National Community Health Strategic Plan

Objectives

Rwanda’s National Community Health Strategic Plan 2013-2018 seeks to provide holistic, sustainable, equitable and quality community health care with full community participation, so that the population can enjoy good health and contribute to sustainable development. Its vision centres on health care for all Rwandans, grounded in equity, solidarity with disadvantaged groups, ethical practice, respect for gender, age and positive cultural norms, and community involvement in planning, implementation, monitoring and evaluation.[1]The plan supports the National Community Health Policy, Health Sector Strategic Plan III and the Economic Development and Poverty Reduction Strategy 2.[2]

• Strengthen decentralised structures and community health worker capacity to deliver an integrated Community Health Package, including maternal, newborn and child health, integrated community case management, nutrition, family planning, communicable-disease control, non-communicable diseases and chronic illness services.[2][3][4]
• Increase community participation, ownership and use of preventive, promotive and curative services through mobilisation, local problem analysis, health education and action in villages and imidugudu.[5][6]
• Improve maternal, infant and child survival, nutrition, access to primary care and progress towards health-related Millennium Development Goals, including by reducing communicable diseases and strengthening referral links between communities and the wider health system.[7][1]
• Prioritise community-level management and referral of malaria, acute respiratory infection, diarrhoea and malnutrition; vaccination; tuberculosis and HIV treatment support; maternal and newborn care; family-planning provision; nutrition surveillance; hygiene and sanitation; and active case-finding through home visits.[8][9]
• Motivate community health workers and their cooperatives through Community Performance-Based Financing, stronger cooperative management, monetary and non-monetary incentives, and improved service utilisation.[10][6]
• Strengthen monitoring, evaluation, coordination, evidence-based planning, data quality and information use from central to community level.[11][12]

Implementation

The strategy uses a decentralised, multisectoral delivery model in which community health workers, organised in village teams and cooperatives, extend integrated services from communities through health centres and district hospitals to referral hospitals.[13][14]The Ministry of Health, principally through the Community Health Desk, leads policy advocacy, coordination, planning, routine management, monitoring and evaluation, while districts, health centres, local authorities, partners and communities implement and oversee activities.[15][16]

• Deliver services through two multidisciplinary community health workers in each village, supported by cell coordinators, assistant cell coordinators, health-centre staff and district structures. Community health workers provide community case management, malnutrition screening, family-planning services, pregnancy and newborn follow-up, health promotion, referrals and household visits.[17][13]
• Develop annual operational plans, guidelines, training materials, management tools and integrated supervision tools. District implementers are expected to prepare annual plans aligned with strategic objectives for Ministry of Health review and approval.[2][18]
• Build capacity through training of trainers, initial and refresher training for community health workers, supportive supervision, performance assessment and strengthened communication between health centres and communities.[18][19][20]
• Strengthen commodity management by training personnel in forecasting and supply-chain management, distributing commodities through central, district, health-centre and community levels, and addressing stock-outs between health centres and communities.[8][21]
• Coordinate stakeholders through the Community Health Technical Working Group, Health Sector Working Group, Joint Action Development Forums and quarterly coordination meetings involving government bodies, development partners, non-governmental organisations, faith-based organisations and other relevant institutions.[22][16]
• Use Community Performance-Based Financing to subsidise cooperative performance against coverage and quality indicators. Under the established allocation model, 30% of transferred incentive funds is distributed among community health workers and 70% is retained by cooperatives for collective and income-generating activities.[23][10]
• Manage performance and accountability through monthly supervision and reporting, verification of referrals and registers, quarterly review and approval of cooperative reports and payments, financial audits, quality assessments and health-centre oversight.[24][25]
• Use the Rwanda Community Health Information Management System, RapidSMS and m’Ubuzima to collect community-level data, support real-time reporting, improve referral and emergency response, and inform decision-making. The systems are intended to reduce parallel reporting and aggregation errors, although data quality, staff analytical capacity, network access and equipment reliability remain constraints.[26][27]
• Apply a monitoring and evaluation cycle that includes joint annual operational planning, joint supervision in March and September, reviews in April and October, annual assessments of priority programme components, and mid-term and final strategic-plan evaluations.[28]
• Mobilise resources through government allocations, donor and partner support, insurance-related mechanisms and cooperative income generation. The full 2013-2018 implementation requirement was estimated at Rwandan francs 57,510,266,704 in the narrative, while the outcome table reported Rwandan francs 57,420,372,004; available funding was estimated at Rwandan francs 10,937,622,345, leaving a stated resource gap of Rwandan francs 46,572,644,359.[29][30]

