines in Burkina Faso: A Shared Responsibility.

WHO 2018. Essential Medicines. Geneva, Switzerland.

World Health, O. (2016) Burkina Faso: Country Cooperation Strategy. Available at: http://apps.who.int/iris/bitstream/handle/10665/136973/ccsbrief_bfa_en.pdf (Accessed: May).

Community Based Health Insurance Can Fight Malaria

Community-Based Health Insurance (CBHI) is seen as a way to promote universal health coverage and protect vulnerable populations from catastrophic financial effects of illness. Malaria can be such an illness is not treated in a timely manner, and having insurance can help prevent delays.

In countries including Rwanda, Burkina Faso and Senegal a particular CBHI scheme known as mutuelles has taken root. For Rwanda USAID (2018) reports that …

The 2014–2015 DHS showed that insurance coverage has remained stable since the 2010DHS and that 79 percent of the households have at least one family member with health insurance and that among those insured 97 percent have community health insurance (mutuelles). Early ANC attendance is also encouraged by providing targeted SBCC, combined with innovative community- and facility-level performance-based financing and high enrollment in community health insurance schemes (mutuelles). The MoH, with the support of partners, has worked to improve the quality of services for case management at health facilities through training and capacity building efforts at national and district levels.

A study looked at health care seeking for children below 5years of age in Rwanda in 2005 to 2010 and found that, “In both years,under-five children with Mutuelles were more likely to use medical care than uninsured children. Children in 2010 had a higher probability of using medical care … regardless of the children’s poverty or Mutuelles status.” The study provides an example of how pre-payment CBHI can not only increase universal health coverage but also address challenges of equity (Mejía-Guevara et al., 2015).

Below is a chart showing the fee structure in Rwanda (Tashobya, 2017). [The trainer should ask participants about fees for CBHIs or other national health insurance schemes in their countries if such exist and how participation in CHBI helps achieve UHC.]

Fees in Rwanda’s community insurance scheme, Mutuelles                                  
Ubudehe/Social Category Annual Rwandan Francs per Household Member Approximate US Dollars
1 0 (Paid by government) 0
2 2,000 2.25
3 3,000 3.35
4 4,000 7.85

Now The East African reports that, “With more than 90 per cent of Rwandans covered under the community-based health insurance scheme locally known as Mutuelle de Santé, Rwanda is one of the few developing countries in the world that have successfully achieved universal healthcare” (Kagire, 2018) This was achieved by addressing enrollment, quality of cane and transferring management of the scheme to the Rwanda Social Security Board (RSSB). Now more than ever, no one needs to die from malaria in Rwanda.

  • Kagire, Edmund (2018). Rwanda Has Achieved Universal Healthcare. The East African. 15 December 2018. https://allafrica.com/stories/201812150128.html
  • Mejía-Guevara I, Hill K, Subramanian SV, Lu C. (2015). Service availability and association between Mutuelles and medical care usage for under-five children in rural Rwanda: a statistical analysis with repeated cross-sectional data. BMJ Open. 2015 Sep 8;5(9):e008814. doi: 10.1136/bmjopen-2015-008814.
  • Tashobya, Athan (2017). Mutuelle Month: Govt targets 100% subscription. The New Times. Published : April 03, 2017. https://www.newtimes.co.rw/section/read/210035
  • USAID/President’s Malaria Initiative (2018) Rwanda Malaria Operational Plan FY19. https://www.pmi.gov/docs/default-source/default-document-library/malaria-operational-plans/fy19/fy-2019-rwanda-malaria-operational-plan.pdf?sfvrsn=3

Malaria funding may never be enough, but better program management should be possible

The World Malaria Report shows that malaria cases are up, and even though there are fewer reported cases in 2017 than 2010, the number is greater than 2016. So once again high burden countries are being targeted. Today this focus is on “High Burden to High Impact”, but in 2012-13 it was the “Malaria Situation Room” that also focused on 10 high burden countries.

