Memoire Online - Assessment of community health workers incentives on maternal and newborn health services performance

ASSESSMENT OF COMMUNITY HEALTH WORKERS INCENTIVES ON MATERNAL AND NEWBORN HEALTH SERVICES PERFORMANCE,

AUGUST, 2015

ASSESSMENT OF COMMUNITY HEALTH WORKERS INCENTIVES ON MATERNAL AND NEWBORN HEALTH SERVICES PERFORMANCE,

A Thesis Submitted to Bugema University in Partial Fulfillment of the Requirements for the Award of the Degree of Master of Public Health

AUGUST, 2015

ACCEPTANCE SHEET

This thesis entitled «ASSESSMENT OF COMMUNITY HEALTH WORKERS INCENTIVES ON MATERNAL AND NEWBORN HEALTH SERVICES PERFORMANCE, IN RWINKWAVU DISTRICT HOSPITAL, KAYONZA DISTRICT, RWANDA .» Prepared and submitted by NDANGURURA DENYS in partial fulfilment of the requirements of MASTER OF PUBLIC HEALTH, is hereby accepted.

Accepted as partial fulfilment of the requirement for the degree of MASTER PUBLIC HEALTH, Bugema University

DECLARATION

I, NDANGURURA Denys, hereby, declare that the thesis entitled «Assessment of Community Health Workers Incentives on Improving Maternal and Newborn Health Services, Case Study of Rwinkwavu District Hospital in Kayonza District, Rwanda», is my personal original work and to the best of my knowledge, it has not been submitted, in part or in a whole, for any degree in any university.

DEDICATION

With love, this thesis is dedicated to my beloved family for their love, care and support during my studies. To all friends and relatives who contributed to this research.

BIBLIOGRAPHICAL SKETCH

The writer was born September 10^th, 1983 in Nzige Sector, Rwamagana District in Eastern Province of Rwanda. He is born to Mr. Andre NDANGUZA and Madeleine KAMAHE. He completed his primary school at Akanzu Primary School, Rwamagana district. In 1996, he joined APEGA secondary school where he completed O' level. Then after from 2000 to 2003 he completed his studies from the school of Agriculture and Veterinry in Veterinary studies. In September 2003, he joined the Universté Ouvrte/Campus de Goma in RDC and in 2006, he got the advanced Diploma in General Nursing then after in the same institution from 2006 to 2008 he completed his undergraduate studies in Public Health getting a bachelor degree in Public Health. He then worked at Rwinkwavu district hospital as a nurse then after he worked in the same institution as the professional in charge of Community Health Program from 2007 to 2014. He is now a District Coordinator for Rwanda Family Health Project, a USAID funded project working with Rwanda through the Ministry of Health to improve family health services. In January 2012, he joined the school of graduate school at Bugema University, a Chartered Seventh Day Adventist Higher learning Institution for Master degree in Public Health at Bugema university, Kampala, Uganda which he completed in July 2015.

ACKNOWLEDGEMENTS

I must convey my deepest appreciation to my chief supervisor Dr Sylvia Callender -Carter and my supervisors Dr. Beth Sigue and Dr. Paul Katamba, who gave me valuable guidance, support. Also the encouragement from Dr. Rhoda Kayongo and Dr. Moses Kayongo the good will from the initial to the final stage of helping me to develop an understanding of this paper. Your advice has played by Stephan S. Kizza. is an outstanding role in shaping this paper. Your comments and observations were vital inputs which enabled me to improve this paper.

It is a pleasure to express my gratitude to my colleagues for helping me and sharing experiences and discussing courses.

My special thanks to my wife, sons, parents, brothers and sisters for their priceless support.

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ABSTRACT

Denys NDANGURURA, School of Graduated Studies, Bugema University, July, 2015. Thesis title; «ASSESSMENT OF COMMUNITY HEALTH WORKERS INCENTIVES ON MATERNAL AND NEWBORN HEALTH SERVICES IN RWINKWAVU DISTRICT HOSPITAL, KAYONZA DISTRICT, RWAND''A.

The study was carried out on assessment of Community Health Workers Incentives on Maternal and newborn health services performance. The sample size was 236 CHWs in charge of MNH distributed in eight health centers of Rwinkwavu district hospital catchment area. To determine the demographic characteristics of respondent, the researcher used descriptive statistics. It revealed that the majority of them 125(53.2%) are those in the age range of 36 to 50 years. All respondents are women that are why when you look at gender 236(100%) were women. The marital status shows that the married are the predominant among other represented by 168 (71.1%). The level of education the majority of respondents 151(64.0%) have is primary. Most of the CHWs in charge of MNH are agro-farmers 193(81.8%) distributed as cultivators 91(38.6%), farmers 55(23.3%) and the farmers-cultivators represented 47(19.9%). The level of CHWs incentives was showed a low mean and standard deviation (

=1.75; SD = 0.82). The results on MNH services performance the study was showed a moderate mean and standard deviation of (

= 3.04; SD = 1.26).

Logistic regression was used to establish influence of CHWs incentives on performance of them in MNH services. CHWs financial incentives to be high are about 3 times as likely to perform in maternal and newborn health services (P=0.012, (1.26-6.26),UR=2.808) however result indicate that being a member of CHWs cooperative is not a significant predictor of performance of CHWs in MNH services(P>0.05

The study recommends reviewing the system of CHWs performance based financing system on equal opportunity and strong monitoring and evaluation based on mentorship of CHWs cooperatives.

CHAPTER ONE

INTRODUCTION

Background of the Study

Globally community based intervention true CHWs is in urgent need to improve health of women and children, particularly in areas of Africa, where Millennium Development Goals (MDGs) 4 and 5 are most lagging. This requires strong community engagement and formal investments in national health systems, especially for those least likely to be reached through current national health strategies, such as those in rural communities. Community Health Workers (CHWs) have been internationally recognized for their notable success in reducing morbidity and averting mortality in mothers, newborns and children. CHWs are most effective when supported by a clinically skilled health workforce, particularly for maternal care, and deployed within the context of an appropriately financed primary health care system. However, CHWs have also notably proven crucial in settings where the overall primary health care system is weak, particularly in improving child and neonatal health. They also represent a strategic solution to address the growing realization that shortages of highly skilled health workers will not meet the growing demand of the rural population. As a result, the need to systematically and professionally train lay community members to be a part of the health workforce has emerged not simply as a stop-gap measure, but as a core component of primary health care systems in low resource settings, Prabhjot Singh (2011).

A National Roadmap to Accelerate the Reduction of Maternal and Infant Mortality was adopted by the Rwandan Ministry of Health in 2008. The roadmap outlines approaches to reducing maternal and newborn mortality, and includes strategies for improving the quality of the facility based primary and referral care, the availability of Kangaroo mother care (KMC) and the availability of community-based services for women during pregnancy and in the post-natal period.

According to the Roadmap builds on the National Reproductive Health Policy and the National Child Health Policy (2008), and the Strategic Plan for Acceleration of Child Survival (2008-2012), all program activities are implemented in the context of the Economic Development and Poverty Reduction Strategy of Rwanda (EDPRS 2008-2012) and the National Health Sector Strategic Plan (Rwanda HSSPII 2009-2012).

General approaches to implementing community-based activities are outlined in the National Community Health Policy of Rwanda (2007). The health system in Rwanda is decentralized to the district level. The country is divided into 4 provinces and the City of Kigali, 30 districts, 416 sectors, around 9,000 cells and 15,000 Imidugudu (villages). A system of community-based health insurance in the form of mutual health insurance was established in 1996. Since 2006 Rwanda has implemented a Performance Based Financing (PBF) model to provide incentives to facility-and community-based health workers. The PBF approach provides quarterly remuneration to health workers based on performance measured by defined indicators (MOH Rwanda, 2012).

