The role of ICT in public bad Ruhuha, Rwanda

TheroleofICTinpublicbadgovernance:thecaseofmalariainRuhuha,RwandaMirtheBoerdijkMScThesisInternationalDevelopmentStudiesAugust2018

August,2018

WageningenUniversity

TheroleofICTinpublicbadgovernance:thecaseofmalariainRuhuha,Rwanda

By

MirtheBoerdijk931217085110

MScThesisInternationalDevelopmentStudiesCourseCode:LAW-80433

Supervisedby:Dr.KatarzynaCieslik,PhD

Secondexaminer:Prof.dr.ArtDewulf

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Acknowledgements

Thisreportcontainsthethesis‘TheroleofICTinpublicbadgovernance:thecaseofmalariainRuhuha,Rwanda’’.IthasbeenwrittentobringtocompletionthegraduationrequirementsoftheMScprogramInternationalDevelopmentStudiesatWageningenUniversity.Iwasengagedinresearchingandwritingthisthesisintheacademicyear2017/2018.

ForthisthesisIjoinedEVOCA(EnvironmentalVirtualObservatoriesForConnectiveAction),whichisacollaborativeinterdisciplinaryprojectofWageningenUniversityandsevenpartnerinstitutions.Itfocusesonknowledgesharingplatforms(knownasEnvironmentalVirtualObservatories,EVOs)andtheirpotentialtotransformthedevelopmentlandscapeinfivecasestudyareasinruralAfrica.Theresearchproposalandresearchquestionswereformulatedtogetherwithmysupervisor,DrKatarzynaCieslikPhD,tofitintheproject.

Iwouldliketothankmysupervisorforallherguidance,feedback,andsupportduringtheproposalwriting,fieldresearch,dataanalysisandreportwriting.Iwanttothankheraswellfortheopportunitytojointhisprojectandforherenthusiasm.IalsowishtothankprofessorMutesa,DominaAsingizweandMarilynMurindahabiforalltheirhelpduringthefieldresearchinRwanda.WithouttheircooperationIwouldnothavebeenabletoconductthisresearch.Furthermore,IwouldliketothankthesistersatRuhahahealthcenterforschedulingtheinterviewsatthecommunitylevel.Moreover,IwouldliketothankDieudonneBarigoraforhisassistanceandthetranslationsKinyarwanda-Englishduringtheinterviewsatthelocallevelofanalysis.Lastly,Iwanttothanktheintervieweesfortheirtimeandwillingnesstoparticipateinmyresearch.

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Abstract

SeveralcountriesinSub-SaharaAfricaarecurrentlyexperiencingaresurgenceofmalaria,amongwhichRwandawitnessedaparticularlysharpincreaseinreportedcasesfromanestimated225,176casesin2011to1,598,055in2014.MyresearchexplorestherolethatICTsmightplayinmalariapreventionandcontrol.ItbuildsonabroadbodyofliteraturethatscrutinizesthepotentialofICTstostrengthenhealthsystemsbyimprovingservicedeliveryandqualityaswellasthroughthegeneralcommunicationfunction.

Inmythesis,IchoseRuhuhasectorinRwandaasastrategicsitetoillustratethemanywaysinwhichICTs–andinparticular,mobilephones–canstrengthenthecapacityofthehealthsystem.Inrecentyears,thegovernmentofRwandahasimplementedanumberofenablingpoliciesandinterventionsinanefforttointegratetechnologyinthehealthsystem.MystudyrevealsthatapartfromthestrategicICT-basedhealthinterventions,mobilephonesalreadyplayacrucialroleinmalariapreventionbyfacilitatingawarenessraising,improvingtheinformationflowswithinandbetweenthestakeholdergroupsandstrengtheningtheimplementationofcommunitylevelmalariapreventionrules.Thiswasdonebyconductinganexploratorystudyconsistingofsemi-structuredinterviewswith32actorsfromthecommunity,district,andnationallevel.

Thecontributionofmystudyistwo-fold.First,mymulti-levelanalysisshedslightontheexistingmeansandrulesconcerningmalariapreventionandcontrolaswellastheirperceivedefficacy.Ifindthatcommunicationandlackofthereofplaysavitalroleininfluencingthestakeholderframingofthedisease.Thisincludesbothface-to-faceandmobilephonebasedcommunication.Second,myfindingsfurtherlookatElinorOstrom’stheoryofcollectiveaction.IarguethatmalariacaninfactbeperceivedasapublicbadandanalyzetheroleofICTsinfacilitatingpeople’scompliancewithOstrom’sdesignprinciples.

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TableofcontentACKNOWLEDGEMENTS..................................................................................................................IABSTRACT.........................................................................................................................................IITABLEOFCONTENT.....................................................................................................................IIILISTOFFIGURESANDLISTOFTABLES...................................................................................VLISTOFABBREVIATIONS...........................................................................................................VI1.INTRODUCTION...........................................................................................................................12.LITERATUREREVIEW...............................................................................................................32.1HEALTHSYSTEM.........................................................................................................................................32.2INFORMATIONANDCOMMUNICATIONTECHNOLOGIES(ICTS).........................................................32.3POTENTIALROLEOFICTINHEALTHSYSTEMSOFDEVELOPINGCOUNTRIES.................................42.4RWANDAICTHUB.....................................................................................................................................42.5ICTHEALTHINITIATIVESANDPOLICIESINRWANDA.........................................................................62.6MALARIAPREVENTIONANDCONTROLINRUHUHA,RWANDA..........................................................72.7ICTSFORSUSTAINABLERURALDEVELOPMENT...................................................................................8

3.THEORETICALFRAMEWORK..................................................................................................93.1RELEVANCEANDMAINOBJECTIVEOFTHESTUDY...............................................................................93.2ICTSANDCOLLECTIVEACTION:INTRODUCINGOSTROM’SDESIGNPRINCIPLES............................93.3RESEARCHQUESTIONS............................................................................................................................11

4.METHODOLOGY........................................................................................................................134.1DATACOLLECTION...................................................................................................................................134.1.1Secondarydata................................................................................................................................134.1.2Interviews...........................................................................................................................................13

4.2DATAANALYSIS........................................................................................................................................145.RESULTSANDDISCUSSION....................................................................................................155.1STAKEHOLDERANALYSIS........................................................................................................................155.1.1Communitylevel..............................................................................................................................165.1.2DistrictLevel.....................................................................................................................................195.1.3NationalLevel..................................................................................................................................19

5.2INFORMATIONANDCOMMUNICATION:ACTORS,FLOWSANDCHANNELS......................................225.2.1Informationandcommunicationflowsbetweenactors................................................225.2.2TheroleofICTs................................................................................................................................39

5.3ANALYSISOFACTOR’SPERCEPTIONS....................................................................................................445.3.1Perceptionsofthefutureroleofmobilephones................................................................445.3.2Situationregardingmalaria......................................................................................................465.3.3Knowledgeandmisconceptions...............................................................................................495.3.4Trust.....................................................................................................................................................595.3.5Sharedperspectiveoftheproblem..........................................................................................64

5.4MALARIAGOVERNANCEARRANGEMENTS...........................................................................................755.4.1Preventionandcontrolmeasures............................................................................................755.4.2Malariaasapublicbad................................................................................................................835.4.3Ostrom’sdesignprinciples..........................................................................................................925.4.4TheroleofICTsinthemalariagovernancearrangements.........................................96

6.CONCLUSION..............................................................................................................................987.RECOMMENDATIONS...............................................................................................................99REFERENCES................................................................................................................................100APPENDICES.................................................................................................................................103

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APPENDIX1–OVERVIEWOFINTERVIEWEES.........................................................................................103APPENDIX2–TOPICLISTOFTHEINTERVIEWS.....................................................................................1072.1Interviewtopics–community.....................................................................................................1072.2Interviewtopics–actorsinhealth/policylevel................................................................108

APPENDIX3–OVERVIEWOFCODES........................................................................................................109

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ListoffiguresFigure1:LocationRuhuhasectorintheredcircleFigure2:Ostrom’sDesignPrinciplesFigure3:Informationandcommunicationflowsaboutmalariabetweenactors

ListoftablesTable1:FactorsthatinfluencedrapidICTdevelopmentinRwanda(Mwangi,2006)Table2:MajorinitiativesinhealthinformationtechnologyinRwanda(Frasieretal,2008)Table3:ActorsinRwanda’shealthsystemregardingmalariapreventionandcontrolinRuhuhaTable4:ICTchannelsusedinmalariapreventionandcontrolinRuhuhaacrosslevelsTable5:ExplanationinformationandcommunicationflowsfromcommunitymembersTable6:ExplanationinformationandcommunicationflowsfromcommunityhealthworkersTable7:ExplanationinformationandcommunicationflowsfromthehealthcenterTable8:ExplanationinformationandcommunicationflowsfromthehealthcenterpharmacyTable9:ExplanationinformationandcommunicationflowsfromtheprivatepharmacyTable10:ExplanationinformationandcommunicationflowsfromlocalleadersTable11:ExplanationinformationandcommunicationflowsfromcooperativesTable12:ExplanationinformationandcommunicationflowsfromthedistricthospitalTable13:ExplanationinformationandcommunicationflowstheRwandaBiomedicalCenterTable14:TherolesofmobilephonesinmalariapreventionandcontrolinRuhuhaTable15:ExamplesofperceptionsthatmalariaisaproblemathighlevelTable16:ExamplesofperceptionsthatmalariaexceededlimitscomparedtothepastTable17:ExamplesofperceptionsthatmalariaexceededcomparedtootherregionsinRwandaTable18:ExamplesofperceptionsthatmalariaincreasesduringcertainmonthsTable19:PerceptionsofactorswhothinkthatknowledgeaboutmalariaisnotenoughTable20:ExamplesofactorswhomentionedtheneedforcontinuousteachingTable23:MisconceptionsaboutmalariaTable24:ExamplesofstatementsthatillustratethattherearecommunitymemberswhodonotbelievethatthetabletsstillcuremalariaTable25:WhatproblemswerementionedbywhichactorsTable26:RulesandregulationsregardingmalariapreventionandcontrolinRuhuhaTable27:ExamplesthatthepreventionmeasuresarenotenforcedTable28:ExamplesofquotationsexplainingcooperationbetweenactorsTable29:ExamplesofquotationsontheimportanceoffollowingtherulesandregulationsTable30:Examplesofquotationsabouttryingtobeanexampletoothercommunitymemberswhenitcomestofollowingtherulesandregulations

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ListofabbreviationsBti BacillusthuringiensisisraelensisCBHI CommunityBasedHealthInsuranceCMATs CommunityMalariaActionTeamsEVOCA EnvironmentalVirtualObservatoriesForConnectiveActionEVOs EnvironmentalVirtualObservatoriesGoR GovernmentofRwandaHIV HumanimmunodeficiencyvirusHMIS HealthManagementInformationSystemsLLIN Long-lastinginsecticidalnetsICTs InformationcommunicationtechnologiesIRS IndoorresidualsprayingITN Insecticide-treatedmosquitonetsMEPR MalariaEliminationProgramNMCP NationalMalariaControlProgramPMI President’sMalariaInitiativeRBC RwandaBiomedicalCenterRDT RapiddiagnostictestRSSB RwandaSocialSecurityBoardSFH SocietyforFamilyPlanningSIScom CommunityHealthWorkerInformationSystemSMS ShortmessageserviceTB TuberculosisUSAID UnitedStatesAgencyforInternationalDevelopmentUSD UnitedStateddollarWHO WorldHealthOrganization

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1.Introduction

Malariaisadiseasethatisconsideredendemicin91countries(WHO,2016).Halfoftheworld’spopulationwasatriskofmalariain2016.In2015therewere212millionmalariacasesglobally,ofwhich429.000resultedindeath.Sub-SaharaAfricaistheregionthatcarriestheheaviestmalariaburdenworldwide(ibid).

Malariacontrolinterventionshavebeenwidelydeployedtoreducemalariacaseincidenceandmortalityrates(WHO,2016).Themostcommonlyusedmethodtopreventmosquitobitesareindoorresidualspraying(IRS)andinsecticide-treatedmosquitonets(ITN).Thesetwocorevectorcontrolinterventionsareestimatedtohavereducedmalariaincidenceratesby50%since2000(ibid).Bothofthesemeasures,however,areheavilyreliantonthecapacityandwillingnessoftheaffectedpopulationstocomplywiththepreventionrulesandregulationsintheirdailychoicesandactivities.Despitelargeincreasesinthefinancingofmalariacontrolandeliminationprogramsovertheyears2000to2015malariaremainsathreattopublichealthinmanycountries(WHO,2016).

Althoughmalariainterventionshavebeenwidelyadoptedandmalariaincidencerateshavegloballydecreasedsince,severalcountriesinSub-SaharanAfricaareexperiencingaresurgenceofmalaria(President’sMalariaInitiative,2016).Inparticular,Rwandahasseenanincreaseinreportedmalariacasesfromanestimated225,176casesin2011to1,598,055in2014.Changesinrainfallandtemperature,increasedimportationofmalariacasesfromneighboringcountries,anincreaseofresistanceofmosquitotoinsecticides,anduseofdistributednetsthatshouldhavebeenreplacedmayhavecontributedtothisincrease(ibid).

MyresearchbuildsontheassumptionthatICTsmightplayavitalroleinmalariaprevention,asICTscanstrengthenthehealthcaresystem(ShiferawandZolfo,2012).WhenICTsareusedeffectivelytheyhavealargepotentialtoboostinformationflowsandknowledge,andtoempowercitizens(Chetley,2006).Inparticular,theconnectivefunctionofmobilephonecommunicationmaybeleveragedtotriggercollectiveactionprocessesbothwithinandbetweenstakeholdergroups.Thisisofspecialimportanceformalaria:asavectorbornedisease,malariaistransmittedbyaparasitefromoneinfectedperson(host)toanother.Effectivepreventionandcontrolmeasuresmustthusentailcommunalresponsibilityandcollectivemobilizing(Ostrom2009).

Interestingly,in2015theGovernmentofRwandadevelopedanationalICTstrategyandplan(GoR,2015).ThepolicyaimstoleverageICTsinallsectorstotransformRwandaintoaninformation-richandknowledgebasedeconomyby2020(ibid).TheGovernmentofRwandaisinvolvedinallleadinginitiativesandemergingtechnologies,astheprivatesectorhasnotyetcomeup(Frasieretal.,2008).Inthisrespect,anumberofenablingpoliciesandinterventionshavebeenputinplaceinanefforttointegratetechnologyinthehealthcaresystem(ibid).

MythesisinvestigatestheroleofICTandtheroleofinformationinthemanagementandcontrolofmalariainRuhuhasectorinBugeseradistrict,easternprovinceofRwanda.Thissectoristhelocallevelofanalysisandislocated42kmfromKigali.Becauseofitsgeographicalfeaturessuchasaltitude,

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ricefieldirrigationschemes,swampsandcrossbordermovements,thisregionisamalariaendemiczone(Ingabireetal,2016b).

Myresultsshowthatmultiplestakeholdergroupsexchangeinformationaboutmalariaaswellasthemeansofitscontrolandpreventionintheireverydaycommunicationboththroughface-to-faceandICTs.SomeadvantagesofICTsarethattheyfacilitateinformationandcommunicationflowsthatarerealtime,lowcost,overlargedistanceandacrossstakeholdergroups.However,thecanalsoincreasethespreadofmisconceptions.Furthermoretheresultsalsoshowthatmobilephonescantoapointfacilitatecollectiveaction.

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2.Literaturereview

Informationplaysanimportantroleintheeffectivemanagementanddevelopmentofhealthcaresystems(HartshorneandCarstens,1990).Informationinhealthisrequiredforthemanagementofoperations,planning,andcontrol(ibid).HartshorneandCarstens(1990)describethat:

‘Toprovidethenecessaryinformationneedsofusersatdifferentlevelsofmanagementinthehealthcaresystem,astructuredinformationsystemcoupledwithappropriateinformationtechnologyisrequired’’.

Suchinformationtechnologies,orICTs,arerevolutionizinglivesanditsapplicationinhealthcouldbenefithealthsystemsandinformationmanagementproblems(ShiferawandZolfo,2012).Inthischapter,IfirstdefinehealthsystemsandICTsfromthepointofviewofaccesstoexpertinformationandknowledge.Secondly,IreviewtherelevantliteratureandpolicydocumentsfocusingontheroleofICTandmalariapreventionandcontrolinRuhuha,Rwanda.

2.1HealthsystemAccordingtoBloomandStanding(2008)healthsystemscanbeanalyzed

as‘’waysoforganizingaccesstoexpertknowledge’’.Thisconceptcontainspublicandprivateactorsandmodernandtraditionalproviders(Lucas,2008).Rwanda’shealthsystemalsoconsistsofpublicandprivatetraditionalandmodernprovidersofhealthservicesforcommunitymemberstoaccessknowledge.FurthermoreLucas(2008)describes,‘’itfocusesonthewaysinwhichhealthknowledgeisgraspedorwithdrawn,whogainsaccesstoitandtheverydifferentwaysinwhichitcanbeorganized’’(ibid).Appropriateinformationandhealthcaresupportempowershealthcarestaff,isastrategyforachievingsustainableimprovementofhealthsystemsinruralareasandiscosteffective(ShiferawandZolfo,2012).ICTsplayaroleinthisbecausetheyhaveshownpotentialtoimprovehealthcaredeliverysystemstobetterhealthandhealthcoverage,theyenhancequality,theycancreateaccess,andenablequickcommunicationbetweenhealthprofessionalswiththeircolleaguesandpatients.ExamplesofICTsinhealthsystemsincludeeLearningtools,telemedicine1,healthinformationsystemswithdecisionsupport,electronicmedicalrecords,andmobilehealth(ibid).

2.2Informationandcommunicationtechnologies(ICTs)Inthisdigitalera,ICTsareconsideredtohaveasignificantpotentialto

stimulatesustainabledevelopmentandgovernance,improvethehealthandwellbeingofmarginalizedpopulationsandthepoor,andtocontributetopovertyreduction(Chetley,2006;Panir,2011).Nayaketal.(2010)definesICTas“technologiesthatfacilitatecommunicationandtheprocessingandtransmissionofinformationbyelectronicmeans”.ICTsarenowadaysbeingusedineffortstofacilitategreaterplanning,control,andcommunication,whichinturncanchangeorganizationalstructures(Bloomfield,1991).Forexample,inhealthICTscanfacilitatepatientdatacollectionandprocessing,helpscreeningandmonitoring,andimproveinformationdeliveranceandeducation(Frasieretal,2008).ShiferawandZolfo(2012)describethatthecurrenttrendofexpandingpenetrationratesofmobiletechnologyindevelopingcountriesisanopportunity

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toimplementrelevanttechnologicalapplicationsinhealthsystems.Theygivesomeexamplesbystating:

‘’Forinstance,inUgandatheuseofaVHFradiobytraditionalbirthattendantsfacilitatedearlyreferralandcontributedtoasignificantreductioninmaternalmortality,showingthattheuseofICTtechnologycanpreventavoidablematernaldeath.InSouthAfricaandRwandamobiletechnologyimprovedadherencetoTBandHIVtreatment,respectively’’(ibid).

Thereforejustlikeintheexamplesofmaternalhealth,TB(Tuberculosis)andHIV,inmyresearchICTsareconsideredtopossiblyalsohavearoleinmalariapreventionandcontrolinRwanda.ThenextsectiondiscussesthisfurtherbyexplainingthepotentialroleofICTinhealthsystemsindevelopingcountries.

2.3PotentialroleofICTinhealthsystemsofdevelopingcountriesDigitaltechnologiesandshareddataareexpectedtohavethepotentialto

radicallytransformthehealthcareinfrastructureofdevelopingcountries(Feganetal.,2011;Lucas,2008).Asdescribedearlier,whenICTsareusedeffectivelytheyhavealargepotentialtoboostinformationflowsandknowledge,andtoempowercitizens(Chetley,2006).Althoughstudiesagreeaboutthispotential,thereisnoagreementyetaboutthelikelynatureofthisimpact(Lucas,2008).

Lucas(2008)arguesthatadistinctioncanbemadebetweenICTinnovationswhichreinforcetheexistinghealthsystemsfrominnovationswhichhavethepotentialtochangethemcompletely.Manycurrentinnovationsfallunderthefirstcategory.Forexample,mobilephonenetworkstoenhancehealthreportingproceduresimprovetheprocessorinformationavailablewithinalreadyexistinghealthsystems.Withthesekindsofinnovationsthe‘’lawofunintendedconsequences’’mightplayarole,aschanginghealthreportingprocedureswasnotanobjectiveofthosedesigningthisinnovation(ibid).Innovationsthatfallunderthesecondcategoryandwhicharedevelopedtotransformexistinghealthsystemsarestillinearlyphasesofimplementation,withnotenoughresearchconductedtodeterminetheirrelevance,costeffectivenessandapplicability(Chetley,2006).Thismakesithardforgovernmentsofdevelopingcountriestodecideontheirinvestmentpriorities(ibid).Again,inbothcategories,itisthepromisingabilityofICT,itspowertoquicklydeveloplocal,nationalandglobalnetworksaroundparticularissuesthatmaystimulatearadicalchangeinthewayhealthsystemsareorganized(Lucas,2008).MythesiscomplimentsthisliteraturebyanalyzinghowICTsareusedinthehealthsystemaroundmalariapreventionandcontrolinRuhuha.Asmentionedearlierinthisparagraph,itishardforgovernmentsofdevelopingcountriestodecideontheirinvestmentprioritiesregardingICTs.ThefollowingsectiondescribesRwanda’sattitudetowardsICTinvestmentsandprovidesabackgroundofRwanda’sICTenvironment.

2.4RwandaICThubThegovernmentofRwandaistryingtopositionRwandaasaregionalICT

hubbycreatingaconducivelegalandregulatoryframework,availabilityofgoodinfrastructureandagrowingandinnovativehumanresourcebase(GoR,2015).Beingoneofthemosttechnologicallydeficientcountriestwodecadesago,RwandahasmaderapidprogressinICTdevelopmentincomparisonwithother

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countriesinSub-SaharaAfrica(Mwangi,2006).AccordingtoMwangi(2006)thisisbecauseofthepolicyenvironment,politicalleadership,emigrantsandrefugeereturnees,andbecauseofnetworkingwithepistemiccommunities(seetable1below).Table1:FactorsthatinfluencedrapidICTdevelopmentinRwanda(Mwangi,2006)Factors ExplanationUnder-contestedpolicyenvironment

-Thecivilwardestroyedpreexistingpoliticalinstitutions,allowingthedevelopmentofICTaspartofthesocialconstructionofthestate,togiveitanewhistoryandidentity.-Rwanda’sdevelopmentframeworkande-governmentinitiativesarepremisedonaneoliberalagenda,whichminimizesfurtheropportunitiesforforeigninterference.-Noorganizedinterest-grouppoliticsthatmighthavecontestedeffortstoestablishthee-governmentsystem.Domesticandnon-stateactorswerefocusingonhumanitarianworkandstatereconstruction.Themainsourceofopposition,Rwandeserefugeesandexiles,lacksavisibleandeffectivefootholddomesticallyorintheinternationalcommunity.

Politicalleadership -BypersonallyengagingwiththevisionofaRwandeseinformationsociety,Kagamewasabletoidentifywithitandassignahighprioritytoitsdevelopment.-Kagamebecamethecountry’sembodimentofthenewRwanda,andhiscommitmenttothevisionhasenabledhimtomobilizesubstantialfinancialresourcesfortheprocess.-TheshiftbyallmembersoftheTransitionalNationalAssemblytoanelectronicconductofHouseandSenatebusinessislikelytospillovertomembers’localofficesandinteractionswithotherpublicagencies,andtherebybroadenandentrenchthesystem.

