In Rwanda, family planning nurses and community health workers (CHWs) partner to provide family planning services to members of their communities. Respondents revealed a number of challenges that create barriers in their work to deliver services, while simultaneously outlining a pattern of success via compassionate counseling of new and continuing family planning clients.
Provider Challenges
Providers noted that the work they do is not without challenge and sacrifice, including both professional and personal obstacles.
We face a lot of challenges. But because we give ourselves out to the community, and the courage that we have, and the friendship we have in the village - we have to do it. CHW, 44 years, female, Musanze
This job of ours is to work, to sacrifice, teach what’s possible, today you sit here…tomorrow there, until in the end they will be able to understand.
CHW, 44 years, male, Musanze
Family planning providers were aware that the challenges in their jobs threatened their ability to have successful relationships with clients. More providers contributed to themes regarding the challenges they faced, although clients contributed to some of those themes as well. The challenges providers confronted fell into the following subthemes: human resource shortages, insufficient supplies, and desire for more training. There were two additional themes that only arose as challenges for CHWs - threats to personal time and a desire for financial remuneration.
Human Resource Shortages
The most common challenge providers noted was a need for additional personnel. According to respondents, adequate staffing would alleviate the majority of provider’s concerns.
M: In your everyday job are there challenges that you face?
R: The biggest challenge is that we have few employees.
Nurse, 42 years, female, Musanze
I: What is the worst problem you have faced in family planning?
R: The problem I experienced is that we don’t have sufficient family planning providers in the village, and also we don't have more nurses or doctors in the domain of family planning program.
Implant user, 35 years, 4 children, Nyamasheke
Family planning providers noted how emergency services take precedence over preventative services in terms of staffing, which then impacts waiting times for new and returning clients. The main concern about the lack of adequate staffing was the delay in service delivery, due to competing priorities for nurses at facilities, leading to long wait times for the family planning clients as well as the lack of services available.
She may potentially come to the clinic and we know that she has an appointment; however, due to the limited amount of nurses she may find that we will prioritize emergency situations before dealing with her…When she grows impatient she will return home without assistance.
Nurse, 40 years, male, Musanze
Some people are accustomed to their CHW, so if they go to the health center it can take a long time for them to be treated. It can take about three hours before she will get treated. So she thinks she is wasting her time, but the problem is that there are many people waiting for the same service. She can feel like she is being treated unfairly. The people in the community think that this is a challenge, and can think that going to the health center is a waste of time.
CHW, 43 years, female, Musanze
… advice I can give is that there are times where you can go to the health center when you want to get family planning services but face the problem that you find that the nurses that are in charge of family planning, they are doing other emergency services. So I can recommend that we can have one permanent family planning services provider at the health center that works every day…
Injectable user, 43 years, 4 children, Nyamasheke
The shortage of needed staff also led to inadequate service provision-which negatively impacts the women using contraception.
She may come once for injection, and you complete her file, you discuss with her the main points, but you give the brief explanation because you don’t have time to go deeply…
Nurse, 45 years, female, Musanze
In order to handle the shortage of human resources at some facilities – family planning services are restricted to a few days a week; however, the schedule of these services may not be known to all who want to access the services.
We want family planning service to be allowed to work every day by the health center just like the other services they provide not just for Tuesday and Friday. For example, due to only two days of services a woman can risk becoming pregnant if she had wanted to see someone sooner. I believe it should be open weekly to be easier for women to come in whenever.
CHW, 39 years, female, Nyamasheke
…add more staff, but also to have an employee who is solely in charge of family planning. So that in the case that a woman comes in for family planning or contraceptives they will know for sure that they will find a doctor who is in charge of that service and there all the time.
Nurse, female, Musanze
Primary concerns and critiques included a need for additional CHWs in the villages. While some respondents said the amount of CHWs was sufficient, in both Musanze and Nyamasheke more identified a need for additional access to more staff.
…to add more community health workers in the village because you see that we have too many villagers but they only have three community health workers; so that they can help a woman to be comfortable because if the community health workers are few they can’t reach all the women, but if they can increase the number of community health workers to five or to six they can reach more women…
Condom user, 41 years, 5 children, Musanze
Insufficient Supplies
Nurses provided suggestions regarding supplies – to have all of the necessary equipment on hand to serve the clients, transportation for those who are coming to the clinic – or to follow up with those that did come to the clinic, and better methods of communication between the providers and the clients.
CHWs discussed additional ways that the Rwandan government could support them with resources – also through adequate contraceptive supplies. Presumably this includes contraceptive methods themselves, as well as the supplies required for administering and keeping track of the supplies. Storage of supplies was also noted as a common request. Resource comments were noted six times more often by Nyamasheke CHWs as compared to Musanze CHWs.
