From evidence to national scale: An implementation framework for micronutrient powders in Rwanda.

Micronutrient powders (MNP) are an efficacious intervention in terms of reducing anaemia among young children, yet challenges remain regarding implementation at scale. Research that can guide effective implementation of nutrition interventions and facilitate integration into existing health care platforms is needed. This paper seeks to advance the implementation science knowledge base by presenting our multiphased strategy and findings for scaling-up MNP in Rwanda. The multiphased implementation strategy, spanning a 5-year period (2011-2016), included (a) a feasibility study involving formative research, (b) a 30-day trial of improved practices (n = 60 households), (c) a 12-month pilot that included an effectiveness study (n = 1,066 caregiver/child pairs), and (d) a staggered approach to national scale-up. At the end of Phase 4, the programme had been implemented in 19 of Rwanda's 30 districts with the scale-up in the final 11 districts completed in the following year. The caregivers of over 270,000 eligible children 6-23 months of age received a box of 30 MNP sachets in the final 3-month assessment period, representing a coverage rate of 87%. Initial problems with the supply chain and distribution and ongoing challenges to monitoring and reporting have been the largest obstacles. Continued success will be dependent on adequate resources for capacity development, refresher training, and responsive monitoring. Rwanda is one of the first countries to successfully scale-up home fortification subnationally with MNP. Lessons learned have implications for other countries.

Rwanda's evolving community health worker system: a qualitative assessment of client and provider perspectives.

BACKGROUND: Community health workers (CHWs) can play important roles in primary health care delivery, particularly in settings of health workforce shortages. However, little is known about CHWs' perceptions of barriers and motivations, as well as those of the beneficiaries of CHWs. In Rwanda, which faces a significant gap in human resources for health, the Ministry of Health expanded its community health programme beginning in 2007, eventually placing 4 trained CHWs in every village in the country by 2009. The aim of this study was to assess the capacity of CHWs and the factors affecting the efficiency and effectiveness of the CHW programme, as perceived by the CHWs and their beneficiaries. METHODS: As part of a larger report assessing CHWs in Rwanda, a cross-sectional descriptive study was conducted using focus group discussions (FGDs) to collect qualitative information regarding educational background, knowledge and practices of CHWs, and the benefits of community-based care as perceived by CHWs and household beneficiaries. A random sample of 108 CHWs and 36 beneficiaries was selected in 3 districts according to their food security level (low, middle and high). Qualitative and demographic data were analyzed. RESULTS: CHWs were found to be closely involved in the community, and widely respected by the beneficiaries. Rwanda's community performance-based financing (cPBF) was an important incentive, but CHWs were also strongly motivated by community respect. The key challenges identified were an overwhelming workload, irregular trainings, and lack of sufficient supervision. CONCLUSIONS: This study highlights the challenges and areas in need of improvement as perceived by CHWs and beneficiaries, in regards to a nationwide scale-up of CHW interventions in a resource-challenged country. Identifying and understanding these barriers, and addressing them accordingly, particularly within the context of performance-based financing, will serve to strengthen the current CHW system and provide key guidance for the continuing evolution of the CHW system in Rwanda.

The health equity dimensions of urban food systems.

There is increasing recognition that the nutrition transition sweeping the world's cities is multifaceted. Urban food and nutrition systems are beginning to share similar features, including an increase in dietary diversity, a convergence toward "Western-style" diets rich in fat and refined carbohydrate and within-country bifurcation of food supplies and dietary conventions. Unequal access to the available dietary diversity, calories, and gastronomically satisfying eating experience leads to nutritional inequalities and diet-related health inequities in rich and poor cities alike. Understanding the determinants of inequalities in food security and nutritional quality is a precondition for developing preventive policy responses. Finding common solutions to under- and overnutrition is required, the first step of which is poverty eradication through creating livelihood strategies. In many cities, thousands of positions of paid employment could be created through the establishment of sustainable and self-sufficient local food systems, including urban agriculture and food processing initiatives, food distribution centers, healthy food market services, and urban planning that provides for multiple modes of transport to food outlets. Greater engagement with the food supply may dispel many of the food anxieties affluent consumers are experiencing.