Emigrantsandrefugeereturnees

-CalledonpowerfulsuccessimagesofSingaporeandSouthKorea-Injectedasubstantial,badlyneededhumanresourceinputintothesystemintheaftermathofthegenocide-Supporteditsdiffusionbecauseofbeinghighlyskilledandsocializedintoe-governmentthroughexposureabroad-Theyprovidedfinancialinvestmentstokick-startthedevelopmentofane-governmentsystem

(International)epistemiccommunities

-RwandaturnedtotheITepistemic(knowledge)community;thatis,globalnetworksofITexpertsthattheyhadengagedwithduringtheircareersabroad,andthroughregionalintergovernmentalorganizations-RwandaalsostartedtappingintoprivateinitiativesthatsupportITdevelopment

ThepotentialroleofICTsanditsusedependoncultural,politicaland

socialfactors(Panir,2011).ICTinterventionsareoftentechnologicallydrivenandsocio-politicalfactorsareoftenignored,causinghealthrelatedICTprojectstofail(ibid).Thefactorsintable1areimportanttogetanunderstandingofthehistoricalpoliticalfactorsthatinfluencedthecurrentcontextofICTuseinRwanda.Firstofall,theunder-contestedpolicyenvironmentandpresidentKagame’spoliticalleadershipenabledthegovernmenttodevelopICTpoliciesallowingthedevelopmentofICTaspartofthesocialconstructionofthestate(Mwangi,2006).Furthermore,emigrantsandrefugeereturneessupportedthedevelopmentofane-governmentsystembyprovidingskills,knowledge,financialinvestmentsandbytappingintotheirglobalnetworksofITexpertsthattheyhadengagedwithduringtheircareersabroad(ibid).AlsoShiferawandZolfo(2012)arguethatthesuccessorfailureofICTinterventionsinhealth

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systemsindevelopingcountriesdonotonlyrelyontechnologicalfactors,butalsorelyonmultisectorialinvolvementofstakeholders,capacitybuilding,e-governance,effectivehumanresourcemanagement,andonanenablingpolicyenvironment.ThenextsectiondescribestheparticularICTinterventionsinRwanda’shealthsystem.

2.5ICThealthinitiativesandpoliciesinRwandaICTisafastdevelopingindustryinRwanda(Frasieretal.,2008).This

developmentislargelysupportedbytheGovernmentofRwanda,astheprivatemarkethasnotcomeup.Therefore,thegovernmentofRwandaisinvolvedinallleadinginitiativesandemergingtechnologies.Theyhavemadeanefforttotrytointegratetechnologyintothehealthcaresystem.Rwandahasespeciallybeenapioneerinthefieldsofelectronichealthrecordsandnationalreportingsystem.Frasieretal.(2008)identifiedsixmajorinitiativesinhealthinformationtechnologyinRwandain2008,seetable2below.Table2:MajorinitiativesinhealthinformationtechnologyinRwanda(Frasieretal,2008)Initiative ExplanationOpenMRS Anopen-sourceMedicalRecordsSystemthattracks

patient-leveldataTracPlusandTRACnet Monthlymonitoringofinfectiousdiseasesincluding

HIV/AIDS,TB,andMalariaCAMERWA DrugandmedicalsupplymanagementsystemTelemedicine ICTusedtodeliverhealthandhealthcareservices,

informationandeducationtogeographicallyseparateparties

HealthManagementInformationSystems(HMIS)

Systemsthatintegratedatacollectionprocessing,reporting,anduseoftheinformationforprogrammaticdecision-making

E-Learning UseofICTininstructionofA2-levelnursesforpromotiontoA1status

Asmentionedearlier,thegovernmentofRwandadevelopedanational

ICTstrategyandplanin2015(GoR,2015).ThegovernmentofRwandawantstoleverageICTinallsectorstotransformRwandaintoaninformation-richandknowledgebasedeconomyby2020.ThisnationalICTplanincludesthreecommunitydevelopmentprojectsthataredirectlyrelatedtohealth,namely1)CommunityHealthWorkerReportingandInformationSystem,2)HealthInsuranceInformationSystem,and3)Telemedicine,whichis“anapplicationofclinicalmedicinewheremedicalinformationistransferredthroughaudio-visualmediaandothertechnologiesforpurposesofdiagnosingortreatingpatients”(ibid).ThecommunitydevelopmentprojectsaimtoimprovehealthcaredeliverythroughICTbyincreasingICTusage,accessandawarenesswithincommunities,improveaccesstoinformationandthereforeincreaseparticipationthroughICT,andtofacilitatetheprovisionofbasichealthservicestocommunitiesusingICT(ibid).Asexplainedinsection2.3,adistinctioncanbemadebetweenICTinnovationsthatarepartiallyunintendedandthosethatarespecificallydesignedforhealthsystems.TheinitiativesinhealthinformationtechnologyinRwandathatarementionedabovefallunderthesecondcategoryandarespecificallydesignedtoimprovethehealthsystem.Thecontributionofmyresearchisabouttheroleofspecificallydesignedinterventionsandthe

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partiallyunintendedimpactofmobilephonesonmalariapreventionandcontrolinRuhuha.

2.6MalariapreventionandcontrolinRuhuha,Rwanda RuhuhasectorinBugeseraDistrictintheeasternprovinceofRwanda(seefigure1below)isamalariaepidemiczone.Thissectoristhelocallevelofanalysisandislocated42kmfromKigali.Thenumberofhouseholdsinthisareaisestimatedat5098with23,893individuallivingin35differentvillages(Ingabireetal,2016b).

Figure1:LocationRuhuhasectorintheredcircle(Rulisaetal,2013)

FourstudiesrelatedtomalariapreventionandcontrolhavebeenconductedinRuhuha,Rwanda.Thefirststudyinvestigatedthepotentialrolesofcommunitystakeholdersinmalariaelimination(Ingabireetal,2014).Long-lastinginsecticidalnets(LLIN),indoorresidualspraying(IRS)andmalariacasetreatmentwithartemisinin-basedcombinationtherapy(ACT)mightreducebutnotleadtotheeliminationofmalaria(Ingabireetal,2015).Therefore,thesecondstudyanalyzedfactorshinderingtheacceptabilityanduseofmalariapreventivemeasures(ibid).Thethirdresearchconductedastakeholderanalysistoexplorepotentialstakeholdersfromnationaltolocalleveltoanalyzewhomtoinvolveforaspecificprojectactivityandthesuitabletimetodoso(Ingabire,2016a).Thelaststudyidentifiedmalariapatternsintheregionanddeterminedbehavioralandenvironmentalaspectsthatcontributetomalariatransmission(Ingabire,2016b).Thismeansthatstudiestoanalyzethepotentialrolesofcommunitymembers,thefactorshinderingtheacceptabilityofpreventivemeasures,stakeholderanalysistoassesswhotoinvolveinspecificprojectactivities,andmalariapatternsandenvironmentalaspectsthatcontributetomalariatransmissionhavebeenconductedalready.

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MythesiscomplementsthisexistingliteraturewithananalysisoftheroleofICTsandgovernanceprocessesinmalariapreventionandcontrolinRuhuha.MythesisaddsanotherdimensiontotheexistingknowledgebyanalyzingthecommunicationandinformationflowsbetweenactorsandtherolesofICTsinmalariapreventionandcontrolinRuhuha.

2.7ICTsforsustainableruraldevelopmentThemajorityoftheworld’spoor(around75%)liveinruralareas(Panir,

2011).Thesepooraswellashealthprofessionalshavebeenatargetofhealthrelatedmillenniumdevelopmentgoals(ibid).Furthermore,thethirdgoalofthesustainabledevelopmentgoalsdescribes‘’healthylivesandpromotingthewell-beingforallatallagesisessentialtosustainabledevelopment’’(UnitedNations,n.d.).

TheconceptofICThasbecomeinformation-centeredandhastworoles(Panir,2011).Thefirstroleistheprocessofhandlingdataelectronically.Inthisprocess,dataischangedintoinformationordataismovedfromsourcestorecipients.ThesecondroleisturninginformationintoknowledgewhenICTsfacilitateassourcesofoutcome.Thisknowledgecanresultintakingaction,learningorindecision-makingprocesses(ibid).Whenthesetworolesareappropriatelyimplementedtheycanbecomestrongenginesofsocial,economicandpoliticalempowerment(Nayaketal.,2010).ICTscancreateinformationrichsocietiesbystimulatingcommunicationandinformationsharingamongruralandmarginalizedpeople.Thiscansubsequentlyempowerruralcommunitiestobeabletocontributetodevelopmentprocesses.Furthermore,ICTcouldcreatemoretransparentandefficientgovernmentprocessesthatalsoadvanceempowermentandparticipationoflocalcommunities(ibid).

InthisliteraturereviewIarguedthatICTsareexpectedtohavealargepotentialtohaveapositiveimpactoninformationflows,knowledge,andtheempowermentofcitizensinhealthsystemsindevelopingcountries.ThegovernmentofRwandahasimplementedseveralICThealthinitiatives.RuhuhasectorinBugeseraDistrictinRwandaisamalariaepidemiczone.Severalstudiesrelatedtomalariapreventionandcontrolhavebeenconductedinthisarea.MythesiscomplementsthisliteraturewithananalysisoftheroleofICTsininformationandcommunicationflowsandingovernanceprocessesinmalariapreventionandcontrolinRuhuha.Thefollowingchapterprovidesmoreinformationabouttheobjectiveandrelevanceofmythesis.

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3.Theoreticalframework

3.1RelevanceandmainobjectiveofthestudyIntheliteraturereview,IdefinedhealthsystemsandICTsfromthepoint

ofviewofaccesstoexpertinformationandknowledge.Furthermore,IprovidedbackgroundinformationonICTpoliciesandhealthinitiativesinRwanda,introducingtheresearchsiteRuhuhasector.Iarguedthatmythesisresearchisrelevant,becausetheroleofinformation,andinparticularICTs,inmalariapreventionandcontrolinRwanda’shealthsystemhasnotbeenstudiedextensively.

Inaddition,abroadstreamofliteratureassertsthattheprocessofICTuseisanespeciallycomplexphenomenonindevelopingcountries(WalshamandSahay,2006).ICTsarealargepotentialbenefittoallpublicandprivatesectorsatvariouslevels(ibid).BothNayaketal.(2010)andSahayandWalsham(1995)stresstheneedformulti-levelanalysisoftheinteractionofactorsatvariouslevelsinICTimplementationanduse.BothnationalandlocalpowerrelationsinfluencetheeffectivenessandpotentialofICTuseindevelopingcountries(Nayaketal.,2010).Therefore,politicalawarenessandanalysisofalllevelsarecrucial(ibid).WalshamandSahay(2006)state‘’itisimportanttostudytheinteractionofthesedifferentactorsandtheprocessofICTimplementationanduse”.TheywouldliketocontinuetoseemoreresearchonforexampletheroleofICTsonlarge-scalegovernmentsystems,butalsoresearchrelatedtotheroleofICToncommunitieswouldbeavaluablefocusaccordingtothem(ibid).MythesiscontributestothisdiscussionbyanalyzingtheroleofICTsininformationandcommunicationflowsofactorsandgovernancearrangementsinthehealthsystemregardingmalariapreventionandcontrolinRuhuhaviaamulti-levelanalysis,involvingactorsfromthecommunity,districtandnationallevel.ThisisdonebecausethereisalackofunderstandingabouttheroleofICTsininformationandcommunicationandinthegovernancearrangementsinmalariapreventionandcontrolinRwanda.Forthisreason,amulti-levelanalysisisconductedtoanalyzetheroleofICTsininformationandcommunicationflowsofactorsinvolvedinmalariapreventionandcontrolinRuhuhaandinthesegovernancearrangements.

3.2ICTsandcollectiveaction:introducingOstrom’sdesignprinciplesSeinandHarindranath(2004)statethat‘’ICTessentiallyrelatesto

enhancinganindividual’scapabilitythroughempowermentandknowledge’’.ThisexplanationhasanindividualemphasisandfocusesonICTonlyinfluencingthedevelopmentofindividualcapabilities.Oxoby(2009)criticizesthisviewbyarguingthatindividualsarenotsociallyexcludedanddependonsocialnetworkstomakeupforalackofindividualresources.Thesesocialnetworkscanfacilitatecollectiveaction(Thapaetal.,2012).Gilbert(2006)describesthat‘’Collectiveactionrequiresajointcommitmentwhichbindsgroupmembersthroughasharedandpersistingreasontocommitandobligethemtoactasagreedupon’’.Ibrahim(2006)states‘’Collectivecapabilityisnotmerelythesumofindividualcapabilities’’,but‘’Rather,thesearepropertiesofagroupwhichanindividualalonewouldneitherhavenorbeabletoachieveifhe/shedidnotjoinacollectivity”.Thapaetal.(2012)explainthatICTsdonotonlyenhanceanindividualscapabilitiesbutcanfacilitateinthebuildingofcollectiveactionby

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increasingflowsofinformation,socialnetworking,participation,transparency,andinteractionsamongcommunitymembersthatfacilitatemaintainingtrust,acceptanceandalignmentnecessaryforsuccessfulcooperation.

ElinorOstromcontributedtotheunderstandingofcollectiveaction(HoldenandTilahun,2018).In2009shereceivedtheNobelPrizeineconomicsforherworkbyshowingthat‘’whencertainconditionsaremet,groupsofpeoplearecapableofsustainablymanagingcommonresources’’(Wilsonetal,2013).Ostromanalyzedalargenumberofworldwidecasestudiesinwhichgroupsattemptedtomanagecommon-poolresources,suchasfisheries,irrigationsystems,pasturesandforests(Wilsonetal,2013).Byanalyzingthecasestudiessheidentifiedconditionsforsuccessfulcollectiveactiontosecuresustainablemanagementofthesenaturalresources(HoldenandTilahun,2018).Basedontheseconditionssheproposedeightdesignprinciples(seefigure2below).Theseprinciplesweredesignedtounderstandtheimportantconditionsoftheinstitutionalarrangementsthatattainedgoodoutcome,oppositetogroupswhoseeffortsfailed(Wilsonetal,2013).Ostrom(1993)describesthat:

‘‘By‘designprinciple’ismeantacharacteristicthathelpstoaccountforthesuccessoftheseinstitutionsinsustainingthephysicalworksandgainingthecomplianceofgenerationsofuserstotherulesinuse’’.

Figure2:Ostrom’sDesignPrinciples(Wilsonetal.,2013)

Thedesignprincipleswereinitiallycreatedtomanagecommon-poolresourcessuchasfisheries,irrigationsystemsandforests.Wilsonetal.(2013)arguethatbecauseofthetheoreticalgenerality,thedesignprinciplescanbegeneralizedtoberelevantforamuchwiderrangeofapplicationthancommonpoolresourcegroups.Theycanbeusedasapracticalguidetonearlyanygroupwhosemembersmustcooperateandworktogethertoachieveasharedgoal(ibid).

Thecommonsareeverycommoninterestthatcanbesharedbyagroupofpeople.Thedifferencebetweencommongoods(orcommonresources)andpublicgoodsisthatcommongoodsarerivalrousandpublicgoodsarenon-rivalrous.Examplesofpublicgoodsaretheairthatwebreatheorthewaterthat

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wedrink.Theyarenon-rivalandindividualsarenotexcludablefromthesepublicgoods.Publicbadsarethesymmetryofpublicgoods.Asexplainedearlier,publicgoodsaretheairthatwebreatheorthewaterthatwedrink.Nowexamplesofpublicbadsareairpollutionorwaterpollution.Ifairgetspollutedthisisapublicbad,becauseindividualscannotexcludethemselvesfrombreathingthispollutedairanditisnon-rivalrousasbreathingpollutedairdoesnotdiminishthepollutedairforotherindividuals.Rulesthatarecreatedforpublicbadsaredifferentfromrulesforpublicgoods,asrulesforpublicbadsareaboutavoidingasharedriskwhilerulesforapublicgoodareaboutsharingabenefit.Anotherexampleofapublicgoodispublichealth.Diseasesthreatenhealthasapublicgoodandareapublicbad.Inthisresearch,Iconsiderthediseasemalariaasapublicbad.Justlikewithwaterandairpollution,thereisnorivalandindividualsarenotexcludablefromgettingmalaria.Malariaisadiseasethatistransmittedifaninfectedvectorstingsahumanbeing.Therefore,everyindividualhasaroleinpreventingthespreadofthediseaseandmalariaisapublicbad.Ifanindividualdoesnottakepreventivemeasuresagainstmalariathisisathreattowardsotherpersonseffortstoreducethepublicbadandtoimprovehealth.Thismeansthatindividualsinacommonsdilemmaarecapturedinaninescapableprocessfromwhichtheycannotremovethemselves(Ostrom,1999).ImprovedcommunicationthroughICTsholdsapromisetomoreeffectivelymonitortheapplicationofpreventivemeasuresbyfacilitatingimprovedcommunication,negotiationanddiscussion.ThisiswhyimprovedcommunicationflowsthroughICTscouldplayaroleinimprovingpublicbad(malaria)governance.Difficultiesthatariseincommonsdilemma’sarehowtoassureallindividualshaveasharedperspectiveoftheproblemtheyneedtosolve,howtocreateruleswhichareagreeabletoalmosteveryone,howtomonitortomakesurethatthosebreakingtherulesaresanctioned,andhowtoguaranteethattrustandcooperationarenotthreatened.TocopewiththeseissuesOstrom(1999)arguedthatpolicyanalystsshouldchangetheirviewsfromindependentgovernancesystemsdirectedbyasinglecentertopolycentricgovernancesystemstomanageoranalyzethesecommonsmoreeffectively.

MythesisbuildsonOstrom’stheorybyanalyzingtheroleofICTsinthegovernancearrangementsofactorsthataredealingwithmalariaasapublicbadinRuhuha.FollowingOstrom,Iscrutinizetheexistingrulesforcontainingmalaria(avoidingasharedrisk)andtheroleofcommunicationinestablishingandmaintainingthem.Foreffectivecollectiveaction,differentactorswithinthemalaria-affectedareaofRuhuhahavetocooperateandworktogethertoachieveasharedgoalofbattlingthedisease.Inthenextsection,Ioutlinemyresearchquestions,showinghowfocusingoncommunication,itsusesandmisusesallowsmetoelaborateonOstrom’sdesignprinciplesofeffectivelypreventingapublicbad.

3.3ResearchquestionsTherearethreemainquestionsguidingmyresearchwithseveralsub

questions.ThemainobjectiveofmythesisistoinvestigatetheroleofICTsinthepreventionandcontrolofmalariaasapublicbadinRuhuhasector,Rwanda.Theresearchquestionsarethefollowing:

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1.WhatarethecommunicationandinformationflowsrelatedtomalariainRwanda’shealthsystem?

• Whathealthsystemsandgovernancenetworksarecurrentlyinplacetomonitorandanalyzemalariaoutbreaks?

• Howistheinformationsharedinthesesystems/networks?Whataretherelationshipsbetweendifferentinstitutionallevels/actors/networks?Howdotheyinteract?Whatistherelationbetweenscalelevels?Howaretheyconnected?Howaremalariacontrolandpreventionstrategiescommunicatedtocommunities?

2.WhatistheroleofICTsinthesesystems/networks?

• WhataretheeffectsoftheemergenceofICTsonhealthsystemsandthegovernancenetworksrelatedtomalariacontrolandprevention?

• TowhatextentdoestheemergenceofICTsinRwandachangetheroleandlegitimacyofactorsinhealthsystemsandgovernancenetworks?

• HowarethenationalICTpoliciesandstrategiesrelatedtolocaloutcomesinICTuseandmalariaprevention?(ArenationalICTpoliciesdeadpiecesofpaperandirrelevantforcesatthelocallevel,orhavethesestrategies,plansandpoliciesincreasinglybeenusedtoimprovepublichealthandmalariaprevention?)

3.Whatisthepotentialofmobile-basedcommunicationtoimprovethecollectivegovernanceofapublicbad(Ostrom,1993)?

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4.Methodology

Thechosenmethodtogetthedataneededwastodoanexploratorystudywithqualitativeresearch.ThisapproachwaschosenbecauseinexistingliteraturethereisnotalotwrittenabouttheroleofICTsandtheroleofinformationinmalariapreventionandcontrol.Forthisreasonanexploratorystudywithqualitativeresearchwaschosenwiththeaimtogainknowledgeandtogiveinsightsintothesetopics.Inordertoanswertheresearchquestionsdifferentstepshadtobetaken.Thischapterdescribesthemethodsfordatacollectionandhowthedatawasanalyzed.

4.1DatacollectionDatawascollectedintwoways,bygatheringsecondarydataandby

conductinginterviews.Bothmethodsareexplainedinmoredetailbelow.

4.1.1SecondarydataFirstofall,secondarydatawasgatheredtryingtoidentifyhealthsystems,

governancenetworks,andfactsrelatedtomalariapreventionandcontrolinRwanda.Thesepolicydocumentsincludedthepresident’smalariainitiativeRwanda,thenationalmalariacontrolprogram,andhealthsectorstrategicplansamongothers.Moreover,literaturewasusedtoexploreanddefinekeytermssuchasICTs,healthsystem,andpublicbad.Furthermore,byanalyzingpreviousstudiesaboutmalariaconductedinRuhuhasectorpotentialstakeholdersthatcouldbeinterviewedwereidentified.

4.1.2InterviewsDuringfieldresearchinRuhuhasectorinRwandaactorsrelatedtothe

managementandcontrolofmalariawereinterviewed(adetailedoverviewoftheintervieweescanbefoundinappendix1).Thiswasdonethroughsemi-structuredinterviews(thetopiclistsoftheinterviewscanbefoundinappendix2).Thesamplingmethodthatwasusedispurposivesampling.FirstactorswereidentifiedbyanalyzingpreviousstudiesaboutmalariainRuhuha.ThesestudiesareconductedbyIngabireetal.(2014,2015,2016a,2016b).Secondly,theselectionofrespondentswasconsultedwithprofessorMutesa(supervisorofthetwoPhDstudentswithintheEVOCA1Rwandacasestudy)bygoingthroughthisdraftedlistofactorsthatcouldpotentiallybeinterviewed,withreferencetotherelevancefortheresearchquestionsandtheoverallfeasibilityofthestudy(timingandavailabilitylimitations).Afterwards,acontractwasmadewithRuhuhahealthcentertofacilitatemyresearch.Theheadofthehealthcenterandthedatamanagerofthehealthcenterweregivenascheduleoftheactorsthatwereidentifiedtobeinterviewed.AccordingtothisscheduleRuhuhahealthcenterstaffarrangedtherequestedactors/participantstobeatthehealthcenterforaninterview.Therefore,thehealthcenterselectedtheparticipantsthat

1EVOCA(EnvironmentalVirtualObservatoriesForConnectiveAction)isacollaborativeinterdisciplinaryprojectofWageningenUniversityandsevenpartnerinstitutions.Itfocusesonknowledgesharingplatforms(knownasEnvironmentalVirtualObservatories,EVOs)andtheirpotentialtotransformthedevelopmentlandscapeinfivecasestudyareasinruralAfrica.

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participatedinmyresearchsuchasthecommunitymembers,cooperatives,religiousleader,localleader,pharmacists,teacher,communityhealthworkers,amongothers.ForthedistrictandnationallevelcontactsoftheEVOCAprojectwereusedandtheinterviewswerescheduledandaccompaniedbyDominaAsingizweandMarilynMurindahabi(PhDresearcherswithintheEVOCAproject).Theinterviewswereallrecordedbyanelectronicdevice.Duringtheinterviewsaresearchassistant/translatorwashiredtotranslateinterviewsatthecommunitylevel.TheinterviewsatthedistrictandnationallevelwereconductedinEnglish.

