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Abel Mote and Joyce Richard

Editors' note:  Throughout East Africa, as in most African countries, governments confront challenges in providing adequate health care for rural populations.  This chapter briefly reviews the evidence as to the nature, causes and possible legislative solutions to the persisting rural health care problems in Rwanda's and Kenya's very different circumstances.   An attempt to draft an East African Community legislative program to improve rural health care in each member state and throughout the region must build on the resources and overcome the constraints posed by those differences.  This chapter compares the evidence available in two research reports that justify quite different bills to improve rural health care in these two countries.   In assessing these proposals, workshop participants undoubtedly will want to consider (1) the evidence as to the likely effectiveness of the implementation and social impact on rural health care services in both countries; (2) socio-economic costs and benefits of each proposal; and (3) the potential advantages and disadvantages of coordinating all EAC member states' human and financial resources to improve rural East Africans' access to effective health care services.

Using the problem-solving approach to structure the available evidence, the two authors of this chapter have each written a research report to provide evidence to describe the problem of providing rural health care in Kenya and Rwanda, whose and what behaviors seem to contribute to those problems, the causes of those behaviors and alternative logically possible legislative solutions to induce new behaviors likely to prove effectively implemented to help to improve rural health care in the region.  

Each author has proposed a somewhat different legislative solution to the problem of providing health care to residents in remote rural areas.   Undoubtedly, this reflects in part the very different national circumstances existing in Kenya compared to Rwanda.  Nevertheless, readers might find it helpful, in light of the available evidence, to assess the advantages and disadvantages of the two proposed legislative solutions.  In doing so, they might consider whether the problem of rural health care seems best dealt with separately by each member state; or whether the proposed East African Health Commission might usefully include elements of both in a regional legislative solution.  To facilitate that assessment, this chapter offers a comparison of the evidence presented by Abel Mote and Joyce Richard in their draft research reports as a basis for their proposed legislative solutions for improving rural health care in Kenya and Rwanda.

In Kenya:

To get antenatal care in Naiborkeju Sub-Location of Samburu District, Kenya, a pregnant woman must walk for hours or days to the nearest health center. If she is lucky, a nurse (hopefully in a good mood) will attend to her.  Too often, she may find the health center closed or lacking supplies, so she must make the long and arduous journey to Maralal, the district headquarters.  There, the woman – whose household struggles for survival on less than two dollars a day – must pay a cost-sharing fee of 200 shillings (approximately 2.5 dollars).⁴¹²   She will then join a long queue of other clients who – seeking health care services – have walked from different villages elsewhere in the vast Samburu District. Like millions of other residents in Kenya's remote rural area, none have adequate access to quality health care services.

In Rwanda:

A mother walks an hour and a half carrying her sick infant to the nearest health center, only to find that the nurse is not scheduled to be there for two days.  Nurses and aides at a clinic do not consistently take patients' vital signs, record a child's weight, comparing it to a weight chart, or give immunizations when needed.   Despite the great progress made since the 1994 genocide, these events still occur too often in the rural areas of Rwanda.

Mote's research report aims to justify a bill to establish mobile clinics equipped with modern communications technologies to enable residents in Kenya's underserved rural areas more easily to access modern health services.  Richard's report calls for Rwandan legislation to increase the number of trained community health workers at the cellule and village areas to levels specified in the Rwandan Government's National Community Health Policy of 2008.⁴¹³

Following institutionalist legislative theory's research report outline, both research reports' Introductory Parts I offer background evidence as to the significantly different, historically shaped country circumstances which today still contribute to both nations' rural inhabitants' difficulties in accessing effective, efficient health care.   Mote's report's Introduction, Part I, observes that Kenya's pyramidal health system, today, in many respects parallels the nation's urban-rural health gap, a gap generated over centuries of Arab trade and British colonial rule.   Richard describes a seemingly similar pyramidal health system that emerged in tiny, land-locked Rwanda after almost a century of, first, German and then Belgian colonial rule, followed by political independence interrupted by the brutal genocide of 1994.⁴¹⁴

MAP 1: RWANDA4
   
Kenya's population appears slightly more than four times the size of Rwanda's.   On the other hand, as Table 1 illustrates, given Kenya's far larger land area, Rwanda's population density appears roughly five times that of Kenya.

Table 1: Estimated 2005 Population and Population Density⁴¹⁵

Approximately eighty percent of all Rwandans live in rural areas, many on mountainous hill sides, some reaching 1700 meters in height.⁴¹⁶ Chronic overuse and soil erosion force many rural Rwandan families to struggle for bare subsistence on land holdings of less than one hectare – a level FAO/Rome has declared inadequate to produce sufficient food crops for the average family.⁴¹⁷
Kenya's much larger land area – in contrast to that of Rwanda – ranges from the rich Rift valley to vast flat areas, some of which stretch across relatively arid plains, not a few of them inhabited by nomadic herders.  

MAP 1:  DISTRICTS IN KENYA⁴¹⁸

Impact of structural adjustment in Kenya

In the 1980's The World Bank and the International Monetary Fund (IMF) pressured the Kenyan Government to implement a Structural Adjustment Policy and Economic Recovery Program. The two policies called for reducing government expenditures and the size of the civil service.⁴¹⁹The Kenyan government declared a blanket freeze on hiring and started a retrenchment program to downsize the civil service. This, together with other push and pull factors and natural attrition, caused a rapid shrinking of the number healthcare workers in public health facilities.⁴²⁰ Because of the skewed levels of development between urban and rural areas, these measures affected the rural areas more. Because the international financial institutions (World Bank and IMF) placed a low ceiling on wage expenditure, the government could neither employ more health workers, nor improve the salaries of its present employees.    

Kenya's Chief Economist at the Ministry of Health, S.N. Muchiri, reported that the government targeted wage expenditures at 8.5% of GDP in 2006 and 7.2% in 2008.⁴²¹  The data from Nyando District Hospital in Nyanza Province illustrated the impact of fund shortages on Kenyan hospital staffs:   Only "one doctor, fifteen nurses and four clinical officers" struggled to serve the 100 new patients who came every day to the hospital for help.⁴²²

Genocide in Rwanda

When the AIDS pandemic swept through Africa in the 1980s, Rwanda became one of the ten countries in Africa most severely affected by the disease.⁴²³  During the 1994 genocide, sexual assault by HIV/AIDS-infected men on an estimated 250,000 women resulted in HIV infection of approximately 125,000 women.  By the end of 2002, seventeen percent, or nearly 24,000 of these women demonstrated symptoms of full-blown AIDS.ⁱ 
The ethnic conflict disrupted the Rwandan economy and infrastructure.  The marauding perpetrators of the genocide destroyed most of the health care facilities.  Health care and other professionals constituted a disproportionate percentage of the estimated one million murder victims.⁴²⁴ Many health care providers not killed in the genocide left the country seeking safety.  Prior to the genocide in 1994, 253 physicians worked in the public sector.  By 2000, the number had dropped to 144.ⁱⁱ  Only forty-percent of Rwanda's rural population has access to safe drinking water sources.ⁱⁱⁱ  Women and children carry jerry-cans of water from these sources to their homes each day. Malaria, infectious water-borne diseases, pneumonia and tuberculosis constitute the leading causes of death.

Summary and Conclusion

In short, for different reasons, as part of a larger  decline of national health care, the brief post-independence period in both Kenya and Rwanda saw a significant deterioration in their rural population's access to health care services.  Nevertheless, in these very different historical and geographical circumstances, the post-independence governments developed health systems with surprisingly similar characteristics.  As Part II provides evidence to suggest, outside of the agricultural marketing sectors established to export crops, impoverished rural inhabitants in both countries experienced difficulties in accessing adequate health care.

As problem-solving's first step requires, both reports' Part II describe the nature and scope of these two countries' health systems, and whose and what behaviors (by definition, 'institutions'⁴²⁵) contribute to their difficulties in providing rural health care.

