On a Sunday morning in June last year, 7-year old Mutoni Aneth was attending prayers at a church near her home. As she walked to the church Altar to give her offertory, she suddenly felt dizzy.
Mutoni held onto her friend to reach the basket. She was able to walk out of the church. She began vomiting and her situation was getting out of control.
Two women seated outside the church entrance rushed to offer help. They held her as she continued to vomit profusely.
“I felt much pain in my head and was too cold. All I wanted was my mother,” Mutoni remembers, and would eventually be helped to reach home while shivering and sweating heavily.
At home, Mutoni’s mother narrates how her mood turned cold. She called the father Gasarabwe Emmanuel who works as a cleaner at a nearby Market.
Gasarabwe scrolled through his cell phone, called Jean Nepomuscene Kwizera – a Community Health Worker serving in one of the villages in Nyarutarama Cell of Remera Sector – a suburb of Kigali. He informed the health worker that his daughter was very sick.
Within 5 minutes, Kwizera arrived with a set of instruments – which in a whole is called ‘Rapid Malaria Test Kit’. Mutoni diagnosed with malaria. The health worker prescribed a dose of Coartem tablets– which is readily available from the kit. The parents were given directives on how to administer pills to their sick daughter.
Kwizera is not paid any money for serving as a Community Health Worker – along with the other over 45,000 colleagues across Rwanda – but loves his service to community.
The health worker Kwizera has a job as a night guard. Cases that reach him during night hours while away on night guard duty, Kwizera refers them to a colleague also working as a voluntary community health worker.
Can Health Workers Win malaria battle?
Rwanda is divided up into 14 837 Villages, and each village has two Community Health Workers or CHWs. They are community members who volunteer to be trained through a government program that aims to ensure nobody develops any symptoms of illness.
These health workers spend much of their free time moving from home to another within their village. In addition to diagnosing malaria and prescribing treatment, the health workers are trained to give first aid, provide nutritional advice and help women give birth.
The daily routine for Kwizera from the Kigali suburb is not as intensely hectic, but never short of emergencies. One Thursday morning, Kwizera had walked out of his house down to a nearby Kimironko market to see a friend from whom he wanted borrow some money. His landlord was expecting rent as it was already past payment deadline.
But then a call came through, and it was a neighbor complaining of sickness. Kwizera knew he would be late if he continued pursuing his personal business. He had to ignore his landlord.
Although he had planned to rest in the morning and later secure money for rent, he instead took a motorbike back to his house, picked the test kit and proceeded to help the sick neighbor that had just called minutes before.
The case of Mutoni, the young whose situation was treated by Kwizera, is only one of several cases across the country. In 2014, malaria cases were 514,173 but increased to 1,957,000 in 2015.
Community health workers existed even before this malaria resurgence, but they were trained to treat malaria as part of the wider government battle against malaria.
Since then, deaths due to malaria have gone down from 499 in 2014 to 424 in 2015; according to the Ministry of Health. Before malaria exploded, Rwanda had nearly eliminated the biggest killer in many regions of Africa.
Rwanda achieved one of the highest parasitological diagnosis rates in Africa, with an estimated 94% of suspected malaria cases being diagnosed, according to the Malaria Program Review 2011. As of 2013, the figure had reached 99%.
And for the dose of Coartem tablets, the ministry of health provides them for free. They are the only efficient available internationally approved malaria treatment. Each worker keeps them in specially design section of the Rapid Malaria Test kits.
According to the Ministry of Health, more than 85% of Rwandan households use mosquito nets. After every two years, households are supplied with mosquito bed nets based on number of beds in a home – making it one of the most effective tools Rwanda has used to combat malaria. The health workers also ensure no family lives without the nets.
As a result of health workers who help rural mothers give balanced diets to their kids, or schedule immunizations, the proportion of underweight children declined from 18% in 2005 to 11% in 2010 and dropped further five years later.
“The health workers ensure both the mother and child are healthy – follow up the child’s growth, weight as well as helping parents understand how to prepare balanced diet from available foods,” says Malick Kayumba, Division Manager of the Rwanda Health Communication Center.
“Ingobyi” is no more
Kayumba told KT Press that the health workers are required to keep a vaccination schedule for all kids in their area. They make sure the expectant mother knows when they have to visit the nearest health center for immunization.