In order to improve the performance of CHWs and obtain good results on agreed upon indicators especially the maternal and infant mortality, payments are made when proof of an agreed level of performance is attained. Every month at the Health Center level data is collected from reports on indicators and entered into a web-based database (SisCom). The Sector Steering Committee oversees the evaluation of different indicators during a quarterly meeting and approves the payment to the CHW Cooperatives. This quarterly C-PBF accompanied with monthly top ups and trainings are the major and in some cases the sole incentives provided to CHWs as a motivation to achieve their different and important tasks (MOH, Rwanda 2009).

Statement of the Problem

Community health workers (CHWs) are increasingly recognized as a critical link in improving access to services and achieving the health-related Millennium Development Goals. Given the financial and human resources constraints in developing countries, CHWs are expected to do more without necessarily receiving the needed support to do their jobs well. How much can be expected of CHWs before work overload and reduced organizational support negatively affect their productivity, the quality of services, and in turn the effectiveness of the community-based programs that rely on them.

Even if the MOH provides different incentives like monthly top up, Community PBF, Trainings, Provision of materials and equipment's to Community Health Workers in order to improve the service they gave in maternal and newborn health services, the objectives of MOH are not yet achieved:

According to the DHS (2010), report indicated the persistent high maternal mortality rate where out of 100,000 women that gave birth 476 deaths occurred within 42 days. According to MDGs this indicator must be reduced to 268/100,000 by 2015. Where the evolution of this indicator was:

In 2008, with the introduction of community based maternal and newborn health implemented by motivated CHWs in charge of maternal and newborn health up to now we are observing the improvement in maternal health where the current statistics shows 210/100,000 lives birth (Rwanda, DHS 2014/2015) and our study is assessing if there a contribution of CHWs in charge of MNH on improving maternal and newborn health services. Rwanda is observing also an improvement in fertility ration where 6.1(DHS2005), 5.5(RIDHS200-2008), 4.6(DHS2010) and 4.2(DHS2014/2015) since the past ten years. Birth occurred in health facilities by skilled provider have been improved in last fifteen years from 27% in 2000 to 91% in 2015. The figures before 2008 and after 2008 with an introduction of community based maternal and newborn health implemented by motivated CHWs in charge of maternal and newborn health shows 27% (RDHS2000), 28% (RDHS2005), 45% (RIDHS2007-2008), 69% (RDHS2010) and currently 91% (RDHS2014-2015).

By 2015, Millennium Development Goal 5 (MDG 5) sets a target of 75 percent reduction in maternal mortality, from 400/100,000 live births to 100/100,000 between the 1990 baseline and 2015. Although progress has fallen short of achieving this MDG by 2015, every region of the world has made important gains, and globally, maternal mortality has fallen by 45 percent over the past two decades (WHO, 2014).

In April 2014, the World Health Organization, Maternal Health Task Force, United Nations Population Fund, USAID and the Maternal Child Health Integrated Program, and representatives from 30 countries agreed on a global target for a maternal mortality ratio (MMR) of less than 70/100,000 live births by 2030, with no single country having an MMR greater than 140. This will require that we collectively build on past efforts, accelerate progress and ensure strong political commitment from all stakeholders (WHO, 2014).

Research Questions

1 What is the Socio-demographic characteristic of community health worker in charge of maternal and newborn health?

2. What are the community health workers in charge of maternal and newborn health incentives?

4. Is there a significant influence between Community Health Worker's incentives on performance of maternal and newborn health services?

General Objective

The general objective was to assess the relationship between CHWs in charge of MNH incentives to performance of maternal and newborn health services.

Specific Objectives

1. To determine the demographic characteristics of respondent CHW's in charge of maternal and newborn health.

2. To determine the level of CHW's in charge of maternal and newborn health incentives.

3. To determine the level of performance of maternal and newborn health services.

4. To establish the relationship between CHW's in charge of maternal and newborn health incentives and performance maternal and newborn health services.

Hypothesis

There is no relationship between CHWs in charge of MNH incentives and performance maternal and newborn health services.

Significance of the Study

The study is significant to the community, CHWs and health providers within Rwinkwavu District Hospital. The overall health sector (Ministry of Health, NGOs and the Rwandese Government) will be benefit from the results in Rwinkwavu District Hospital, Rwanda.

CHWs: The findings of this study will help Community Health Workers to actively participate in maternal and newborn health improvement and they will be aware at which level they contribute in that improvement referring to the incentives they receive from different partners.

Public: The public will benefit from this research because the improved maternal and newborn health services will contribute to the reduction of maternal and newborn mortality rate with social economic growth.

Policy Makers and Government: The findings will promote leaders of Rwinkwavu District Hospital, Kayonza District, Ministry of Health and NGOs to advocacate the way of incentivizing CHWs which may promote income generating activities of CHWs cooperatives and sustainability of the program. It will make recommendations to the district, Ministry of Health and partners involved in national maternal and newborn health to improve their policies and guidelines.

Researchers: The findings will stimulate the interest of other researchers to carry out more empirical studies in order to set up strategies to improve maternal and newborn health with the greater way of incentivizing the CHWs in charge of maternal and newborn health.

Scope of the Study

Rwinkwavu District hospital catchment area is located in Kayonza District in the Eastern Province of Rwanda. It is boarded by the Gahini and Mwiri Sectors of Kayonza District in the north, Kirehe and Ngoma District in south, United Republic of Tanzania in the East and Rwamagana District in the West. It has 8 administrative sectors, 8 health centers, 33 cells, 251 villages dispatched on a surface of 64.5 square kilometers and the population of 194248 (Rwanda HMIS, 2015).

The study was conducted in its 8 health centers which are Rwinkwavu, Cyarubare, Ndego, Nyamirama,Kabarondo, Karama, Rutare and Ruramira health centers. The research was concentrated on CHWs in charge of maternal and newborn health incentives and improvement of maternal and newborn health services that that was accomplished from January, 2015 to July, 2015 (Rwanda HMIS, 2015).

Limitation of Study

The major limitation of this study was the unwillingness of some respondents to give true information during data collection as it was intended to investigate the contribution of incentives they receive on improvement of services they deliver to mothers and newborns. Probing and encouragement was done by the researcher to divulge the necessary information to respondents.

The findings from this study was arguably limited by the fact that the study cannot claim to be truly nationally representative because the study was conducted to CHWs in charge of maternal and newborn health of only one district hospital among 46 district hospitals country wide.

Theoretical Framework

The study was based on Maslow's Theory of Human Motivation. This framework will contain aspects of other psychological theories of motivation, corporate management models, and volunteer management models. Applying Maslow's theory to existing corporate management models were established the theory's relevance to management structures. Because volunteer work differs from corporate work, the Theory of Human Motivation was adapted to non-paid, volunteer work.

The framework was applied to major areas of existing CHW programs in order to review the incentives, and ultimately, the incentives in place. The goal of incentive structures should be to motivate CHWs to complete their tasks effectively, while ensuring that they will stay committed with the intervention. Motivation can be achieved in many ways, either extrinsically or intrinsically. In analyzing an intervention, it is important to distinguish the types of incentives motivating CHWs in charge of maternal and newborn health, because they reflect the sustainability of the program that can contribute to an improvement of maternal and newborn health.

Conceptual Framework

Operational Definitions of Terms

Community PBF: is mechanism of CHWs motivation through their performance based financing. Payments made when proof of the agreed level of performance, Community PBF guide details management at different levels, the Sector Steering Committee oversees the implementation and approves payment to the CHW Cooperative. Indicators entered at HC level into web-based database after quarterly approval by committee with feedback.

This was measured by analyzing the level of agreement from one to four meaning that: strongly agree (SA) = 4, agree (A) = 3, strondly disagree (SD) = 2 then disagree (DA) = 1.