In both countries, the health systems consist of predominantly government-administered health institutions, functioning alongside, and sometimes cooperating with, private, faith-based and traditional medicine.  Mote's complex flow chart, below, describes the relationships between the Kenyan government system and the private sector institutions. 

Chart 6-1:  KENYA'S HEALTH SYSTEM

The Kenyan central government manages about 52% of all Kenyan health services. The private sector, faith-based organizations and local governments manage the remaining 48%. "The central government manages about 79% of the health centers, 92% of the sub-health centers and 60% of the dispensaries."⁴²⁶ The government partners with faith-based health facilities by providing some staff and essential drugs. 
Kenya's health system functions at three levels: At the top, through the ministry headquarters; at the middle-level, the provincial facilities; and at the district-level through district offices. 
"The headquarter sets policies, coordinates the activities of the NGOs and manages, monitors and formulates policy formulation and implementation. The provincial tier acts as an intermediary between the central ministry and the districts. It oversees the implementation of health policy at the district level, maintains quality standards and coordinates and controls all district health activities. In addition it monitors and supervises district health management boards (DHMBS) which supervises the operation of health activities at the district level."⁴²⁷ 

District level officials concentrate on the delivery of health care services to the district's inhabitants.   These officials generate their own expenditure plans and budget requirements based on the guidelines delivered from the ministry headquarters through the provinces.⁴²⁸
Mote observes that, in Kenya, relatively few Kenyans, who live in remote regions, enjoy access to essential health services.  Only about 30% of Kenya's rural inhabitants – compared to 70% of its urban population – live 2.5 miles or less from any health facility.⁴²⁹   

A. Kenya's health care system pyramid

Mote's Table 6-2 (below) shows that the highest number of nurses – 53.7% of the nursing staff, barely half the number recommended – work in district hospitals and sub-district hospitals.⁴³⁰   Health centers and dispensaries – the facilities that serve most rural inhabitants – have less than 20% of the recommended staff.⁴³¹

TABLE 6-2: NUMBERS AND DISTRIBUTION OF MEDICAL STAFF WORKING IN PUBLIC SECTOR HOSPITALS, HEALTH CENTERS AND DISPENSARIES⁴³²

While more than 50% of the Kenyan dispensaries have the capacity to communicate requests for transport during emergencies, only 3.5 percent have transport facilities.⁴³³   These capacities improve as one goes up the referral pyramid.  More than 90 percent of district hospitals have capacities both to communicate requests and to transport patients.   Less than 5 percent of the district hospitals, however, have sufficient funds to purchase essential equipment.   Less than 10 percent have sufficient funds for maintaining buildings and purchasing medicine.⁴³⁴

Government-sponsored facilities fall into two classifications:  Those run by the central government, and those financed by the local government authorities.  The health care system operates on a referral basis, organized in a pyramid structure.⁴³⁵  Dispensaries and sub-district hospitals, which in most cases provide the initial contact with rural clients, occupy the bottom of the pyramid.⁴³⁶
 
In some cases, a hospital or health center provides the initial contact. Their facilities provide preventive health care.   Health centers provide first line curative services for diseases common in their areas of jurisdiction and preventive care. Some provide ambulance services.   District hospitals give comprehensive health care.  Provincial hospitals provide referral services for district hospital and specialized care. National referral hospitals provide advanced diagnostic, rehabilitative and therapeutic services. The flowchart⁴³⁷ below shows how the referral system works. 

CHART 6-1: KENYA'S HEALTH REFERRAL SYSTEM

Mote's Table 6-3 illustrates the district health facilities' inability – in comparison with provincial or central offices – either to communicate and to provide transport for referral cases or to train local health care workers.  

TABLE 6-3: THE CAPACITY OF DISTRICT HEALTH FACILITIES TO COMMUNICATE, PROVIDE TRANSPORT FOR REFERRAL CASES AND TRAIN DISTRICT HEALTH CARE WORKERS⁴³⁸

The chart⁴³⁹  below describes the top-level management of the ministry.⁴⁴⁰

In Kenya, the Provincial Health Management Team (PHMT) and the Provincial Medical Officer act as the interface between the ministry headquarters and the health workers and stakeholders. In each province, the PHMT coordinates and supports district and sub-district facilities. The District Health Management Team (DHMT) and District Health Management Board (DHMB) supervise and manage rural health facilities i.e. health centers, sub-district hospitals and dispensaries.⁴⁴¹  Nurses provide the services in rural health facilities. Of the 2,158 health facilities in Kenya, 1,536 comprise dispensaries; 440, health centers; 132, district hospitals; and 7, provincial hospitals.⁴⁴²

B. Rwanda's health care system pyramid

In 2003, Paul Kagame became Rwanda's first democratically elected president.  Kagame's administration adopted a decentralization policy, seemingly similar to Kenya's.  It divided the government into six provinces and thirty districts.   It split these districts into four-hundred thirty-two municipalities and divided each municipality into sectors and each sector into cells. 

Thus, Rwanda, too, adopted a pyramidal health care structure consisting of central, intermediary, and peripheral levels:

    Ministry of Health
    Provincial Health Director
    District Health Director
        Health Center
        Head Nurse of Health Center

The central level includes the Ministry of Health and the three national referral hospitals. The provincial/intermediary level manages policy issues, but does not provide care.⁴⁴³  At the peripheral level, each district provides health care to its target population through an administrative office, a district hospital, and, in the more remote rural areas, through health centers, health posts, and dispensaries.
In both Kenya and Rwanda, however, rural residents still have trouble accessing adequate health care services.   Because a law⁴⁴⁴ cannot command health services to provide themselves to rural inhabitants, as an important part of problem-solving's first step, legislative theory requires identification of the behaviors — the institutions — that perpetuate these difficulties.

C. Whose and what behavior constitute difficulty

In this second section of their reports' Part II, both authors describe the problematic behaviors of the social actors – the nurses, the district managers (in Kenya, the DHMBs and DHMTs, and in Rwanda,  the District Mayor's offices) and the national ministry of health (in Kenya, two ministries, including the Ministry of Public Health and Sanitation and of Medical Services;⁴⁴⁵ in Rwanda, the Ministry of Health) – which seem to contribute to rural residents' difficulties in accessing adequate health care services:   Mote's and Richard's reports describe how those social actors' behaviors perpetuate the problem of inadequate rural health (But we need more evidence!)  In both countries, those problematic behaviors comprise the particular 'institutions' the authors' proposed bills seek to change.

D. Nurses problematic behaviors

In both countries, nurses tend, if possible, to avoid working in rural areas. Nurses opt for employment in urban government health facilities or take jobs in the private facilities located in urban areas. Those initially assigned to the rural areas typically seek transfers or promotions to urban facilities, or move to the private sector.   Many migrate to developed countries.

E. The Nursing Council of Kenya

The Nurses Act Cap. 257 of the Laws of Kenya established The Nursing Council of Kenya (NCK).  The council has responsibility
"to make provision for the training, registration, enrolment and licensing of nurses; to regulate their conduct and to ensure their maximum participation in the health care of community and for connected purposes."⁴⁴⁶ 

This organization does make efforts to improve the standards of healthcare in communities.   It has no jurisdiction, however, over the formulation of policies that might make nursing, especially in rural areas, more attractive.

F. District level management

As illustrated by the charts and tables above, both countries' governments decentralized their health systems⁴⁴⁷.  In 1992, Kenya's government issued Legal Notice No. 162 of the Public Health Act (Cap. 242), which created the DHMBs.⁴⁴⁸  Each District Board's membership consisted of –

1. a chairman appointed from among the Board members by the Minister (of Health);
2. the area District Commissioner or a representative;
3. one person with experience in finance and administration from within the District;
4. two persons nominated by the NGOs recognized by the Minister, one to represent the interests of religious and the other private health services;
5. one person nominated by the Local Authority having jurisdiction over the area;
6. not more than three persons to represent community interests; and
7. the area Medical Officer of Health (MoH) who serves as the Board's secretary.