It would also be beneficial if they gave CHWs enough material because it is hard when the client comes looking for a contraceptive method for the first time and the materials needed are not available.
CHW, 45 years, female, Nyamasheke
The majority of responses from providers regarding a lack of resources shared a concern for the impact it would have on current and future family planning clients. Providers recognized that negative family planning experiences for clients could have repercussions for other women in the community and their desire to seek out family planning services.
Desire for More Training
A common need for more training of providers also emerged from the data analysis – both in general family planning services and for more specific technical needs, i.e., providers trained in the provision of long term and permanent methods.
The other thing they can help with… you see not all the staff are trained about family planning. For example, a person can come to the hospital and need to use the IUD method and has a problem, because there is only one person who is trained about IUDs. And that person who is trained about IUDs is not always at the health center. So if there is a person who needs that method, they have to wait. This is a problem.
Nurse, 35 years, female, Nyamasheke
The topic of training CHWs also arose in nearly all FGDs and a quarter of the IDIs.
…they have to have a lot of information about contraceptives because they cannot give what they don’t have.
Pill user, 45 years, 2 children, Nyamasheke
There was a recognition of the need for ongoing training of CHWs – as well as the impact of training CHWs on a broader audience of the entire community.
I think that they should continue to give more training because we will benefit from them.
Injectable user, 41 years, 5 children, Musanze
Threats to Personal Time
CHWs in every focus group brought up issues related to the time it takes to serve their neighbors as a CHW.
Another problem we face is that to do well in your work, you need to have a lot of time to put into it.
CHW, 46 years, male, Musanze
CHWs worked hard to follow-up with neighbors.
…some of the mothers might have appointments to come see us at our house but they won’t show up and as a CHW you are worried because they did not show and then you feel like you must go out and visit them or find them. That problem keeps following you, you get to her house and find she is not there and that means you have to go back. A CHW faces a lot of challenges and sometimes you have to go and look for people more than three times. You feel you have to make the sacrifice and not stop until you find them.
CHW, 56 years, male, Musanze
CHWs noted how the time it takes to serve clients takes away from their own needs to take care of their families either through caretaking or for financial gain.
I use most of my time as a CHW instead of caring for my family.
CHW, 46 years, female, Nyamasheke
Because I have a lot of clients at my house, my kids eat late or have to sleep without food. To be a CHW means sacrifice.
CHW, 44 years, female, Musanze
Even if I am in the middle of my own job, when the client comes I must help her without taking care of my own tasks that could bring in profit.
CHW, 51 years, female, Nyamasheke
Desire for Financial Remuneration
The topic of compensation for hard work arose in every FGD with CHWs and even among the IDIs with experienced contraceptive users. CHWs felt that “motivation” in terms of financial payment would help them accommodate their own needs to provide for their families while maintaining their ability to serve their neighbors. CHWs also noted how their work would feel more valued and appreciated with financial compensation. This topic arose three times more often among Nyamasheke CHWs as compared to CHWs in Musanze.
A difficulty we encounter is we use all of our time as CHWs and do not work for our families. We do all of this without financial compensation.
CHW, 51 years, female, Nyamasheke
According to the time we spend doing this, we deserve to be compensated, even if it is not a big sum. We need to get that support. This will help me. For example, suppose that I am a farmer, if the government gives me some money, I can send someone else in my place to cultivate my field while I am doing this work as a CHW.
CHW, 46 years, male, Musanze
...our community health workers also need to work for their families and sometimes they cannot manage to both provide for their families and also to work for us when we are seeking their services. Because sometimes we go to look for community health workers and find that they are not available due to maybe their personal plans. And based on this, I think that the government of Rwanda may look for ways to give community health workers motivation and money also so that they can work as if it is their job. So that any time, hour to hour, we can access them.
Injectable user, 32 years, 3 children, Musanze
Rewarding Provider-Client Relationships
Despite the numerous challenges that family planning providers face in contraceptive service provision in Rwanda, there was more emphasis on the positive in their loving and compassionate interactions with their communities. The nurses and CHWs describe their interactions with family planning clients with strong senses of empathy, respect, and the importance of utilizing listening skills. Providers came across as patient, kind, and loving with their clients.
It’s inside you to give every client the services she wants.
Nurse, 44 years, female, Nyamasheke
…welcome people well, because the way we welcome them is how we will lead them to love family planning.
Nurse, 38 years, female, Nyamasheke
In terms of provider and client relationships, many positives were reported, primarily by providers, but also clients. The positive subthemes include: reliable access to providers and methods, providing comprehensive information, respecting client privacy, compassionate counseling, and counseling dissatisfied users with care.