Provision of Equipment and Materials: The community health workers in charge of maternal and newborn health are provided with different tools and materials from government of Rwanda and different partners local and international those help them to accomplish their tasks those are bags, umbrella, timer, thermometer, balance, mobile phone, rain cost, register for information recording, reporting register and the register for the in reproductive age and pregnancy women. This was measured by analyzing the level of agreement from one to four meaning that: strongly agree (SA ) = 4,agree (A) = 3, strongly disagree (SD) = 2 then disagree (DA) = 1.

CHWs Monthly Perdiem: This amount most of the time paid by partners to strengthen the self-motivation based on monthly home visits, daily accompaniment & key maternal health activities, timely completion of a monthly report. This was measured by analyzing the level of agreement from one to four meaning that: strongly agree (SA) = 4, agree (A) = 3, strongly disagree (SD) = 2 then disagree (DA) = 1.

Income Generation for Membership in CHW's Cooperatives: All CHWs are organized in cooperatives and everyone is supposed to benefit income generation from cooperative project. This was measured by analyzing the level of agreement from one to four meaning that: strongly agree (SA) = 4, agree (A) = 3, strongly disagree (SD) = 2 then disagree (DA) = 1.

Maternal and Newborn Health Services: are the tasks the CHWs in charge of maternal and newborn health are assigned to accomplish. Those are almost 12 indicators seen in this research questionnaire. The respondents gave the number then the surveyors made percentage after the mean of measuring scare was calculated.

This variable was be measured using the scale as follow:6=81-100% interpreted as high or very good performance, 5 = 61-80% interpreted as good performance, 4 = 41-60 % interpreted as moderate or neuter performance , 3 = 20-40% interpreted as low or poor performance, 2 = less than 20% very poor performance then after 1 is interpreted as not any activity accomplished.

CHAPTER TWO

LITERATURE REVIEW

The Context of Community Health Workers

The global policy of providing primary level care was initiated with the declaration of Alma-Ata in 1978s. The countries signatory to Alma Ata declaration considered the establishment of CHW program as synonym with Primary Health Care approach (Mburu, 1994; Sringernyuang Hongvivatana, & Pradabmuk, 1995). Thus in many developing countries PHC approach was seen as a mass production activity for training CHWs in 1980s (Matomora, 1989). During these processes the voluntary health workers or CHWs were identified as the third workforce of «Human resource for Health» (Sein, 2006). Following this approach CHWs introduced to provide PHC in 1980s are still providing care in the remote and inaccessible parts of the world (WHO, 2006a).

The CHWs have evolved with community based healthcare programme and have been strengthened by the PHC approach. However, the conception and practice of CHWs have varied enormously across countries, conditioned by their aspirations and economic capacity. This review identified seven critical factors that influence the overall performance of CHWs which are discussed in this section. In discussing these issues, our aim is to (a) highlight certain empirical knowledge and (b) point out, if any, gaps in the design, implementation and performance of CHWs(Prasad BM, Muraleedharan VR2007).The above review highlights several aspects to be kept in mind in designing and implementing effective CHW schemes. The review emphatically shows that (a) the selection of CHWs from the communities that they serve and (b) population-coverage and the range of services offered at the community levels are vital in the design of effective CHW schemes. It should be noted that smaller the population coverage, the more integrated and intensive the service offered by the CHWs(Prasad BM, Muraleedharan VR2007).

Despite advances in reaching remote communities, there are many opportunities for improvement and expansion of CHW programs, especially related to the development of new tools and evidence-based policy to «guide global health policy and implementation.» This is where the One Million Community Health Workers (1mCHW) Campaign comes into play. By coordinating existing CHW programs with African governments, and making it clear where the core interests of local and global organizations fit into national frameworks, 1mCHW is developing the tools necessary to guide CHW policies. Moreover, 1mCHW is developing an «Operations Room,» an online dashboard to provide comprehensive information about CHW activities on the ground. The «Operations Room» will chart progress in different countries and contain the compiled evidence demanded by the article's authors to deepen our understanding of CHW programs and of the most effective means of implementation.We know the plan works: a comprehensive review of CHW literature conclusively conveys the effectiveness of CHW programs, especially given the recent access to mobile technologies. 1mCHW will help turn this promising literature into life-saving results on the ground(One million community health workers campaign2013).

In the study conducted by USAID (2010) on Community Health Worker Programs: A Review of Recent Literature, the research concluded that key components were identified as central to the design and implementation of functional and sustainable CHW programs: defined job description with specific tasks or responsibilities for volunteers, recognition and involvement by local and national government, Community involvement (especially in recruitment and selection, by making use of existing social structures, consider cultural appropriateness, address needs of community, etc.), resource availability (funding, equipment, supplies, job aids, etc.).

Monitoring and evaluation of programs , linkages with formal health care system training (including refresher trainings), supervision and feedback, incentives or motivational component and advancement opportunities which are all similar to this research.

Community Health Workers' Incentives in Rwanda

Performance-Based Financing is thoroughly embedded in the Rwandan Health system. It is practiced in health centers and district hospitals nationwide using common approaches. Ministry of Health Performance-Based Financing has started at the central ministerial level (Basinga, 2009).

Performance-Based Financing systems are being designed for the national Community Based Health Insurance system, and for the CDLS. A national model for Community Performance-Based Financing has been developed, using a broad consultative process. The model is based on experience gained during the implementation of the health center and hospital Performance-Based Financing models, and benefits from a close fit with these models. The purpose of this Community Performance-Based Financing (PBF) Guide is to document the tools and processes used in Community PBF. This guide is primarily meant as a background document for trainers, sector PBF Steering Committee members, and the Community Health Worker Cooperatives. However, it will be used by all working in the Rwandan Health System (Basinga, 2009).

The community PBF is not for individual performance remuneration. The purpose of the incentive is for community health workers to increase the capital of their cooperatives. The cooperatives on their turn will then start income generating activities to the benefit of the individual members. The remuneration of individual community health workers will be from the profit of the cooperative activities (MOH Rwanda, 2009).

Resource poor countries, particularly in sub-Saharan Africa, face many challenges improving maternal health due to financial and human capital constraints, lack of motivation among health providers and lack of physical resources. One of the key policies implemented in Rwanda in response to these issues is Performance Based Financing (MOH Rwanda, 2009).

PBF provides bonus payments to providers for improvements in performance measured by indicators of specific types of utilization (e.g. prenatal care) and quality of care. While the approach promises to improve health system performance, there is little rigorous evidence of its effectiveness, especially in low-income settings.

This study examines the impact of the incentives in the Rwandan PBF scheme on prenatal care utilization, the structure and process quality of prenatal care, institutional delivery, and modern contraceptive use. The analysis uses data produced from a prospective quasi-experimental design nested within the program's rollout. The rollout was implemented in two phases: in 2006, 86 facilities (treatments) in rural areas enrolled in the PBF, and another 79 facilities (control) enrolled two years later.

In order to isolate the incentive effect from the resource effects, the control facilities were compensated by increasing their traditional budgets with an amount equal to the average PBF payments to the treatment facilities. Baseline and end line data were collected from all of the facilities and a random sample of 14 households in each facility's catchment area.

Using a different approach, PBF had a large and significant impact on the quality of prenatal care measured by process indicators of the clinical content of care and deliveries in facilities. However, no such effect was found on prenatal care visits or on the use of modern contraceptives (MOH, Rwanda2009).

The results provide evidence to support the hypothesis that financial performance incentives can improve both the use and quality of maternal health services. Policy recommendations include increasing incentives for prenatal care service, complementary training to increase quality and combining PBF with a demand-side intervention such as conditional cash transfer involving community health workers (Basinga, 2009).