In Kenya, a DMHB (ie, provincial health board) supervises health services, presents revenue, expenditure estimates to the minister and advises the minister on development plans for its district. Once the minister approves a plan, the board implements it.   To carry out its tasks, the board appoints committees, each headed by a chairman, to assume responsibility for Primary Health Care, Finance, and Quality of Clinical Services.⁴⁴⁹

A Kenyan District Medical Health Team (DHMT) consists of the District Medical Officer of Health (DMOH), District Public Health Nurse, District Clinical Officer, District Public Health Officer, and District Laboratory Technician.   Each team plans and coordinates health activities in its district.  It works with the board to supervise and coordinate the implementation of district health policies, monitor the utilization of resources and control quality of services. Together, the DHMT and the DHMB manage and support the supervision of the district's rural health facilities.   

G. Ministries of Public Health and Sanitation and of Medical Services

The Department of Planning and Policy at the ministry headquarters in Nairobi supposedly drafts policies and advises the minister.  However, the two ministries of health now in place seem not to have worked together to tackle this task.⁴⁵⁰  (Editor's note:  if possible, please describe their 'behaviors' here; and explain them in Part III)  The lack of policies, to address health care service delivery in rural areas, indicates that officials in neither ministry believed the law required them to focus on rural health issues.

In Rwanda, the new 2008 National Health Policy makes district mayors, responsible for managing rural health programs. The Ministry of Health, having received significant international financial support,⁴⁵¹ has tried to implement international recommendations for acquiring technological devices like computerized medical records,⁴⁵² TRACnet, a cellular phone based means of communicating HIV/AIDS patients' test results and the need for medications to urban health facilities and the Ministry of Health,⁴⁵³  and a plan to install solar power to 47 percent of its health centers in 2009.⁴⁵⁴  Despite these technogical and schematic advances, the lack of sufficient health care workers persists in rural areas.⁴⁵⁵  "There is one doctor for every 50,000 people and one nurse for every 3,900 people; the impact of this lack of human resources is most severe in rural areas."⁴⁵⁶  Both doctors and nurses still seem prefer to work in the urban areas, or for higher paying non-governmental organizations, rather than for the public system.  Of the 3570 nurses in Rwanda in 2004, 2,066 worked in urban areas⁴⁵⁷ where less than 20 percent of the population resides.⁴⁵⁸

In 1995, the government began to train community health workers (CHWs) to promote health in their own communities.   The Ministry of Health invited the United States-based Partners in Health to set up a hospital to provide health services to the inhabitants of the impoverished remote province of Rwinkwavu, and provide a training center for CHWs.⁴⁵⁹   Nevertheless, by 2008 the number of trained CHWs had reached only 12,000, far short of the 60,000 projected as necessary to implement the National Community Health Policy.⁴⁶⁰ 

In sum, both research reports identified and described the shortages of personnel required to provide health care for all Kenyans and Rwandans, especially those in remote rural areas.   They also identified the role occupants and implementing agencies – nurses, middle-level managers, and health ministry officials – whose behaviors apparently contributed to perpetuating the inadequacy of rural health care services.

As required by problem-solving's second essential Step 2, both authors' reports offer explanatory hypotheses as to the causes of the problematic behaviors of role occupants (the nurses), the district level implementing agencies, and the two countries' Ministries of Health.   In their reports' third Part, to ensure consideration of all possible explanatory hypotheses, both authors reviewed legislative theory's ROCCIPI categories⁴⁶¹ for the three sets of social actors' problematic behaviors: nurses, district administrators, and national health ministries.  Both authors sought to use those hypotheses to guide their search for the available relevant evidence.   To the extent that these hypotheses prove consistent with that evidence, they lay the essential basis in facts for drafting the authors' proposed bills' detailed provisions.   Once they have thus warranted their hypotheses with evidence in this Part III, in Part IV, the authors must demonstrate that their bills' detailed provisions seem logically likely to alter or eliminate the causes of existing problematic behaviors.   Only then can they predict, with any degree of confidence, that their bills will likely induce appropriate new behaviors (institutions) to help provide more adequate rural health care.

A. Explanatory hypotheses and the available evidence for the nurses' problematic behaviors

1. Kenyan nurses

The government may deploy nurses to work in any location in Kenya.  Existing law does not in any way bind Kenyan nurses to work in the rural areas.  Kenya has neither a migration policy nor rules and regulations to control migration of nurses abroad.⁴⁶²

Medical students at universities spend the last eighteen months of their studies doing internship at government hospitals. Upon graduation, nurses may seek employment with either the government or the private sector.

Nurses receive little or no training in managing rural health facilities.   Those with the most experience practice in urban settings; "senior and experienced health workers are posted at the provincial and national hospitals only."⁴⁶³  Fresh graduates posted to rural health facilities have neither training nor experience on which to draw.   Not surprisingly, they find it difficult to manage those facilities adequately.  They lack supervision and mentorship because experienced workers have taken posts located in far away urban facilities.

After three years, nurses who work for the government qualify for further training. Upon completion of the advanced training, the nurses may receive a promotion to higher-level facilities at the provincial or national level or ministry headquarters—all based in urban areas.⁴⁶⁴ These promotions frequently shift the nurses' duties from health care to managerial responsibilities.  This reduces the number of nurses who work directly with patients, contributing to what experts term, "maldistribution of staff."⁴⁶⁵ According to Ndetei et al (2008), "senior and experienced health workers are posted at the provincial and national hospitals only;"⁴⁶⁶ as a result, fresh graduates posted to rural health facilities may not manage them effectively because they lack experience.   Because experienced workers have re-located in far away urban facilities, those who remain cannot adequately supervise or mentor the newcomers.

In urban areas, nurses may supplement their incomes by setting up their own clinics or working in private hospitals part-time or as consultants.  Nurses migrate to urban areas to benefit from these opportunities of generating more income.  Some nurses migrate to developed countries in hopes of working in better facilities for higher pay.  The World Health Organization (WHO) reports that more than 30% of developing countries' doctors have migrated to developed countries. ⁴⁶⁸

Nurses also migrate to urban areas to access amenities such as schools for their children.    Some consider deployment to rural areas as punitive.    Lack of rural infrastructure and social amenities contribute to this attitude among nurses. Those working in rural areas tend to develop a low self-esteem compared to those in the urban areas – an ideology that encourages them to migrate to urban areas.

Under The Nurses Act Cap. 257 of the Laws of Kenya, it established The Nursing Council of Kenya (NCK).⁴⁶⁹  The Council has worked to improve the standards of healthcare in communities; it has no jurisdiction over the deployment of nurses.   [Note:   Hopefully, workshop participants will provide further evidence to facilitate a more in-depth analysis of the Council's Opportunity and Capacity to carry out its tasks; its members' Interests, and Ideology; and, perhaps most important, the extent to which its decision-making Processes prove transparent, accountable, and participatory – including inputs and feedback from the rural inhabitants so neglected by the national health care system.]

2. Rwandan nurses

Apparently, causal factors similar to those in Kenya tend to influence Rwandan nurses to escape rural postings to work in urban areas.   The existing Rule as to where they should work – explicated in the Human Resources for Health Strategic Plan, 2006-2010, and the National Community Health Policy of Rwanda, 2008 – constitute broad statements of policy, strategy and health goals.  Although these policy documents note the shortage of doctors and nurses in the rural areas, they do not specify who should do what to implement those policy goals. 
 
Evidence indicates that, in Rwanda as in Kenya, relatively few nurses who have the necessary Capacity to work in rural areas welcome the Opportunity to do so. Available evidence suggests that, like Kenyan nurses, Rwandan nurses too seek employment in urban health facilities for personal reasons related to potentially increased incomes, better educational opportunities for their children, and an ideology that values urban life to that available in the rural areas⁴⁷⁰.

In 1995, the Rwandan Government initiated a program to train locally based community health workers with the hope that they would remain to work in their home areas. Fifteen years later, however, only one out of five of the targeted number of CHWs had attained the desired level of competence.⁴⁷¹    

B. Middle level health management: The districts

In both Kenya and Rwanda, decentralization policies have assigned district level managers the primary responsibility for implementing rural health care policies. Kenya's government established and elaborated its district level health care system in the early 1990s, while Rwanda's government set up its district system in the first decade of the new millennium.