4.2DataanalysisAfterfinishingthefieldworktheinterviewsweretranscribed.The

programAtlas.tiwasusedtocodeandanalyzedata.Aninductiveapproachwasusedasacodingtechnique,sothecategoriestocodeemergedfromthedata.Anoverviewofthecodescanbefoundinappendix3.

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5.Resultsanddiscussion

Thischapterdescribesandanalyzestheresultsoftheresearch.ItstartswithastakeholderanalysisofactorsinvolvedinmalariapreventionandcontrolinRuhuha.Thisisfollowedbyananalysisoftheperceptionsofactorsaboutthefutureroleofmobilephones,thesituationregardingmalaria,knowledgeandmisconceptions,trust,andsharedperspectiveoftheproblem.Thelastsectionanalyzesthemalariagovernancearrangements,thecompliancewithOstrom’sdesignprinciples,andtheroleofICTsinthegovernancearrangements.

5.1StakeholderanalysisThisfirstsectionidentifiesthestakeholdersinvolvedinmalaria

preventionandcontrolinRuhuhaandanalyzestheirroleinmalariapreventionandcontrol.Theactorsthatwereinterviewedduringmyresearchcanbecategorizedincommunity,districtandnationallevel(seetable3).Furthermore,therearetwotypesofactorsonthecommunitylevel.Thefirsttypeofactorsarestakeholdersthatarerelatedtohealth.Thesecondtypeofactorsareotherstakeholderswhoarenotdirectlyrelatedtohealth,butwhoalsoplayaroleinmalariapreventionandcontrolinRuhuha.Table3:ActorsinRwanda’shealthsystemregardingmalariapreventionandcontrolinRuhuha CommunityLevel DistrictLevel NationalLevelActorsthatarehealthrelated

CommunityHealthWorkers

NyamataDistrictHospital

RwandaBiomedicalCenter(RBC)

RuhuhaHealthCenter

NationalHealthInsuranceScheme

Pharmacies CommunityMalariaActionTeams(CMATs)

MalariaEliminationProgram(MEPR)

TraditionalHealers OtheractorsthathavearoleinmalariapreventionandcontrolinRuhuha

Communitymembers

LocalLeaders Religiousleaders Schools Cooperatives

Itwasdefinedintheliteraturereviewthathealthsystemscanbe

analyzedas‘’waysoforganizingaccesstoexpertknowledge’’(BloomandStanding,2008).Asillustratedinthetableabove(table3),theactorsinmalariapreventionandcontrolinRuhuhaincludepublicandprivateactorsandmodernandtraditionalprovidersforcommunitymemberstoaccessknowledge.Nowwillbeanalyzedhowthishealthsystemisorganizedandhowthewaysofaccess

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toexpertknowledgeisorganizedusingamulti-levelanalysisstartingwiththecommunitylevel,followedbythedistrictlevelandlastlythenationallevel.

5.1.1CommunitylevelAsexplainedabove,therearetwotypesofactorsonthecommunitylevel.

Firsttheroleofthehealthrelatedactorswillbedescribedindifferentsub-sections.Afterwardstheroleoftheactorswhoarenotdirectlyrelatedtohealthbutwhoalsoplayaroleinmalariapreventionwillbedescribed.

CommunityHealthWorkersEveryvillageinRuhuhasub-sectorhastwoorthreecommunityhealth

workers.Thecommunityhealthworkersareelectedbythecommunitymembersinavillage.Therearerulesthatarefollowedwhilerecruitingcommunityhealthworkers.Thoseruleshavecommunityvalues,suchasbeingintegrated,beinghonest,havingonenationality,andknowinghowtoreadandwrite.Thereisnoenddatetothepositionofacommunityhealthworker.Inthepast,communityhealthworkersusedtotreatchildrenunderfiveyearsold.Theyusedtotreatmalnutritionandmalnutritionhasnowimproved.Therefore,theynowtreatthewholecommunitywhenitcomestoillnessesandtheyadviceregardingpregnancies.Communityhealthworkersreceivedtrainingtoadviseandimpartcommunitymembersaboutmalaria,asmalariahasbecomeaprobleminthecommunity.Theycantestcommunitymemberstocheckiftheyaresufferingfrommalariaandgivetabletswherenecessary.Furthermore,whentheyseeaseveremalariapatienttheycantransferthispersontothehealthcenter.Communityhealthworkersalsovisitcommunitymember’shomesonceamonthtoteachpeopledifferentwaysoffightingagainstmalaria.Duringthesevisitstheygivetheservicesthatthepeopleneedandtheycomeintothehousetocheckwhethertherearebednets.Whenevertheyseethatthatthereisnobednetthecommunityhealthworkeradvisesabouthowtopreventmalariaandtheyexplainhowtheycangetbednets.Theprocedureofgettingbednetsstartsduringthevisitsofthecommunityhealthworkerswhowritedownallthepeoplewhodonotpossesbednets.Thenthecommunityhealthworkersgotothehealthcentertoreportthepeoplewhodonothavemosquitonets.Wheneverthebednetsareavailable,themessengers(inchargeofadvertisingandspreadinginformation)informvillagerstopickthemosquitonetsatthehealthcenter.Furthermore,thecommunityhealthworkersmobilizecommunitymemberstogethealthinsuranceintime.

RuhuhaHealthCenterTheroleofRuhuhahealthcenteristoteachandadvisecommunity

membersaboutthecausesofmalaria,preventionmeasures,andtocometothehealthcenterassoonaspossiblewhenevertheysufferfrommalariaorwhentheyidentifysignsofmalaria.Therefore,thehealthcenterteachescommunitymembersmeasuresoffightingagainstmalariaandcurepeopleintimewhoarecomingformedicaltreatment.Furthermore,thehealthcenterstaffgoesintotheareatocheckifthemalariapreventionandcontrolmeasuresarefollowedandusedbycommunitymembers.Theycheckwhethercommunitymembersusemosquitonets,removestagnantwateraroundthehouse,andwhethertheyclosewindowsanddoorsduringevenings.Thenursesofthehealthcenteralsooccasionallyhavedaysatthesectorsofficewheretheytreatcommunity

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memberswhodonothavemedicalinsurance.Furthermore,thehealthcentersupervisesthecommunityhealthworkers.Nexttotrainingcommunitymemberstheyalsoadviseandtraincommunityhealthworkersaboutmalariapreventionandcontrolmeasures.

PharmaciesThereisapharmacyinRuhuhaatthehealthcenter.Inaddition,thereare

alsoprivatepharmacieswithinvillages.TheprivatepharmaciesarelicensedbytheMinistryofHealth.Theroleofthepharmaciesistoprovidemedicinestothecommunitymembers.Atthehealthcenterpharmacycommunitymemberswhohaveahealthinsurancecangettheirmedicinesforfreeoratlowcostastheyarereimbursedbytheinsurancesdependingontheirsocialcategory.Atthehealthcentercommunitymemberswhodonothaveahealthinsuranceneedtopayforexaminationandconsultationfeesbeforebeingabletobuymedicinesatthehealthcenterpharmacy.Forthisreason,communitymemberswhodonothaveamedicalinsuranceusuallygototheprivatepharmacies.Furthermore,alsocommunitymemberswhohavemoneyandwhodonotwanttowaitinlineatthehealthcenteroftenattendprivatepharmaciesbecauseitisaquickerwaytogetmedicinescomparedtothehealthcenterpharmacy.

MalariaEliminationProgram(MEPR)Themalariaeliminationprogramwasagroupofresearchers,whichwas

madeupoutoffivestudentswhoweredoingtheirPhDfromtheNetherlands.Theywereresearchersbuttheresearchhasended.Theirresearchhadtwointerventions.ThefirstonewastheapplicationofBti(Bacillusthuringiensisisraelensis).Btiisalarvicidingprocessthatkillsmosquitolarvaeinricefields.Thesecondinterventionwastheestablishmentofcommunitymalariaactionteams(CMATs),moreinformationaboutCMATsinthefollowingsub-section.

CommunityMalariaActionTeams(CMATs)Everyvillagehasacommunitymalariaactionteam.Thecommunity

malariaactionteamsexistofthreepeoplewhoareselectedtorepresentotherswithinavillage.Thethreemembersworktogethertofightagainstmalaria.Theseteamsareunderthesocialaffairsadministrationofthesectorsoffice.ThecommunitymalariaactionteamshaveameetingeverySaturday.Duringthesemeetingsthemobilizecommunitymemberstoreachthehealthcenterontimewhentheyaresufferingfrommalaria,tosensitizecommunitymembersabouttheroleofsleepinginmosquitonets,toclosewindowsduringtheevenings,tomobilizecommunitymemberstoacceptfumigatorsintotheirhouses,andtheyteachcommunitymemberstoremovestagnantwaterandbushesaroundtheirhouses.

TraditionalHealersInthepastcommunitymembersusedtogototraditionalhealers

whenevertheyweresufferingfromadisease.Nowadayscommunityhealthworkershavetakenoverthisroleandthemajorityofthecommunitymembersgotothecommunityhealthworkerstogetinformationorforexamination.However,therearestillanumberoftraditionalhealersinRuhuha.Acommunitymembermentionedthatinhisvillagetherearearoundfourpersonsinhisvillagewhohavepermissionfromthegovernmenttoworkasatraditionalhealerand

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othertraditionalhealerswhohideintheirhouseswithoutbeinglicensedbythegovernment.Thetraditionalhealerthatwasinterviewedisatraditionalhealerandafarmeratthesametime.Heexplainedthatbecomingatraditionalhealerdependsonheritageandancestors.Hehasbeengiventhelegacyfromhisgrandfather.

Accordingtothetraditionalhealer,hisroleistocuretraditionalsicknessesandheadvisescommunitymembersaboutdifferentdiseases.Heexplainedthatthedifferencebetweentraditionalandnon-traditionalsicknessesisthattraditionalsicknessesarerelatedtobewitcheryandpoisonousactivities,whereasnon-traditionalsicknessesareillnessesthatrequirepeopletoreachhealthcenterandhospitals.Thetraditionalhealerexplainedthathedoesnotcuremalaria.Whenpeopleattendhishouseholdfornon-traditionalillnesseslikemalaria,headvisesthemtogotothehealthcenter.However,accordingtocommunitymemberstherearepeoplewhostillbelieveinthetraditionalhealers.Theyexplainedthatthesecommunitymembersattendtraditionalhealersinsteadofgoingtohealthcenterstobetreatedwhensufferingfromanillness.Thetraditionalhealerswillthentellapatientthatheorsheisnotsufferingfromotherdiseasesexceptbewitcheryormagicpower.Afterthatapersonmaydieofmalariawhereastheherbalistsortraditionalhealersaresayingthepersonissufferingfrombewitcheryandthepatientreachesthehealthcentertoolatewhenmalariahasreachedseverestages.

OtheractorsthatarepartofmalariapreventionandcontrolinRuhuhaThefollowingparagraphsdescribetherolesofthenon-healthrelated

actorsinmalariapreventionandcontrolinRuhuha.

CommunitymembersTherearetwogroupsofpeoplewithinvillages,whichareclubandcare.

Bothclubandcareareformalgovernancegroupsmobilizedthroughsectorlevelbythegovernment.Careisnotrelatedtomalariapreventionandcontrol,butitdealswithmoneyandloans.However,withinclubcommunitymembersoftentalkaboutmalaria.Clubexistsofallpeoplewithinavillageandthemeetingisonceaweek.Clubhelpspeopletosolveconflictswithintheirfamiliesandhelpspeopletobeawareofdifferentdiseases.Withinclubtheyadvisepeopleaboutmalariaandotherdiseases.Noclubcancometogetherwithoutacommunityhealthworker,whoisexpectedtoinformpeopleaboutmalariaandthewaysofpreventingmalaria.Furthermore,anotherroleofthecommunitymembersistofollowtherulesandregulationsregardingmalariapreventionandcontrolinRuhuha(moreinformationaboutthisin5.6.1).

LocalleadersLocalleadersareatcelllevelandbeingtheleaderisadailyjob.The

leaderofacellisnotelected,butgetsappointedforanunspecifiedtimeafterpassinganexam.Theroleofaleaderistomobilizecommunitymemberstobeawareofmalaria.Furthermore,theroleofaleaderistoadvocateandmakepeopleonhigherlevelsawareofproblemsthatareexperiencedbycommunitymemberswithinthecell.Whenthereisaproblemrelatedtomalaria,thelocalleadertalkstoleadersofhigherlevelstoinformthemaboutthisproblem.

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ReligiousleadersTheroleofthereligiousleadersinmalariapreventionandcontrolisto

encouragepeopletopayforhealthinsurance.Peoplefromthesocialadministrationofsectorsometimesaskthechurchtoencouragepeopletogethealthinsurances,becausetheyknowthatpeoplegetitquicklywhenthepriestisannouncingit.Onsuchoccasions,theycangivecommunicationsrelatedtomalariaduringamass.

SchoolsWithinprimaryschoolsmalariaisdiscussedwithindifferentsubjects.

MalariaisdiscussedduringSocialStudies,Kinyarwanda,EnglishandSciences.Accordingtotheprimaryschoolteacher,eachofthebooksofthesesubjectscontainsachaptertalkingaboutmalaria.Theteacherisresponsibleforteachingchildrenhowmalariaattackspeople,howitispreventedandhowtheymayhelpneighborsandfriendshowtofightagainstmalaria.

CooperativesTherearedifferentcooperativeswithinRuhuhaandtworicecooperative

memberswereinterviewed.Theyexplainedthataricecooperativecontainsaround900persons,andwithinthisbiggrouptherearesmallergroupsofaround40persons.Everygrouphasit’sownplace,thisplaceisdividedintosmallerplots,andwithinthoseplotseverypersonhashisorherownplot.Acooperativeismadeupoutofdifferentcategoriesofpersons.Forexample,therearealsocommunityhealthworkerswhoareamemberofacooperativeworkingasafarmer.Withinthecooperativethosecommunityhealthworkershelpthemtounderstandandtofightagainstmalariabyillustratingthemeasuresthatareusedsoastofightagainstit.

5.1.2DistrictLevelAtthedistrictlevelthereisoneactorrelatedtomalariapreventionand

controlinRuhuha,whichistheNyamataDistrictHospital.

NyamataDistrictHospitalTheroleofthedistricthospitalistosupervisethehealthcentersandthe

communityhealthworkers.Thedistricthospitalisinbetweenthecommunitylevelandthenationallevel.Theheadofthedistricthospitalexplainedthattheyashealthprofessionalsconnectthecentralleveltothelocalauthority,becausetheyhavemoreknowledgeaboutmalariacomparedtothehealthprofessionalsatthecommunitylevel.ThedistricthospitalforexampleworkstogetherwithRBCtotrainthehealthprofessionalsfromthehealthcentersandcommunityhealthworkers.Furthermore,thedistricthospitalhasadistrictpharmacythathasamandatetodistributedrugsinruralareastothehealthcenterpharmacies.

5.1.3NationalLevelOnthenationalleveltherearetwomajoractors,whicharetheRwanda

BiomedicalCenter(RBC)andtheNationalHealthInsuranceScheme.

RwandaBiomedicalCenterTheRwandaBiomedicalCenterisundertheMinistryofHealth.Theyhave

amalariadivisionandanationalmalariacontrolprogram.TheRwandabiomedicalcenterhasdifferentrolesregardingmalariapreventionandcontrol.

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Thefirstroleistoensureprevention,treatmentanddiagnostics.InJanuary/February2017theydistributedbednetscoveringeachhousehold.Afterthedistributionofthesebednetstheydidnotfindadeclineofmalaria.Theydonotknowwhathappened.Furthermore,withintreatmenttheyalsousesprayingthehighburdendistrictasastrategy.Theyidentifiedeighthighburdendistricts,butonlysprayedfiveofthesedistrictsbecausetheydidnothaveenoughresourcestosprayalleight.Themosquitonetsandsprayingofhousestargetindoortransmissions.Fortreatmentanddiagnosticstheyarenowensuringtreatmentanddiagnosticofmalariatargetingallgroupsofage.ThesecondroleisoftheRwandanBiomedicalCenterisbehaviorcommunicationchange.Theyworktogetherwithlocalgovernmenttoensurebehavioralcommunicationchangefortreatmentandpreventionofmalaria.Theselocalgovernmentstakeholderstaketheleadinsensitizationandmobilizationtowardsbehaviorcommunicationchange.Thethirdroleismonitoringandevaluation.Formonitoringandevaluationtheyhavemonthlyreportstomonitorthenumberofmalariacases.ThefourthroleoftheRwandabiomedicalcenterisoperationalresearch.Theyconductoperationalresearchintermsofprevention,casemanagement,andinnovationsfortesting,preventionandtreatment.Thefifthroleismalariacontrol.TheRwandaBiomedicalCenterusedtohaveagoaltoeliminatemalariaby2017.However,nowinthenewstrategicplanfrom2013to2020theyhaveagoaltocontrolmalariaandtoreducethemalariaburden,becausetheyfoundoutthatmalariaeliminationisnoteasyastheyneedtomobilizemoreresources.

NationalHealthInsuranceSchemeTheNationalHealthInsuranceSchemehasdecentralizedservicesto30

administrativedistrictsinRwanda.ThismeansthatateveryadministrativedistrictthereisanRSSB(RwandaSocialSecurityBoard)branchwheremostoftheservicesareprovided.Forthecommunitybasedhealthinsurance,theyhaveanofficeoftwopeopleateveryhealthcenter.Intheseofficesathealthcenterscommunitymembersreceivetheirmembershipcards.Communitymembersalsogotothisofficewhentheywanttobetreated,theyarethengivenamedicalformandtheycanenterthehealthcenter.AccordingtotheintervieweefromtheNationalHealthInsuranceSchemeabove90%oftheRwandanpopulationhavemedicalinsurance.TheNationalHealthInsurancereimburseswhatisnotgivenforfreebythegovernment.Forexample,mosquitonetsandindoorresidualsprayingarenotreimbursedbecausethegovernmentprovidesthesemeasuresforfreetothecommunitymembers.Ifacommunitymemberfallssickthentheconsultation,laboratoryexamination,andmalariadrugsarepaidbytheinsurance.However,themalariadrugsaresubsidizedbythegovernmentanddevelopmentpartners,tomakethemaffordableforinsuranceinstitutionsorforthosewithoutamedicalinsurance.

Insummary,themostimportantactorsrelatedtomalariapreventionandcontrolinRuhuhaarethecommunityhealthworkers,CMATs,pharmacies,healthcenter,districthospital,andtheRwandaBiomedicalCenter.Theseareactorsinvolvedindiagnosing,treatingpatients,andmobilizingawarenessaboutmalariapreventionandcontrolmeasures.Inaddition,thereareotheractorssuchasthelocalleaders,religiousleaders,andschoolswhoplayaroleatraisingawarenessandknowledgeaboutmalariapreventionandcontrolmeasuresin

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Ruhuha.Furthermore,theNationalHealthInsuranceSchemeistheretoprovideinsurancesandreimbursecostsofconsultation,laboratoryexaminationandmedicinestothosewhohaveinsurance.Moreover,thecommunitymembersmostimportantroleistofollowtherulesandregulationsregardingmalariapreventionandcontrolinRuhuha(moreinformationaboutthisin5.6.1).

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5.2Informationandcommunication:actors,flowsandchannelsTheprevioussectionintroducedtheactorsinmalariapreventionand

controlinRuhuhaandidentifiedtheirrole.Thissectionanalyzestheinformationandcommunicationflowsbetweentheseactorsandthechannelsusedtosendorreceiveinformation.Firsttheinformationandcommunicationflowsbetweenactorsareanalyzed.AfterwardstheroleofICTsinmalariapreventionandcontrolinRuhuhaisdescribed.

5.2.1InformationandcommunicationflowsbetweenactorsThissub-sectionanalyzestheinformationandcommunicationflows

betweenthestakeholdersrelatedtomalariapreventionandcontrolinRuhuha.FriedmanandMiles(2006)describethatRowley’snetworktheorycanbe

usedtomapstakeholdernetworks.Anetworkmapsinteractionsthatexistinstakeholderenvironments.Networkdensityandcentralityofstakeholdersareusedtoanalyzenetwork.Densityismainlyabouttheinterconnectednessbetweenstakeholders.Thecentralityshowsthepositionofastakeholderinthenetworkrelativelytootheractors.Whendensityincreasesthecommunicationbetweenstakeholdersimprovesanditislikelythatsharedexpectationsandbehaviorincreases.Themorecentralthepositionofastakeholderinanetwork,themorepowerthestakeholderhastoinfluence(ibid).Asdescribedearlier,thestakeholderenvironmentinthecaseofmythesisareactorsinvolvedinthepreventionandcontrolofmalariainRuhuha.Thefollowingmap(figure3)showsanetworkmapoftheinformationandcommunicationflowsaboutmalariabetweentheseactors.Italsoshowshowinformationisshared,eitherface-to-face,bymobilephone,SIScom,HMIS,radioorvideoprojections.

Figure3:Informationandcommunicationflowsaboutmalariabetweenactors

Ascanbeobservedfromfigure3,thecommunitymembershavethehighestdensityandthemostcentralpositioninthenetwork.Thismeansthattheyareinvolvedininformationandcommunicationflowsaboutmalariawiththemajorityofotheractors.Onthecommunitylevel,thehealthcenter,localleaders,andcommunityhealthworkersalsohaveahighnetworkdensity.Asdescribedinthestakeholderanalysis,thedistricthospitalconnectsthecentralleveltothelocalauthority.Thenetworkconfirmsthisbecausethedistricthospitalhasinformationandcommunicationflowstobothnationalandcommunitylevelactors.Inaddition,thedistricthospitalalsohasarelativelyhigh

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networkdensityandmainlycommunicateswithhealthrelatedactors.Nexttothedistricthospital,thecommunityhealthworkersandthecommunitymembersalsohaveinformationandcommunicationflowsaboutmalariatoandfromactorsfromalllevels.Ascanbeanalyzedfromthenetwork,therearebothhealthandnon-healthrelatedactorswithalownetworkdensity.Thismeansthatthehealthrelatedactorsdonotnecessarilycommunicateorshareinformationaboutmalariawithahigheramountofactorscomparedtonon-healthrelatedactors.Stakeholdersthathavearelativelylownetworkdensityaretraditionalhealers,ricecooperatives,religiousleaders,CMATs,MEPR,privatepharmaciesandthenationalhealthinsurancescheme.AccordingtoFriedmanandMiles(2008),thismeansthatthereislimitedcommunicationandthereforelimitedcooperationwiththeseactorstopreventandcontrolmalaria.However,thenetworkdoesnotillustratedataaboutthefrequencyofcommunicationandquantityandqualityofinformationflowsaboutmalariabetweenactors.Therefore,actorswithalownetworkdensitymightstillhaveanimportantroleandcouldstillbeeffectiveininfluencingperceptionsandbehaviorregardingmalariapreventionandcontrol.Moreaboutthisisanalyzedinsections5.3and5.4.