Reliable Access to Providers and Methods
Many study participants noted that they did not find any barriers in accessing family planning providers and contraceptive methods. Of those who mentioned a lack of barriers, more lived in Musanze than in Nyamasheke.
The other thing I can say the country helped us in is that at the health center every nurse is capable to give family planning methods. This means that they trained us about family planning. Every hospital staff knows how to give family planning methods.
Nurse, 35 years, female, Nyamasheke
Nothing is difficult to us in getting services because anytime you go to the health center or to the community health workers they try to help us every day so it is also easier for us to get medicine.
Implant user, 36 years, 3 children, Nyamasheke
They are already ready to help us. Even if you come on Sunday they help you.
Condom user, 38 years, 2 children, Nyamasheke
I: Is there a time you wanted to get the injectable, but it was not available?
R: No, every time I want it I can get it.
Injectable user, 41 years, 6 children, Musanze
Despite the ease of access with community health workers, a few women in Nyamasheke voiced their preference for nurses at the health center due to their superior knowledge. Regardless of the fact that accessing nurses is often more challenging in terms of scheduling and travel distance. Nurses are viewed as more knowledgeable about family planning and broader health concerns as well.
For me, I don’t like to get the method from the community health workers. When I want the method I go to the health center and I go to look for nurses, because the community health workers know many things but there are things they don’t know. There are things you can ask them and they won’t have more information about. That’s why I choose to go to the health center.
Pill user, 45 years, 2 children, Nyamasheke
Providing Comprehensive Information
Providers shared the all-inclusive information they would provide to the clients – it was clear they wanted the clients to fully understand their options, so they could make informed decisions. When clients did decide on a method, providers wanted to help them strategize how to make the experience successful and sustainable.
…I will show them the good and the bad of using family planning.
Nurse, 49 years, female, Nyamasheke
Respecting Client Privacy
Providers noted how they would treat clients with respect – and honor their privacy.
…she will come to you according to how you present yourself. We emphasize a lot that we will keep their secret if they come to us.
CHW, 45 years, female, Musanze
The CHW that understands her circumstances will help her to get an appointment with family planning providers in order to keep the services she gets a secret. CHWs are going to protect this secret so that no one can find out that she is using contraception.
CHW, 61 years, male, Nyamasheke
It was particularly clear that CHWs would maintain client confidentiality – as a way to protect their clients but also to avoid ruining current and future client relationships.
…a CHW has to be a closet of secrets…if you are not a closet of secrets your advice is already broken.
CHW, 56 years, male, Musanze
Compassionate Counseling
Nurses were confident in their ability to provide and treat clients with respect – and that the outcome of their efforts would be positive.
If the discussion with her was successful, there is no other thing that can stop a woman from using a contraceptive method.
Nurse, female, Musanze
Similarly, the vast majority of women reported positive experiences with providers and felt confident in conversing with them regarding a variety of issues. Providers were reported to be knowledgeable, helpful, and supportive of women’s decisions regarding family planning use. Musanze participants contributed to this theme more so than Nyamasheke contraceptive users.
I: How did they receive you at the health center?
R: They received me well, with a smile and with much appreciation, and they give more advice about the advantages of using family planning.
Injectable user, 31 years, 3 children, Musanze
When contraceptive users were asked what family planning providers could do to improve most responded that they could not give advice because they perceived providers as already doing all that they could.
I have never had a problem with the services given by family planning providers so I don’t have any advice for them because they do a great job and I am thankful to them.
Injectable user, 26 years, 1 child, Musanze
It is difficult for me to give advice for family planning providers because for me now I see the way that they provide services to us is good, they receive us well and they always take care of us…
Pill user, 34 years, 2 children, Musanze
Counseling Dissatisfied Clients with Care
Providers also shared the compassionate way they receive and counsel current dissatisfied family planning users.
I need to have a deep conversation with her, because I need to know everything and after we can make a decision based on our conversation.
Nurse, 29 years, female, Nyamasheke
…they will discuss why she stopped using the pill in those two months and if she wants to continue using family planning. They will work together in order to find another method for her to use.
Nurse, 34 years, female, Musanze
A common theme that arose was providers counseling unsatisfied users with the experience of side effects. These conversations were handled with great sensitivity.
She might start the method of taking pills. And then a few days later, she will gain weight, she will be just like my size. And she might not be able to handle it and she might come back saying she wants to stop. At that moment we will have another discussion, but different from the first one…You have to remind her of the first discussion you had about side-effects that she is going to have. And then you will ask her, between getting fat or getting pregnant, what would be more of a burden?
Nurse, 50 years, female, Nyamasheke
The positive influence of providers likely plays a strong role in the continued use of contraception despite experienced side effects.