1. Kenya's District Health Management Boards (DHMBs) and Teams (DHMTs)

These two bodies coordinate and supervise health care service delivery in Kenyan rural districts. The Boards develop district plans and keep the national ministr(ies?) informed. They coordinate health care services, and control funds allocated to the Teams within their districts. 

Each District Board has responsibility for supervising and coordinating the Management Team's activities in its District.  Apparently, however, few Boards have developed guidelines for their districts' teams.  That seems to grant the team members discretion to decide how to 'behave,' with few specific requirements as to how to respond to the rural residents' health needs.  

2. Rwanda's Mayors as District Level Managers

Rule:  In Rwanda, the National Community Health Policy (2008), in broad general terms, assigns the task of district health director to the district mayor's office.  That includes responsibility for coordinating and funding the district's health program.  A national Community Performance-Based Financing User Guide (2008) requires the district administration to provide quarterly reports on specific health indicators.  These must include detailed information on issues like the numbers of screenings for malnutrition, children treated for various illnesses, family planning users, and child and maternal deaths.⁴⁷²  

Opportunity and Capacity:  The Community Health Policy strongly emphasizes training and recruiting community health workers to bring health to the peripheral areas.   However, the government first published the policy in 2008.  That fact, coupled with the lack of infrastructure, the need to develop appropriate training personnel and facilities⁴⁷³ in the rural areas, underscores the difficulties confronting district administrators seeking to achieve the essential training goals.

Just gathering the necessary information relating to the required health indicators may prove a formidable task. In the last five years, Rwanda has undergone rapid, sweeping administrative changes.  The government has consolidated the provinces from 12 to five (with plans ultimately to eliminate them from the administrative structure), and consolidated the districts from one hundred six to thirty.⁴⁷⁴  In the process, government transferred employees from central to district level positions, reassigning former district supervisors to district hospitals, and appointing new district supervisors.⁴⁷⁵ Most received little training to strengthen their capacity for undertaking their new tasks.
 
Today, a district may comprise approximately two hundred thousand people, most of whom reside in hard-to-reach rural areas.  Lack of basic transport and communication infrastructure renders regular communication with rural health centers and dispensaries difficult.  Newly appointed local health staff may not always have the capacity to gather, record, and provide the relevant facts to the district administrative office – let alone carry out the required screenings and treatments.

Communication of the new rules may still prove necessary to ensure the relevant role occupants implement them effectively.  The Community Health Policy remains a 'vision', not a law.  It does not specify in detail how district officials should carry out their responsibilities.   The Community Performance-Based Financing Guide, also published in 2008, appears somewhat complicated, and may prove difficult for district health directors to interpret.

Interest: The requirement that health workers agree to performance-based contracts may provide them with more incentive to carry out new local level programs. Careful monitoring and supervision, however, seem essential for assessing those incentives' actual social consequences.

Process: Little evidence seems available as to the processes of designing and implementing Rwanda's new health policies.   Experience elsewhere⁴⁷⁶ indicates that engaging rural residents seeking improved health care, as well as health workers responsible for implementing the new health policies, in the decision-making process will more likely contribute to altering or eliminating existing problematic behaviors.

Ideology:  The available evidence suggests that many health workers, from community level health providers to nurses and doctors, still believe that employment in urban, rather than remote rural areas will prove more beneficial to them and their families.   Unless effectively countered, this ideology might effectively undermine Rwanda's proposed new Community Health Worker training program.

C. Hypothesized causes of the Ministries of Health' difficulties in strengthening rural health care services

1. Kenya's Ministry for Health and Sanitation and Ministry of Medical Services

These two ministries, created as part of the attempt to reconcile the conflicting political parties after the 2008 elections (?)⁴⁷⁷ lack clear jurisdiction.   Apparently, this causes confusion in several aspects of health service delivery.  The Kenyan Daily Nation reported that nurses, who must report to different ministries, find it difficult to do their jobs effectively.⁴⁷⁸  If true, this suggests that neither ministry provides a sufficient support network for the nation's health workers, or supervises and monitors their efforts.  Nor do the ministries release adequate funds to hospitals, contributing to demoralization of staff and lack of medicines, especially in rural areas.⁴⁷⁹ In addition, corrupt officials divert medicines meant for the poor and give them to the wealthy at a fee.⁴⁸⁰  This behavior reduces medical supplies that could go to rural areas.

The Kenyan National Health Sector Strategic Plan (NSSP 1991-2004) and the revised NSSP II (2005-2010) prioritize the decentralization of health service delivery as central to distributing health services to rural areas.⁴⁸¹ NSSP II focuses on the disease burden and the provision of services to address the specific needs. The decentralization however focuses on developing structures and capacity at district levels with the assumption that this will improve services in the rural areas. The policy does not, however, specify detailed measures to provide services to rural areas that lack health facilities.

The national health plans seem to hold Kenya's two health ministries responsible only for monitoring and supervising urban health services.  In part, that may reflect strain on urban health facilities imposed by the high rate of rural-urban migration.⁴⁸²   In any event, apparently on the assumption that the District Health Management Boards and Teams (DHMB and DHMT) coordinate the provision of rural health services, the ministries only govern the health sector above the district level.  The ministries' headquarters therefore do not directly communicate with rural health facilities.

2. Rwanda's Ministry of Health

Although like Kenya's government, Rwanda's government has decentralized the management of rural health care facilities to the district level, its Ministry of Health apparently still has played an active role in formulating and implementing rural health care services.   Recovery from the decimation of the Rwandan health care system following the 1994 genocide required ten-years just to restore it to the pre-genocide level.⁴⁸³  In 2008, the MoH published its Vision for 2020, along with its implications for Community Health programs.   In particular, it has emphasized the importance of training local community members to serve as community health workers.   Nevertheless, despite high levels of donor financial and technical assistance, MoH personnel experienced difficulties in attaining their stated objectives.   A review of the ROCCPI categories suggests the following hypotheses:

(Joyce, can you fill these in, and provide whatever evidence or sources of evidence you have?)

Rule:
Opportunity and Capacity:
Communication:
Interest:
Process:
Ideology:

Hopefully, the workshop participants will draw on their own knowledge of Rwandan circumstantial evidence to assess and revise these hypotheses.

To summarize:  In Part III of their research reports, both authors reviewed the available evidence as to the probable causes of the three sets of relevant social actors' seemingly problematic behaviors.   More evidence would provide greater insight into those causes.   Nevertheless, it seems apparent that in both countries the existing rules and regulations relating to rural health care services remained vague.  That seemed to give the nurses and their district level supervisors broad discretion to determine whether and how to ensure adequately trained personnel could provide better health care to their countries' remote rural inhabitants.   The responsible monitoring and supervisory agencies seemed to pay insufficient attention to the local health centers' and dispensaries' personnel's qualifications, not only for carrying out their health care responsibilities, but also for managing rural health care facilities – a task for which few had received any training.   In the end, the local health personnel, themselves, often made their own decisions as to whether and what they might do to help rural residents gain greater access to essential health care.   Not a few -- returning to urban areas, or even emigrating out of the region in hopes of earning more money and gaining greater prestige -- simply abdicated that task.

The problem-solving methodology requires that a proposed legislative solution address the causes of the problem.  As required by problem-solving's Step 3, this Part IV describes the alternative possible solutions which Mote and Richard considered in comparison to their proposed bills.   Both explore the possibilities of integrating elements of those alternative solutions into their own bills.   They seek to demonstrate that the bill's provisions logically seem likely to alter or eliminate the causes of the present institutions' seeming failure to improve rural health care.   Finally, they provide data to show that the social and economic benefits of implementing their bills seem likely to outweigh their costs.