In the study conducted by JSI (2009), on the ''Non-financial incentives for voluntary community health workers'' they concluded the following: Community acceptance for voluntary CHWs and their own attitudes to their work is generally positive. Nevertheless, continual efforts to enhance recognition and understanding of their voluntary work in the community are needed to maintain their morale. Their work was also found to be very `doable' and expectations from them quite clear. The teaching materials and the support provided to them by HEWs in the form of monthly meetings and work visits can be further strengthened however.

The motivations of voluntary CHWs, in terms of their reasons for being involved in their work and the benefits they expected, were strongly characterized by their desire to promote health in their community including themselves and their families. Steps taken to enhance their efficacy in this regard will therefore have a positive impact on their motivation levels. Volunteers were also strongly motivated by the responsibility and acceptance they received from the community, as well as the recognition, respect, credibility and political status they have gained. Conversely, they were sometimes discouraged by misunderstanding of their voluntary role on the part of the community. VCHWs can therefore be further motivated by promoting community understanding and recognition of their work. Their aspirations for learning and employment opportunities can also be considered in relation to ways of sustaining volunteerism.

Provision of Equipment

The community health workers are provided with different tools and materials from government of Rwanda and different partners local and international witch help them to accomplish their tasks. They have Arthemeter Lumefatrin (Primo) for treatment of Malaria and rapid diagnosis test (RDT) to confirm Malaria; they have amoxicillin for pneumonia with a timer to count respiratory frequency, zinc and oral rehydration solution (ORS) against diarrhea and RUTF for malnutrition.

There are equipped also with monitoring and evaluation tools for data recording and reporting with innovation of Rapid SMS with cell phones for tracking the first 1,000 days of life, preventing unnecessary mother and new born death in Rwanda. They have also boots, torches and radios. The cell coordinator has bicycles, MOH, Rwanda (2011).

Community health workers need access to the proper equipment and supplies to deliver expected services. This requires procurement of supplies on a regular basis to avoid any substantial stock out periods. Community must be equipped with a steady stock out of supplies and commodities needed for their day to day operations.

Community health workers also need materials to support their mobility, with reliable and safe transportation between households (such as an umbrella or bicycles as appropriate in a given context) and backpacks for supplies (Lehmann et al. 2007).

Community health training and deployment without immediate continuous and reliable supplies to accomplish task is inefficient demotivating and damaging to community health workers credibility (Lehmann et al. 2007).

Therefore, a functional community health workers system requires a robust supply management chain, with a keen eye to transport and drug supply, as well as reliable supply chains for all other equipment required by community health workers to perform their job functions. Reliable and sustainable supply chain systems are a challenge for large scale primary health care and community health programs in general (WHO, 2010).

In Pakistan, each lady health worker should have a supply kit that includes contraceptives and essential drugs in order to perform her work. These community health workers are resupplied each month at their local clinics (Muhamood et al. 2010).

A research conducted in Rwanda on community based provision of family planning services revealed that one of the major barriers mentioned by CHWs and supervisors was the difficulty of keeping all the required materials in stock. CHWs reported that since they receive only 2 - 3 units of each method of family planning that they sometimes quickly ran out of stock. CHWs often live far from the HC that resupplies them. CHWs are required to go to the HC to retrieve commodities and consumables but they are not given a means of transport (Rwanda Ministry of Health, 2011).

In Zambia, a large community health worker program in Kalabo District almost completely collapsed. Key reasons identified were a shortage of drugs and community health workers' selection criteria. Furthermore, the authors found that the community members in charge of CHWs selection knew little about selection criteria. Further quality of supervision was poor and in 50% cases nonexistent (Stekelenburg et al. 2003).

Compensating CHWs and Perdiem as an Incentive

This an amount most of the time paid by partners to strengthen the self motivation based on monthly home visits, daily accompaniment and key maternal health activities, timely completion of a monthly report form and participation at monthly training. This perdiem is between10 to 20$ depending on performance of community health workers qualitatively and quantitatively (MOH, Rwanda 2011).

Compensating CHWs has a number of important benefits for both the health care program and the communities it serves. First payment for meaningful work provides a needed income for those in resource limited setting.

Secondly, compensating CHWs can strengthen their roles as an essential member of the clinical team, thereby creating a stronger bridge between the community to the clinic or hospital based setting. Third, payment particularly when it is a fair wage and paid on time can serve as a source of motivation for CHWs in performing their work reliably and effectively. Fourth, payment can also increase the amount of time CHWs are available on a weekly basis, can prevent turnover, and can promote program consistency.

Finally, investment in CHWs can potentially increase uptake in medical services, promoting adherence to HIV and TB medication and resulting in long term improved health outcomes in the community (MOH, Rwanda 2011).

Compensation structures will vary by country and program. Find out whether there are labor regulations that affect compensation in addition to any minimum or maximum wage requirements or other regulations, when budgeting for the CHWs program. Some programs either choose to or are mandated to cap salaries at the same level as those paid to schoolteachers or other civil servants. In some contexts, CHWs are paid a baseline salary and are then given an incentive bonus for each sick community member they see. In other places, CHWs receive compensation through a cooperative, whose members pool their funds to support it and equal control over its operation. Additionally many systems involve performance based financing, in which CHWs receive compensation following the completion of certain responsibilities such as monthly home visits or the accurate collection of household data (MOH, Rwanda 2011).

CHWs who have a higher skill level, such as those that work with patients with MDR/TB may receive a higher monthly salary compared with CHWs who are responsible for more general outreach (MOH, Rwanda 2011).

In Haiti, women's health workers are compensated more than the typical CHW due to the greater knowledge base necessary to carry out their work. When planning a compensation structure, consider if and how CHWs will be paid , whether or not they will receive bonuses, top - up, or other financial incentives. If CHWs receive payment, determine how much they will receive and the schedule of payment (Healthy villages 2002). Types of payment may include: money for meals, transportation, income from the sales of products, monthly stipend, monthly salary, performance based financing, cash for task, access to membership in a cooperative (Healthy villages 2002).

Membership in CHW's Cooperatives

CHWs cooperatives membership: All CHWs organized are in cooperatives to ensure income generation and accountability of expected results. Community PBF payments used for cooperative income generating projects include: poultry, cattle/goat/pig rearing, crop farming, basket making, etc that improves performance of CHWs by motivating them to rise agreed upon performance indicators, the payments made when proof of the agreed level of performance. The Sector Steering Committee oversees the implementation and approves payment to the CHW Cooperative (MOH, Rwanda, 2011).

The study done by Havard School (2011), on CHWs in Zambia entetle'' incentives design and management it shows incentives and desincentives summirized in below :

Motivation factors	Incentives	Disincentives
Monetary incentives that motivate CHWs	Ø Satisfactory numeration, materials incentives, financial incentives Ø Possibility of future payment	Ø Inconsistent remuneration Ø Change in tangible incentives Ø Inequitable distribution of incentives among different CHWs
Nonmonetary incentives that motivate CWHs	ü Community recognition ü Acquisition of valued skills ü Personal growth and development ü Accomplishment ü Peer support ü Preferential treatment ü Clear role	ü CHWs from outside of the country ü Inadequate refresher training ü Inadequate supervision ü Lack of respect from HFs a staff
Community factors that motivate CHWs	ü Community involvement selection ü Community organizations that support CHWs ü Community involvement in CHWs training ü Community information system	ü Inappropriate selection of CHWs ü Lack of community involvement in CHWs selection, training and support.
Factors motivate communities to support and stain CHWs	Ø Visible change Ø Contribution to the community empowering Ø CHWs associations Ø Successful referral to health facilities	Ø Unclear role and expectation(preventive versus curative care) Ø Inappropriate CHWs behavior Ø Failure to take community need into account
Factors that motivate MOH staff to support and sustain CHWs	Ø Policy and legislation to support Ø Visible change Ø Government community finding for supervisory activities	Ø Inadequate staff and supply

Maternal and New Born Health Services

Community Health Workers identify and register women of reproductive age (encourage family planning,), identify pregnant women and encourage ANC, birth preparedness and facility based deliveries, identify women and newborns with danger signs and refer them to health facility for care, accompany women in labor to health facilities, encourage early postnatal facility checks for both newborns and the mothers and report those activities by using Use Rapid SMS (MOH, Rwanda 2011).

