According to the World Health Organization, there were 7841 cases of tuberculosis in Rwanda in 2008. This has gradually reduced to about 5800 cases in 2020, thanks to the contributions of the Community Health Workers (CHWs).
Since its inception in 2005 following the adoption of the health decentralization policy by the Ministry of Health, the CHWs program in Rwanda has helped to increase diagnosis and adherence in effective TB treatment.
The aim of CHWs program is to increase uptake of essential maternal and child clinical services through education of pregnant women, promotion of healthy behaviors, and follow-up and linkages to health services.
According to the Ministry of Health sources, there are an estimated 45,000 trained CHWs operating at the village level to provide the first line of health service delivery. There are three CHWs in each village.
The male-female CHWs (called binômes in French) are paired to provide basic care for common disease; integrated community case management (ICCM) for childhood illness, and maternal health, called an ASM (Agent de Sante Maternelle).
Before the introduction of the CHWs program to help move healthcare closer to the people, most community members wrongly believed that their common illnesses were as a result of somebody bewitching them. Superstition dominated people’s conception of the causes of illnesses.
According to a number of sources interviewed for this story, people had a culture of visiting traditional healers instead of going to the hospital first when they became sick. .
“When someone is coughing, they would blame it on anyone they were in conflict with, such as a neighbor they don’t get along with or a business opponent, but not the natural causes, such as viruses. As a result many people died of treatable diseases like TB that was never properly diagnosed because it was confused to be poison,” said Ntaganzwa Radjab, a TB survivor.
Charles Rukundo from Shyogwe sector in Muhanga district, also intimates that his own father died of TB before they knew he was suffering from it. They took him to various traditional doctors until the family ran out of money, leading to the father’s demise in 1997.
Clementine Nyirabaderevu, a community health worker at Byimana sector Ruhango district says in her home town, a man suffered from a TB infection for a long time without knowing why because witch doctors used to tell him that it’s poison and took his money. He was later taken to Rwamagana (Gishali) hospital and got cured.
People didn’t believe in modern medicine instead they believed in their witch doctors who used to tell them ‘it’s poison’ instead of going to hospital many would die in their homes or those of traditional healers, Nyirabaderevu adds. This contributed to the increase in TB cases in the country.
Ntaganzwa, a man in his 60s and father of seven, who resides in Kamonyi district, believed he had intestinal worms because he used to have unclear throat from time to time and would cough incessantly.
This continued even after a medical specialist visited their village, prescribed some medicine, and told him to visit Gishali hospital center. He visited the hospital and found that he had TB but he didn’t believe it. He went back to his home and continued to take the medicine he had.
Consequently, Ntaganzwa’s condition deteriorated rapidly and could have died were it not for the timely intervention of CHWs . The health worker found frail Ntangazwa and took him to the hospital. He was hospitalized for two months because his TB had become so severe and infectious he even infected his three children, who also had to be treated.
From 2005 when the decentralization policy started being implemented nationally, the Ministry of Health increased efforts to train and provide supplies to the CHWs.
This has led to the growth of the program to include an integrated service package, such as the treatment of TB patients with Directly Observed Treatment whereby every TB patient has a helper who follows up the treatment and makes sure they take their medication on time and without skipping.
The training involves imparting basic knowledge on TB and how to handle TB patients, and since it’s a country wide program, every sector or district trains their CHWs but only hospitals deal with treatment of patients.
Part of the training also involves case identification, whereby CHWs are advised that if somebody has persistent coughs for about two weeks, they should be brought to the hospital. Thus, they go to the community and on identifying such cases, they take them to the hospital, where they are tested and put on medication.
The community health workers do follow ups on the positive cases on a daily basis to make sure they take their medicine (Directly Observed Treatment). They visit the patients throughout the six months treatment and advise them on healthy behaviors.
Based on WHO Global TB reports, the incidence of TB in Rwanda has decreased from 96 patients per 100, 000 population in 2000 to 57 patients per 100, 000 population in 2020. This represents a decline of 41% of TB incidences in the last 20 years.
According to the governor of the Southern Province, Alice Kayitesi, the fact that CHWs work within their communities greatly helps in ensuring closer supervision of TB patients to ensure they go to hospitals for proper diagnosis and to take their medication regularly as prescribed until they are healed.
Despite their great contributions to the reduction of severe tuberculosis and well-being of the community, CHWs still face some difficulties in carrying out their duties.
Philippe Mujyanama (name changed), a community health worker, for example, says that most of them still struggle to find the right balance between their everyday lives and their heavy responsibilities as CHWs.
“We are not paid salaries yet we are expected to be present anywhere we are needed, even if it’s at night. We leave our homes without any caretaker and sometimes we even lack time to attend to our farming duties in time like the rest of our neighbors,” he said .
Some CHWs also complain that they lack safe and conducive places to store the medicines under their care for illnesses like malaria, intestinal worms, contraceptives, and TB. This exposes their children to the danger of taking such powerful drugs not meant for minors.