InformationflowsinmalariapreventionandcontrolinRuhuhaarefacilitatedbyface-to-facecommunication;communicationusingmobilephonestocall,tosendtextmessages,toaccessradio,andtoaccesssocialmedia;reportsusingSIScom;reportsusingHMIS;andcommunicationthroughradioandvideoprojections.Table4givesanoverviewofhowthesecommunicationchannelsareusedacrossthedifferentlevels.Table4:ICTchannelsusedinmalariapreventionandcontrolinRuhuhaacrosslevels Tocommunity Todistrict TonationalFromcommunity

Face-to-face,mobilephone,SIScom

Face-to-face,mobilephone,HMIS

Mobilephone

Fromdistrict Face-to-face,mobilephone

Onlyoneactorincludedondistrictlevel

Face-to-face,mobilephone,HMIS

Fromnational Mobilephone,radio,videoprojections

Face-to-face,mobilephone

Face-to-face,mobilephone

Asillustratedintable5theICTsusedonthecommunitylevelareSIScom

andHMIS,whichareusedtoreportfromthecommunityhealthworkerstothehealthcenterandfromthehealthcentertothedistricthospital.Furthermore,face-to-facecommunicationisusedacrossalllevelsexceptbetweenthecommunityandnationallevel.OtherICTssuchasmobilephone,radioandvideoprojectionsareusedforcommunicationflowsfromthenationaltocommunitylevel,whilefromthecommunitytothenationallevelonlymobilephonesareusedasacommunicationchannel.Regardingthesimilaritiesanddifferencesbetweenhowstakeholderschoosetocommunicate,MEPR,traditionalhealersandricecooperativesonlycommunicateaboutmalariaface-to-facewithotherstakeholders.Allotheractorsalsousemobilephonesnexttoface-to-facecommunicationtoshareorreceiveinformationaboutmalaria.

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Thefollowingsub-sectionsexplaintheinformationandcommunicationflowsofthenetworkinmoredetail,startingwiththecommunitylevelactors,andthenthedistrictlevelactorfollowedbythenationallevelactors.

5.2.1.1Communitylevel

CommunitymembersThecommunitymembershavethehighestdensityandthemostcentral

positioninthenetworkofinformationandcommunicationflows.Thecommunitymemberscommunicatewithlocalleaders,privatepharmacies,thehealthcenterpharmacy,communityhealthworkers,thehealthcenter,andthenationalhealthinsuranceschemebymobilephoneandface-to-face.Inaddition,theycommunicatetoreligiousleaders,personsfromthemalariaeliminationprogram,andthedistricthospitalface-to-face.Theseinformationandcommunicationflowsareexplainedmoredetailedintable5below.Table5:ExplanationinformationandcommunicationflowsfromcommunitymembersFromortowhichactor

Occasionwhentheycommunicateaboutmalaria

Whattheinformationisabout

Face-to-faceAmongcommunitymembers

Athomewhenthereisavisitor,withintheneighborhood,withfriends,duringculturalevenings,duringspecialevenings(eveningsforadultstotalkaboutsocietalproblemsandproblemsintheirlives),whensomeoneissufferingfrommalariawithinthehousehold,orwhenapersoninthevillagehasdiedofmalaria.

Mosquitonetsandotherpreventionmeasures,wherethisepidemiccomesfrom,andwhyisitdifferentfromthepreviousone.Furthermore,theyalsodiscussthatthetreatmentdoesnotlastlong,forexampleifIgetmalariaitcomesbackafteronemonthortwoweeksandtheyadviseeachothertogetmoreknowledge.

Localleaders Whenevercommunitymembersaregatheredinmeetingswiththelocalleaderstheytalkaboutmalariaface-to-face.Examplesareduringvillagemeetingsorattheendofthemonthlypublicwork.Attheendofpublicworkthecommunitymemberssittogetherandtheleaderstalkaboutdifferentwaysofpreventingagainstmalaria.

Duringthesemeetingscommunitymembersdiscussandreportproblemssuchasmalaria.

CommunityHealthworkers

Thecommunitymemberscommunicateaboutmalariawithcommunityhealthworkersface-to-faceduringmeetingsandhomevisits.Therearemeetingswherethecommunityhealthworkershaveaspecifictimewhentheytalkaboutmalariatocommunitymembers.

Duringthesemeetingsandhomevisitsthecommunityhealthworkersteachandadvisecommunitymembersabouthowtopreventmalariabyremovingstagnantwaterthatsurroundsthehouse,tosleepinmosquitonetsduringthenight,toclosewindowsduringtheevening,tocutdowntrees,andbycleaningmosquitobreedingsites.Furthermore,thecommunityhealthworkerstellthecommunitymemberstheconsequencesofmalaria,toreachthehealthcenterearlywhentheyseesignsofmalaria,andaboutthepeopleatrisk.Thecommunityhealthworkerstellthemthat

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especiallyyoungkidsandpregnantwomenarevulnerablegroups,althougheveryoneisatrisk.

Healthcenter Thecommunitymemberscommunicatewiththehealthcenterface-to-facewhentheycomeformedicaltreatmentatthehealthcenter.Beforeconsultationsthenursesgatherthepatientsandtheysittogethertotalkabouthowtheycanpreventmalaria.Furthermore,thehealthcenterstaffoccasionallyalsogoestothevillagestodiagnosecommunitymembersusingrapiddiagnostictest.

Whencommunitymembersaregatheredatthehealthcenterbeforebeingtreatedthehealthcenterstafftalkstothemabouthowtopreventmalaria.Furthermore,wheneverthehealthcenterstafffindsapersonsufferingfrommalariawhenusingrapiddiagnostictestsinthevillagestheyreferthesecommunitymemberstothehealthcenter.

MEPRresearchers

CommunitymembersexplainedthattheMEPRresearchersusedtocomewithfumigationthatwasgiventocommunitymemberswhoarefarmersofrice.

Ontheseoccasionstheywouldtalkaboutthefumigation.Thisfumigationwastopumpintheswampswherericeiscultivatedsoastokillmosquitos.

Religiousleaders

Thecommunitymemberscommunicateaboutmalariaface-to-facewithpriestsduringchurchservices.

Apriestsometimesasksduringmasswhatisnowadaysoccurringandthencommunitymemberstalkaboutmalaria.Duringmasspriestscanalsogiveexamplesofcommunitymemberswhoweresufferingfrommalariabyexplaininghowsuchpersonrecoveredfrommalariabecauseofattendingthehealthcenter.

Districthospital

Whenacommunitymemberistransportedtothedistricthospitaltogettreatedmalariainaseverestage.

Aboutthediagnosisandtreatment.

MobilephoneAmongcommunitymembers

Tocallothercommunitymemberstoaskforhelpwhensufferingfrommalaria.Theyalsoreceiveinformationregardingmalariabyaccessingsocialmediathroughtheirmobilephones.Onecommunitymemberbetween18-35yearsmentionedshereceivesinformationaboutmalariafromsocialmediaplatformssuchasFacebookandWhatsApp

ShementionedtheinformationgotfromFacebook,WhatsApp,andInternetisveryimportantforthemsoastobeawareofmalariaandhowitisprevented.Mostofthetimethisinformationfromsocialmediacontainmessagesthathelppeopletoknowthesignsofmalaria,thecausesofmalariaandthewayofpreventingagainstmalaria.

Localleaders Whenanymosquitobreedingsiteisobservedwithinthevillagecommunitymembersusemobilephonestocalllocalleaders.

Bycallinglocalleadersthecommunitymemberscanindicatethemosquitobreedingsitessothattheycanprovidesupportandorganizecommunityworktocleanthemforexampleduringpublicwork.

Communityhealthworkers

Thecommunitymembersalsousemobilephonestocallcommunityhealthworkerswheneverthereisacaseofmalariawithinthehousehold.Accordingtocommunitymembersallpersonsinavillagehavethephonenumberofacommunityhealthworker,sowheneverthereisamalariacasetheycallthem.

Communitymemberscallcommunityhealthworkerstoaskforhelpandtogetmedicineswhentheysufferfrommalaria.Thereasonforcallingistosavetime.Forexample,thecommunityhealthworkermightbewithoutmedicinessotheycallfirsttocheckandmakeadecisionofreachingthecommunityhealthworkersor

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healthcenterdependingontheavailabilityoftreatment.

Healthcenter Communitymemberscallthenursesfromthehealthcenterwhentheyaresickandwhentheywanttoaskforinformationoradvice.Thissavestimeinsteadofgoingtothehealthcenter.

Communitymemberscallnursesfromthehealthcentertotellthemsignsofwhattheyaresufferingfromsoastogetadviceonwhattodo.Theyalsocallthehealthcentertoaskforinformation,forexamplewhethertotaketheseconddoseafter10or12hours.

Nationalhealthinsurancescheme

Whentheyneedinformationaboutthehealthinsurance.

Anyquestionrelatedtothehealthinsurance.

RadioRBC Communitymembersreceive

informationthroughtheradio.AccordingtoacommunitymembermostRwandanshaveportableradiosorlistentotheradiousingausemobilephone.Duringaninterviewwithacommunitymemberstheresearchassistanttranslatedanexample:‘Andhehasalsoillustratedanotherroleoftelephonewherebyhehasexplainedthatphoneisnowadayshelpinghimtogettolistentotheradio.Hemayusephonesoastoturnonradio’.Thisexampleshowsthatcommunitymembersusemobilephonestoaccessradio.EveryWednesdayat7amthereisaradioshowwheretheyinviteaguesttotalkaboutmalaria.DuringthisradioshowlistenerscansendfreeSMStextmessagesorcanmakeafreecalltoaskquestions.Accordingtocommunitymemberstherearealsoadvertisementsontheradiothatcommunicateinformationaboutmalaria.

Thequestionsaresendbycommunitymemberstotheradioprogramarewrittendownandareansweredduringtheradioshow.Duringtheinterviewacommunitymembertheresearchassistanttranslated:’Themessagethatistransmittedthroughthisradioprogramisbrief.But,thisprogramtalksaboutthewayofpreventingagainstmalariawherebytheyexplainhowmosquitonetsareused.Explainingthatwheneverproductsthatarespecializedatgivingmosquitosareexpiredwithinmosquitonets,youaddothers.Whenevermosquitonetisexpired,whenevermosquitonetisnotfunctioningwellorhasexpiredyouhavetoreportandgetanewone.Andwhattheytalkaboutalsois,whattheyalsoexplainduringthisradioprogramtheyalsoexplainthewayofremovingthisstagnantwater,cuttingdowntrees,cuttingdownbushes,andhavinghygienicconditionswithinhouseholdssoastofightagainstthismalaria’.Thisstatementshowsthatwhenlisteningtotheradioshowcommunitymembersreceiveinformationaboutmeasureshowtopreventmalaria.Furthermore,theadvertisementsforexamplecommunicateinformationregardingthesymptomsofmalaria,toreachthehealthcenterintimefordiagnosingandtreatment,andhowbednetsshouldbeused.

VideoRBC Onseveraloccasionscommunity

membersreceiveinformationviavideosorplays.Firstofall,onTuesdaysandFridaysthereisanopenmarketinRuhuha.OnthismarkettheMinistryofhealthortheRwandanBiomedicalCenterprojectatelevisionshowwithaprojector

Thesevideosshowpeoplewhohavebeenattackedbymalariacomparedtopeoplewhohavenotbeenattackedbymalariabecauseofpreventionmeasuresthattheyused.

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aboutmalaria,HIVandotherdiseases,andabouttheworkofcommunityhealthworkers.Inaddition,sometimescommunitymembersareshowedvideosatthesectorsoffice.Moreover,therearemeetingsinvillageswhereinactorsperformaplaythatexplainsaboutmalariatoinformcommunitymembers.Lastly,therearealsotheatersontelevisiontoinformcommunitymembersmoreaboutmalaria.

Asillustratedinthetableabove,communitymembersmainlycommunicateface-to-faceandthroughmobilephoneswithcommunitylevelhealthandnon-healthrelatedactors.Moreover,theycommunicateface-to-facewiththedistricthospitalwhenbeingtreatedthere.Inaddition,theycallthenationalhealthinsurancewhentheyhaveanyquestionregardingtheirinsurance.

CommunityHealthWorkersThecommunityhealthworkerscommunicatewithothercommunity

healthworkers,communitymembers,thehealthcenter,thedistricthospital,andRBC.Theseinformationandcommunicationflowsareexplainedinmoredetailintable6below.Table6:ExplanationinformationandcommunicationflowsfromcommunityhealthworkersFromortowhichactor


Whatthecommunicationisabout

Face-to-faceandmobilephoneCommunitymembers

Theytalkaboutmalariaduringdifferentmeetingswhencommunitymembersaregathered.Theseoccasionsincludemeetingsheldatvillagelevel,afterpublicwork,withinCLUB,duringmeetingsofcooperativesandduringspecialevenings.Furthermore,theytalkaboutmalariawithcommunitymemberswhentheygodownintothevillagestovisithouseholdstocountthenumberofbedsandtocheckifcommunitymembersfollowtherulesandregulations(moreabouttheserulesandregulationsinsection5.6.1).Inaddition,communitymemberscallthemincaseofanemergencyorwhentheyhavequestionsregardingmalaria.

Duringthesemeetingstheymainlytalkaboutdifferentmeasuresoffightingagainstmalariaandhowtousethem,theyexplaindifferentsignsofmalaria,theyalsoencouragecommunitymemberstogetmedicalinsuranceontime,andtheyinformcommunitymembersaboutwhatcausesmalaria.Furthermore,duringaninterviewwithacommunityhealthworkertheresearchassistanttranslated:‘Theyhavetelephonestheyusewithintheirdailywork.Andthesetelephoneshelppeopletoreceiveinformationaboutmalaria.Andallpeoplewithinavillage,allpeople,havetheircontact.Havethecontactofthecommunityhealthworkerssoastocallthemanytimetheymeetanemergency’.

CMATs Thehealthcenterisanindicatorofthesituationregardingmalaria,becausetheynoticewhenmalariaisincreasing.Whenevermalariahasbeenfoundincreasingwithinthehealthcenter,thehealthcentercalls

Afterinformingthemabouttheincreaseofmalaria,thecommunityhealthworkersgoandcommunicatetotheCMATs.ThenafterinformingthemtheCMATsinformthecommunitymembersaboutthenews.Thismeans

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thelocalleadersandthecommunityhealthworkerstoinformthem.

thatthehealthcentercommunicatestothecommunityhealthworkersandthecommunityhealthworkerscommunicatetotheCMATs.

MobilephoneOthercommunityhealthworkers

Communityhealthworkersuseamobilephonetocallothercommunityhealthworkers.CommunityhealthworkershavefreenetworkpaidbytheMinistryofHealth.Therefore,wheneverapatientreachesacommunityhealthworkerandtherearenomedicines,thiscommunityhealthworkercancallanothercommunityhealthworkertoaskwhetherheorshehasmedicines.

Theresearchassistanttranslatedthatacommunityhealthworkersexplained:’Phonehasplayedagreatroleinbattlingmalaria.Wherebywheneverpatientreachescommunityhealthworkerssoastobesupported,soastobecured.Whenevertherearenomedicalmentsnomedicationsarenotaccessible.Sheorhemaycallimmediatelytheothercolleaguebyaskingwhethertherearemedicalments.Thenmedicalmentsmaybegained,maybegotbyusingphone’.

RapidSMSandSIScomHealthcenter,districthospital,RBC

Thecommunityhealthworkersreportthroughmobilephones.ThetextmessagesthattheyusetoreportarecalledrapidSMS.WhenapatientissufferingfrommalariaandshowingdangeroussignstheyuserapidSMStoreportthem.TheserapidSMSmessagesaresentimmediatelywhenthecaseisthereandaresentfreelytotheMinistryofHealth.Acopyofthemessagesissendtothedistricthospitalandthehealthcenter.Inothernotseverecasesofmalaria,thecommunityhealthworkersuseasystemcalledSIScomtoreport.TheyuseSIScomtoreportthenumberofcasesthattheytreatedweekly.Thisisanotherchannelofgivingreportsusingbookregisters.Theygivethisbookregistertothedatamanagerfromhealthcenters.ThenthedatamanagerofthehealthcenterentersthesereportsintoHMISandtheysendittothecentrallevel.

Duringaninterviewwithacommunityhealthworker,theresearchassistanttranslatedthecontentoftheserapidSMSmessages:‘Themessagethattheysendtoministryofhealth.Themessagesissendbyusingtheircodes.Therearesomecodes.Thereisonelineatministryofhealth.But,aslongastheyfacilitatethosedifferentpersonswhoarenowsufferingfromdifferentsicknesses.Thereisacodethatsheputsatmalaria.Andthereisalsoacodethatsheputsatammonia.Thosecodesarenotthesame.SoastomakethosepeoplefromMinistryofHealthnoticetherealsickness.Soitmeansthattheirmessagecontainsthesicknessthathasbeencured,thesignsofthepatient,themedicalmentsthatweregiventothepatient,andthestageofwhichthepersonifthepersonwastotalsufferer.Wasatagreatlevelofsuffer.Andifthepatientwasatalowerstageofsuffering.Ya.Themessagecontainsthose’.AfterreportingthatthereisapatientbeingtreatedattheirlevelbysendingtherapidSMS,innotmorethanthreedaysthecommunityhealthworkersreceiveatextbackaskingwhetherthepatientisstillsuffering,sotheyreceiveinformationfromtheMinistryofHealthaskingaboutthesituation.

Theexamplesinthetableaboveshowthatmobilephonesplayarolein

savingtimeandtoaskforinformationquickly.Furthermore,theyshowthatcommunitymembershavethephonenumbersofthecommunityhealthworkersandthatmobilephonesplayanimportantroleincaseofemergencies.

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HealthCenterThestaffofthehealthcentercommunicatesaboutmalariawith

communitymembers,communityhealthworkers,localleadersandthedistricthospital.Theseinformationandcommunicationflowsareexplainedinmoredetailintable7below.

Table7:ExplanationinformationandcommunicationflowsfromthehealthcenterFromortowhichactor



Face-to-faceCommunitymembers

Thestaffofthehealthcentertalksface-to-facetocommunitymembersaboutmalariaonseveraloccasions.Firstofall,inthemorningstheygatherpatientsthathavecomeformedicaltreatmenttogivetheminformationregardingdifferentsicknesses.Inaddition,theheadofthehealthcenteralsoexplainedthatbecauseofdecentralizationtheworkersofthehealthcentergodowntolocalareastodiscusssicknesseswithcommunitymembers.Forexample,thenursesofthehealthcenterattendmeetingswithcommunitymembersthatareheldatcell.Furthermore,attheendofthemonthlypublicworkstaffofthehealthcenterinformscommunitymembersaboutmalaria.Thismeansthatwheneverpeoplearegatheredthehealthcentertakestheoccasiontoinformpeopleaboutdifferentdiseases.Furthermore,thehealthcenterstaffalsotalksaboutmalariatocommunitymemberswithinlocalareaswheretheylive.Thehealthcenterworkersalsotalkaboutmalariaintheirfamilieswherebytherearealsopeoplewhoareattackedbymalaria.

Duringthesemeetingstheydonotonlytalkaboutmalaria,theyalsotalkaboutotherdiseases.However,oftentheytalkaboutmalariaasitisatagreatlevelcomparedtootherdiseases.Mostofthetimetheinformationdiscussedisaboutmalariaasmalariahasbecomeepidemicwithinthisregion.Astheyarestaffofthehealthcenter,thepeopleoftenvisitthemtotalkaboutmalaria.Communitymemberscomeandaskthemmoreinformationregardingtomalaria.Theyinformthemastobeawareofmalariaandtellingthemdifferentmeasuresoffightingagainstmalaria.

Face-to-faceandmobilephoneLocalLeaders Thehealthcentercommunicates

withlocalleadersface-to-faceandbymobilephone.Thehealthcentercommunicatestothelocalleadersbymobilephonewhentheywanthelptogathercommunitymembersforameeting,sothatthehealthcentercaninformthemaboutcurrentissuesregardinghealth,includingmalaria.

Thelocalleaderdiscusseswiththehealthcenteraboutthenumberofcommunitymembersthatsufferfrommalariaareattendingthehealthcenter,whytheysufferfrommalaria,whatmaybedonetosolvetheproblem,measuresoffightingagainstmalaria,andwheneverpossibletheytalkaboutadvocacytohigherlevelsofleadership.

Face-to-face,mobilephone,andSIScomCommunityhealthworkers

Thehealthcenterstaffcommunicatestocommunityhealthworkersface-to-faceandbymobilephone.Thecommunityhealth

Duringthesemeetingsthehealthcentersharesinformationaboutmalariathatthecommunityhealthworkersneedtoinformthe

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workerssometimeshavemeetingsatthehealthcenterwheretheycommunicateface-to-face.Regardingthecommunicationviamobilephone,thehealthcenterusesaphonetocallcommunityhealthworkersincaseofemergencies,forexamplewhensomeoneescapedfromthehealthcenterwhilesufferingfrommalaria.Inaddition,thehealthcenterreceivesreportsfromthecommunityhealthworkersusingbooks(SIScom).

communitymembersabout.Forexample,whentherearerumorsthatthemedicinesathealthcenterarenolongercuringmalaria.Furthermore,thehealthcenterusesaphonetocommunityhealthworkers.Duringtheinterviewwithahealthcenterstaff,anexamplewastranslatedofwhenacommunitymemberquitsthehealthcenterwhilesufferingfrommalaria:’Thenafterquittingtheyareinchargeofreportingthistothehealthcommunityworkersbycallingtellingthemthatthereissomeonewhoisnowescapinghealthcenter.Butbeingtotallysick.Beingtotallyinbadconditions.Sothosecommunityhealthworkerswillinterveneafterhearingthisinformationbyusingphone.Thenthepersonalsoisbackistransportedalsosoastochecktheelement.Thisisthefunctionthatthephoneisnowplaying’.Inaddition,theSIScomreportscontaininformationaboutthenumberofpatientstheytreatedandwhichillnesses.Thehealthcenteralsoreceivesreportsfromthecommunityhealthworkersaboutthehouseholdsthatneedbednets.

Face-to-face,mobilephone,HMISDistricthospital

Thehealthcentercommunicatesandsharesinformationwiththedistricthospitalface-to-face,bymobilephone,andusingHMIS(moreinformationaboutHMISin5.2.2.2).Furthermore,theyuseamobilephonetocallthedistricthospitalincaseofanemergenceorwhenthereisalackofmedicinesatthehealthcenter.Moreover,thedatamanageratthehealthcentersendsthereportsreceivedbythecommunityhealthworkersandcombinesthisinformationwithreportsfromthehealthcenterandsendsthistothedistricthospitalusingHMIS.ThesereportsfromthehealthcentertothedistricthospitalinHMISarereportedweeklyandthesystemusesInternet.Lastly,theheadofthehealthcenterusesamobilephonetoaccesssocialmediatocommunicateinformationaboutmalariatothedistricthospital.

Firstofall,thereportssendviaHMIScontaintheinformationthatisgatheredviaSIScomfromthecommunityhealthworkers.Thisinformationisaboutthenumberofbednetsneeded,theamountofpatientstheytreatedandotherproblemsrelatedtomalaria.Secondly,theresearchassistanttranslatedthattheinformationthattheheadofthehealthcenterandthedistricthospitalshareviasocialmediaisabout:’Itdependsuponcurrentproblem.Shehasgivenanexamplewherebydistricthospitalmayseethatthereisincreasingincreasementthereisoccumentationofmalariawithincertainlocationcertainarea.Thentheymaycallthesehealthcenters.Arehealthcommunityworkersfunctioningwell?Dotheyhavesomemedicaltreatment?Dotheyhavesomemedicaltablets?Dotheyhave,aretheyequippedwithmaterials?Thenthroughthisway,throughWhatsApp,viaWhatsApptheymaysharethisinformation’.

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Theexamplesinthetableaboveshowthatthehealthcentercommunicatestheinformationthatthecommunityhealthworkersgathertothedistricthospital.Furthermore,theycommunicatetothecommunitymembersandcommunityhealthworkerstospreadinformationaboutmalariasuchasthemalariapreventionmeasures.

HealthcenterpharmacyThehealthcenterpharmacycommunicatesface-to-facewithcommunity

memberswhoaretheirpatients/customersandtothehealthcenter.Furthermore,theyusemobilephonetocommunicatewithcommunitymembers,communityhealthworkersandthedistrictpharmacy.Theseinformationandcommunicationflowsareexplainedinmoredetailintable8below.Table8:ExplanationinformationandcommunicationflowsfromthehealthcenterpharmacyFromortowhichactor




Firstofall,thehealthcenterpharmacycommunicatesface-to-faceaboutmalariaamongtheworkersofthehealthcenterandthepatients(communitymembers)onadailybasis.Furthermore,thehealthcenterpharmacyalsoreceivesphonecallsfromcommunitymembers.