Relationship between CHWs Incentive and Improve Maternal and Newborn Health

Working with the community gives health workers a platform from which to strengthen their relationship with the community and receive community feedback, as well as a structure for regular interaction with health facility staff. Community participation is an integral part of CHWs' incentives. Without involvement, communities lack interest and expectations, leaving CHWs without a support system we can't achieve MDGs 4 and for improving maternal and child health (MOH, Malawi, 2014).

The rate of decline in child mortality is too slow in most African countries to achieve the Millennium Development Goal of reducing under-five mortality by two-thirds between 1990 and 2015. Effective strategies to monitor child mortality are needed where accurate vital registration data are lacking to help governments assess and report on progress in child survival. They present results from a test of a mortality monitoring approach based on recording of births and deaths by specially trained community health workers in Malawi (MOH, Malawi, 2014).

Results from systematic reviews of CHW program confirm that CHWs provide critical links between rural communities and the formal health system and have been shown to reduce child morbidity and mortality when compared to the usual healthcare services (MOH, Sierra Leone 2013).

With appropriate support and sufficient training, CHWs can potentially play a pivotal role in strengthening health systems in areas with poor human resources for health. More specifically, they are an important resource for implementing interventions targeting reductions in neonatal mortality and tracking women throughout their pregnancy while simultaneously promoting appropriate maternal and newborn care practices (MOH, Sierra Leone 2013)..

Their potential however, is hampered by inadequate supervision, lack of locally relevant incentive systems, loss of motivation, insufficient recognition and community support, poor connectivity to health facilities, and knowledge retention problems. Moreover, higher attrition rates are often observed in programs where CHWs are asked to volunteer.

The motivation of CHWs and the risk of high attrition rates therefore have important implications for the effectiveness, success, cost, credibility and continuity of CHW-based programs, (MOH, Sierra Leone 2013).

Summary of Identified Gaps

We now know that CHWs can play a crucial role in broadening access and coverage of health services in remote areas and can undertake actions that lead to improved health outcomes, especially, but not exclusively in the field of child and maternal health. CHWs represent an important health resource whose potential in providing and extending a basic health care to underserved populations must be fully tapped. Despite the experience with community health workers worldwide, the research gap remains in community health worker literature especially in terms of Incentives strategies and maternal and infant mortality improvement (MOH, Rwanda 2011).

Despite the availability of Rwandan community health policy and strategies there is no study conducted on contribution of CHWs' incentives on the improvement of maternal and infant health services. The evaluation done by MOH, Rwanda (2011), where the main objective was to assess the quality of services provided by the CHWs and their access to necessary supplies. This was mainly assessing what CHWs do and how they give services but this didn't relate to the quality of services provided in terms of maternal and infant health with incentives they get. The study was conducted in the district of Djenné, Mali by Perez in 2009, concerning the role of community health workers in improving child health programs which mainly compared the knowledge and practice between households with and without community health workers.

The researcher mentioned the results in terms of knowledge/practices the family with CHWs might have but didn't relate the incentives given to CHWs to their contribution on infant and maternal health (MOH, Rwanda 2011).

The study conducted by Winch et al., (2001) was assessing the contribution of CHWs on improvement of health system including drug availability and the skills of Community Health Workers to assess, classify, and treat children accurately. This included the three following elements: improving partnerships between health facilities and services and the communities they serve, increasing appropriate and accessible care and information from community-based providers, integrating promotion of key family practices critical for child health and nutrition but they didn't asses the relationship between CHWs' incentives and maternal and infant health improvement.

In all the literature above there is no specific research, which explains well the assessment of incentives given to CHWs to their contribution on improving maternal & newborn health. Hence, for the purpose of this study, the research intends to assess the relationship between CHWs' in charge of maternal and newborn health incentives on improvement of maternal and newborn health services. Child health intervention that warrants considerably more attention, particularly in Africa and South Asia. (Oxford University Press, 2005).

CHAPTER THREE

METHODOLOGY

This Chapter gives the procedure that was used in this research so as to achieve the set of the study objectives. The researcher adopted cross-sectional survey design. The researcher adopters both qualitative and quantitative approach. The researcher also adopted correlational research design to find the relationship between the two variables.

Population of Study

The study was conducted in eight health centers of Rwinkwavu District hospital in Kayonza District of Rwanda those are Rwinkwavu, Ndego, Cyarubare, Nyamirama, Karama, Rutare, Kabarondo and Ruramira health centers. The total target population of this study was 236 CHWs in charge of MNH working in HCs catchment areas presented as follow: 38 CHWs from Rwinkwavu, 45 CHWs from Cyarubare, 27 CHWs from Ndego, 26 CHWs from Nyamirama, 38 CHWs from Kabarondo, 7 CHWs from Rutare, 28 CHWs from Karama and 27 CHWs from Ruramira.

Sample Size

The sample consisted of eight health centers and the selection was based on the number of CHWs in charge of MNH in health center catchment area. Considering the number of CHWs in charge of MNH the sample was drawn to be 236 target population and the sample size calculation is based on the simple random sampling method because all population was subject of the study; this was used because it is applicable for academic research and it is more helpful when data collected for the whole population is available. The sample size in each health center has been calculated based on proportionate allocation sampling technique by Kothari (2004). Ni = n .NJ/N.

Where n = sample size of entire target population, NJ = number of population of each health center and N = total number of target population, ni = sample size of every health center.

Sampling Procedure

The target population of the study was 236 respondents. Morgan and Krejcie (1970), recommend that if a researcher has a target population of 236, the sample size for the study is 236. Therefore the study sample size was 236 respondents, the probability methods gave us simple random sampling to be applied because the whole population is available and easily participated in responding to the questionnaire given by the researcher.

NO	Health Centre	Total Population	Sample size

1	Rwinkwavu	38	n₁= 263.38/236 = 38
2	Cyarubare	45	n₂= 236.45/236 = 45
3	Ndego	27	n₃= 236.27/236 = 27
4	Nyamirama	26	N₄= 236.26/236 = 26
5	Ruramira	27	N₅= 236.27/236 = 27
6	Kabarondo	38	n₆= 236.38/236 = 38
7	Ruatare	7	N₇= 236.7/236 = 7
8	Karama	28	N₈= 236.28/236 = 28
TOTAL			236

Research Instruments

Data collection was carried out by using a questionnaire; that questionnaire was designed in English and the researcher translated directly into Kinyarwanda. The questionnaire is divided into three sections: Section A which includes Socio- demographic characteristics of respondents, section B is based on the closed ended question which is in accordance with the second objective by materials or equipment received and section C is questions related to the third objective evaluating the rate of accomplishment of target. The objectives one was measured using descriptive statistics and was interpreted using percentages. Objectives two and free was measured and interpreted using mean and standard deviation while objective four was interpreted using simple linear regression.

Validity

It indicates the extent to which an instrument measures what it is supposed to measure. Six experts in the field have checked the questionnaire for the consistency of the items, conciseness, intelligibility and clarity. The checking of items, consistence, relevance, clarity and ambiguity; pretesting was done in two health centers that were not part of the target population.

