AnnaMüller

4.3.1 Health Promotion

Table 21. Baseline and targets for Health Promotion

EXPECTED OUTPUTS/ OUTCOMES BASELINE 2011

TARGETS 2015

TARGETS 2018

Diarrhea prevalence among children <5

2.8 2.1 2.0

% Community Health Clubs with enhanced health promotion and BCC capacity

14% 50% 70%

Health communication activities were until recently implemented separately by the different health departments. Programs with more resources, like HIV, were active in terms of sensitization campaigns both at national and at local levels. Behavior change communication messages were disseminated through various mass media channels with little interpersonal and other forms of communication. There was also a clear lack of coordination of these activities.

This coordination function is now fulfilled by the Rwanda Health Communication Center (RHCC), which has recently been mandated to do this as part of the Rwanda Biomedical Center (RBC). RHCC collaborates with and provides technical support to the many units and programs in the health sector through the services of its focal points. The RHCC’s mandate is to:

 Support all health promotion and BCC activities of MOH units, desks, departments, and the RBC;

 Mainstream media information flow within and outside the health sector, including public relations for the Ministry of Health.

Challenges and constraints facing the Health Promotion/BCC function

There are a variety of guiding strategies on health promotion that need to be harmonized for the sector. The existing BCC Policy needs to be updated to adapt to quickly evolving communications technology. Commonly used approaches need to be more dynamic and explore the use of new and emerging media to complement the usual IEC/BCC materials such as pamphlets, booklets, and posters. Coordination of health promotion and behavior change interventions across the health sector also needs to be strengthened, and communication efforts should strategically address all the main diseases affecting the Rwandan population, rather than focus on a few programs that receive specific funding. Donor dependency is undoubtedly a constraint, as it causes lack of financial management flexibility.

Another important challenge is the inadequate health promotion expertise of RHCC staff, both in quantity and in competency. There is lack of funding to ensure specialized training on health promotion. There is also lack of harmonization in content, frequency, and quality of training of key partners such as local leaders, CHWs, service providers, journalists, and so on to ensure adequate dissemination of messages to the general population.

Resources to carry out effective and consistent community outreach activities for infectious diseases and NCDs are also limited, while BCC strategies, training materials and methods used are often not evidence driven. Target audiences are in most cases not sufficiently involved in the design and pretesting of health

promotion interventions. Monitoring and evaluation of health promotion interventions are not considered a priority. There are also gaps in the effective distribution of IEC/BCC materials.

The printing unit based at the Rwandan Health Communication Center that produces materials needs equipment upgrading to fulfill its role.

Health promotion and BCC interventions and strategies

The logical framework describing the priority interventions to overcome the identified challenges focuses on three main strategies:

1. Adopt a more strategic approach to health promotion and BCC.

 The first key intervention will be to review and finalize the national Health Promotion Strategic Plan. This will ensure harmonization of health promotion interventions and provide the guiding principles for health promotion and BCC practices.

 The Health Promotion TWG will be strengthened to oversee the process and provide technical guidance, support advocacy, and mobilize resources for the implementation of the Health Promotion Strategic Plan.

 The Health Promotion Strategic Plan will be rolled out nationally, and will have several key areas:

 Evidence-based interventions and impact evaluation to assess effectiveness and appropriateness of tools and media utilized;

 Pretesting as a key component of every health promotion and BCC intervention;

 Monitoring of all health promotion and BCC interventions;

 Communication approaches adapted to needs of the audience and include innovative approaches (community theater, use of emerging media, etc.);

 Peer-to-peer group sensitization through existing networks such as Community Health Clubs (CHCs) and school clubs, particularly for youth and adolescents;

 Strategic partners (FBOs, CSOs) engaged to facilitate community dialogue on key health- seeking behaviors and practices;

 Documentation and sharing of best practices and lessons learned;

 Mainstreaming of gender and equity in all health promotion and BCC interventions. 2. Capacity development of health promotion and BCC providers;

 Develop the capacity of RHCC staff at the central level in strategic health promotion and BCC theory and practice;

 Recruit and deploy health promotion BCC staff at decentralized level;

 Develop the capacity of CHWs and local leaders at the periphery in health promotion-BCC, 3. Efficient coordination of health promotion and BCC programs and interventions:

 Strengthen the National Health Promotion/BCC TWG;  Establish District Health Promotion/BCC TWG;

 Establish a network of health promotion and BCC practitioners and professionals;  Strengthen and expand the existing call center;

 Upgrade the RHCC printing and production infrastructure;

4.3.2 Environmental Health and Medical Waste Management

Table 22. Baseline and targets for Environmental Health and Medical Waste Management

Ensure

environmental sustainability

Target 10. Reduce by half the proportion of people without

sustainable access to drinking water.

EXPECTED OUTPUTS/ OUTCOMES BASELINE

2011

TARGETS 2015

TARGETS 2018

% Food establishments with satisfactory hygiene standards

0 40 90

% Villages with functional Community Hygiene Clubs (CHCs) meeting at least twice a month)

8 50 80

% HF with effective waste management systems

55 83 >90

According to the statistical data collected in health facilities in Rwanda, a large proportion of pathologies requiring consultation in health centers and district hospitals are related to factors in the natural and built environment, including personal and environmental hygiene, water quality, food safety and hygiene, indoor air quality, and management of domestic and medical wastes (e.g., injections).