Duringtheinterviewwiththehealthcenterpharmacytheresearchassistanttranslated:‘Telephonesplaysagreatrole.Wherebyapatient,apersonwhohasapatientmaybemotherhasherchildwhoissick.Thismotherwillcallthispharmacistbyaskingmoreinformationandbyaskingmoretellingsregardingtomedicalments,regardingtowhatshemaysoastocureherchild.Thenthispharmacistmaytellhersomemoreinformationbytellingthis:goandlookforsometablets,whicharelikethis,whichareinthiscategory.Thenaftergivingsuchgivingsuchtabletstoyourchildmakeherormakehimreachthishealthcenterassoonaspossible.Thesemedicalmentsareforreducingthepain,thismaybedone’.

MobilephoneDistrictpharmacy

Whenthereisashortageofmedicinesatthehealthcenterpharmacyorwhencommunication/informationsharingisneeded.

Aboutthedistributionofmedicines.


Thehealthcenterpharmacyalsousesamobilephonetoreceivecallsfromcommunityhealthworkers.

Duringtheinterviewwiththehealthcenterpharmacytheresearchassistanttranslatedanexampleofwhattheytalkaboutduringsuchaphonecall:‘YouhavegivenussomemedicalmentsandIamnowdealingwithacaseofmalariawherebyIamnowgoingtocureachildoffiveyears,howdoIprescribemedicalments.Thenafterbeingcalledshewillexplainthisbygivingexplanationtothesecommunityhealthworkerstoknowthemedicalmentsthatcouldbeprescribedtoapatient’.

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Ascanbeseeninthetableabove,thehealthcenterpharmacymainlyusesmobilephonetoadvicecommunitymembersandcommunityhealthworkers.Furthermoretheyuseamobilephonetoexchangeinformationaboutthedistributionofmedicines.

PrivatepharmaciesTheprivatepharmaciescommunicateaboutmalariatotheleadersand

nursesofhealthcentersandtocommunitymemberswhoaretheirpatients.Theseinformationandcommunicationflowsareexplainedinmoredetailintable9below.Table9:ExplanationinformationandcommunicationflowsfromtheprivatepharmacyFromortowhichactor




Theprivatepharmacistscommunicatewithcommunitymemberswhentheycometothepharmacytobuymedicinesorwhentheycallthepharmacytoaskforinformationoradvice.

Duringtheinterviewwithaprivatepharmacisttheresearchassistanttranslated:‘Hehasgivenanexamplewherebypatientmaycallhimtellinghimthatheissufferingfrommalaria.Thenalsoasking,whatkindofmedicationcanbetakensoastocuresuchelement.Thenhe,astheprivatepharmacist,mayadvicesuchpersonviaphone’.

Healthcenter Theprivatepharmaciescommunicatewithhealthcentersviamobilephonetoaskthemforinformationaboutthecurrentsituationregardingmalaria.Furthermore,theinterviewedprivatepharmacistmentionedthatthehealthcenteralsoplaysagreatroleinadvisingtheprivatepharmacies,astheworkersathealthcentersaremoretrainedandmorefamiliarandinformedaboutmalariaandotherkindofillnessescomparedtotheprivatepharmacists.Therefore,therearetrainingsatthehealthcenterwherethehealthcentertrainsandadvisesprivatepharmacies.Thismeansthattheprivatepharmacistsalsoreceiveinformationface-to-faceaboutmalariafromthehealthcenter.

Duringtheinterviewwithaprivatepharmacisttheresearchassistanttranslated:‘Heisgivinganexamplewherebyhemaycallheraskingwhethertherearesomenewmedicationsaboutmalaria.Askingwhetherthereareothernewmedicalments.ArethereothernewmedicalmentswhicharenotCoartem.Oraretheresomenewmedicalmentswhichmayfacilitatemesoastocuremypatients.Andhemayalsocallthisleaderofhealthcenteraskingsomeinformationsoastobegivensomeadvice.Askinghowisthelevelofmalaria?Howisthesituationofmalariawithinyourhealthcentercompared.Becauseweseeherethatmalariaisnowincreasing.Isitthesameasyours?Yaaskingthiskindofinformation’.

Thetableaboveshowsthatprivatepharmacistsusemobilephonesto

advisecommunitymembersandtoaskforinformationfromthehealthcenter.Italsoshowsthatthesepublicandprivateactorsonthecommunitylevelshareinformationineffortstofightagainstmalaria.

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LocalleadersThelocalleadercommunicatesface-to-faceaboutmalariawith

communitymembers,religiousleaders,thehealthcenter,andCMATs.Furthermore,thelocalleadercommunicatesbymobilephonewithcommunityhealthworkers.Theseinformationandcommunicationflowsareexplainedinmoredetailintable10below.

Table10:ExplanationinformationandcommunicationflowsfromlocalleadersFromortowhichactor



Face-to-faceCommunitymembers

Thelocalleadertalksaboutmalariaface-to-facewheneveragreatnumberofcommunitymembersgather.

Thewaysofhowtopreventagainstmalaria.

Religiousleaders

Localleaderaskreligiousleaderstoallowthereadingofadvertisementsaboutmalariaduringmass.

Thelocalleaderwritesadvertisementsthatcontaininformationaboutthecauseofmalaria,howitistransmitted,andhowcommunitymemberscanpreventagainstit.

CMATs WhentheCMATsareinthevillagesspreadingawarenessaboutmalariaanditspreventivemeasures.

Themalariapreventivemeasures.

MobilephoneCommunitymembers

Communitymemberscallthelocalleadertoinformhimaboutcurrentnewswithinthearea.

Theycalltodiscussnewsandthesituationregardingmalaria.


Thelocalleadercommunicateswithcommunityhealthworkerstoaskaboutthesituationregardingmalariabycallingthem.

Duringtheinterviewwithacommunityhealthworkertheresearchassistanttranslated:’Ortheleaderofacellmaycommunicatetothemaskingcurrentinformation.Howarepatientswithinlocalareas.Howareyoutreatingtheirillnesses.Howareyou,areyounowgettingmanytablets.Whataretheproblemsnowareyousufferingfrom.Thoseare,thisistheactivity,thisisthemessagethattheygiveeachotherwhilecalling,whileusingtheirphones’.

Religiousleadersandhealthcenter

Duringtheinterviewwithalocalleadertheresearchassistanttranslated:‘Yestheyworkhandinhand.Eithertheleaderofcell,executivesecretaryofacell,priestorthesetheleaderofthishealthcenter.Nomonthwhichtheycantgooveronemonthwithouttalkingeachother.Theycommunicateeachothertalkingaboutthecurrentproblems.Mostofthetimemalariaandalsosharingideasaboutthemedicalmentsthatarebeinggiving.Theycalloneanother’.

Duringthesephonecallstheytalkaboutthenumberofcommunitymembersthatareattendingthehealthcentersufferingfrommalaria,whydotheysufferfrommalaria,whatistheproblem,whatmaybedonetosolvetheproblem,theydiscussmeasuresoffightingagainstmalaria,andwheneverpossibletheytalkaboutadvocacytohigherlevelsofleadership.

Ascanbeseenfromthetablebelow,thelocalleadersareincontactwiththehealthcenterandcommunityhealthworkerstobeuptodateaboutthe

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currentsituationregardingmalaria.Thelocalleadersneedtobeuptodateastheyaddressmalariaandthepreventivemeasureswhenevercommunitymembersgatherandbecausethecommunitymalariaactionteamsfallunderthelocalleaders.

CooperativesMembersfromricecooperativescommunicateaboutmalariaface-to-face

withothermembersfromricecooperativesandtheyusetheirmobilephonestocallwithpeopleinotherareasinRwanda.Theseinformationandcommunicationflowsareexplainedinmoredetailintable11below.

Table11:ExplanationinformationandcommunicationflowsfromcooperativesFromortowhichactor



Face-to-faceOthermembersofthecooperative.

Withinthericecooperativescommunitymemberstalkaboutmalariaface-to-facetoothermembersofthecooperativeswhiletheyarecultivatingrice.

Forexample,thereisatimeoneoftheirneighborswithinaswampisattackedbymalariaandisnownotcultivatingandtheytalkaboutit.Thetranslatormentionedthatamemberofacooperativeexplained:‘Whattheytalkaboutitisthatmalariahasbecomeanepidemic.Ithasincreaseditsforces.Ithasexceeded,ithasgonebeyondtopasttimes.Pasttimesapersoncouldbeattackedbymalariaoneadayduringfiveyears.Oroncefiveyears,butnowadaysmalariacannotattackmostofthepeoplemonthlyortwiceduringthemonth.Sotheytalkaboutitandtheytrytoillustratetoexplainthatmalariahasgonebeyondtheirimagination’.

MobilephonePeopleinotherareasinRwanda

Amemberofricecooperativementionedthatshesometimescallspersonsfromthesouthprovincetotalktothemaboutmalaria.

Thesepersonsfromthesouthernprovinceimmediatelybecomesurprisedaskingwhysheissufferingfrommalaria.Theytellherthatsheissufferingfrommalariabecausespendsalotoftimeintheswampwhereshecultivatesrice.Thismemberofthecooperativementionedthatshetellsthemthisisnotthereason,becauseherchildrenwhodonotreachtheswamparealsosufferingfrommalaria.Itisinsuchprocesswherethemembersofricecooperativediscussinformationaboutmalariaonphone.

Thetableaboveshowsthatthemembersofacooperativecommunicateaboutmalariaineverydaysituationsandthattheydiscussaboutthecurrentsituationregardingmalaria.

CommunityMalariaActionTeams(CMATs)Thecommunitymalariaactionteamstalkaboutmalariaondifferent

occasionssuchasvillagemeetingsandafterpublicwork.Theysensitize

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communitymemberstoreachthehealthcenterearlywhenevertheyareattackedbymalaria,toknowtherolesoflayinginmosquitonets,toclosewindowsduringtheevening,andtheyplayagreatroleatinformingpeopletoacceptpersonswhoareinchargeoffumigatingintotheirhouses,andinexplainingcommunitymemberstoremovestagnantwaterandbushesaroundthehouses.Therefore,thecommunitymalariaactionteamscommunicateface-to-faceaboutmalariawithcommunitymembers.

Furthermore,thecommunitymalariaactionteamscommunicateface-to-faceandbymobilephonewithlocalleadersandcommunityhealthworkers.Theyusemobilephonestocommunicatetolocalleaderstoshareinformationaboutmalaria.Furthermore,theyusemobilephonestocallcommunityhealthworkerstobegiveninformationregardingmalaria.Moreover,theyalsocallothermalariaactionteamsinothersectorswherethereisalowerrateofmalariatoaskinformationonwhattheydidtoreducethemalariaburden.

TraditionalHealersThetraditionalhealersreceiveinformationaboutmalariaface-to-face

fromthehealthcenterandfromthedistricthospital.Thetraditionalhealerthatwasinterviewedmentionedtherearetrainingsorganizedbythehealthcenterwheretraditionalhealersareinformedabouthowtofightagainstmalaria.Duringthesetrainingstheyaretaughthowtousemosquitonets,howtoremovestagnantwateraroundthehouse,andaboutothermeasuresthataretheretofightagainstmalaria.Furthermore,theheadofthedistricthospitalmentionedthattheysometimeshavemeetingswiththetraditionalhealers.

ReligiousleadersThereligiousleaderscommunicateface-to-facewiththehealthcenterand

thecommunitymembersaboutmalaria.Apriestgaveanexampleofasituationwhenhetalksaboutmalariawithacommunitymember:

‘YeswhenImeetwiththosepeoplewhosufferfrommalaria.Italkaboutwiththemandaskingthemwhattheyaresufferingandwhatreasonsoftheirsufferings.Andwhytheydidn'tdosomeprotection’.

Thisexampleshowsthatprieststalkaboutmalariawithcommunitymembers.Priestsalsooccasionallytalkaboutmalariaduringmass,forexamplewhencurrentproblemsarebeingdiscussedorwhenpriestsareaskedtoencouragecommunitymemberstobuyhealthinsurances.

MalariaEliminationProgram(MEPR)Themalariaeliminationprogramisnolongeractive.Theresearchproject

anditsinterventionshaveended.Theresearchersusedtocommunicateface-to-facetocommunitymembers,thehealthcenterandricecooperatives.

SchoolsTeachersatprimaryschoolscommunicateaboutmalariaface-to-faceto

theirstudents.Theyareresponsibleforteachingchildrenhowmalariaattackspeople,howitispreventedandhowtheymayhelptheirneighborsandfriendstoknowhowtofightagainstmalaria.Theinformationthatistaughttothestudentsaboutmalariaisfromdifferentbooksofdifferentsubjects,suchasbooksfromsocialstudies,Kinyarwanda,EnglishandScience.Thebooksofthese

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subjectscontainsomechaptersthatareaboutmalaria.Furthermore,duringtheinterviewwithateachertheresearchassistanttranslated:

‘Theyusemobilephone,theyusemobilephoneseitheramongteachersamongthemselves.Oreitheramongatutorofanyclasscallingcommunityhealthworkersoastocometoschoolwhencommunityhealthworkerlivesnearbytheschool.Theremaybeanincident,therewillbeincidentwhereachildmaybecomesick.Immediatelyafterbecomingsickateacherlooksdifferentmeasuresofhelpingpatient.Thensheorheastheteacherhemaycallorshemaycallsuchcommunityhealthworkersoastocometoschooltohelpachild’.

Thisstatementshowsthatschoolsusemobilephonetoreachcommunityhealthworkerswhenachildissufferingfrommalaria.

5.2.1.2DistrictLevel

DistrictHospitalTheNyamatadistricthospitalcommunicatesaboutmalariawiththe

RwandaBiomedicalCenter,thehealthcenter,healthcenterpharmacy,localleadersandtraditionalhealers.Theseinformationandcommunicationflowsareexplainedinmoredetailintable12below.Table12:ExplanationinformationandcommunicationflowsfromthedistricthospitalFromortowhichactor



Face-to-faceLocalleaders Whentheyobservethatmalariacases

areincreasing.Thedistricthospitalcommunicatesface-to-facewiththeadministrativeandlocalleaderstoensurethatpracticesregardingmalariapreventionandcontrolareinplace,becauselocalleaderscanhelpsensitizethepopulation.

Traditionalhealers

Thedistricthospitalsometimeshasface-to-facemeetingswithtraditionalhealers.

Practicesregardingmalariapreventionandcontrol.

MobilephoneHealthcenterpharmacy

Thedistricthospitalincludesadistrictpharmacy,justlikethehealthcentersatcommunitylevelhavehealthcenterpharmacies.Thedistrictpharmacyreceivesmedicinesfromthenationallevelandisinchargeofdistributingandsendingthosemedicinestothehealthcenters.

Thehealthcenterpharmaciesreporttothedistrictpharmacytoorderfornewstockofmedicines.

RBCorMinisterofHealth

ThedirectorofthedistricthospitalusesemailandWhatsApptocommunicatetotheheadofthemalariadivisionatRBCortheminister.Hestated:‘Uhm,centrallevel..theyhavetheirownWhatsAppgroup.WealsohaveourownWhatsAppgroup.ButifweneedtoshareinformationIcansendinformationthroughWhatsAppgrouptotheheadof

Theheadofthedistricthospitalexplained:‘Highprevalenceofmalaria.Anduhm,wegotherewherethereishighprevalence,butthereisnopeoplearenotsleepingundermosquitonetsforexample.Andtheyneedmosquitonets,wecommunicatewithRBCandsayheretheyneedmosquitonets.Soweneedmoreintervention.Orifcommunityhealthworkersdonothave

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malariadivisionforexample.Evenminister.IcanwritetoheranemailorWhatsAppgroup’.

whatwecallrapiddiagnostictestordrugswecommunicatewiththem.Yeah.SoforthemtogivethissupportofdrugsorRDT’.

Healthcenter Thedistricthospitalusessocialmediatocommunicateinformationtotheheadofhealthcenters.

WiththehealthcenterandotherhealthprofessionalstheyhaveWhatsAppgroupsinwhichtheyshareinformation.Forexample,whenthereishighprevalenceofmalariainthedistricttheycansendmessagesthroughWhatsAppinforminghealthcentersthattheprevalenceisincreasingandaskingthemtotakemeasures.

HMISHealthcenter Thedistricthospitalreceivesreports

fromthehealthcentersthroughHMIS.Thesereportscontaininformationaboutthenumberofbednetsneeded,theamountofpatientstheytreatedandotherproblemsrelatedtomalaria.

RBC ThedistrictcombinesthereportsfromallhealthcentersandsendsthisthroughHMIStoRBC.

Thesereportscontaininformationaboutthenumberofbednetsneeded,theamountofpatientstheytreatedandotherproblemsrelatedtomalaria.

ThedistricthospitalworkscloselytogetherwiththeRBCmalariadivision.Thedistricthospitalisthelinkbetweenthenationallevelandthecommunitylevel.Thehealthprofessionalsatthedistricthospitalhavemoreknowledgeaboutmalaria,sotheyareinbetweenbothlevelsandworkcloselytogetherwiththem.Thisalsoreflectsintheirinformationandcommunicationflows,becausetheymainlycommunicatetoRBCfromthenationallevelandtothehealthcenterandlocalleadersonthecommunitylevel.Thehealthcenterisresponsibletosupervisethecommunityhealthworkers,whilethelocalleaderssupervisetheCMATs.Subsequently,thecommunityhealthworkersandtheCMATsareresponsibletospreadawarenessandknowledgeaboutmalariainthecommunity.Thereasonthatthedistricthospitaldoesnotcommunicatedirectlywithotheractorsthroughsocialmedia,suchasthecommunityhealthworkersandCMATs,isbecausethemajorityofthemdonotusesocialmediabecausetheydonothavesmartphonesbutsimplephones.

5.2.1.3NationalLevel

RwandaBiomedicalCenter(RBC)TheRwandaBiomedicalCenterhasinformationandcommunication

flowsfromthedistricthospitalandcommunityhealthworkers.Furthermore,theysendinformationtocommunitymembersthroughradioandvideos.Theseinformationandcommunicationflowsareexplainedinmoredetailintable13below.Table13:ExplanationinformationandcommunicationflowstheRwandaBiomedicalCenterFromortowhichactor



HMISDistricthospital

ThedistricthospitalworkscloselytogetherwiththeRwanda

Thesereportscontaininformationaboutthenumberofbednetsneeded,

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BiomedicalCentermalariadivision.TheRwandaBiomedicalCenterreceivesreportsfromthedistricthospitalsendthroughHMIS.

theamountofpatientsthecommunityhealthworkersinthewholedistricttreatedandotherproblemsrelatedtomalaria.

MobilephoneCommunityhealthworkers

TheRwandaBiomedicalCenterreceivesrapidSMSmessagesfromcommunityhealthworkersincaseofapatientwhoissufferingfromseveremalaria.

TheseSMSmessagesarecopiedtothedistricthospitalandthehealthcenter,sotheycanreadaswellwhatisoccurringattheground.

RadioandvideoCommunitymembers

TheRwandaBiomedicalCenterusesradioandvideosontelevisiontosendinformationaboutmalariatocommunitymembers.

TheheadofthemalariadivisionoftheRwandaBiomedicalCenterstated:‘Andweusealsomedia.WeusemediathroughradioandalsothroughTV.ForradiowehaveatalkshoweveryWednesdaymorning.From7amto8amwehaveatalkshowonRwandaRadio,ontheradio.ButthecoordinationforalltrainingforallmediaisdonebyRwandaCommunication,UhRwandaHealthCommunicationCenter.ItisanotherdivisionofRBCbutinchargeofthetrainingandcommunitymobilizations,allmedia,andalsotrainings’.

Asisillustratedinthetableabove,RBChasinformationflowsfromandtoalimitedamountofactors.TheymainlyreceiveinformationfromthedistricthospitalthroughHMIS,andfromcommunityhealthworkersthroughSMSmessages.Furthermore,theysendinformationtocommunitymembersthroughradioandvideoprojections.

NationalHealthInsuranceSchemeTheNationalHealthInsuranceSchemecommunicatesface-to-faceto

communitymembers.AttheheadquartersoftheNationalHealthInsuranceSchemeinKigalitheydonotprovideanyservices.However,theyhavedecentralizedservicesinthirtyadministrativedistrictsweretheyhaveanRSSBbranch.Thisiswheremostofthetechnicalservicesareprovidedtocommunitymembers.Furthermore,theyhaveanofficeoftwopeopleateveryhealthcenterforthecommunitybasedhealthinsurance.Thisiswherecommunitymembersreceivetheirmembershipcards.Moreover,whencommunitymembersenterthehealthcenterthisiswheretheygotoreceiveamedicalformwhentheywanttogettreated.

Inaddition,theNationalHealthInsuranceSchemeusesmobilephonesinseveralways.Firstofall,thisyearthenationalhealthinsuranceschemewillstartofferingcommunitymemberstopayfortheirhealthinsuranceusingmobilepaymentsviatheirphones.Furthermore,thenationalhealthinsuranceusestextmessagestoremindcommunitymemberstopayfortheirhealthinsurance.Communitymemberscontributetotheinsuranceonannualbasis.TheyearrunsfromJulytoJuneofthefollowingyear.FromJanuarytoJunetheywanttostartmobilizingcommunitymemberstostartpayingcontributionsviainstallments.TheysendSMSmessagestomobilephonestoremindcommunitymembersto

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makecontributionsfortheirhealthinsurance.Inthisprocess,theNationalHealthInsuranceSchemedealswithtelephonecommunicationcompaniestosendmessagestoeveryoneregardlessiftheyaretheirinsuredmembers.TherearearoundeightmedicalinsurancesinRwanda,however80%belongstoRSSBsothereforetheyknowthatthemajorityisconcernedbytheirtextmessages,astheydonothavethephonenumbersoftheirmembers.Moreover,theNationalHealthInsuranceSchemeusesphonestoassistoranswerquestionsfromcommunitymembers.Theyhaveashorttelephonenumberoffourdigits4044thatmemberscanfreelycalliftheyhaveanyquestions.Thisistwo-waycommunicationwheretheycanaskanyquestion.

5.2.2TheroleofICTsTheprevioussectionanalyzedthecommunicationandinformationflows

betweenactors.Myresultspointtothevitalroleofcommunitymembers,communityhealthworkers,healthcenter,localleaders,andthedistricthospitalbecauseoftheirhighdensityinthenetworkofinformationandcommunicationflows.Thissub-sectionanalyzestheroleofICTsincommunicationwithinandbetweenstakeholdergroups.Asdescribedearlier,theresultsshowthattheICTsthatareusedinmalariapreventionandcontrolinRuhuhaaremobilephones,HMIS,radios,andvideosprojectedonscreens.Intheliteraturereview(section2.3)adistinctionismadebetweenICTsthatareinventedespeciallyforhealthsystems,andthosewherethelawofunintendedconsequencesplayaroleastheobjectiveofdesigningtheseinnovationswasnotspecificallytoreinforcethehealthsystem.InthecaseofmyresearchHMISfallsunderthefirstcategoryandisanICTspecificallydesignedforthehealthsystem.Contrarily,mobilephones,radios,andvideoprojectionsfallunderthesecondcategoryastheyreinforcethehealthsystem,buttheyarenotICTsspecificallydesignedwiththisobjective.ThemainroleofallICTsusedinmalariapreventionandcontrolinRuhuhaistoshareinformation.Therolesofmobilephones,HMIS,andradiosandvideoprojectionsareexplainedinthesectionsbelow.