Their input helped to ensure that the instrument measured adequately what it is intended to measure. The researcher used CVR (Content Validity Ratio) where the expert will agree with the items. The formula to be used is: CVR = (E -N/2) / (N/2)

Where E: number of who rated the object or person in question; N: total number of expert. CVR can measure between -1.0 and 1.0. The closer to 1.0 the CVR is, the more essential the object is considered to be. Conversely, the closer to -1.0 the CVR is, the more non-essential it is.

The research instrument was valid when the CVR is 0.6 or above indicated the extent to which an instrument measures what it is supposed to measure. A supervisor was always consulted for checking the items, consistence, relevance and clarity.

Reliability

Twenty CHWs from Kabarondo Health center were randomly selected for testing research instrument, the estimation of reliability will be ascertained by a pilot testing of the instrument and applying Cronbach's Alpha coefficient by means of a Statistical Package for Social Sciences (Gal,et al,2009). Cronbach's Alpha coefficient will be used to measure internal consistency of the research tool. The instrument are reliable when the results of twenty respondents give an alpha coefficient of > 0.7 (Gal, et al, 2009).

Data Collection Procedure

The researcher obtained a letter of introduction from Bugema University, Graduate school to the Director of Rwinkwavu District Hospital. The researcher submitted the letter in person to the office of Rwinkwavu District Hospital Director and upon authorization; the researcher made an appointment through the community health workers in charge of health center level to confirm when he could visit to collect data as community health workers involved in this study live in different areas. The questionnaire was given to the respondents after ensuring them that the information given will be kept confidentially and would be used only for academic and research purpose.

The researcher ensured voluntary participation of respondents to be clearly informed about the objective and benefits of the study, the confidentiality of records was protected and no name of respondents were asked during the data collection.

Data Analysis

After a successful data collection exercise, the researcher coded and entered data, tabulated and interpreted the findings. For quantitative data, the computer package, SPSS was used to analyze and interpret the data. Descriptive statistic including frequency and percentage was used to answer objectives one, the mean and standard deviation was used to answer the objective two and three. Linear regression logistic was used to analyze the objectives four that was to establish the influence of incentives on improving maternal and newborn health services. Descriptive statistics allowed the researcher to reduce bias and estimate sampling errors and precision of the estimates derived through statistical calculation. Data collected from the document analysis was analyzed manually and results were used to supplement and support the findings from the main instrument.

CHAPTER FOUR

RESULTS AND DISCUSSION

This chapter presents the result of the study and their discussion in line with research objectives. This discussion of the study result was done while comparing the present research findings with those of previous and recently related research studies. Still in discussing the study results, the findings were used to answer the research questions from which the objectives of the study evolved.

Demographic Characteristics of Research Participants

The first research objective included 236 respondents, and in the course of data collection, the research succeeded to collect all the questionnaires, that is; there was no questionnaire which represented an error of omission. Descriptive statistics, mainly frequency and percentages, were used to analyze data on objective one which was to find out the demographic characteristics of the respondents in term of age, gender, marital status, education background and occupation.

The entire respondents were women because in Rwandan community health policy the CHWs in charge of newborn and maternal health are the women. The frequency and percentage were meant to establish the most frequently occurring responses and the least frequently occurring response.

The Table 3 presents the summary of findings, showing the socio-demographic information of the respondents to the study which demonstrate age, gender, marital status, education background and occupation in order to know more information about the improvement of MNH services compared to the incentives they get.

Item	Categories	Frequency	Percent
Age	15-19 20-35 36-50 51-60	2 106 125 3	0.8 44.9 53.2 1.3
Gender	Females	100	100
Marital status	Single Married Widow/Widower Divorced	7 168 60 1	3.0 71.2 25.4 0.4
Educational level	No-formal Primary Secondary Post-secondary	1 151 69 14	0.8 64.0 29.2 5.9
Occupation	No job Farmer Cultivator Farmer cultivator Professional Trading	4 55 91 47 11 28	1.7 23.3 38.6 19.9 4.7 11.9

Age: the findings on age range of CHWs in charge of maternal and newborn health revealed that the majority of them 125 (53.2%) are those in age range of 36 to 50 years followed by those of 20 to 35 represented by 106 (44.9%).

Gender: the category of 15 to 15 and 51 to 60 has the lowest number of respondents as indicated by table 3. All respondents are women that are why when you look at gender 236 (100%) were women.

Marital status: the marital status in this table shows that the married are the predominant among other represented by 168 (71.1%) then widow/Widower 60 (25.4%), one was divorced and 7(3.0) were single.

Education: the level of education was assessed in other to test the knowledge of the respondents where we have found that the majority of respondents 151 (64.0%) have primary level education, 69 (29.2) represent those who have accomplished the secondary school level of education, 14 (5.9%) had done post-secondary education and only one who had not accomplished the primary school.

Occupation: most of CHWs in charge of maternal and newborn health are in agriculture business; where 91(38.6%) are cultivators, 55(23.3%) are the farmers, 47 (19.9%) are the farmers-cultivators, 28 (11.9%) are traders, 11 (4.7%) are in professional employment and 4 (1.7%) are reported jobless.

In this line with the research findings of Global Journal of health Science (2012), on effect of social-demographic characteristics of CHWs on performance of home visit during pregnancy where it was ascertained that there was a significant relationship between age group than other and good record with tasks performance.

Contrary to my research where the Rwandan Community health policy put in place only women for follow-up of maternal and newborn health this research conducted by Global Journal of health Science (2012), shows that the male have a positive record more than the female while females were more likely to counsel and enable their clients. That is why they have been choose by Rwandan government to fill the position of CHWs in charge of maternal and newborn health than their lower literacy level counterparts. Global Journal of health Science (2012), concludes by emphasizing on reasons why the Socio-demographic characteristics of community health workers affect the performance of home visits in various ways. The study also confirmed that CHWs with lower literacy levels satisfy and enable their clients effectively. Also in the study conduct by Bagonza J et all, 2014, they find that females are performing well.

In this study also, due to the policy in place which emphasizes that all CHWs must accomplish at least primary school education and above that is why their level of education mainly indicated 151(64.0%) who accomplished primary school, 69(29.2%) have a secondary certificate, well as 14 (5.9%) have post-secondary education and only one among all respondents had not accomplished primary school.

In the study conducted on Community Health Workers: Essential to Improving Health in Massachusetts; 66% of respondents hold some form of community college, college or university degree. Of the CHWs, 60% reported holding some form of degree beyond high school. 19.2% had attended some college level courses beyond high school. 12.5% hold a high school degree or its equivalent, and only 4% do not hold a high school degree or its equivalent (Massachusetts 2005).

Level of Community Health Workers incentives

In results as indicated in Table 4 in this study involved three sub variables which are both monetary and non-monetary incentives grouped in three categories such as: first the community performance based financing (CPBF) and incentives which they receive every after quarterly evaluation by sector steering committee.

Secondly, the provision of equipment and materials for facilitating the accomplishment of their assigned duties, and thirdly, membership in community health workers cooperatives for income generation with mentorship for capacity building.