Progress was being made up to around 2015-16, it then started to reverse. The challenge was not just funding. As the WHO Director General noted in the foreword to the 2018 World Malaria Report (WMR), “Importantly, ‘High burden to high impact’ calls for increased funding, with an emphasis on domestic funding for malaria, and better targeting of resources. The latter is especially pertinent because many people who could have benefited from malaria interventions missed out because of health system inefficiencies.”

Over the years there have never been enough pledged funds to fully achieve targets, but as funding has never reached desired levels, attention is now being drawn more and more to the source of that funding (more emphasis on domestic/endemic countries) and especially how the health system functions to use the funds that are made available. In 1998 during one of the early meetings establishing the Roll Back Malaria Partnership, a speaker stressed that malaria control could not succeed without concomitant health systems strengthening and reform. That 20-year-old thought was prescient for today’s dilemma.

First, what is the funding situation? As outlined in the World Malaria Report …

  • In 2017, an estimated US$ 3.1 billion was invested in malaria control and elimination efforts globally by governments of malaria endemic countries and international partners – an amount slighter higher than the figure reported for 2016.
  • Governments of endemic countries contributed 28% of total funding (US$ 900 million) in 2017, a figure unchanged from 2016.
  • Funding for malaria has remained relatively stable since 2010
  • To reach the Global Technical Strategy 2030 targets, it is estimated that annual malaria funding will need to increase to at least US$ 6.6 billion per year by 2020

The question remains – does investment lead to results. The WMR shows, for example, that “Between 2015 and 2017, a total of 624 million insecticide-treated mosquito nets (ITNs/LLINs), were reported by manufacturers as having been delivered globally. This represents a substantial increase over the previous period 2012–2014, when 465 million ITNs were delivered globally”.

At the same time the report states that, “Households with at least one ITN for every two people doubled to 40% between 2010 and 2017. However, this figure represents only a modest increase over the past 3 years, and remains far from the target of universal coverage.” Is it simply a matter of funding to reach the other 60% of households, or are there serious management problems on the ground?

Then there is the issue of using nets. The WMR traces new ownership and use from 2010 to 2017, and we can see that overall the proportion of the population at risk who slept under a net increased from around 30% to 50%, but only 56% of those with access to a net were sleeping under them. This can be attributed in part but not completely to the adequacy of nets in a household.

We should ask are enough nets getting to the right places, and also are efforts in place to promote their use. Behavior change efforts should be a major component of malaria program management. Even the so called biological challenges to malaria control have a human element. Monkey malaria transmission to people results from deforestation. Malaria parasite resistance to medicines comes from poor drug management on individual and systems levels.

The target year 2030 will be here before we know it. Will malaria still be here, or will countries and donors get serious about malaria financing AND program management?

Tanzania: Slow Progress in Preventing Malaria

The full 2017 Malaria Indicator Survey (MIS) results have been published for Tanzania providing an opportunity to look at the findings in more detail. Several important factors need highlighting since Tanzania is part of a regional block where some countries are activly considering malaria elimination – the E8 countries of the Southern Africa Development Community.

So far Tanzania has come close to achieving a target of 80% of households owning insecticide treated nets (ITNs) with 78% on the mainland and 79% in Zanzibar. A closer look shows that there is still a ways to go to get to universal coverage or at least one net for every two persons in the household. With this indicator 45% of mainland and 42% of Zanzibar households have met the target, meaning that there are unprotected people in a majority of households across the country. This indicator experienced a drop from a 2011 “high” of 56%, a drop to 39% in 2015 and a slight recovery to 45% in 2017.

Even the universal coverage target requires that people actually sleep under the nets. What the MIS report shows is that although 63% of people had access to an ITN, only 52% reported sleeping under one the night before the survey.

Equity remains an issue with 69% of households in the lowest wealth quintile owning at least one net compared to 81% and 83% in the middle and fourth quintiles. Although households in the highest quintile had 78% ownership, this group is more likely to live in better quality housing that prevents the ingress of most mosquitoes. Also residents in urban areas have an edge over rural counterparts in terms of net access.