5.2.2.1TheroleofmobilephonesMobilephoneshavemanyrolesinmalariapreventionandcontrolin

Ruhuha.Therolesareexplainedintable14belowwithsupportingquotesthatgiveexamples.

Table14:TherolesofmobilephonesinmalariapreventionandcontrolinRuhuhaFunctionofamobilephone

Supportingquote(translatedbyresearchassistantduringinterviews)

Tofacilitateconversationsinwhichmalariaistalkedaboutasatopicingeneralamongcommunitymembers

’Nowadaysapersonmaycallyouaskingyouinformation,askingyounews.Thenyoumayaskherhowareyou?Areyousick?Andmostofthetimeapersonmayrespondtoanothertellinghimortellingherthatsheissick,sheissufferingfrommalaria.Thenyouashisorherfriendmaycallforhelp,maycallforotherpersonssoastohelpher,soastointervene.Butwhenthepersonbeingcalledeachothertheymostofthetimetheyaskeachotheraboutlife’(communitymember).

Tocalltoaskorshareinformationaboutmalariaamongdifferentactors

‘Duringthiscontact.Theleaders.Theytalkaboutthenumberofpeoplethatarenowattendingheresufferingfrommalariabycomparinghowwhyaremostofthepeoplecomingsufferingfrommalaria,whatistheproblem,whatmaybedonesoasto

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solvetheproblem.Theydiscussmeasuresoffightingagainstmalaria,thenumberofpeoplenowattending,andwheneverpossibletheyhaveadvocacytohigherlevelofleadership’(localleader).

Tocalltoaskforhelpfromneighbors,family,friends,communityhealthworkers,orthehealthcenterstaffincaseofillness

‘Telephoneisimportantforher,aswhensheissufferingfrommalariashemaycallherchildwhoisinKigalicity.Tellinghimthatsheissuffering.(…)Shecallsherboyaskingforhelp.Forexamplebringingabikesoasmakeherreachhospital.Andshemayalsousephonesoastocallaneighborsoastoreachhospitalintime’(communitymember).

Tocalltohelpsavetimeandmoney

‘Telephoneisveryimportanttothem.Wherebyshemaycallanursebeinginbed.Tellingherthatherchildwhohasbeenrecentlybeenattackedbymalariaandwhohasbeenrecentlycuredathospitalatclinicalcenterthatheorsheisalsobeingattacked.Andimmediatelythenursemayreplyhertellinghertogobackwiththechildtothehospital.Thenaphonemayhelphertosavetime,tosavemoney.Wherebyshemayreachhospitalwithoutcallingthenurseandthenursemayreplyhertogobackandtogobackhomesoastoattendhospitallater.Sotelephonesavesthetimeandsavesmoneysoastosolveproblems’(communitymember).

Tocallincaseofanemergence

‘Hereathealthcenterthereisonetelephonethatisusedsoastocallcommunityhealthworkersandtoimpartthemdifferentinformationregardingtodifferentsicknessesasheretheydon’ttreatonesicknessmalaria.Andtheyalsofunctionsthisphoneagreatrolewherebytheremaybeanemergence.Anunexpectedeventwherebythereisonewhoisabouttodie.Andinthisoneneedsemergence.Needsquicksupport.ThistelephonewillfunctiongreatrolewherebytheywillcallathospitalNyamatasoastoinformthatthereisonepersonwhoisgoingwhoneedsemergence,whoneedssupport,quicksupport’(healthcenterstaff).

Tofacilitateingatheringpeopleforameetingaboutmalaria

‘Thenshehasalsogivenanexamplewherebytheymayusephonebycallingthesecellleaders,executivesecretaryofcells.Theseleadersofcells.Thentheytellthem.Couldyouhelpustocallpeoplesoastocomeforthemeetingsoastoimpartthemsomethingimportantabouthealth.Thenthroughthiswayofcallingtheleaderofthecellwillalsointerveneandcallpeopleandtellmessengerstherearenowmessengerswhoarenowindifferentlocalareasspreadinginformationfromleaders.Thenthesemessengerswillgoduringtheeveningorduringthemorningbeforepeoplequittheirhomes,tellingthemthatthereisameeting,thereisameetingthatwilltakeplace.Thenaftercomingtogether,throughthismeetingtheinformationthatispreparedbyhealthcenterwillbespread.Andalso,alsoatthevillagelevelitmaybedonethroughthisway’(headofthehealthcenter).

Toreceiveorsendinformationviasocialmedia

‘TheinformationgotfromFacebook,WhatsApp,internetisveryimportantforthemsoastobeawareofsoastobeawareofmalariaandhowitisprevented.Yes.Andshefollowssuchinformationcollectivelysoastoknowanytimeshemeetmalariasoastoknowtheproblemsheissufferingfrom’(communitymember).

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Toaccessradiofromwhichcommunitymembersreceiveinformationaboutmalaria

‘Andhehasalsoillustratedanotherroleoftelephonewherebyhehasexplainedthatphoneisnowadayshelpinghimtogettolistentotheradio.Hemayusephonesoastoturnonradio’(communitymember).

Tosendmoneyincaseacommunitymemberneedsmoneyfortransporttothehealthcenterorfortreatment

‘Ofcoursenowpeoplearefamiliarwithusingmobilephones.Especiallywhenitcomestosendingmessages.AndmoreoftennowitisabigchallengetoexchangemoneyifyouarelivinghereinKigaliandtosendmoneytoyourfamilymemberslivinginremoteareas.Butnowaspeoplearesendingmoneytotheirparentsortotheirrelativesusingmobilephonesitbecame,itbecameatoolthateveryhouseholdatleasteveryhouseholdthatinhouseholdeveninruralareasyoucanfindthateveryonehasitsmobileset,butatleastineveryhousehold,eveninpoorhousehold.Becausethepooresthouseholdtheyaretheonesthatneedthosemobilephones,becausehavingthosemobilesetanyonecansendyoumoneythroughthemobilephone’(nationalhealthinsurancescheme).

Toreportsevereincidentsofmalariafromcommunityhealthworkerstothenationallevel,withcopiestothedistricthospitalandthehealthcenter

‘ThemessagethattheysendtoMinistryofHealth.Themessagesissendbyusingtheircodes.Therearesomecodes.Thereisonelineatministryofhealth.But,aslongastheyfacilitatethosedifferentpersonswhoarenowsufferingfromdifferentsicknesses.Thereisacodethatsheputsatmalaria.Andthereisalsoacodethatsheputsatammonia.Thosecodesarenotthesame.SoastomakethosepeoplefromMinistryofHealthnoticetherealsickness.Soitmeansthattheirmessagecontainsthesicknessthathasbeencured,thesignsofthepatient,themedicalmentsthatweregiventothepatient,andthestageofwhichthepersonifthepersonwastotalsufferer’(communityhealthworker).

Tocalltothedistrictorotherhealthcentersincasethereisalackofmedicinesatthehealthcenterpharmacy

’Andshehasgivenanexamplewherebytheremaybeaproblemwheretherearenomedicalmentsforthosecommunityhealthworkers.Thosecommunityhealthworkersarenowlosingmedicalments.Theymayreportthattheyareincaseoflosingmedicalmedicalments.Thenhereafternoticingthattheymayalsolookfordifferentplacesthentheyseealsothattheydonothavethosemedicalments.Theyquickly,theyimmediatelyreporttothedistrict.Ortheyquicklycalldifferenthealthcenters,whicharelocatedwithinthisregionsoastoknowwherethosemedicalmentsareaccessible.Thentheyimmediatelyfacilitatetheirhealthworkerssoastogetthosemedicalments’(healthcenterpharmacy).

Topayforhealthinsurance

‘Forourcasewhatwearegoingtouse,whatwearegoingtodowithmobilephonesistopaytheircontributions.Sotheywillbefromthisfinancialyeartheywillbeabletomaketheircontributionusingmobilepayment’(nationalhealthinsurancescheme).

Tosendandreceivereminderstopayforhealthinsurance

‘Soastheycontributeonannualbasis.AndtheyearrunsfromJulytoJuneofthefollowingyear.ThenfromJanuarytoJunewemobilizethemtostartcontributingmaybeininstallment.Sothemessagethatwesendthroughmobilephoneistoremindthemmakingcontributionforinsurance’(nationalhealthinsurancescheme).

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Asillustratedintable14,actorsmainlyusemobilephonestoshareinformationquicklyacrossdistances.TheresultsshowthatmobilephoneshelpinmalariapreventionandcontrolinRuhuhaforseveralreasons:1)Byusingmobilephonestoshareandreceiveinformationactorsdonothavetomeeteachotherphysically,whichwouldcostmoneyfortransportandmoretime.2)Whensickitcanbedifficulttomove,socommunitymembersusetheirmobilephonetocallforhelpfromfamily,neighbors,friends,orcommunityhealthworkerswhenbeingsickorincaseofanemergence.3)Mobilephoneshelpingettingcommunitymembersinformedaboutmalariapreventionandcontrolmeasures,forexamplebyaccessingradioorsocialmediathroughmobilephones.Theyalsohelpinremindingcommunitymemberstobuyhealthinsuranceintime.4)Byfacilitatingcommunitymemberstousemobilemoney,phoneshelpintransferringmoneyfortransport,treatment,orhealthinsurancequicklyandacrossdistances.5)Mobilephonesalsohelpinmonitoringandevaluationofseveremalariacasesbyallowingquickreportingofpatientsacrossalllevels.

5.2.2.2TheroleofHMISThehealthcenterandthedistricthospitaluseHMIS(RwandaHealth

InformationManagementSystem)toreporttotheRwandaBiomedicalCenter.HMISisanICTthatisused(nexttoSIScom)formonitoringandevaluationbytheRwandaBiomedicalCenter.TheheadoftheRwandaBiomedicalCenterstated:

‘Anotherstrategyismonitoringandevaluation.Monitoringandevaluationweareusingtwosystems.Theonesystemismonitoringofpatientsandcasestreatedatcommunitylevel.ThesystemisnamedSIScom.ThesecondoneathealthfacilitieswereusingRwandaHealthInformationManagementSystemHMIS.Weareusingthetwosystemsformonitoringofmalariacasesandthereportisdoingeverymonth.Thefirstweekofeverymonth’.

Ascanbereadinthestatement,reportingthroughHMISisdonemonthly.ThecommunityhealthworkersreporttothehealthcenterthroughSIScom,usingpaperreports.ThedatamanageratthehealthcenterthenreportsallthedatafromdifferentcommunityhealthworkersfromSIScomintoHMIS.Thedatamanagerentersthisdatausingacomputerorlaptop.AfterthisinformationisenteredintoHMISitissendtothedistricthospital.Thereisalsoadatamanageratthedistricthospitalthatsupervisesthedatamanagersatthehealthcenterstoensureaccuratedataandtomakesuretheysendthedataontime.ThedatamanageratthedistricthospitalreportsthedatareceivedfromthehealthcentersinthedistricttoHMIS.AftersendingthisreportthecentrallevelcanaccesstheinformationandusestheinformationthatisreportedthroughHMISformonitoringandevaluationpurposes.TheroleofHMISinmalariapreventionandcontrolinRuhuhaismainlythereportingfromcommunityleveltodistrictandnationallevel.

5.2.2.3TheroleofradioandvideoprojectionsTheroleofradioandvideoprojectionsismainlytoinformcommunity

membersandtomakecommunitymembersawareofmalaria.ThesechannelsareusedbytheRwandaBiomedicalCentertobroadcastinformationandadvertisementsaboutmalaria.Theadvertisementsandshowsonradiomainlycommunicateinformationaboutmalariapreventionmeasures,symptomsof

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malaria,andtoreachthehealthcenterintimefordiagnosingandtreatment.Inaninterviewwithacommunitymemberthetranslatormentioned:

‘Butagaintheyreceivetheinformationfromtheradio.Mostofthetimestheycanbelikearadioshowaboutmalariaoradvertisementaboutmalaria.Andmostlyrelatedtomalariasymptoms,whentheyashowfromacertain,akidhasamalaria,heorsheisvomiting,sotheymentionthosesymptomsandthentheycanimmediatelyshownowthisismalaria,thenheorshehastogotothehealthcenterortheclinicfordiagnosingandtreatment.Sotheymostlylistentothatfromtheradio’.

Thisquotationgivesanexampleofthecontentoftheinformationthatcommunitymembersreceivethroughradio.TheWednesdaymorningradioshowthatwasdescribedearlierisintheformofadialoguewherecommunitymemberscanaskquestionsbysendingtextmessages.Furthermore,theroleofthevideoprojectionsthataredisplayedatthemarketandatsectorsofficeisalsotosensitizecommunitymembersabouthowtopreventthemselvesagainstmalaria. Tosummarizethissection,informationflowsinmalariapreventionandcontrolinRuhuhaarefacilitatedbyface-to-facecommunication;communicationusingmobilephonestocall,tosendtextmessages,toaccessradio,andtoaccesssocialmedia;byreportsusingSIScom;byreportsusingHMIS;andbycommunicationthroughradioandvideoprojections.Variousactorsamongwhichcommunitymembersexchangeinformationaboutmalariaaswellasthemeansofitscontrolandpreventionintheireverydaycommunicationbybothface-to-facecommunicationandthroughICTs.ThismeansthatapartfromthestrategicICTbasedhealthinterventionssuchasHMIS,mobilephonesalreadyplayacrucialroleinmalariapreventionbyfacilitatingawarenessraisingandbyimprovinginformationflowswithinandbetweenstakeholdergroups.TheadvantagesofICTsarethattheyallowinformationandcommunicationflowsrealtime,acrossdistances,atlowcosts,andacrossdifferentstakeholdergroups.However,increasedspreadofinformationcouldalsomeanincreasedspreadofmisconceptionsandinformationthatisnottrustworthy.Thereforethenextsectionwillanalyzeactor’sperceptionsaboutthesituationregardingmalaria,includingknowledge,misconceptionsandtrust.

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5.3Analysisofactor’sperceptionsThissectionofmyanalysisfocusesonthestakeholders’perceptions

regardingmalaria,mobilephonesandtheirpotentialroleinpublichealth.Perceptions,orframing,arecrucialfortheanalysisofinformationnetworkschannels,astheyrevealhowindividualsandgroupsmakesense,organize,andcommunicateaboutreality(Venot2016).

Thefirstsub-sectionprovidesanoverviewoftheperceptionsofactorsonthefuturerolesofmobilephones.Afterthat,IanalyzewhatactorsthinkaboutthesituationregardingmalariainRuhuha,includingperceptionsonknowledgeandmisconceptions.Moreover,Iinvestigatehowthedifferentactorsassignlegitimacytotheinformationtheyreceive,focusingontheroleoftrust.Thelastsub-sectionanalyzestowhatextenttheseperceptionsaresharedbymultiplestakeholdergroups.

5.3.1PerceptionsofthefutureroleofmobilephonesAstable14illustrates,mobilephoneshaveseveralrolesinmalaria

preventionandcontrolinRuhuha.Mobilephonesarealreadyusedineverydaycommunicationtoexchangeinformationaboutmalaria.Duringtheinterviewsactorswereaskediftheythinkthatmobilephonesmightplayalargerroleinmalariapreventionandcontrolinthefuture.Differentstakeholdersgaveexamplesofwhattheyperceivedasfuturerolesofmobilephones,whicharetoexaminepatients,toteachcommunitymembersaboutpreventionmeasures,toaccesspastdataaboutmalaria,toidentifymosquitospecies,andabiggerroleofsocialmediatocommunicateinformationregardingmalaria.Theseperceptionsaboutthefuturerolesareexplainedinmoredetailbelow.

ToexaminepatientsSeveralcommunitymembersandthetraditionalhealerthoughtthatin

thefuturemobilephoneswillbeusedtoexaminepatients.Theyexplainedthattheyheardinformationaboutthisontheradio.Thetranslatorstatedanexampleacommunitymembergave:

‘Abouttheroleoftelephonewithinfuture.Hehasunderstoodnews.Heunderstoodnewsfromradio.RadioRwanda.Sayingthatthereisatimewhenpeoplewillbeexaminedusingphone.Medicalexaminationswillbecarriedoutbyusingphone.Andafterbeingdiagnosedtherewillbealsosomemedicalmentsbyusingphone.Yaheunderstoodsuchinformation’.

Thisisexampleofoneoftheactorswhothinksthatinthefuturecommunitymemberswillbeabletohavemedicalexaminationbytheuseofaphonefromanylocation.Furthermore,theythinkphoneswillplayaroleinfacilitatingmedicaltreatment.

ToteachcommunitymembersaboutpreventionmeasuresAstaffmemberofthehealthcentersharedthathethinksthatinthe

futuretheremightbemobileapplicationsthatteachcommunitymembersmalariapreventionmeasures.Thetranslatorstatedthathementioned:

‘Yaheisnowsayingthathedoesnotreallyseetheimportanceoftelephones,theimportanceoftelephoneswithinfuture.Thatwillexceedtheimportanceoftoday.Exceptthetimewhenthosetelephoneswillhavesomeprograms,software’s.Wherebythose

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software’smaybeteachingpeopledifferentwaysofpreventingagainstmalaria.Andthosesoftware’swillalsoplayagreatroleathelpingpeopletoknowdifferent,forexampleheisgivinganexamplewherebytelephonewillbepossessing,willbewithaprogramofhelpingpeopleonhowtousemosquitonet.Thistelephonewillplayagreatrolewithinsuchcase’.

Thisstatementshowsaperceptionthatinthefuturemobileapplicationscouldbeusedtoteachcommunitymembersmalariapreventionandcontrolmeasuresandhowtousethem.Thestaffmemberofthehealthcenteraddedthatthiscouldonlybeusefulifcommunitymembersownsmartphonesthatcanallowthemtousetheseapplicationsontheirmobilephones,otherwisetheyareonlyavailabletocommunitymemberswhocanaffordexpensivemobilephones.

ToaccesspastdataaboutmalariaTheintervieweefromthecommunitymalariaactionteamsexplainedthat

hethinksthatinthefutureitwillbepossibletoaccesspastdataaboutmalariathroughmobilephones.Thetranslatormentionedthathestated:

‘Whatheisnowexplainingisthattheywillusephoneswithinfuture.Tohelpthemtorecallthepastinformationaboutmalaria.Wherebytheywillbeenablingeachothertalkingaboutdifferentpercentageswithinacertainyear.Acertainpastyear.Thesephonesmayplayagreatrolesoastoknowthepast,historywithinmedicalsituation.Thenafterrecalling,afterrememberingthepasteventsaboutmalariatheremaybeimprovementortheremaybesomethingwhichcouldbedonesoastofightagainstit.Therewillbesomethingthatmaybedonesoastofightagainstmalariaaccordingtophones’.

Thisexampleshowsthataccordingtothisactor,inthefuturemobilephonescouldbeusedtoaccesspastdataaboutmalariaincidentsbyusingphones.Hethinksthatthiscouldbeusefultoimprovestrategiesonhowtofightagainstmalaria.

ToidentifymosquitospeciesTheheadofthemalariadivisionoftheRwandaBiomedicalCenter

explainedthatthedayaftertheinterviewtherewasademonstrationaboutanewinnovationregardingmalaria.Therewasademonstrationabouthowyoucanidentifymosquitosbyanalyzingvibrationsofthewingsthroughamobilephoneapplication.Heexplained:

‘Thatmeanswithmobilephone,communitymembersshouldidentifydirectlyaspecies.Usingvibrationofwings.Yourecordvibrationofwingsandeachspecie,hetoldmethat,howcanIsay.Microbone...Uhmwaves(…)WewouldliketoworkwithRuhuhaandotherlocalgovernmentagencieshownowweshouldintroducenewtechnologyinhealthsectorsincludingmalaria.Sothatinthefutureweidentifyworkingwithmobilephone’.

ThisstatementshowsthattheRwandanBiomedicalCenterwouldliketoworkwithlocalgovernmentactorsinRuhuhatointroducenewtechnologyinthehealthsector,sothatinthefuturetheroleofmobilephoneswillincrease.

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BiggerroleofsocialmediatocommunicateinformationregardingmalariaLastly,theheadofthedistricthospitalgaveanexampleonhowsocial

mediamightplayabiggerroleinthefuture.Hestated:‘Whenforexampleifyouneedtotakesomemeasuresagainstmalaria,weusemobilephonestocommunicatewithuhhealthcentersorrepresentativesofthesecommunityhealthworkers.Sowecommunicatethem,theycomeafewtogether,orwemakesomecommunicationstosocialmedia,uhmonhowtopreventmalariaorhowtocombatmalaria’.

Thisquotationisanexampleofhowtheheadofthedistricthospitalthinksthatmobilephonesandsocialcouldplayalargerroleincommunicationwithcommunitylevelactorsregardingmalariapreventionandcontrolinthefuture. Thissub-sectiongaveexamplesofperceptionsofthepotentialfutureroleofmobilephonesinmalariapreventionandcontrol.Theactorsmainlygaveexamplesofhowtheroleofmobilephonescouldincreaseinthefutureonthecommunitylevelbyexaminingpatients,teachingcommunitymembersaboutmalariapreventionandcontrolmeasures,forhealthrelatedactorstoaccesspastdataaboutmalariaonmobilephonesinordertodeterminestrategies,toidentifymosquitospecies,andmoreinformationandcommunicationflowsregardingmalariaviasocialmediatocommunitylevelactors.

5.3.2SituationregardingmalariaTheprevioussectionsexplainedtheactor’sperceptionsaboutthe

potentialfutureroleofmobilephonesinmalariapreventionandcontrol.ThissectionanalyzeswhatactorsthinkaboutthesituationregardingmalariainRuhuha.ActorswereaskedwhattheythinkaboutthesituationrightnowregardingmalariainRuhuha.Themainthemesthatwerementionedarethatmalariaisaproblemathighlevel,thatmalariaexceededlimitscomparedtothepast,thatmalariaexceededitslimitscomparedtootherregionsinRwanda,andthatthereisanincreaseofmalariaduringcertainmonths.Theseperceptionsareexplainedbelowillustratedwithviewsfromdifferentactors.

AproblemathighlevelIntervieweesgenerallyexpressedmalariaisnowbeingaproblemathigh

levelinRuhuha.Table15illustratesthiswithexamplesfromdifferentactors.Table15:ExamplesofperceptionsthatmalariaisaproblemathighlevelExamples Quotations(translatedbyresearchassistantduringinterviews)Malariaatgreatlevelcomparedtootherdiseases

’Malariaisnowatagreatlevelcomparedtootherelements,comparedtootherillnesses.Andcomparedtootherpatientswhocomefortreatmentsufferingfromotherelements.Malariaisatthetoplevelofproblemwithinthisarea’(headofthehealthcenter).

ManypatientsofmalariainRuhuha

‘Ihaveconsideredthatthereismanypatientsofmalaria.Mainlymalaria.Thereissomepeoplewhosufferfromdifferentseasons,maybefourtimesperyear.Sothatthereismainlymanymalariainthisregion’(religiousleader).

Malariaisexceedingasinoneinthreehouseholdsyoucanfindsomeonesufferingfrommalaria

‘Malariahassurpasseditslimit.Youcan’tquittwohouseswithouthearingsuchinformationaboutmalaria.Threehousesareenoughsoastohearthatthereisonewhoissufferingfrommalaria.Threehomesareenough.Somalariaisnowexceeding’(communitymember).

Attackedbymalaria ’Sheissayingon13Novemberthisyearshewasattackedbymalaria,

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twiceamonth andinthesamemonthon27ththisNovemberthislastyearshewasalsoattackedbymalaria.Andithasbeenmarkedthatmalariahasexceeded’(communitymember).