Item	Mean	SD	Interpretation
Community financial incentives
Receiving sufficient salary after monthly target visits	1.55	0.79	Low
Receiving incentive of monthly bonus	1.93	1.05	Low
Receiving quarterly incentive of BPF	1.94	0.73	Low
I receive a bag	1.63	0.90	Low
I receive umbrella	1.79	1.14	Very low
I receive rain coat	3.35	0.98	High
Register book for monthly reporting	1.95	1.25	Low
Register book for pregnant women/productive age	1.03	0.22	Very low
Register of follow up for pregnancy women	1.05	0.32	Very low
Receiving training and follow-up	1.28	0.71	Very low
Conducting monthly inventory based on my store card	2.39	1.35	Low
Advice to clients (referral) to use health facility services	1.06	0.37	Very low
Aggregate mean and SD	1.75	0.82	Low
CHWs' non-financial incentives (equipment and materials)
Timer equipment for respiration count	1.19	0.65	Very low
Mobile Phone equipment	1.24	0.74	Very low
Thermometer equipment	1.20	0.69	Very low
Weighing scale equipment	1.09	0.48	Very low
Measurement of upper arm circumference equipment	2.35	1.48	Low
Aggregate mean and SD	1.41	0.81	Very low
Membership in CHW's cooperatives
Receive quarterly supervision from health facility	1.45	0.78	Very low
Receive per-diem during the monthly meetings	2.71	1.08	Moderate
Member of community health workers' cooperative	1.09	0.40	Very low
Receive 30% of quarterly PBF from my cooperative	1.45	0.79	Very low
Access loans from my cooperative	3.14	1.18	Moderate
Aggregate mean and SD	1.97	0.85	Low
Grand Mean	1.71	0.82	Low

Legend: 1.00-1.49 (Very low); 1, 50-2.49 (Low); 2.50-3.49 (Moderate); 3.50-4.49 (High); 4.50-5.00 (Very high)

Table 4 therefore, shows the study results on the community performance based financing (CPBF) and incentives showed that there was low mean and standard deviation (

= 1.75; SD = 0.82) well as on CHWs' equipment and materials the results showed a very low mean and standard deviation (

=1.41; SD = 0.81) lastly, membership in community health workers cooperatives for income generation with mentorship for capacity building the result showed a low mean and standard deviation (

=1.97; SD=0.85) . The general result on community performance based financing and other incentives showed also a low mean and standard deviation (

=1.71; SD=0.82).

This is in line with the research findings of WHO Regional office for Africa (2013), which shows that the total catchment population for the 31 health centers in 2010 was 720 40814. Of these, 4.1% (29 537) were expected to be women in need of maternal health services per annum.

The antenatal care indicator (visit before or during 4th month of pregnancy) was targeted to reach at least 30% of women in 2010 or 738 women per month.

The indicator on delivery was targeted to achieve 85% of women delivering in health facilities. The postnatal indicator was targeted to reach 15% of women in 2010.

Furthermore, the third object research objective showed in table 5 was to determine the findings on level of maternal and newborn health in Rwinkwavu district hospital in Rwanda.

Item	Mean	SD	Interpretation
Census of women in reproductive age	1.57	0.92	Low
Visit 3 times all pregnancy women in the village	1.55	0.99	Low
Women visited in first prenatal care visits to homes	2.86	1.58	Moderate
Women visited by CHWs during pregnancy	2.47	1.43	Low
Women who completed 4 standards ANC	3.42	1.44	Moderate
Deliveries at health facilities by health professionals	2.60	1.68	Moderate
Home deliveries	4.63	0.91	Very high
Home deliveries referred to health facility	4.91	1.95	Very high
Women presented in postpartum consultation within	4.28	1.24	High
Women vaccinated against tetanus during pregnancy	1.72	1.14	Low
Women receive iron for anemia to prevention	1.61	1.15	Low
At risk pregnancies referred to health facility	4.85	0.69	Very high
Grand mean and SD	3.04	1.26	Moderate

Legend: 1.00-1.49 (Very low); 1,50-2.49 (Low); 2.50-3.49 (Moderate);3.50-4.49 (High);4.50-5.00 (Very high)

The result revealed a moderate mean and standard deviation of (

=3.04; SD = 1.26). In the article, `Rwanda's Success in Improving Maternal Health', strategies that were used to reach the success story of maternal mortality (a decrease of 77% between 2000 and 2013 in Rwanda's maternal mortality ratio currently at 320 deaths per 100,000 live births, under-5 child mortality reduced by more than 70 percent), Worley (2015), identified the factors that created this story. Among them were maternal health as a priority in postwar rebuilding, maternal and child health core of community-based health insurance, and family planning key to sustained success in maternal health. However, some challenges were identified among which was the need for 586 more midwives to reach 95 percent skilled birth attendance.

Midwives are the ones who train, supervise, and help in monitoring and the evaluation process of the community health workers, if such a big number is still lacking in the rural areas, not so different from the current study, then it could one of the reasons why there was a weak positive relationship between community performance based financing and other incentives and maternal and newborne health services in this study.

More so, rural areas are still underserved (Worley, 2015). Forty percent of women live more than an hour away from a health facility. Even with the increase in family planning and decline in the total fertility rate, contraception remains unavailable to or underused by many Rwandans. And nearly one in every two children under 5 are stunted. The researcher recommends that rural areas be staffed with the necessary incentives like increase in the number of midwives to help in the training, supervision and monitoring of community health workers.

Relationship between CHW's Incentives and Performance of Maternal and Newborn Health Services

To answer research objectives 4, to establish the influence of CHW's incentives on performance of maternal and newborn health services program, data was run by using a logistic regression from Wikipedia is a statistical test used to find the relationship where the dependent variable (DV) is categorical. The results are indicated in the tables below with explanations given in the details.

Table 6: Logistic Regression of Community Health Workers Related incentives and Performance Maternal - Newborn Health Services in the Study Area

Predictor	Performance of maternal & newborn health services [frequency (percentage]		Odds ratio	p	95% CI
	Poor	Good
CHW (BPF) incentives			2.808	0.012	1.26 - 6.26
Low	159 (77.6)	46 (22.4)
High	16 (55.2)	13 (44.8)
CHW's cooperatives Membership			0.838	0.592	0.44- 1.59
Low	118 (73.8)	42 (26.2)
High	57 (77.0)	17 (23.0)

Table 6 provides that the p = 0.012, (1.26-6.26), OR = 2.808 for CHWs incentives on performance of MNH services program then also shows the p > 0.05, (0.44-1.59), OR = 0.838 when we look at CHWs cooperative membership on performance of MNH services program.

CHWs Financial Incentives on Performance of MNH

Results in table 6 show that Community Health Workers who perceive the incentives to be high are about 3times as likely to perform in maternal and newborn health services program(p = 0.012, (1.26-6.26), OR = 2.808)

These results goes in the same line with the research conducted by Basics II 2001, on community health workers incentives and disincentives on how they can affect motivation, retention and sustainability where they have find that satisfactory remuneration, materials incentives, financial incentives and possibility of future paid employment as they key incentives that can motivate CHWs to perform better the tasks assigned to them. The same way of motivation of CHWs in our study area where they receiving monthly bonus, performance based financing every quarter and different kinds of equipments and materials that are supporting them to perform the tasks assigned to them. In the same study of Basics 2001, they're underlining also the factors that are demotivating CHWs and that affect directly retention and sustainability of CHWs those are: inconsistence of remuneration, change in tangible distribution of incentives among CHWs.

Membership in CHWs Cooperatives on Performance of MNH

Also results in table 6 indicate that being a member of community health workers cooperative is not a significant predictor of performance of maternal and newborn health services program (p > 0.05, (0.44-1.59), OR = 0.838).

This study goes in the same line of the study conducted by Gisore, et all 2013) entitled; commonly cited incentives in the community implementation of the emergency maternal and new borne care study in western Kenya; a rural area, and thus be able to identify the incentives that could result in their sustained engagement in the project. Results showed that 769 respondents out of 881 surveys indicated their need for a certain form of incentive.

For example-monetary allowance, bicycle for transportation, uniforms for identification, provision of training materials, training in home based lifesaving skills, first aid kits, training more facilitators and provision of free medication. In this, respondents felt that if monetary allowances, improved transportation and some sort of identification were provided, it would increase their engagement in community maternal and new borne health services.

Drawing from our results, which indicate that there is a very low provision of incentives (see table 4); this could be one of the reasons for the lack of a relationship of maternal and newborn health services community health workers incentives (CPBF)

Another study examined the perceptions of community members and experiences of CHWs around promoting maternal and newborn care practices, and the self-identified factors that influence the performance of CHWs so as to inform future study design and program implementation.