Monitoring & Evaluation

The strategy establishes a multi-level monitoring, evaluation and accountability system for Rwanda’s Community Health Programme, combining routine community reporting, mobile and electronic information systems, supportive supervision, data-quality controls, periodic reviews and formal evaluations.[31][1][28][32]

• Use the Rwanda Community Health Information Management System, Health Management Information System, RapidSMS and m’Ubuzima to collect community-level data, improve timeliness and support responses from health-centre, district and national levels.[31][26][27][32]
• Monitor community health workers through monthly supervision, register review, referral verification, medicine-stock checks, report validation and feedback meetings.[13][24][20]
• Track maternal, newborn, child-health, nutrition, immunisation, family-planning, malaria, tuberculosis, HIV/AIDS, mortality, referral and service-utilisation indicators through routine reports and surveys.[33][34][35][4][36]
• Strengthen data quality through harmonised tools, data cleaning, audits, triangulation, counter-verification, quarterly indicator analysis and feedback bulletins.[10][37][32][38][39]
• Develop joint annual operational plans by May, conduct joint supervision in March and September, and hold joint operational-plan reviews in April and October.[28]
• Undertake annual assessments of priority programme components and mid-term and final evaluations of strategic-plan implementation.[28]
• Use quarterly Community Health Technical Working Group and coordination meetings to support joint planning, implementation, monitoring, evaluation and supervision.[16][39]
• Link Community Performance-Based Financing payments to verified performance indicators, cooperative reports, financial records and quarterly approval processes.[40][23][24]

Important weaknesses include inconsistent indicator definitions, duplicated reporting, limited local data-analysis capacity, incomplete death-audit scale-up, unreliable death data, network and mobile-phone constraints, and limited feedback to volunteer community health workers.[26][27][1]The supplied material does not provide a single complete indicator dictionary, national reporting timetable or fully specified accountability framework.[41][42][32]

Costing & Financing

The Community Health Strategic Plan used ingredient costing for fiscal years 2013 to 2018, estimating the inputs, quantities, frequencies and unit costs required for planned activities.[29]The narrative estimates total implementation requirements at Rwandan francs 57,510,266,704, while the outcome table reports Rwandan francs 57,420,372,004, creating a documented discrepancy.[29][30]

• Estimate available funding at Rwandan francs 10,937,622,345 and the stated resource gap at Rwandan francs 46,572,644,359 for 2013-2018.[30]
• Assume that donors provide more than 70% of implementation resources, continued government and donor support, a 5% inflation rate, current prices, and growth in gross domestic product and income per capita.[29]
• Use government allocations to the Community Health Desk and Global Fund support in resource-gap analysis, treating World Bank support for the community health worker intervention as government budget support.[30]
• Maintain Community Performance-Based Financing, under which 30% of central transfers is distributed among community health workers and 70% supports cooperative collective funds and income-generating activities.[23][10]
• Mobilise additional resources for community-level interventions, training, supply chains, electronic health systems, supervision, monitoring and evaluation, and cooperative sustainability.[25][43][44]
• Recognise financial constraints affecting nutrition programmes, Hygiene Clubs, commodity availability, training, cooperative remuneration and timely transfer of performance-based payments.[45][40][8]

Funding options identified include increased government health allocations, donor support, community-based health insurance, user fees, cooperative income generation and potential insurance-sector involvement.[25]Several activities are recorded as having no separate cost because they are integrated into routine supervision, travel or existing departmental work.[19][46][47]