As problem-solving's Step 4 also requires, in Part IV, each author's research report also describes the their proposed bills' provisions for establishing a mechanism for monitoring and evaluating the draft bills after their enactment into laws.   Legislative theory underscores the importance of ensuring those feedback provisions prove transparent and accountable, and ensure adequate feedback – especially from the previously neglected rural residents – as to the bills' implementation and social impact in improving their access to efficient, affordable health care remote rural areas.

Mote research report recommends that Kenya's Parliament enact a law to ensures that the government through the Ministry of Medical Services provides mobile clinics to deliver essential health care to Kenyans living in the most remote corners of the nation. Qualified health workers of the rank of a registered nurse or higher should receive the training required to operate these mobile clinics.  The new law will require universities and other training institutions, in both their residential and internship programs, to equip nurses and medical personnel to operate the mobile clinics.⁴⁸⁴   The law will require clinic operators to spend part of their internship period doing on-the-job training as members of mobile clinic teams.  This will ensure that the mobile clinics have adequate staff, and enable the trainees to improve their capacity and, hopefully, their interest in providing efficient modern medical serves to impoverished Kenyans living in remote rural areas.

The proposed law will address the maldistribution of staff by enabling nurses who work in district hospitals to use the mobile clinics to extend their services throughout the entire district. The law will require the Ministry of Medical Services to request mobile health clinic funds as part of the national health system's annual budget supplied by the Treasury.  The Ministry will distribute those funds through the DHMBs and DHMTs as necessary to finance the increased numbers of mobile clinics required to serve the needs of all rural residents within their jurisdictions.
   
The bill recommends a monitoring and evaluation process using the existing structures.  The bill proposes to use the DHMBs to ensure adequate communications between the Districts and the Ministry headquarters.  One important aspect of this communication will constitute regular annual reports on the DHMTs' implementation and social impact of the expanding mobile clinic services in every district.   Each DHMT report must clearly identify and report on who does (or does not do) what the law requires to implement effective mobile health clinic services.  In that way, the new law will help to ensure transparency and accountability to enable those affected – especially the poor and vulnerable rural residents – to participate in ensuring that the mobile health clinic services do reach every rural area.

A. Alternative solutions

This section briefly reviews the alternative possible solutions, and, where it seems useful, suggests incorporation of some of the alternative provisions in the proposed bill.   The alternatives here considered include the American Medical Research Foundation's (AMREF's) Accenture e-learning initiative; its Telemedicine Project; and the Emergency Hiring Program initiated by USAID and the Ministry of Health.

1 .AMREF Accenture e-learning initiative

Africa Medical Research Foundation (AMREF) has partnered with Accenture, a management consulting firm, to set up an e-learning program for nurses in Kenya. The program seeks to address the shortage of nurses by improving the skills of those who are in service and lack access to training opportunities.⁴⁸⁵   Through the program, enrolled nurses upgrade their skills to qualify as registered nurses. The program establishes e-learning centers throughout Kenya and in participating nursing schools.

While this project addresses the problem of capacity by improving the skills of the nurses in remote places, it does not solve the maldistribution of nurses. It also does not address the lack of services in the un-served areas. The proposed bill ensures that mobile health clinic services do reach the currently un-served areas.

2. AMREF's Telemedicine Project

Safaricom, a mobile phone service provider in Kenya, has teamed up with AMREF to set up a project that uses ICT to provide health services in remote places in Kenya⁴⁸⁶. The project works by linking patients in rural health facilities with doctors at AMREF centers in Nairobi in real time. An audio-visual satellite link enables health workers in rural facilities to communicate with consultant doctors in the cities.  Nurses and rural health service personnel can send case notes and digital images through the intranet to a well-qualified consultant who then diagnoses and sends prescriptions back to the rural health facility. Health workers can send digital images such as x-rays and photos of patients through the intranet. They may relay the same information via the Internet to another doctor for a second opinion on a case.   AMREF rolled out the pilot phase of this project in Kakuma and Mandera towns in the semi-arid areas in northern Kenya.

The AMREF project addresses a fundamental obstacle to health care delivery in rural areas – that of providing primary health care and referral services to the rural population. It also cuts down on the expenses the rural populations incur travelling to provincial and national referral hospitals by bringing the services of the specialists to the rural areas. The project, however, still relies on existing health facilities that, as this report has shown, do not adequately serve the marginalized sections of the rural areas.  The mobile clinic services, proposed in this report, will improve its services by incorporating telemedicine to track clients who receive care from the mobile clinics and link them to specialists in referral hospitals.

3. Emergency Hiring Program

The US Agency for International Development (USAID), in partnership with the then-Ministry of Health, has established a Capacity Project to address the shortage of health workers in public health facilities.⁴⁸⁷  The Project adopted a business model and used the vertical approach of focusing on a single disease, in this case HIV/AIDS. The Emergency Hiring Plan employed qualified staff on short contracts.   The program recruited Delloite & Touche to coordinate the business components of the program while Africa Medical Research Foundation (AMREF), Kenya Medical Training College and Kenya Institute of Administration provided training for the participants.

The Project recruited unemployed health workers and focused employing them in the areas that most needed staff.  This strategy aimed to attract qualified staff from the local residents who would less likely seek later transfer to urban areas.  Those recruited under this plan received a three-year contract and obtained regular permanent government posts.  The strategy helped to recruit staff in health centers that previously, due to lack of human resources, appeared about to close.⁴⁸⁸   As Adanu (2008) states, as a temporary measure, the project should augment "long term systemic interventions" (p.3).⁴⁸⁹

By incorporating these changes into the legal structure that that creates mobile health clinic services within the health system, the proposed bill aims to create sustainable systems to ensure that all rural inhabitants have access to adequate health care services.   Integrating the Emergency Employment plan into the bill to set up the mobile clinic services will help to ensure that the mobile clinics do not lack qualified staff.

4. The Proposed Legislative Solution for Mobile Health Clinics, Summarized

This research report aims to justify the detailed provisions of a bill to establish mobile health clinics to help overcome the difficulties that Kenyans, living in rural areas, experience in trying to access adequate health facilities.  The draft bill proposes to establish the office of a manager as part of a District Health Management Team (DHMTs) to set up and coordinate mobile clinics assigned to work in that team's district.  The bill also establishes a committee in each district to oversee the activities and funds of the mobile clinics. The committee comprises members from the relevant DHMB, DHMT, nurses from the mobile clinic department, and local community leaders. The committee will manage funds and other resources for the mobile clinic services. It will draw up a development plan and map out the areas that need the mobile health clinic services. It will submit timely reports to the DHMT on the progress of the mobile health clinic services. The committee will audit records of clients to monitor who gets the services, and whether those services prove effectively implemented and help the clients' regain their health.  The committee will employ community health workers (CHW) who will assist in mobilizing communities to use the mobile health services and report to the committee on the services' grassroots impact. The CHW will also track clients who receive treatment.  The mobile clinics will incorporate AMREF's Telemedicine system to link rural patients with specialists in referral facilities.

When enacted, the bill will require a DHMB to assume responsibility for funding the mobile clinics' operations, and regularly reporting on those mobile clinics' activities and plans to the relevant department of the Ministry of Medical Services' headquarters. The bill requires a DHMB to use the existing communication structures between the DHMB and the Ministry headquarters since they appear efficient and will reduce costs.

The Ministries of Health, the Nursing Council of Kenya and universities and colleges training health professionals will design a curriculum and conduct trainings on management and operation of mobile health clinics.   The trainings will also focus on improving the skills of nurses and other health workers currently working in rural areas.   Since AMREF already offers nurses training in the required skills, the government will bring them on board in designing and training mobile health clinic staff members.

5. How Mote's proposed solution addresses the causes of the difficulty

By establishing mobile clinics, the bill ensures that nurses will have the capacity to bring health care services to rural populations that currently have difficulty accessing health facilities. After the bill's enactment and implementation, residents of remote areas – currently unable to access medical services because they appear too sick or lack the money to travel to travel – will have an opportunity to access essential medical services provided by the mobile clinics.  Also, the mobile clinics will provide preventive health care, reducing outbreaks of preventable diseases. This will help to improve local residents' economic productivity and well-being.

