Three decades of community health workers in primary healthcare delivery in Rwanda: evolution, impact and policy lessons.

BACKGROUND: Community health workers (CHWs) have been instrumental in the delivery of primary healthcare (PHC) services in Rwanda since 1995, with their responsibilities expanding from basic health promotion to integrated community case management. This study explored the evolution, contributions, challenges and policy implications of Rwanda CHW programme over the past three decades. METHODS: A qualitative descriptive study was conducted across 15 districts in Rwanda, using in-depth interviews with 46 purposively selected CHWs and key informants. Data were analysed thematically using Braun and Clarke's framework, supported by NVivo software. RESULTS: The majority of CHWs were female (65.2%) and had completed primary education (71.7%). CHWs exhibited extended knowledge on PHC services delivery, including maternal and child health, family planning, diagnosis and treatment of malaria, management of tuberculosis (TB), nutrition, non-communicable diseases and outbreak response. Lived experience from the pioneers of CHWs revealed how community-based health services were gradually embraced and highlighted CHW's significant contribution to managing HIV and TB. Key enablers of CHW effectiveness revealed by the study included supportive local leadership, community trust, positive community feedback, performance-based financing and participation in local development cooperatives. The study also highlighted the digitalisation of reporting tools and continuous advanced trainings as essential strategic recommendations to strengthening CHWs' service delivery. CONCLUSION: CHWs have significantly contributed to the transformation of Rwanda's health system and remain key to advancing universal health coverage. Continued investment in scaling up of existing digital tools and continuous trainings will be key to enhance CHWs' performances and sustain the progress in community health programmes.