Current Environmental Health Program activities

In Rwanda, environmental health has received strong political support from the highest country leadership. A multisectoral policy and strategy has been designed and is implemented through a strong coordination mechanism involving all relevant sectors at central, district, and community levels. The Environmental Health Desk of the MOH leads the technical working subgroup handling issues related to health facility waste management, household sanitation, and hygiene promotion. Limited dialogue is taking place between government entities and various development partners (e.g., UN, NGOs, DPs, community -based organizations) and, to some extent, the private sector.

The Environmental Health Program consists of a variety of interventions, such as food safety, drinking water quality surveillance, health care waste management and injection safety, hygiene inspection, hygiene behavior change, occupational health and safety, indoor air pollution, and climate change, natural disasters and emergency environmental health intervention. The unit ensures M&E of all activities being conducted countrywide.

The Government of Rwanda, through the MOH, launched the Community-Based Environmental Health Promotion Program (CBEHPP) in 2009. The overall purpose of this program is to reduce the prevalence of environmental health related diseases, such as diarrhea and intestinal worms through promotion of best hygienic practices. The program strategically uses Community Hygiene Clubs based at the village level to address hygiene issues, such as clean water, sanitation, and behavior change. So far, the program has been started in nine districts and will be rolled out countrywide.

The MOH also developed a draft Food Safety Policy that emphasizes decentralization of hygiene inspections and the grading of food establishments. Hygiene inspections in public institutions are being done by national and district teams.

The Ministry of Health is taking all necessary measures to ensure injection safety and rational management of medical waste, both in health facilities and within communities. There is a national strategic plan for the management of health care waste (2011–2016). Training of health workers has been conducted on health care waste management (HCWM) and injection safety. District hospital incinerators have been purchased and plans to purchase additional ones are underway. Provision of personal protective equipment and availability of post-exposure prophylaxis to victims of accidental occupational exposures (e.g., blood and amniotic fluid during labor and delivery) is being implemented.

Special attention is paid to the transport and disposal of medical waste. If this is done by the private sector, safe conditions for collection and transport should be imposed.

Environmental Health challenges

The main challenges identified during the recent health sector situation analysis are:

 Funding for the CBEHPP is insufficient, and for the most part the Community Hygiene Clubs that have been put in place are not fully functional.

 There is an important lack of human resources for the strengthening of the Environmental Health program at the central level, and even more so at DH and HC levels. Medical and other health workers are not implementing guidelines for hygiene and safe medical practices in HF, partly due to lack of knowledge but also due to lack of incentives (no indicators on hygiene in PBF program).  Food establishments are still weak in applying hygiene and food safety measures. There are no

food quality control kits at the decentralized level to conduct hygiene inspection visits.

 Sanitation and hygiene activities are not well captured by the HMIS resulting in a lack of baseline information and M&E for hygiene and sanitation.

Environmental Health strategies and interventions

To respond to these challenges, the following key interventions have been prioritized. 1. Develop and review various environmental health policies and strategies:

 Review the current Environmental Health Policy and develop a new strategy (currently underway);

 Contribute to development of a national BCC Strategy;

 Establish national guidelines and norms for sanitary infrastructures in HFs and households;  Develop several substrategies for indoor air pollution, adaptation of public health to climate

change, food safety, and other factors;

 Develop jointly a national plan for surveillance of health and the environment;

 Validate several substrategies that are waiting review (hygiene and sanitation law, health care waste management, drinking water quality surveillance, and Food Safety Policy); 2. Strengthen capacity of environmental health entities from the national to the village level:

 Recruit environmental health officers (EHOs) at central and decentralized levels;  Train EHOs at district and sector levels in established procedures;

 Conduct refresher training for hygiene inspectors and CHWs; 3. Decentralize hygiene inspections to empower districts and sectors:

 Ensure the inventory of food establishments is in place by December 2012;  Introduce hygiene-based categorization of food establishments;

 Provide hygiene certificates for the best-performing establishments. 4. Implement the Community-Based Environmental Health Promotion Program:

 Mass education campaigns using IEC materials, social media, and outreach programs;  Establish and train Community Health / Hygiene Clubs in all imidugudu;

 Initiate an impact assessment of the CBEHPP.

5. Streamline the implementation of water quality surveillance, food safety, domestic and health care waste management and injection safety, school hygiene, indoor air pollution, disaster management and preparedness, and occupational health:

 Ensure construction and procurement of waste management facilities (incinerators, transportation vehicles, latrines, etc.);

 Provide hygiene budget for district hospitals;

 Integrate hygiene indicators in performance-based financing;

6. Monitoring and evaluation:

 Conduct baseline and evaluation surveys;

 Carry out an annual HH assessment to obtain hygiene data at the community level;  Conduct regular sanitary educative inspections and supervision;

 Integrate hygiene-related data into Sisteme d’Information Sanitaire des Communautes (SISCom) and HMIS;

 Conduct a situation analysis and needs assessment based on the Libreville Declaration on Health and Environment.9

9

The Libreville Declaration promotes joint efforts between the Ministry of Health and the Ministry responsible for Environment to implement public health measures to reduce the impact of climate change on health of the population.

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Overall Objective of Component 2:

Strengthen policies, resources and management mechanisms of health support systems to ensure optimal performance of the health programs (output, input, and process levels)