6. Costs and benefits of bill

The initial costs of setting up the mobile clinics will include the purchase and/or fabrication of the clinics, and procurement of essential equipment.   The administrative costs will remain low, however, since the bill embeds the clinics' management structures into existing district government offices.  The Ministry of Health will have to train and employ managers and more nurses to use and manage the mobile clinics.   For that purpose, the bill requires existing health training programs in Kenyan universities and colleges to integrate appropriate curriculum changes to strengthen their graduates' capacity to use mobile health clinics to bring needed health services to all Kenyans – no matter how far they live from urban centers.

As the new law's main benefit, it will facilitate provision of health care services to the all un- or under-served areas of rural Kenya.  By eliminating the need for clients to travel or pay for the same services offered by private practitioners and traditional healers, mobile clinics will reduce rural households' health expenditures.  By providing preventive health care services, the mobile clinics will reduce the prevalence and outbreak of preventable diseases thus improving the general well being of the people living in rural areas. Economic activities will increase as household expenditures of time and money for health care decline.  Also a healthy population will contribute to increased household incomes to provide for healthy lifestyles.

7. Monitoring and Evaluation

Each DHMT's mobile clinic department will keep records of clients. These will enable the Ministry to determine the number of people who receive services from the mobile clinics. Currently, the law gives DHMBs the authority to access information from facilities within their jurisdiction; this authority will extend to the mobile health clinic services for monitoring and evaluation purposes and any other purposes required to improve implementation of the Public Health Act (Cap.242) Researchers from local universities and colleges will carry out periodic surveys to assess the impact of the bill and ways of improving the services. These surveys will give all the institutions involved an opportunity to learn how to improve their training programs.   DHMBs will supervise the activities of the mobile clinics through reports submitted to it by DHMT.   The presence of DHMB members in the mobile clinic committees ensures that the DHMBs need not rely on reports submitted to them, but actually participate in implementing the mobile clinics' service programs. The bill also gives the Minister of Medical Services the authority to appoint an independent monitoring and evaluation expert to audit the mobile clinics. The government will use the monitoring and evaluation reports to amend the law and address any new problems that may arise in the course of implementing the law.

This Part IV has explained the need for a solution to change the problematic behaviors that impeded rural Kenyans' access to effective health care services. It described alternative solutions that other organizations have developed and proposed to integrate them into the proposed bill's detailed provisions. Throughout, the report has provided evidence to demonstrate that the law, when enacted, will likely prove cost-effective in helping rural Kenyans to access adequate health care services.  This fourth Part describes the bill's monitoring and evaluation provisions essential to ensure that, as necessary, Kenyan law-makers may revise the law to respond to Kenya's changing social environment. 

The proposed law, once enacted and implemented, the bill, will help to fulfill Kenya's two Ministries in charge of health declared mission:   The promotion and provision of "quality curative preventive, promotive and rehabilitative health care services to all Kenyans."⁴⁹⁰ In so doing, it will also promote the achievement of the Millennium Development Goals (MDGs) 4, 5, and 6.⁴⁹¹ The new law will provide a framework for providing health care services to the poor and marginalized sections of Kenya's impoverished rural populations, and thus promote the development of the rural areas.

As Part III of Richard's research report mentioned,⁴⁹² Rwanda's government put in place a policy for recruiting and training Community Health Workers (CHWs) as early as 1996.   In recent years,  Rwanda's Ministry of Health incorporated training for CHWs in its national policy, using international financial support,⁴⁹³ incorporate into that policy training for use of international funds for using technological devices like computerized medical records,⁴⁹⁴ TRACnet, a cellular phone based means of communicating HIV/AIDS patients' test results and the need for medications to urban health facilities and the Ministry of Health,⁴⁹⁵  and a plan to install solar power to 47 percent of its health centers in 2009.⁴⁹⁶   Nevertheless, as of 2006, the nurse/population ratio remained at 1:3,138,87 suggesting the necessity for accelerating implementation of the CHW training program.   

Richard therefore proposed to incorporate in her proposed bill the detailed provisions as to who should do what to accelerate the effective implementation of Rwanda's program to increase the quantity of Rwandan Community Health Workers trained, as well as to improve the quality of their training.   

The workshop participants should assess her bill's detailed provisions to determine whether they would likely help to ensure more effective implementation of the MoH's program for training the numbers and quality of CHWs.   They should also consider whether the bill's monitoring and evaluation provisions appears likely to prove effective in identifying and helping to resolve emerging new problems.

1. General Purpose

1.1 This Act is the first in a series of legislation that has the ultimate purpose of developing health care resources in rural Rwanda, where eighty-percent of the population resides.
 
1.2 This bill specifically requires the District Health Officer to recruit and train community health workers (CHW)s to work at the village level as a link between the district health center and community members, to identify and refer the sick or people otherwise in need of health and social services, assist in treatment of illness, promote good health practices, prevent communicable and infectious disease, promote prenatal care, reproductive health, good nutrition and provision of community support.

2. Rule Pursuant to Section 7 Regarding Rule Making

2.1 The District Health Officer shall recruit and appoint CHWs in numbers proportionate to the district population.   

2.2 The District Health Officer shall consult with a committee of local villagers and members of the local district clinic to obtain recommendations for people to work as the CHWs for that area.

2.3 The District Health Officer shall appoint one male CHW, one female CHW, and one maternal health CHW for each fifty-to-150 households in the village.

2.4 The District Health Officer may appoint as a CHW only those persons with the following qualifications:

2.4.1  The CHW must be: 

1. over 18 years of age
2. a member of the local community
3. a trustworthy and respected member with a strong desire to help the needy
4. possessed of an empathic attitude toward the sick and vulnerable members of the community
5. literate

2.4.2  The CHW may be HIV positive or formerly infected by and cured of Tuberculosis.

2.5  The District Health Officer shall establish a training program and teaching manuals for CHWs, which must include the following areas:

2.5.1 Orientation to the health care facilities and services offered in the district, including enrollment in Community based insurance program.

2.5.2 Education about air-bourne and water-bourne illnesses, their prevention and treatment.

2.5.3 Education regarding poor sanitation and hygiene;

2.5.4 Education regarding HIV/AIDS, including transmission, prevention, treatment, and side-effects of medications.

2.5.5 Education regarding Tuberculosis, including treatment and side effects of medications.

2.5.6 Education regarding Malaria including prevention, treatment, and side effects of treatment.

2.5.7 Education regarding malnutrition and proper nutrition for all age levels.

2.5.8 Education regarding reproductive health, birth control, and sexually transmitted illnesses.

2.5.9 Description of the roles and responsibilities of CHWs, including the need for confidentiality, good record-keeping, problem identification, and performance-based payment.

2.5.10 Education regarding recognition and reduction of stigma and discrimination.

2.6  The District Health Officer shall appoint Supervisory CHWs in numbers proportionate to the number of CHWs working in each village.

2.6.1 Orientation to the health care facilities and services offered in the district, including enrollment in Community based insurance program.

2.6.2 Education about air-borne and water-borne illnesses, their prevention and treatment.

2.6.3 Education regarding poor sanitation and hygiene;

2.6.4 Education regarding HIV/AIDS, including transmission, prevention, treatment, and side-effects of medications.

2.6.5 Education regarding Tuberculosis, including treatment and side effects of medications.

2.6.6 Education regarding Malaria including prevention, treatment, and side effects of treatment.

2.6.7 Education regarding malnutrition and proper nutrition for all age levels.

2.6.8 Education regarding reproductive health, birth control, and sexually transmitted illnesses.

2.6.9 Description of the roles and responsibilities of CHWs, including the need for confidentiality, good record-keeping, problem identification, and performance-based payment.

2.6.10 Education regarding recognition and reduction of stigma and discrimination.

2.7  The District Health Officer shall appoint Supervisory CHWs in numbers proportionate to the number of CHWs working in each village.