The results indicated that CHWs are continuously needed in improving maternal and newborn care and linking families with health services but the process for building CHW programs needed to be adapted to the local setting, including the process of training, deployment, supervision, and motivation within the context of a responsive and available health system.

These results maybe out of the scope of this study because this study looked at community performance based financing and other incentives. However, a recommendation can be made that above the financial and material incentives, CHWs may be motivated to provide better maternal and newborn health services if CHW programs are adapted to the local setting, including the process of training, deployment, supervision, and motivation within the context of a responsive and available health system.

CHAPTER FIVE

SUMMARY, CONCLUSION AND RECOMMENDATIONS

This chapter gives a summary, conclusion and recommendation generated from the discussed finding and directed to relevant studies. This was directed from objectives of this research.

Summary

The study was carried out on, `'Assessment on community health incentives on maternal and newborn health services performance''. The sample of this study was 236 respondents, the research collected 236 questionnaires. Quantitative approach was used because of numerical data was applied.

A cross-sectional survey was used as the study aimed to assess the relationship between community health workers incentives on improved maternal and newborn health services. In addition the qualitative approach was applied to describe the collected information from respondents that could that could not be easily described numerically. Descriptive statistics and advanced statistics (logistic regression) was used to establish the relationship between independent and dependent variables.

The general objective of this study was to assess the relationship between community performance based financing and other incentives on improving maternal and newborn health services.

The first specific objectives was to determine the demographic characteristics of respondents; the research used the descriptive statistics; revealed that the majority of respondents 125 (52.3%) have the age range between 36to 50. All 236 respondents (100%) are women due to Rwanda community health policy. The study shows that the married women are the most predominate among the other respondents represented by 168(71.1%). Most of the respondents have accomplished the primary education at the rate of 64.0% (151). As presented in Rwandan DHS (2014/2015) the study respondents revealed that 91 (38.6%) are cultivators, 55 (23.3%) are the farmers then 47 (19.9%) are both farmers and cultivators with total 193 (81.8%) of agribusiness as their occupation.

The second objective shows the study result on community performance based financing and other incentives received by community health workers. The respondents show low mean and standard deviation (

=1.75; SD = 0.82). The results shows the majority of indicators in low and very low a part two indicators of per-diem during the monthly meetings and access loans from CHWs cooperatives shown in moderate.

The third objectives determine the level of improvement of maternal and newborn health services among respondents revealed a moderate mean and standard deviation (

= 3.03; SD = 1.26).

The indicator of home deliveries have been improved at a very high level (

= 4.91) followed by high improvement of consultation within ten day post-partum by very high mean and standard deviation ((

=4.9 1; SD = 1.95).

Logistic regression was used to establish influence of CHWs incentives on performance of CHWs to accomplish MNH services program. This shows that CHWs financial incentives to be high are about 3 times as likely to perform in maternal and newborn health services (p = 0.012, (1.26-6.26) ,OR = 2.808) however result in table 6 indicate that being a member of CHWs cooperative is not a significant predictor of performance of CHWs in maternal and newborn health services (p > 0.05).

Conclusion

It was concluded that the level of CHWs who perceive incentives to be high are about 3 times as likely to perform maternal and new health services program. It was further concluded that being a member of community health works cooperative is not a significant predictor of performance of maternal and newborn health services programs.

Recommendations

Since the results revealed that being a member of community health workers cooperative is not a significant predictor of performance of maternal and newborn health services program.

The researcher recommends that the government of Rwanda through the Ministry of Health should revise the system of community health workers' cooperatives in four ways:

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APPEND ICES

Dear Sir/ Madam, I am a student at Bugema University, Uganda. I am carrying out a research on «Assessment of community health workers incentives on improving maternal mortality rate, a case study of Rwinkwavu district hospital, Kayonza District, Rwanda». The purpose of this questionnaire is purely academic. I request you to spare a few minutes of your precious time to answer this questionnaire. Your responses will be treated with confidentially that they deserve as academic material. I thank you in anticipation of your cooperation because you aid my research education through your responses.

SECTION A: Social - Demographics Characteristics of the respondents: Please tick ( ) your answer on the following demographics information

1. CHWs financial incentives	SA	A	SD	DA
1.1.I receive sufficient salary when I meet the monthly target visits
1. 2.I receive the following incentives
a) Monthly bonus
b) Quarterly BPF
2. CHWs non-financial incentives
a) A bag
b) Umbrella
c) Rain coat
d) Register for monthly reporting
e) Register for women in reproductive age and pregnancy women
f) Register of follow up for pregnancy women
2.I receive training and assistance in community maternal and new born health
2.3. I conduct monthly inventory based on my store card
2.4. I advise clients (referral) to go to use health facility services
2.5. I have sufficient equipment to conduct maternal health services
a) Timer for respiration count
b) Mobile Phone
c) Thermometer
d) Weighing scale
e) Measurement of upper arm circumference
3. Membership in CHWs cooperatives
3.1. I receive quarterly supervision from health facility
3.2. I receive perdiem during the monthly meetings
3.3. I am a member of community health workers' cooperative in my sector
3.4. I receive 30% of quarterly PBF from my cooperative
3.5. I access loans from my cooperative

Concept of Maternal and newborn Health Services	Actual Total visit	Target
1.Census of women in reproductive age
2. Visit 3 times all pregnancy women in the village
3. Women visited in first prenatal care visits to homes
4. Women visited by CHWs free times during pregnancy
5. Women who completed 4 standards ANC
6. Deliveries at health facilities by health professionals
7. Home deliveries
8. Home deliveries referred immediately at health facility
9. Women presented in postpartum consultation within 10 days
10.Women vaccinated against tetanus during pregnancy
11.Women who receive iron to prevent anemia during pregnancy
12. At risk pregnancies referred to health facility

Appendix 5: Map of Rwanda Showing Kayonza District where Located Rwinkwavu District Hospital in South

Assessment of community health workers incentives on maternal and newborn health services performance

AUGUST, 2015

AUGUST, 2015

ACCEPTANCE SHEET

DECLARATION

DEDICATION

BIBLIOGRAPHICAL SKETCH

ACKNOWLEDGEMENTS

TABLE OF CONTENTS

LIST OF TABLES

TABLE PAGE

LIST OF FIGURES

LIST OF APPENDICES

LIST OF ABREVIATION

ABSTRACT

CHAPTER ONE

INTRODUCTION

Background of the Study

Statement of the Problem

Research Questions

General Objective

Specific Objectives

Hypothesis

Significance of the Study

Scope of the Study

Limitation of Study

Theoretical Framework

Conceptual Framework

Operational Definitions of Terms

CHAPTER TWO

LITERATURE REVIEW

The Context of Community Health Workers

Community Health Workers' Incentives in Rwanda

Provision of Equipment

Compensating CHWs and Perdiem as an Incentive

Membership in CHW's Cooperatives

Maternal and New Born Health Services

Relationship between CHWs Incentive and Improve Maternal and Newborn Health

Summary of Identified Gaps

CHAPTER THREE

METHODOLOGY

Population of Study

Sample Size

Sampling Procedure

Research Instruments

Validity

Reliability

Data Collection Procedure

Data Analysis

CHAPTER FOUR

RESULTS AND DISCUSSION

Demographic Characteristics of Research Participants

Level of Community Health Workers incentives

Relationship between CHW's Incentives and Performance of Maternal and Newborn Health Services

CHWs Financial Incentives on Performance of MNH

Membership in CHWs Cooperatives on Performance of MNH

CHAPTER FIVE

SUMMARY, CONCLUSION AND RECOMMENDATIONS

Summary

Conclusion

Recommendations

REFERENCES

APPEND ICES