“These Community Health Workers will even escort the patients to health centers when necessary,” he said.
In Tyazo village of Rugera Sector, Nyabihu district in deep rural western Rwanda, residents had to walk over 4km to Nyakiriba Health Centre.
Emmanuel Habumuremyi is a father of five, and has a painful story about malaria.
“Many years ago, my daughter developed fever in the middle of the night. I had no car or bicycle yet her mother was heavily pregnant. I went out to get local herbs but the child’s situation worsened,” Habumuremyi remembers.
He woke up neighbours for help. They escorted him carrying his daughter to the health centre. Despite intervention of medical staff, she died few hours later.
“I wish the government at the time had introduced Community Health Workers,” says Habumuremyi. They find us at home, or we follow them to their houses and they help us. My daughter would still be alive”.
Nyabihu district lies in a hilly region. Locals in many villages have had to walk long distances. They have to climb steep slopes and maneuver around giant rocks to reach the hospital.
“Even when the ambulance is available, it can only be able to park at least two hours away from our village and waits for us to reach it,” says Habumuremyi.
Previously, when a resident fell terribly sick, they would be put on ‘Ingobyi’ – a traditional stretcher made of ‘papyrus. Aid agency Actionaid called it ‘a magic medical ambulance’. It is about 25 centimeters wide and 100 centimeters long. On its sides, there are two handling poles made from eucalypts. Normally four men carry it.
Today, residents in many Nyabihu district villages will get help from a health worker. And when it is too late in the night, the patient will have gotten first aid – so they could be moved to the hospital without a rush.
In Rutsiro District – also in Western Rwanda, residents used to take epileptic patients to traditional healers until the country introduced Community Health Workers.
Mukankusi Marasiyana speaks of her case: “My son was 6 years when he started suffering strange seizures – I thought he was possessed by demons. I had started consulting witch doctors when a neighbor advised me to notify the Community Health Worker. I was linked up to a doctor at a nearby hospital, the boy was diagnosed with epilepsy and prescribed with medicine; he is doing fine and has even started school.”
Another resident Maniragaba Celestin says he suffered from epilepsy for years but his relatives believed he had been bewitched.
“A Community Health Worker convinced me to see a medical doctor – and even accompanied me to hospital. I have since been getting medicine that has reduced my seizures; I used to get attacks three to four times in a day but are rare nowadays,” says Maniragaba.
For 78-year old Kantengwa Chantal in Rwamagana District, in the Eastern Province, she lives with 5-year old grandson Shami David and a house maid.
“Shami was coughing heavily last week but I had no money so I called a health worker lady. Her brother answered the phone – telling me she was in her cassava farm tilling. I found her in the farm. We returned home where she conducted tests and my grandchild diagnosed with Pneumonia,” says Chantal.
A health people, a health nation
In 1995 when Rwanda introduced the Community Health Workers program, the number of volunteers mobilized was about 12,000. By 2010, the number had grown to 45,011.
Currently each village elects a pair of male and female volunteer health workers, and a supervisor. They play different roles. The female is often in charge of maternal antenatal care and children below 9 months. Each village in Rwanda has between 100 to 200 households.
Government provides mobile phones to each of the health workers. The phones are toll-free to allow for free calls from patients, as well as free calling between the health workers themselves. They diagnose and treat malaria, diarrhea, and pneumonia; give family planning advice; facilitate outreach for vaccination, and sensitize residents on HIV.
The community health workers have note books in which they record all cases they have handled. They in turn compile regular reports which give a clear picture of health status of their community – which are filed at the Sector. The reporting climbs up until the final destination at the health ministry.
In Northern Rwanda, community health workers have saved many lives. Due to ignorance, poverty and sometimes sheer negligence, residents have died waiting at home.
Clementine Korerimana residing at Ngazo Cell, Gahondo village in Gakenke District says that she does not worry of malaria or any other diseases these days.
“By the way, when a health worker escorts you to the hospital, you will be treated as priority before other patients who have come on their own because the doctors know the health workers in person,” Korerimana said.
Additional reporting by: Safari Viateur(Southern Province), Musabwa Euphrem (Western Province), Talib Abdul (Northern Province) and Musanabera Ernestine (Eastern Province)