2.7.1 The Supervisory CHW must be an experienced CHW who has demonstrated high quality of work and leadership qualities.

2.7.2 The Supervisory CHW shall ensure that CHWs carry out their responsibilities, through home visits with the CHW and discussion with community members and clinic staff.

2.7.3 The Supervisory CHW shall complete reports, attend scheduled meetings and communicate with the cellule officer.

2.7.4 The Supervisory CHW may recommend and participate

2.7.5 in improving a district's CHW  training program.

2.8 The District Health Officer shall develop weekly report forms and Supervisory report forms to document the work of the CHW, the Supervisory CHW, and vital events.

2.8.1 The reports shall include the following information:

1. Name of CHW/Supervisor
2. Name and diagnosis of patient visited;
3. Activity carried out by CHW;
4. Problems identified by CHW;
5. Vital events including pregnancy, birth or death
6. Suggestions for improvement

2.8.2 The District clinic shall transmit copies of these reports to the District Health Director, and use these reports as the basis for determining the CHW and Supervisory CHW salary, under Rwanda's performance-based payment system.

2.8.3 The District Health Officer shall review the weekly reports, create summaries of the data and send a monthly summary to the Ministry of Health.

2.8.4 The District health officer shall use the data contained in these reports to develop and community-based health information system.

3. Implementing Agency

3.1 The Minister (Director) of Community Health at the Ministry of Health
  (Yet to be appointed – by what criteria and procedures?)

3.2  Upon a request from a District Health Director, the Minister shall provide such technical/financial or other support as needed to carry out the purpose of this act.
     
4. Conformity-inducing measures

4.1 A failure of the District Health Director to carry out the provisions of this Act shall be recorded in the Director's monthly performance contract.

4.2 The Minister of Community Health shall reduce the Director's monthly salary based upon the extent and severity of the non-performance.

5. Dispute Settlement

5.1 Any community member aggrieved by the action or non-action of a CHW may complain to the Supervisory CHW.

5.2 The Supervisory CHW shall investigate the circumstances of the complained action and discuss the matter with a representative of the district clinic and the CHW.

5.3 If no remedial action results, the member may file a complaint to a committee consisting of a member of the district clinic, the Supervisory CHW, three members of the CHW, and three members of the community.

5.4 The aggrieved member may appeal the decision of the committee to the District Health Officer.

6. Funding

6.1 The Minister of Health shall include in the Ministry budget request sufficient funding to enable each district to carry out the purposes of this act.

CHAPTER ONE. INTRODUCTORY

Article 1. Short title

This Act may be cited as the Community Health Workers Act.

Article 2. Purposes

(1)  In this Act –

'CHW' means a community health worker appointed pursuant to Articles 3, 4 and 5.

'MoCH' means the Minister of Community Health, established in the Ministry of Health pursuant to Article 13.

'Rural District' means a District in which, by decree pursuant to Article 23  the MoCH has declared this Act in force.

 (2)  This Act has the following purposes:  For Rwanda's Rural Districts, to select, train, organize and supervise CHWs to assess, and monitor the health of the community, to report on the results of that assessing and monitoring; to provide elementary health information to the public; to provide first aid and elementary health care services in connection with assessing and monitoring community health; to facilitate the passage of the rural sick, injured and diseased into technologically more advanced urban health systems

Article 3. Appointment of CHWs

 (1)  In this Act, 'DHO' means District Health officer;

 (2)  Within budgetary constraints, and in conformity to a rule made
pursuant to Article 17 by the MoCH, a DHO in a Rural District shall appoint one male CHW, one female CHW, and one female maternal health CHW for each 50 households in the DHO's District.

Article 4. Procedures for appointment of a CHW.

(1)  Subject to rules made pursuant to Article 14 by the MoCH, prior to making an appointment, the DHO shall solicit suggestions for nominations as CHW from the inhabitants of the Rural District in which on first appointment the CHW will serve.

(2)  As part of that solicitation, the DHO shall hold a meeting of  the inhabitants of each of the villages within  the Rural District  and of the local District Clinic that serves that village.   

Article 5. Criteria for appointment as CHW

 (1) As a CHW, a DHO may appoint only a person with the following qualifications:

1. More than eighteen years of age;
2. A member of the Rural District;
3. A reputation in the Rural District as a trustworthy and respected person, with a strong desire to help the needy sick;
4. With an empathetic attitude towards sick and vulnerable members of the community; and
5. Literate.
6. Such additional qualifications as the MoCH may by rule requires

(2) In making an appointment as CHW, a DHO may not discriminate on
 grounds of the HIV/AIDS positive status of an otherwise qualified candidate, or on grounds of the applicant's earlier history of tuberculosis.

Article 6. Training for a CHW

(1)The DHO shall undertake training the CHW, using a syllabus, text and other materials as pursuant to Article 14 the MoCH shall supply.

Article 7. Duties of a CHW

A CHW shall:

1. So far as possible observe and assess the community's state of health;
2. Pursuant to Article 10 (1)(a), report weekly to the DHO what the CHW has learned in terms of sub-paragraph a;
3. Provide elementary information concerning health care and maintenance to members of the community;
4. In connection with observing and assessing the state of health pf the community, to provide first aid and elementary health care to members of the community; 
5. Observe and report to the DHO vital events among members of the community;
6. Facilitate the passage of the rural sick, injured and diseased into technologically more advanced urban health systems

CHAPTER THREE. SUPERVISORY COMMUNITY HEATH WORKERS 

Article 8. Appointment of Supervisory Community Heath Workers

1. In this Act, 'SCHW' means Supervisory Community Health Worker.
2. The DHO shall appoint one SCHW for each five CHWs that work in a village within the jurisdiction of the DHO.
3. As SCHW, the DHO may appoint only a CHW with a strong record of experience as a CHW who, as a CHW, demonstrated leadership qualities.

Article 9. Duties of a SCHW

1. The DHO shall direct the SCHW to oversee the performance of   specified CHWs  in their capacities as CHWs, and to report about their performance to the DHO.
2. Subject to directions by the DHO pursuant to sub-Article (1), by home visits in company of a CHW and by discussion with community members and local clinic personnel, a SCHW shall oversee the performance of a CHW. 
3. Subject to directions by the DHO pursuant to sub-Article (1), and subject to rules and on forms made pursuant to Article 14 by the MoCH, the SCHW shall report on the results of oversight conducted pursuant to sub-Article (2)
4. In addition to supervisory duties, the DHO may assign a SCHW to carry out the duties of a CHW

CHAPTER FOUR. THE DISTRICT HEALTH OFFICER

Article 10. Duties of a DHO:  Appointing and supervising CHWs and SCHWs
                  
(1) Pursuant to Articles 3, 4, 5 and 6, and subject to rules made pursuant to Article 14 by the MoCH, a DHO shall appoint and supervise the training and activities of CHW in the DHO's District.
 
(2)    Pursuant to Articles 8 and 9, and subject to rules made pursuant to Article 14 by the MoCH, a DHO shall appoint and supervise the training and activities of a SCHW in the DHO's District.

Article 11. Duties of a DHO: Ensuring weekly reporting by CHWs and SCHWs.

1. On a report form supplied pursuant to Article 14 by the MoCH, and as pursuant to sub-paragraph b the DHO may modify it, the DHO shall ensure that a CHW and an SCHW reports weekly to the DHO on the CHW's and the SCHW's work, the vital events of their patients, and the state of their health.
2. A DHO shall ensure that a report made pursuant to sub-Article (3) contains at least the following information about each patient whom a CHW or a SCHW visits: 

1. The name of the relevant CHW;
2. The name of the relevant SCHW
3. The name of the patient visited
4. An hitherto unreported vital event (birth, death, pregnancy, marriage)
5. Symptoms of the patient visited
6. Steps and procedures taken by the CHW with respect of the patient
7. Suggestions for improvements

(2)    A DHO shall ensure that a report made pursuant to sub-Article (3) contains sufficient information to permit the DHO to make an evaluation of the work of the subject CHW or SCHW for purposes of determining the appropriate level of the CHW's and the SCHW's salary.

