Rwanda

CCM, or community Integrated Management of Childhood Illnesses (c-IMCI) as its often called in Rwanda, is an important component of the community health policy. Of the 45,000 community-elected CHWs situated in 15,000 villages, 30,000 provide CCM to children under 5 in their Umudugudu or village. CHWs are volunteers and members of one of the 420 health cooperatives in the country that provide health services to communities and manage up to 7 commodities for CCM. CHWs are overseen by a cell coordinator (CC), an experienced CHW, who conducts supervision, collects logistics data, and resupplies CHWs with health products each month. 

Only three simple tools are needed for the CHW resupply process: a stock card, the resupply worksheet (RSW) and the “magic resupply calculator” that the CC uses to record monthly stock data for CHWs and determine required quantities to inform the health center pharmacy. The RSPs were designed to provide a simple, predictable way in which CHWs can be resupplied every month so that they know when, how, and where to collect products, using a standard calculation and easy-to-use tools. The intervention aims to:

• Document procedures for ordering, reporting, inventory control of CCM health products, and have the procedures be harmonized for the entire country
• Train district and health center staff and CCs in the standard procedures and processes and clarify their respective roles in recording, reporting and resupply
• Provide CHWs, CCs and HC staff with forms and tools for resupply
• Create simple procedures, to avoid over-burdening CHWs, who are volunteers and may have limited time to devote to routine supply chain tasks. 

QITs are comprised of HC staff and CCs who oversee CHWs in their cells (generally 7-10 cells per HC).  Individual QITs focus on improving the use of RSPs through a Quality Improvement Process. QIT members use data from CHWs in their cells to identify performance gaps between desired and actual performance in use of the product resupply procedures, set a performance objective and then try to close gaps by testing activities, tracking performance, and maintaining practices that improve performance.

Elements of the QIT process include:

The CCs make home visits to individual CHWS, provide supportive supervision and gather data on selected performance areas.

Individual QITs meet monthly at HCs to review the data the CCs collected and track progress against a pre-determined performance objective using simple tools. The process used by QITs is the data driven Plan-Do-Study-Act (PDSA) cycle.  Teams identify problems and solutions to implementing the RSPs and close performance gaps. Once one objective has been met the teams move on to another performance objective.

District level staff provide coaching and/or supervision support each quarter for QITs and individual team members in the use of the QC tools, methods, and use of RSPs. 

IcSCI builds on and aims to strengthen the commodity supply chain portion of the existing community based performance-based financing (PBF) scheme for CHWs that is in place in Rwanda as a means of improving delivery of health services at the village level. Through the existing PBF system, robust national structures are in place to implement, validate, monitor and evaluate existing schemes, and CHWs are organized into self-managed cooperatives. The incentive system works by determining a key set of health indicators for cooperative members/CHWs to achieve; after submitting results every quarter, cooperatives receive incentive payments from health centers related to their achievement levels.

A list of nine indicators was developed for the three priority supply chain areas: meeting attendance, reporting, and good inventory control procedures and CCs collected data on these from the CHWs in their cells quarterly for scoring. The indicators were weighted to reflect the level of priority of behavior necessary for improved performance of supply chain tasks. One of the nine indicators was selected to be included in the scale-up package.