The report show that 55% of children under 5 years of age and 51% of pregnant women slept under an ITN. This is down from 72% and 75% respectively in 2011.

We learn that 90% of existing nets were obtained through some form of public sector campaign including mass distribution (62%), village coupons redeemable at health centers (15%), and school campaigns (4%). Only 5% were obtained through routine services (ANC, child immunization) indicating that efforts to ‘keep up’ after mass campaigns need to be strengthened. The 10% of nets, whether treated or not, that were obtained in shops and markets cost the owner in the neighborhood of US$5.00.

Uptake of doses of intermittent preventive treatment for malaria in pregnancy has slowly but steadily increased over the past 15 years and stood at 83% for one dose, 56% for two doses and 26% for three in this most recent MIS. With the current target being three or more doses needed for optimal protection, Tanzania still has a far long way to go, especially considering that accessing ITNs through ANC services is also low..

Malaria Death Audits: A tool to help improve severe malaria case management and prevent malaria related deaths in Mashona East, Zimbabwe

Anthony Chisada, Paul Matsvimbo, Munekayi Padingani, Tsitsi Siwela of Jhpiego,the USAID ZAPIM Project, Harare, Zimbabwe,  and the Zimbabwe Ministry of Health and Child Welfare, Harare, Zimbabwe presented their experiences using death audits at the 2018 Annual Meeting of the American Society of Tropical Medicine and Hygiene. Their findings follow.

Nearly 50% of the Zimbabwean population is at risk for malaria. Total numbers of malaria related deaths have remained almost constant over the past 5 years. The National Malaria Control Program’s National Malaria Strategic Plan aims to reduce malaria-related deaths by 90% from 2015 levels (462 deaths) by 2020.

To improve severe malaria care and reduce mortality, NMCP documents and investigates all malaria deaths to ascertain the cause of the death and understand if and how it was avoidable. Malaria death audit meetings are held quarterly with health facility staff using a standard death investigation form and case management notes and form a learning platform to look at qualitative and quantitative data related to the deaths.

The audits also examine the quality of care offered as per treatment guidelines and seek to identify ways to prevent future malaria deaths based on omissions and errors in presented cases.

This review examines the findings from death audit meetings facilitated by the PMI-funded Zimbabwe Assistance Program in Malaria project in the Zimbabwean provinces of Mashonaland Central, Mashonaland East and Matabeleland North. Six death audit meetings were conducted over an 18-month period, resulting in a total of 80 deaths audited. The audited deaths were purposely sampled for the potential learning value they offered and to diversify lessons learned.

According to audit reports, the main contributing factors to malaria deaths included: delayed presentation by patients, lack of comprehensive assessment and documentation of cases, inadequate care for patients with reduced level of consciousness and shock, inadequate follow-up of patient progress, lack of supportive investigations, and lack of access to renal replacement therapy/dialysis and blood transfusion.

Most deaths in age groups: under 5s(30%) and over 15(44%). Children are at risk of dying from malaria because of underdeveloped immunity, women taking children to gardens at night, delayed presentation  since mothers are busy. Problem most pronounced in UMP. People over 15 years also at risk of dying: Suggestive of exposure as they indulge in outdoor activities without any protection from mosquito bites.

Death audits reapportion delays (3rd delay increased from 8% to 28%). First delay remains the major contributory factor- need for strengthening SBCC efforts. Malaria death audit meetings enhances the usefulness of the malaria death surveillance system and provides an opportunity for identification and discussion of health system challenges. Some challenges identified are rectifiable thus mitigating deaths. These enable holistic patient care: Identification and management of co-morbidities is critical. Findings contributed to justification of introduction malaria clinical mentorship for improving QoC.

The introduction of malaria death audit meetings has added an active, learning platform to complement the use of the malaria death investigation form and also served as a useful learning tool within Zimbabwe’s clinical mentorship program. Regular malaria death audit meetings are potentially useful in improving malaria care and reducing malaria related deaths.