Article 12.  Monthly reports   

The DHO shall review the reports made pursuant to sub-Article (3)
create a monthly summary of the data and send that summary promptly to the MoCH.

CHAPTER FIVE.    THE MINISTER OF COMMUNITY HEALTH

Article 13. The Minister of Community Health: Appointment as a Deputy Minister of Health.

The Minister of Health shall appoint as Mo1CH a person qualified by
education and experience to serve as Deputy Minister of Health, and to perform the duties
of the MoCH as prescribed by this Act.

Article 14. The Minister of Community Health:  Powers and Duties

1. The MoCH shall have general supervision over the community heath system as prescribed by this Act.
2. The MoCH shall prepare the syllabus, course Handbook and other materials as required for the training courses for CHWs and SCHWs prescribed by sub-paragraphs 16(2)(a), and supply them as necessary to a DHO.
3. The MoCH shall make rules pursuant to Chapter Six concerning the structure and procedures of the community health worker system as prescribed by this Act.

Article 15.  Conformity-inducing measures

1. The MoCH shall record in the record of a DHO a failure of the DHO to carry out an obligation prescribed by this Act.
2. After repeated failures in terms of sub-Article (13)(1), and repeated warnings concerning those failures by the MoCH addressed to the DHO concerned, by a decision in writing, stating reasons the MoCH may reduce the DHO's salary in proportion to the extent and severity of those failures.
3. Upon a report by a DHO of repeated instances of substandard performance by a CHW or a SCHW, and repeated warnings concerning those failures by the MoCH addressed to the CHW or SCHW concerned, by a decision in writing, stating reasons, the MoCH may reduce the CHW's or SCHW's  salary, as the case may be,  in proportion to the extent and severity of those failures.

CHAPTER SIX.  RULE-MAKING

Article 16.  Power to make rules

1. The MoCH shall make rules better to achieve the purposes of this Act.
2. In particular, the MoCH shall make rules --
   
   • pursuant to sub-Article 14(2), concerning the organization, teaching, and content of educational measures for CHW and SCHW training;
   • pursuant to sub-Article 14(3) concerning reporting of matters relating to community health, including prescribing and supplying necessary forms for reporting; and
   • concerning the procedures for selecting and appointing CHWs, and SCHWs
3. In the syllabus for the basic course for CHWs, the MoCH shall include instruction on basic information that the MoCH believes necessary for a competent CHW to know concerning, but not limited to, at least the following subjects:
   
   • Orientation to the health care facilities offered in the Rural District, including enrollment in a local, community-based health insurance program;
   • Air- and water-borne diseases, their prevention and treatment;
   • Poor sanitation and hygiene practices;
   • HIV/AIDS, including transmission, prevention, treatment, and side-effects of medications;
   • Tuberculosis, including treatment and side effect of medications;
   • Malaria, including prevention, treatment and side effects of medications;
   •  Malnutrition and proper nutrition for all age levels;
   • Reproductive health, birth control and sexually transmitted diseases;
   • First aid;
   • recognizing and reducing stigma and discrimination on account of physical and mental ailments and conditions;
   • the rules and responsibilities 0f CHWs, including the need for confidentiality, good record-keeping, problem identification, and performance-based payment;
   • the Rwandan system of health care, including how to deal with medical problems as they arise in the Rural District in which the CHW works, and procedures for transferring patients to higher levels of health care;
   • Administering injections; and
   • Taking and recording vital signs.

Article 17.  Procedures for rule-making.       

1. In making a rule pursuant to Article 16, the MoCH shall:
   
   • upon assigning a drafter to draft a rule, so far as reasonably feasible, publicize that assignment to the rural populace and their advocacy non-governmental organizations, inviting suggestions as to the content of the prospective rule;
   • upon completing a draft rule, so far as reasonably feasible, publicize that draft to the rural populace and their advocacy non-governmental organizations, inviting comments on the draft, including suggestions for its improvement, and setting a closing date for receiving those comments and suggestions.
2. In publicizing a draft rule pursuant to sub-paragraph (1)(b), the MoCH shall accompany the draft rule with a justification for that draft rule, in which the drafter –
   
   • a. describes whose and what problematic behavior constitutes the social problem to ameliorate which the draft rule aims;
   • b. explains those behaviors; 
   • c. describes the legislative solutions considered, and the legislative solution prescribed in the proposed bill, and explains in terms of cost/benefit analysis why the drafter chose the legislative solution embodied in the draft rule; and
   • d.describes the rule's provisions for monitoring and evaluating the implementation of the rule, so far as feasible supporting that justification with evidence.  
3. After considering the comments and suggestions made pursuant to sub-paragraph (1)(b), if any, the MoCH shall either –
   
   • a. amend the proposed draft rule mentioned in sub-Article (1) in accordance with a comment or suggestion, or,
   • b.if the MoCH declines to change the rule with respect to a comment or suggestion, accompany the proposed rule with a document explaining why the MoCH declined to adopt the comment or suggestion.

CHAPTER SEVEN.  DISPUTE SETTLEMENT

Article 18.  Grievances of a member of the community about CHW behaviors..

1. A community member aggrieved by the action of a CHW may complain to the relevant SCHW or  to the relevant DHO.
2. The SCHW or DHO shall endeavor to mediate betweejn the aggrieved party and the CVHW concerned.
3. If mediation does not succeed in resolving the issues, the SCHW or DHO shall refer the issue to the DHO for decision.
4. The DHO shall hear the parties in person or by counsel, making a record of the evidence adduced, and decide the issue in writing, stating reasons.
5. On the record made before the DHO, a party aggrieved by the DHO's decision may appeal to a court of competent jurisdiction.

a.   On appeal to a court pursuant to sub-Article (5), the court may deny the appeal, or grant the appeal in whole or in part, but only on the ground that the decision of the DHO rested on fraud in the making, or on mistake of law, or had no rational support in the evidence.

Article 19.  Grievances concerning a decision made pursuant to Article 15.

1. In this Act, 'MoH' means the Minister of Health.
2. A CHW. SCHW or DHO aggrieved by a decision made pursuant to Article 14 may appeal the decision to the MoH.
3. The MoH shall hear the parties in person or by counsel, making a record of the evidence adduced, and decide the issue in writing, stating reasons.
4. A party aggrieved by theMoH's decision may appeal to a court of appropriate jurisdiction on the record made before the MoH.

a.   On appeal to a court pursuant to sub-Article (4), the court may deny the appeal, or grant the appeal in whole or in part, but only on grounds that the decision of the MoH rested on fraud in the making or mistake of law or had no rational support in the evidence.
  
CHAPTER EIGHT. FUNDING

Article 20.  Funding.

The MoCH shall include funding for the community health system prescribed by this Act in the estimates for the Ministry of Health.

CHAPTER NINE.  MONITORING AND EVALUATION

Article 21.  Monitoring and evaluation

1. Annually the MoH shall appoint a committee of three senior civil servants in the Ministry of Health to examine and report in writing to the MoH on the implementation of this Act, pointing out the strengths and weaknesses of that implementation, and, where feasible, making suggestions for its improvement.
2. Upon receipt, the MoH shall make that report available to the press and other media.

CHAPTER TEN.  MISCELLANEOUS

Article 22.  Definitions

In this Act –

'CHW' has the meaning assigned to it in Article 2(1)

'DHO' has the meaning assigned to it in Article 3(1)

'MoCH' has the meaning assigned to it in Article 2(1)

'MoH' has the meaning assigned to it in Article 19(1)

'Rural area' has the meaning assigned to it in Article 2(1)

'SCHW' has the meaning assigned to it in Article 8(1)

Article 23.  Coming into force.

This Act comes into force for a District when, in writing, the MoCH finds that –

1. 90% or more of the population of the District engages in agriculture as their principal means of livelihood,  and
2. the District's health care delivery systems perform below desirable and attainable standards.

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