Malariaisanepidemic ’Becauseitseemsnowmalariaisanepidemic.Youcangointoonehouseholdandyoufindlikethreeorfourpatientssufferingfrommalaria’(communitymember).

Whenapersoninahouseholdisattackedbymalaria,othermembersofthehouseholdsalsogetmalaria

’Somepeoplearecuredforalongtimeandtheydon’tcomebacksoastogetthosemedicaltreatmentfrommalaria.Andotherscan’tspendtwoweeks,oneweekwithoutbeingbacksoastobecuredhereathealthcenter.Soitmeansthatmalariahasexceeded.Andhehasalsogivenanexamplewherebynohousehold,whenmalariahascomeandhasenteredhousehold,itcan’tgoawaywithoutmovingaroundallpersonsinhousehold.Allpersons,oneiscuredtoday,theotheroneisgettingsufferingfrommalariatomorrow.Thepeoplereplaceeachotherwithinhouseholduntilallareattacked.Yathatishowmalariaisnowcirculating’(staffmemberofthehealthcenter).

Theexamplesinthetableaboveshowthatdifferentactorsperceive

malariaasaproblemathighlevel.Ingeneralallactorshadthisperceptionandthesearesomeexamples.Therewasnoactorwhoexpressedthatmalariaisnotaproblemathighlevel.

MalariaexceededlimitscomparedtothepastDifferentactorsexplainedthatduringthisyearmalariahasshown

exceededlimitscomparedtootheryears.Table16illustratesexamplesofactorsthatmentionedthatmalariaexceededlimitscomparedtothepast.Table16:ExamplesofperceptionsthatmalariaexceededlimitscomparedtothepastExamples Quotations(translatedbyresearchassistantduringinterviews)Therewereyearswithoutmalaria,butnowadaysatgreatlevel

‘Malariaisatahighlevelwithincommunity,nowadays.Hehasgivenanexamplebysayingthattherewasatime,therewereyears,whenmalariawasnotaccessible.Butnowadaysmalariaisnowatgreatlevel.Hehasgivenanexamplethattodayhehashelpedpeople,fivepatientsofmalaria’(communityhealthworker).

Malariamorecommonnowcomparedtopastyears

‘Malariahasexceeded,hasadvancedcomparedtosomepastyears.HehasgivenanexamplewherebyhewascomparingNovember,uhmSeptember,October,NovemberandDecemberandJanuary.Thosemonthswereaccustomedtohavelittlemalaria.Butnow,ithaschanged.Malariaisexceedingandnowadaystheyarereceiving180patientsaday,then160patientsarethosepatientsofmalaria’(staffmemberfromthehealthcenter).

Malariahasexceededcomparedtopastyears

’Nowadaysmalariahasgonebeyond.Hasexceededcomparedtosomepastyears.Malariahasnowbecomelikeanepidemic.Andespeciallywithinthislocation,withinthisdistrict.Malariahasexceededitslimits’(privatepharmacist).

Malariahasincreased ’Malariahasnowincreasedcomparedtothelasttimes.Comparedtothepasttimes.Asnowadaysyoumaytakemedicalmentsortabletswhicharespecializedtocuringmalaria.Butafteronlytwoweeksoroneweekyousufferfrommalariaagain.Thatiswhytheyarenowsayingthatmalariahasexceededitslimits.Andithasbeenconstantlikeapandemic’(communitymember).

Inpastyearssomeonecouldsufferfrommalariathreetimesayear,butnowadaysthreetimesamonth

’Rightnowmalariahasexceeded,hasincreased.Comparedtoyears.Hehascompared2017and2016wherebyheillustratedthatduring2016apersoncouldbeattackedbymalariathreetimesayear.Butduring2017apersoncouldbeattackedbymalariathreeortwotimesmonth.Yaamonth’(memberofcooperative).

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Alltheexamplesinthetableaboveshowthatactorsperceivethatmalariahasincreasedcomparedtothepast.Thisisperceivedbyhealthandnon-healthrelatedactorsatthecommunitylevel.TherewasnoactorwhoperceivedthatmalariadecreasedinRuhuhacomparedtothelastyears.

MalariaexceededlimitscomparedtootherregionsinRwandaCommunitymemberswereamazedandsurprisedbymalariaand

explainedthatmalariahasexceededitslimitscomparedtootherregionsinRwanda.AccordingtothemincomparisonwithotherregionsinRwanda,BugeseraDistrictishigheratbeingattackedbymalaria.Someexamplesaregivenintable17below.Table17:ExamplesofperceptionsthatmalariaexceededcomparedtootherregionsinRwandaExamples Quotations(translatedbyresearchassistantduringinterviews)AmountofcommunitymemberssufferingfrommalariaishigherinBugeseraDistrictcomparedtootherregionsinRwanda

’HehasmentioneddifferentareasofRwanda.Bygivingexamplesoffarsouthernprovincewherebymalariaisnotseen.AndsomeofthenorthernpartofRwandawherebymalariaisnotseen.HehascomparedmalariafromthoseareaswithmalariafromBugeseradistrict,wherehehasillustratedthatwithinourareamalariahasexceeded’(communitymember).

DifferenceinmalariafromBugeseraandSouthernprovince

’HeisnowcomparingmalariafromBugeseratomalariafromsouthernprovince.Heisnowshowingthatthereisadifference.Malariawithinthisarea,Bugesera,istotallydifferentfromsuchmalariainsouthernprovince.Andhedoesn’tknowwhythereisadifferencebetweenmaybethesemalaria's.Becauseheisnowthinkingmaybemalariafromsouthernprovinceisshorterthanmalariafromthislocationbecausesouthernprovinceisaplaceofcoldness’(communitymember).

MalariaisfoundinregionsinRwandawithgreathotness,suchasBugeseraandMutara

‘MalariaismostlyfoundwithinthoseregionsofRwandawherebythatisgreathotness.ShehasexplainedthisEasternprovince.MostlyBugeseraandMutarathosearetheregionsthatarelocatedinEasternProvinceinRwandaisknowntobehot.AndshehasalsoexplainedsomedistrictsinSouthernProvinceandsomeinNorthernProvincewherebycoldplacesarenotknownatmalaria’(MEPR).

Thesequotationsshowthatdifferentactorsperceivethatmalariain

BugeserahasexceededitslimitscomparedtootherregionsinRwanda.ThiswasalsomentionedduringtheinterviewwithRBC,astheyidentifiedBugeseraasoneoftheeighthighmalariaburdendistrictsinRwanda.

IncreaseofmalariaduringcertainmonthsAnotherperceptionthatIidentifiedaboutthesituationregardingmalaria

inRuhuhaisthatdifferentactorsmentionedthatthereisanincreaseofmalariaduringcertainmonths.Table18containsexamplesofstakeholderswhomentionedthis.

Table18:ExamplesofperceptionsthatmalariaincreasesduringcertainmonthsExamples Quotations(translatedbyresearchassistantduringinterviews)Nowadaysmalariaepidemic,butinOctoberandNovembermoremalariathaninDecemberandJanuary

’Sonowadaysmalariaisseenasanepidemicwhencomparedtotheprevioustime.Butwhencomparinglikemonthtomonth.InOctoberandNovembermanycaseswhereseeninthehealthcenter.Therewasalongcuetillevening.ButtheseDecemberandJanuarytheystarteddecreasing’(communitymember).

Highprevalenceinthe ’InRuhuhasinceAugust,October,November,Decemberwehavehada

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pastmonthsbutnow(January)itisdecreasingalittlebit

highprevalenceofmalaria.Butnowitisdecreasingalittlebit’(headofthedistricthospital).

Nowadaysmalariaisperiodic.Highernumberofmalariapatientsduringrainseasoncomparedtodryseason

‘Nowadaysmalariaisperiodic.Thatmeansitcomesaccordingtotheseasonoftheyear.Shehasgivenanexamplethathereathealthcenterduringrainreason,mostofthepeoplewhoarenowcomingforhelphereathealthcenterformedicalcarearethesufferersformalaria.Andshehasalsogivenanexamplewithinsummer,withinsunnyseason,thereisnobignumberofmalariapatients’(communitymember).

Duringrainseasontherearemoremalariapatientscomparedtodryseason

’Malariaisnowexceeding,isnotimproving.Atagreatlevel,becauseofthisrainyseason.Thismonthisexpectedtohavesmallrain.Butnowadaysithaschanged.Maybeclimatehaschanged.Thismonthisnotcharacterizedbymuchrain.Thenitmeansthathehasexplainedthatmalariahasexceededastherainisnowraining’(CMAT).

However,acommunitymembermentionedthatevenduringdryseasonmalariaattackedatahighlevellastyear(2017)

’Shehasmentioneddifferentmonthsaccordingtotheincreasementofmalaria.ShehasexplainedJulyandJuneandaugustlastyear,malariawasattackingmostoftheregionandthepeopleweresufferingfromit.Andshewondersherself.Shewondersherselfbysayingthatwhyismalariaattacking,weareaccustomedtosufferingfrommalariaduringrainseasons,butduringsummeroflastyearmalariaattackedus.AndshehasmentionedNovemberandDecemberwherebymalariahasdecreasedcomparedtothosethreemonthsshementioned.Andshehasexplainedtoobysayingmalariahasdecreasedinsomemonths.Inthosetwomonthsago’(communitymember).

Ahealthcenterstaffexplainedthatduringrainseason90%ofthepatientsthataretreatedatthehealthcenteraresufferingfrommalaria

’Malaria,nowadays,hassteppedforward.Shehasexplainedthisbygivingsomeperiodssomeseasonsofhere.Shehasexplainedthatduringsummerduringdryseason,duringdryseasonisatalowlevel.Itisnotseenbecausemosquitosarenotabletomultiplyandwithindifferentareas.Whereasshehasalsoexplainedthatwithinrainseasonmalariahasisatagreatlevel.Shehasexplainedthisbygivingpercentages.Wherebyshehasexplainedthatthosepatientsthatarenowadaysbeingtreatedhereathealthcenter,over90%arenowbeingseensufferingfrommalaria’(healthcenterstaff).

Thequotationsinthistableaboveillustratethattheperceptionofactors

isthatmalariaincreasesduringcertainmonthsoftheyear. Fromtheanalysisofperceptionsinthissectionaboutthesituationregardingmalariacanbeconcludedthatmalariaisperceivedagrowingproblem.

5.3.3KnowledgeandmisconceptionsIntheprevioussub-sectionIanalyzedthatmalariaisperceivedagrowing

problem.Theawarenessaboutmalariaasaproblemishigh.AllactorsperceivemalariaasaprobleminRuhuha.Duringtheinterviewsactorswerealsoaskedwhethertheythinkthereis(enough)knowledgeinthecommunityorregionaboutmalaria.Inaddition,theywereaskediftherearemisconceptionsregardingmalaria.Thefirstpartofthissub-sectionexplainstheperceptionsofactorswhothoughtknowledgeaboutmalariaisnotenoughinRuhuha.Secondly,theperceptionsofactorswhothoughtknowledgeaboutmalariainRuhuhaisenoughareanalyzed.Inthelastparttheperceptionsregardingmisconceptionsaboutmalariaaredescribed.

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5.3.3.1KnowledgeisnotenoughTheactorswhothoughtknowledgeinmalariaisnotenoughgavevarious

reasons,whichareillustratedintable19.Thetableprovidesargumentsgivenbyintervieweeswhoexplainedthatknowledgeaboutmalariaisnotenough.Table19:PerceptionsofactorswhothinkthatknowledgeaboutmalariaisnotenoughArgumentknowledgeisnotenough MentionedbythefollowingactorsCommunitymembersknowsomepreventivemeasures,butdonothavemoreknowledgeaboutmalaria

Threecommunitymembers

Communitymembersknowsomesignsofmalaria,buttheydonotknowmuchaboutmalaria.Theyseeitastheysufferfromit

Onecommunitymember,onecommunitymemberwithouthealthinsurance

Communitymembersdonotfinishtheprescribeddoseoftabletsbecauseofsharingthemwithothers

Onecommunitymember,healthcenterpharmacy

Knowledgeisnotenoughandmorecontinuoustrainingsandteachingisneeded

Onecommunitymember,CMAT,MEPR,traditionalhealer,communitymemberwithouthealthinsurance,districthospital,religiousleader,headofthehealthcenter

Therearecommunitymemberswithlowerunderstandingwhodonotreachthehealthcenterintimewhensufferingfrommalaria

Healthcenterstaff,districthospital

Somepeopleareaware,butothercommunitymembersarestillconfusingmalariawithpoisonousactivitiesorarenotawareofitssignsandattendtraditionalhealers

Twocommunitymembers,healthcenterpharmacy,districthospital

Understandingofmalariahasimprovedbecauseoftrainings,buttheknowledgeaboutmalariaisnotenoughandmoretrainingsandknowledgeisneededtototallyremovemalaria.

CMAT,healthcenterpharmacy

Therearepeoplewhohavemisunderstandingsabouttherulesandregulations.Thereisaneedtochangesuchunderstandings

Communitymemberwithouthealthinsurance

Communitymemberswonderwhytheydonotneedtobeinmosquitonetsduringthedayandwhytheyshouldremoveplantationsaroundtheirhomes

Onecommunitymember

Thereisawarenessaboutmalariaascommunitymembersseethatmalariaissteppingforward,butmoreexplanationisneededascommunitymembersareaskingthemselveswhymalariaisincreasingcomparedtopasttimes

Memberofcooperative

Thereisnotenoughknowledgeascommunitymembersarenotabletoproducetheirownmedicines

Memberofcooperative

Thereisknowledgeaboutmalariaasitisatopicduringthemeetings,howeverthereisalsolowerunderstandingandpeoplewhodonothavemuchknowledgeaboutmalaria

Schoolteacher

Lackofawarenessthatapersoncanstillgetattackedbyamosquitowhiletakingmalariatablets

Healthcenterstaff

Intermsofsymptoms,diagnosticandtreatmenttheknowledgeishigh,buttheknowledgeaboutpreventionandecologyofvectorsisstillverylow

RBC

Ascanbeanalyzedfromthetableaboveisthatthemajorityofactors

thoughtthatknowledgeaboutmalariaisnotenoughinRuhuha.Themainperceptionsaboutwhyknowledgeisnotenougharethattherearestillcommunitymemberswhodonotreachthehealthcenterintime,thatthe

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communitymembersneedcontinuousteaching,thatthereisnoawarenessthatapersoncanstillgetattackedbyamosquitowhiletakingmalariatablets,thatthereisnotenoughknowledgeaboutprevention,andthatmoreknowledgeisneededaboutmalariaingeneral.Thesereasonsareexplainedinmoredetailbelow.Afewotherimportantperceptionsfromthetableabovesuchasthatcommunitymemberssharetabletswithothersandthebeliefinpoisonousactivitiesandbewitcheryaredescribedinmoredetailinsection5.3.5aboutsharedperspectiveoftheproblem.

TherearecommunitymemberswhodonotreachthehealthcenterintimeThehealthcenterstaffandthedistricthospitalaretwohealthrelated

actorswhodealwithtreatingcommunitymembers.Theybothmentionedthatknowledgeaboutmalariaisnotenoughbecausetherearestillcommunitymemberswhodonotreachthehealthcenterintime.Duringtheinterviewwithastaffmemberofthehealthcenterthetranslatorexplainedthathesaidthefollowing:

‘Somepeopledie.Therearesomepeoplewhohavelowerunderstandingaboutmalaria.Andthosepeopletheyspendtwoormaybealongtimebeingthereathomesufferingfromtheelement.Sufferingfromthesickness.Sufferingfrommalaria.Thenafterspendingalongtimethereandnoticingthattheyareabouttodie.Theycometothehospitalortheycometothehealthcentersoastobetreated.Thenafterreachinghere,aftermakingsomeexaminationstheyuseblood,theyusewhat,afteracertainperiodtheydie.Becauseofcominghereathospitalontimewhichisnotappropriate.Delaying,theirdelaymakethemdie’.

Theheadofthedistricthospitalalsomentionedthattheknowledgeisnotenoughandthattheyneedtosensitizepeopleaboutmalaria.Hestated:

‘Forsomepeoplesomepersonstheyhavebelieves,theystillhavebelievesthatwhentheyaresick,theydon’ttrustthatitismalaria.Itmaybeotherthings,otherdisease,sotheygolookfortraditionalhealersandsometimestheygotohealthcenterstoolate.Sometimeswehavesomedeathduetomalaria’.

Thisstatementalsoillustratesthattherearecommunitymemberswhoreachthehealthcentertoolate.Thisexamplealsoshowstheirperceivedeffectofthebeliefintraditionalhealers,whichisthatitmakescommunitymembersreachthehealthcentertoolate.

NeedforcontinuousteachingAscanbeseenintable19thereareanumberofactorswhomentioned

knowledgeisnotenoughbecausethereisaneedforcontinuousteaching.Someexamplesofactorswhomentionedthisaregivenintable20below.Table20:ExamplesofactorswhomentionedtheneedforcontinuousteachingActor Supportingquotation(translatedbyresearchassistantduring

interviews)MEPR ’Noonewhocangoandtestifyandconfirmsthatknowledgeisenough.Every

timeweneedtolearn.Everytimeweneedtolearn.Aswealwaysneedtolearn,wealwaysalsoneedtobethought.Thatmeansthatneedthepeopleneedalwaystobethought.Itisalongprocess.Ya,itisnotastillprocess.Itislongandmovingprocess.Itisaperpetualprocess’.

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Traditionalhealer

‘Thepeopledonotunderstandthingsatthesamelevel.Theyhavedifferentunderstandings.Itmeansthattheyneedtobethoughteverytime.Theyneedperpetualteaching’.

Communitymemberwithouthealthinsurance

‘Theknowledgeisnotenough.AllRwandansneedbeingthought,needendlessteaching.Theyneedtobethoughtforeversoastobeawareofthisillness’.

Religiousleader ‘No,notenough.Wehavetomaybegivesomeinformationeverytime.Butitisnotsufficient’.‘Everyonehasinformationaboutmalaria,butthereisalsosomeignorance.Sothatjusthavetogiveinformationeverytime’.

Thequotationsinthetableabovearesomeexamplesofanumberof

actorswhothinkthatthereisnotenoughknowledgeaboutmalariaandthatthereisaneedforcontinuousteaching.

NoawarenessmalariamayattackwhiletakingtabletsThehealthcenterpharmacistexplainedthattheknowledgeisnotenough

becausethereisnoawarenessthatmalariamayattackwhiletakingtablets.Thetranslatorexplainedthatshementioned:‘Peoplearenotawareofthatmalariamaybemayattackthemwhiletakingthesetablets.Ya.Itmeansthattheyarenotawareofit’.Thisexampleshowsthatthehealthcenterpharmacythinksthatthereisnotenoughawarenessthatmalariamayattackapersonagainwhiletakingtabletstocuremalaria.

NotenoughknowledgeaboutpreventionTheheadofthemalariadivisionoftheRwandaBiomedicalCenter

mentionedthatthereisnotenoughknowledgeaboutthepreventionofmalaria.Hestated:

‘Ok,therearedifferentreportsandpublicationsdone.Theknowledgeisveryhighintermsofdiagnosticandtreatmentofmalariaandsymptoms.Butknowledgeisstilllowintermsofprevention.Thegooduseofbednets.Evenofspraying.Andalsoothermethodsforprevention.Becausetherearedifferentmethodsforpreventionagainstmalaria.Buttheknowledgeisveryhighintermsofskillsintermsofhowtoknow,symptomsofmalaria,howtotreatmalaria,andsofort.Diagnosticofmalaria,butintermsofpreventionknowledgeisstilllow.Butecologyofmosquitos,knowledgeonmosquitosofthebreedingsites,mosquitolarvae,isstillverylowintermsofecologyofvectors.Knowledgestillveryverylow’.

ThisstatementshowsthattheknowledgeaboutmalariaisperceivedaslowbytheRwandaBiomedicalCenter.Theprivatepharmacistalsomentionedthattheknowledgeisnotenoughbyexplainingthattherearecommunitymemberswhoarenotusingpreventionmeasures.Thetranslatormentionedthathestated:

‘Theunderstandingsofthepeoplearenowatabadarenowwithinabadconditionduetodifferentreasons.Asexplainedthatthepeoplearenotusingmosquitonetsproperly.Theydonotusemosquitonet.Andtheydon’t,somepeopledon’thavesuchcleanliness,suchhygienicconditions’.

Thesequotationsillustratethattheseactorsthinkthattheknowledgeaboutmalariapreventionandpreventionmeasuresisnotenough.

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KnowledgeistherebutmoreknowledgeisneededThereareseveralactorswhothoughtthereisknowledgeinthe

communityaboutmalaria,butnotenough.Anumberofexamplesareillustratedintable21below.

Table21:ExamplesofactorswhomentionedtheneedformoreknowledgeActor Supportingquotation(translatedbyresearchassistantduring

interviews)Schoolteacher ’Theyhaveknowledgeaboutmalaria.Theyhaveenoughknowledgeabout

malaria,asmalariaisthetopicduringthemeetingswheretheyattend.Andisalso,malariaistalkedaboutindifferentfamilies.Itmeanstheyknowit.Butthereisaproblemoflowerunderstanding.Asthepeoplehavedifferentunderstandings,lowerunderstandings.Therearesomewhodonotposses,whodonothavemuchknowledgeaboutmalaria’.

Healthcenterpharmacist

‘Itisnotgreatknowledge,theydon’thavemuchbuttheyhavesomeknowledgeabout’.

Headofthehealthcenter

‘Peopleareinformedaboutmalaria.Theyarenowinformedaboutdifferentpointsaboutmalariawherebytheyknowthecauseofmalaria.Andtheyalsothepeopletheyknowthewayofpreventingagainstthiskindofelement.Andalsopeopleareinformedaboutthewaytopreventit,thewaythattheymaytreatitandthewaythattheytakethistabletstakenfromhereathealthcenters.Peoplearereallyinformedaboutthis’,butthat:‘Theknowledgeofthepeopleaboutmalariaisatagreatlevel.Butasthisisaproblem.Itrequiresdailyteaching.Itrequiresdailyadvises.Peopleneedbeingtalked,beingeducatedaboutthiskindofillnesses’.

Communitymemberfromcooperative

‘Theyareawareofmalaria,little.But,thereistheyarenowadaysaskingthemselves.Whyismalariaexceeding?Whyismalariaprogressing?Whyisitadvancingcomparedtothepasttimes.Itmeansthattheyneedfurtherexplanation.Peoplearenowwonderingsoastobeexplainedmoreaboutmalaria.Becausetheyseethatmalariahassteppedforward’.

Thequotationinthetableaboveillustratethatseveralactorsthinkthat

thereisknowledgeaboutmalaria,butthatmoreknowledgeisneeded.Thisissomehowsimilartotheactorswhomentionedthatthereisaneedforcontinuousteachingasexplainedearlierinthissection.

5.3.3.2KnowledgeisenoughOtheractorsmentionedthattheythoughtthereis(enough)knowledge

aboutmalariawithinthecommunityorinRuhuha.Theseperceptionsareillustratedintable22.Table22:PerceptionsofactorswhothinkthatknowledgeisenoughArgumentknowledgeisenough MentionedbythefollowingactorsCommunitymembersareadvisedbycommunityhealthworkersandresearcherssendbyhigherlevels

Onecommunitymember

Knowledgewaslow,butisnowincreasingbecauseofthehighmalariaprevalence

Twocommunitymember

Knowledgeisthere,buttheproblemisputtingintopracticetheknowledgethatisbeingthoughtandadvisedbydifferentactors

Onecommunitymember,localleader

Increasinginformationaboutmalariareducedtraditionalwaysoffightingagainstmalaria

Onecommunitymember

Theyaretotallyawareofmalariaandknowledgeisenough

Onecommunitymember,localleader,traditionalhealer

Knowledgeisenough,butcommunitymembersare Communityhealthworker

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wonderinghowtouprootmalariacompletelyandtheywonderiftheyshouldstillgotoworkinswampsasthatiswheremosquitosareKnowledgeisthere,buttheproblemisthatmosquitonetsarenotavailable

Communityhealthworker

Communitymembershaveknowledgeaboutmalariaaswhentheyaretoldtobuyinsurancecards,theyimmediatelyunderstanditsimportanceandthesituationthattheyarenowadaysphasingmalaria

CMAT

Knowledgeisenough,butthereisaneedforadvocacysoastobesupportedtofightmalaria

Traditionalhealer

Knowledgeaboutmalariaisenough,thecauses,symptoms,treatmentareallknown.Theproblemisthatpreventivemeasuresarenotapplied100%astheyshouldbeandthereisignorance

NationalHealthInsuranceScheme,privatepharmacy

Asillustratedinthetableabove,therearefeweractorswhothinkmalaria

isenoughcomparedtothosewhothinkthatthereisalackofknowledge.Stakeholderswhothoughtthatthereisenoughknowledgeaboutmalariamainlymentionedthatbecauseofadvisefromcommunityhealthworkersandtheincreaseofmalariacommunitymembershavegainedknowledgeaboutit.Otheractorsthinkthatthereisknowledgeaboutmalaria,butthatcommunitymembersdonotapplythepreventionmeasures.Theseperceptionsareexplainedinmoredetailbelow.

CommunityhasknowledgeaboutmalariaDifferentintervieweesmentionedthatthecommunityhasknowledge

aboutmalaria.Duringtheinterviewwithacommunitymemberwithouthealthinsurancethetranslatormentionedthatheexplained:

‘Thepeoplehaveknowledgeaboutmalaria.Hehasexplainedthisbygivinganexamplewherebytheyattenddifferentmeetingswithintheirvillage.Duringthesemeetings,duringthismeetingthatisorganizedatvillagelevel.Theytalkaboutdifferentinformationregardingmalaria.Hehasmentionedsomesignsthattheymostlytalkaboutwithinthemeeting.Hehasillustratedmuchfever,havingpainwithinbodyandhavingpainwithinbodyinallaspirationswherebonesattachtoothers.Andvomiting,beingdiscouraged,being,havingfewlittleforcebecauseofbeingattackedbythisillness’.

Thisexampleshowsthatitisperceivedthatcommunitymembershaveknowledgeaboutmalaria.Alsoaccordingtooneofthehealthcenterstaffcommunitymembershaveknowledgeaboutmalaria.Thetranslatormentionedthatheexplained:

‘Thereisenoughknowledgeinthecommunityregardingtomalaria.Becauseheisoneofthestaffofthehealthcenter.Heisnowsayingthatmanypeoplecomeheresoastomedicaltreatment.Andaftermakingadiagnosis.Aftermakinganexaminationandgivinghimorhersomemedicalmentssayingthatsheorheisnotsufferingfrommalaria.Asthepeopleareaccustomed.Areawareofthesigns,thedifferentsymptomsofmalaria,theymaytellyou,whoareyou?Doyouknowwhatyouaredoing?IreallyknowthatIamsufferingfrommalaria,whyareyougivingmethesetabletswhyIreallyknowthat

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IhavecomefromhomeknowingthatIknowthatIamsufferingfrommalaria.Ireallyknowthesigns.Whyareyousayingothers.(…).Itmeansthepeoplereallyknowit’.

Thesestatementsareexamplesofactorswhothinkthatthecommunityisinformedaboutmalariaandthattheknowledgeisenough.

ThereisknowledgebutcommunitymembersdonotapplymeasuresThenationalhealthinsurancerepresentativeexplainedthatcommunity

membershaveknowledgeaboutmalaria,howeverthattheydonotapplythepreventionmeasures.Hestated:

’Knowledge?Ya.Whatwerealizedisthatinthecommunitythereisnoproblemaboutknowledgeaboutmalaria.Theyknowthecausesofmalaria,theyknowthesymptomofmalaria,theyknowthetreatmentofmalaria.Soeverythingisknown,whenyoucomparetothepast.Inthepastmanypeoplehadwronginformationaboutmalaria,aboutcauses,aboutsymptoms.Butnow,whenyouseethattheknowledge,itisabove90%theyknowexactlywhatarethecausesofmalaria,whatarethepreventivemeasures,buttheproblemistheapplicationofthosepreventivemeasures.Theyknowthepreventivemeasures,buttheyarenotapplied100%astheyshouldbe.Buttheyknowthem.Theyknowthatmosquitobednetareveryeffective,theyknowthattheyhavetocleanthesurroundingsoftheirhomes,theyknoweverything.Butwhenitcomestoapplythosepreventivemeasuresitbecomesaproblem’.

Thisexampleshowsthatthereisknowledgeaboutmalariainthecommunity,butthatthereareactorswhothinkthatthecommunitymembersdonotapplythepreventionmeasureswell.

5.3.3.3MisconceptionsAccordingtotheperceptionofactorsthereareseveralmisconceptions

thatstillexistwithinthecommunityorregion.Themisconceptionsaboutmalariathatareidentifiedduringtheinterviewsareillustratedintable23.Thetableshowsthemisconceptionsthatwerementionedbywhichactorsduringtheinterviews.Table23:MisconceptionsaboutmalariaMisconceptions MentionedbyBewitcheryandpoisonousactivities,attendingtraditionalhealers

Fivecommunitymembers,schoolteacher,localleader,communitymemberwithouthealthinsurance,districthospital

Eatingsorghumandmaizesticks Twocommunitymembers,cooperativeEatingsugarcanes Threecommunitymembers,RBC,religious

leader(butthinksthatthiswas10yearsago)Drizzleandnewlyharvestedbeans PrivatepharmacyMedicinesatthehealthcenterdonotcuremalaria

Threecommunitymembers,cooperative,staffofthehealthcenter,healthcenterpharmacy

Unbalanceddietandfoodthatisnotwellprepared


Nomisconceptionsaboutmalaria Ruhuhahealthcenterstaff,communityhealthworker,traditionalhealer

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Asillustratedinthetableabove,notallactorsthinkthattherearemisconceptionsaboutmalariainRuhuha.However,misconceptionswerementionedbybothhealthandnon-healthrelatedactorsandbystakeholdersfromalllevels.Themisconceptionsthatareidentifiedareexplainedinmoredetailedbelow.

BewitcheryandpoisonousactivitiesMostactorscriticizedthetraditionalhealersandthecommunity

memberswhostillvisitthem.Forexample,thetranslatorexplainedthatacommunitymembermentioned:

‘Therearesomepeoplewhogoformedicaltreatmenttotraditionalhealers.Andhavingunderstoodthattherearesomesignsofmalariasomepeoplethinkthattheyhavebeenbewitched.Theyhavebeengivensuchapoison.Thentheygotosuchtraditionalhealers.Inrealofcominghereathealthcenter’.

Thehealthcenterpharmacyalsogaveanexampleofcommunitymembersbelievinginbewitcheryandpoisonousactivities,thetranslatorstatedthatshementioned:

‘Therearesomepeoplewhoareunawareofmalaria.Shehasgivenanexamplewherebymothermayseethatherchildissufferingfromsicknessthatshedoesnotreallyknow.Thenafterseeingthatthechildisnowbeingparalyzed,achildisnottalkingisnotmoving,nothingasmovementthatistakingplace.Thenshemaytakeconclusionthatsheisgoingtoreach,thatsheisgoingtogototraditionalhealer.Thiscasethisconditionoftraditionalmedicines,thiscaseofattendingthosetraditionalhealersmaytakeplaceinthiscondition.-Interviewer:Andwhydotheygotothetraditionalhealerinsteadofthehealthcenter?-Translator:Becauseofnotbeinginformedaboutthesignsofsuchsicknesses’.

However,thetraditionalhealermentionedthattherearenomisconceptionsaboutmalaria.Thetranslatorstatedthatthementioned:

‘Peoplehaveknowledgeaboutmalariaastheyimmediatelyhospitalsorhealthcenterswhenevertheyareattacked.Andthereisalsosomepost..thoseclinics.Everycellhasitsclinic.Thisisaplacewherethosepatientssufferingfrommalariaarereachedassoastogettabletsandothermedicalmentsaboutmalaria.Thismeansthatpeoplereallyknowaboutmalaria.Whenevertheycomesoas.Whenevertheygotothosehealthcenters,theygohavingmindthattheyaresufferingfrommalaria.Asalsotheyhavebeentrained,peoplearemostofthetimebeingtrainedaboutmalaria,sohethinksthattheyknowit’.

Theseexamplesshowthatthereareactorswhothinkthattherearecommunitymemberswhobelieveinbewitcheryandpoisonousactivitiesandgototraditionalhealerswhensickinsteadofgoingtothehealthcenter.However,thetraditionalhealerthatwasinterviewedthinksthatthereisenoughknowledgeaboutmalaria.

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EatingmaizesticksAnothermisconceptionthatwasmentionedduringtheinterviewsisthat

malariamaybecausedbyeatingmaizesticks.Thetranslatormentionedthatamemberofthericecooperativeexplained:

‘Shehasgivenanexamplewherebyshewasthinkingthatmalariamaybecausedbymaizesticks.Mostofmaizesticks.Inheradolescenceshegrowshegrewupthinkingthatmalariawascausedbymaizesticks.Anduntilnoweventoughshehasbeentrained,shehasbeeninformedaboutmalaria.Butisatthefirstpositionattellingherchildrentonoteatthosemaizesticks.Becauseshethinksalsothattheremaybesomethingbadregardingtomalaria.Andshealsosheisinformedaboutmalariaasshegrowuphavingsuch,itislikeaculture,shehasexplainedthatitislikeaculture.Shegrowupunderstandingpeopletalking,understandingpeopletalkingaboutthatmalariaiscausebymaizesticks,soshethinksthatalsothereissomethinghiddenbehind’.

Thisexampleshowsthateatingmaizesticksisanotherperceivedmisconception.

EatingsugarcanesActorssuchastheRwandaBiomedicalCentermentionedthatanother

misconceptionisthatpeoplebelievethateatingsugarcanescausesmalaria.Afteraskingwhythismisconceptionisexistshesaid:

‘Youknow,howcanIsay.Butthisismyinsight.Hm.Itdependsoneducationofpeople.Ithinkitislinkedtothelevelofeducationofpeople.Andalsowelfare.Welfareandalsolevelofeducationofpeople’.

ThisexampleshowsthattheintervieweefromtheRwandaBiomedicalCenterthinksthatmisconceptionsaretherebecauseoflowlevelofeducation.

DrizzleandnewlyharvestedbeansTheprivatepharmacistgavetwootherexamplesofmisconceptions,

whicharesmallrainandeatingnewlyharvestedbeans.Thetranslatorstatedthatheexplained:

‘Therearesomepeoplewhohavemisunderstandingsaboutmalaria.Hehasgivendifferentexampleswherebyhehasexplainedsmallrain.Therearesomepeoplewhoarenowadayswhoarebelievingthatthisrainthatisnotsufficient.Afterbeingcaughtbythissmallrain,theremaybemalaria.Becauseofbeingcaughtbysuchsmallrain.Andalsonewlyharvestedbeans.Somepeoplearenowbelievingthatnewlyharvestedbeansareattheleavesofmalaria.Thesebeansthatarenownewlyharvested.Whicharenowcookedwithouthavingwithoutbeingputatthesun,performingdifferent’.

Thisquotationshowsthatthereareperceivedmisconceptionsthatmalariaiscausedbydrizzleandbyeatingnewlyharvestedbeans.

MedicinesatthehealthcenterdonotcuremalariaAnothermisconceptionthatwasfrequentlymentionedisthatthereare

communitymemberswhodonotbelievethatthetabletsatthehealthcenterstillcuremalaria.Table24givesexamplesofstatementsthatillustratethattherearecommunitymemberswhodonotbelievethatthetabletsstillcuremalaria.

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Table24:ExamplesofstatementsthatillustratethattherearecommunitymemberswhodonotbelievethatthetabletsstillcuremalariaActor Supportingquotation(translatedbyresearchassistantduringinterviews)Healthcenterstaff

’Peoplethinkdifferenttomalaria.Therearesomepeoplewhoarenowthinkingthatthemedicalmentsthattheyarenowbeinggivenhereathealthcenterhavebecomelikebeans’.‘Theydon’tconsiderthosemedicalmentsasrealmedicalments.Theyconsiderthoseseeds.Andtheysaythosemedicalmentsfromhealthcenterarenolongercuringus.Soitmeansthereisnoneedofgoingtherebecausetheirmedicalmentsaresomehowunabletocureelements’.

Communitymembers

’Aresomemedicalmentsdecreasestheircapacityofcuringmalaria?Howaremedicalmentsnowbeing,howaremedicalmentsnowcuringmalaria?Maybemedicalmentsarebeingexpired,becausemalariahasexceededitslimits.Thepeoplearewonderingthemselveswhethermedicalmentshaveexpired’.‘Thenheproposedthattheymaygetothertreatmentothertabletsothermedicalmentswhicharechanged,whicharenewlychanged.Becausethesemedicalmentsthattheyaretakingnowadaysarenotsufficient,arenotabletocuremalaria.Theyneedimprovement,theyneedinnovationwithinmedicalmentproduction’.’Inadditiontothatpeoplearenowadaysmumblingaboutmalaria.Theyaretalkingaboutdifferentviews,sayingthatmalariaisnowdrugresistant.Whatdoesthegovernmenthelpussoastogetmedicalmentsformalaria?Malariahasbecomedrugresistantanditneedsnewmedicalments.Medicalmentsthatarenowadaysbeingusedarenotablearenotgoodatcuringmalaria.Soweneedsupportfromthegovernmentorfromthenursessoastosupportustogetnewmedicalments.Becausethemedicalmentsthatarenowadaysbeingusedisnotappropriate’.

Thetableaboveshowsthattherearecommunitymemberswhowonder

whetherthemedicinesarestillcuringmalaria.Othersmentionedtheneedfornewmedicinestocuremalaria,astheybelievethatmalariahasbecomedrugresistant.Thequotationsinthetableillustratethatseveralactorsthinkthatmedicinesnolongercuremalaria.

UnbalanceddietandfoodthatisnotwellpreparedInaddition,anothermisconceptionmentionedbytheheadofthehealth

centeristhatsomepeoplebelievethatmalariaiscausedbyunbalanceddietandfoodthatisnotwellprepared.Duringtheinterviewwithhertheresearchassistanttranslated:

‘Theunderstandingsofthepeople,themisconceptionsofthepeoplearedifferentaccordingtotheirlevelofbeingataccordingtothelevelofunderstanding.Ignorancewithincommunity.Therearesomepeoplewhoareignorantaboutthiskindofmalaria.Andtherearealsosomepeoplewhothinkthattheymaygetthiskindofillnessfromunbalanceddiet.Thisfoodthatiswellprepared.Throughconsumption,theremaytheymaygetmalaria.Itmeansthatsomepeoplethinkdifferentlyaboutthiskindofsickness’.

Thisquotationexplainsthattheheadofthehealthcenterthinksthattherearecommunitymemberswhobelievethatmalariaiscausedbyunbalanceddietandfoodthatisnotwellprepared.

Themostimportantfindingsinthissub-sectionarethatthemajorityofactorsperceivetheknowledgeaboutmalarianottobeenoughinRuhuha.Accordingtotheseactorsthereisaneedforcontinuousteachingtoincreaseknowledge.Otheractorsexplainedthatknowledgeisthere,butthatthe

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preventivemeasuresarenotappliedenough.Furthermore,accordingtoanumberofactorstherearestillsomemisconceptionsaboutmalaria.FormyresearchthesefindingsmeanthattherecouldalsobedisadvantagestoICTs,astheyinthiscasecanfacilitatethespreadofmisconceptions.Furthermore,thefindingsdescribedabovealsomeanthattherearegapsintheinformationflowsasmanystakeholdersmentionedthattheythinkthatknowledgeaboutmalariaisnotenoughinRuhuha.However,earlierwasalsoidentifiedthatcommunitymembersperceivemalariaasagrowingproblemwithinthecommunityandthatawarenessishigh.Asactorsfrombothhealthandnon-healthrelatedactorsfromalllevelsmentionedthattherearemisconceptionsandthatknowledgeaboutmalariaisnotenough,thefollowingsectionwillanalyzehowthedifferentactorsascribelegitimacytotheinformationtheyreceive,focusingontheroleoftrust.

5.3.4TrustTheprevioussectionexplainedwhetheractorsthoughtthereis(enough)

knowledgeaboutmalariaandwhethertherearemisconceptionsaboutmalaria.Thissectionidentifieswhetherthereistrustamongactorstoseehowknowledgeisgraspedorwithdrawn.Firsttheactorsthataretrustedwillbedescribed,followedbytheactorsthatarenottrusted.

5.3.4.1ActorsthataretrustedWhenaskedaboutwhomtheytrustmostwhengettingreliable

informationaboutmalaria,thecommunitymembersmainlymentionedtheytrustinthecommunityhealthworkersandthenursesorstaffofthehealthcenter.Furthermore,theyalsomentionedtheybelieveinlocalleadersandreligiousleadersastheysharethesameinformationcomparedtothecommunityhealthworkersandthehealthcenter.Thereasonsaredescribedinmoredetailbelow.

CommunityhealthworkersarepartofthecommunityThecommunitymembersbelieveincommunityhealthworkers,because

thecommunitymembersselectthecommunityhealthworkersatlocallevelthemselves.Communitymembermentionedthattheytrustcommunityhealthworkers,becausetheyarepartofthecommunity.Duringaninterviewwithacommunitymembertheresearchassistanttranslated:

’Youknowwhytheymostlybelieveinthiscommunityhealthworkers.Theyarenotmosteducatedbecausemosthaveprimaryeducationbutatprimarylevel,butbecausetheyareinthosevillages.Theyknoweachhousehold.Theyarenotoutsidefromthevillages.Sotheybelieveaslongastheyarepartofustheyarewithineithermyneighbor,ormyrelative,ormyfriendsotheybelievewhatevertheinformationtheyget,theyarecorrect’.

Thisexampleshowsthatcommunitymembersbelieveinthecommunityhealthworkersastheyarepartofthecommunity.Anothercommunitymemberalsomentionedthisandthetranslatorstated:

‘Theybelieveinthosecommunityhealthworkersbecausewheneverapersonissufferingfromanydisease.Sheorhecallsthecommunityhealthworkerforsupport.Mostofthetimeshealthcommunityworkersaretogetherwiththepersonsaretogetherwiththepatientsinlocalareas.Sotheybelieveinthemandtheyconsiderthemas

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nurses.Andtheyconsidersuchactivity.Shehasgivenanexamplewherebyhealthvillage,healthcommunityworkers,maytellsuchpersonstoremovetoputoffthecloths.Andimmediatelyheorshewouldputoff,becauseofbelievinginthem.Theyarecommunityhealthworkersaretotallybelievedinlocalareas’.

Furthermore,anothercommunitymembermentionedthatcommunityhealthworkersarebelievedbecausetheycheckinformationthattheyreceivedfromothercommunicationchannelswiththecommunityhealthworkers.Thetranslatorstatedthatanothercommunitymembermentioned:

‘Theybelieveinallpersonsbutthosepersonsarenotatthesamelevel.Communityhealthworkersaretotallybelieved.Andotherpersonsarenottotallybelieved.Becausewheneverapersonseesorhearsinformationfromtheradio.Sheorheimmediatelygotothecommunityhealthworkertoaskhaveyouunderstoodwhatisbeingadvertisedonradio?Haveyouseenwhathasbeenspreadattv?HaveyouwatchedTV?Theygothereathealthcommunityworkers,soastoaskmore.Believingthatthosecommunityhealthworkersaretotallyinformed’.

Theseexamplesshowthatcommunityhealthworkersaretrustedbycommunitymembers,becausetheyarepartofthecommunity.

NurseshavestudiedandareliterateThecommunitymembersbelieveininformationfromnursesbecause

theythinkthatnurseshavestudiedandthattheyarespecialized.Theresearchassistanttranslatedanexampleduringaninterviewwithacommunitymember:

‘Theymosttrustthosenurse,becausetheythinktheyareliterate,theyhavespecializedwithinsuchspecificationandtheyarealsogoodatworkingtheirduty.Sotheythinkbecauseofbeingliterate.Becauseofhavingknowledge,becauseofstudyingtheybelievethatnursesaremostlyrelied’.

Furthermore,anothercommunitymembermentionedthattheytrustnursesbecausetheyrelyonthem.Theresearchassistanttranslatedbystating:

‘Andtheyalsobelieveinthosenursesbecausethepeoplethinkthatnurseshavetheirlivesintheirhands.Soitmeansthatthenursestakecareoftheirlives,takecareofthelivesofthepeople’.

Theseexamplesillustratethatcommunitymemberstrustnursesastheyareliterateandbecausetheyhavestudiedtotakecareoftheirlives.

LocalleadersandreligiousleaderssourcesaretrustedInaddition,communitymembersmentionedtheybelieveinlocalleaders

andchurchrepresentatives.Theresearchassistanttranslatedduringaninterviewwithacommunitymember:‘Theybelieveinthoselocalleaders.Theybelievealsointhosecommunityhealthworkers.Inthosechurchesrepresentatives,likepriests’.Anothercommunitymembergaveanexampleonwhytheytrustlocalleaders,theresearchassistanttranslated:

‘Itmeans,shehasgivenanexamplethatthosechiefofvillage,thechiefsofvillagesarealsoreliable,becausesuchinformationthatthechiefsofvillagestellthemismostofthetimegottenfromthisplace.Ismostofthetimegottenfromhigherlevel,sotheirinformationisreliable’.

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Thisexampleshowsthatlocalleadersaretrustedbecausetheirsourceofinformationseemsreliable.Furthermore,thecommunitymembersbelieveintheinformationthattheygetfromleaders,becausetheinformationissimilartoinformationthattheyreceivefromotherchannels.Duringaninterviewwithacommunitymemberthetranslatorstated:

‘Mostofthetimetheybelievein,theytrust,communityhealthworkersandnurses.Buteventhoughtheybelieveinthose,theyalsobelieveinthoseleaders.Becausewhentheycomeforameetingandtalkaboutmalaria.Thereisalinkbetweenthisinformationfromleadersandlinkbetween,thereissimilarity.Thereisnodifferencebetweenthisinformationfromdifferentareas,fromdifferentspeakers.Thereisnodifference’.

Therefore,thesequotationsshowthatcommunitymemberstrustlocalleadersandreligiousleaderswhenitcomestogettingreliableinformationaboutmalaria,becausetheirsourcesaretrustedandbecausetheinformationissimilartotheadvisereceivedfromotheractors.

WhatsAppistrustedbecauseliteratepersonsshareinformationRegardingthesocialmediachannels,communitymemberssaidtobelieve

WhatsAppmorethanFacebook.Thetranslatorstatedthatacommunitymembermentioned:

‘Shereallytrusts,shereallybelievesinWhatsAppinformation.BecauseWhatsAppisaplacewhereliteratepeople.Doctors,leaders,aregatheredsoastosharetheinformation.Sosheisnowsayingthatshedoesnotthinkthatthoseliteratepeopledoctorsleadersmaypostinformationthatisnotreliable.ShebelievesinWhatsApp’.

ThisstatementshowsthataccordingtothiscommunitymemberWhatsAppistrusted,becauseliteratepersonsshareinformationthroughWhatsApp.

5.3.4.2ActorsthatarenottrustedWhencommunitymemberswereaskedwhomtheydonottrustwhenit

comestospreadingreliableinformationaboutmalariatheymentionedtraditionalhealers,illiteratepersons,neighbors,privatepharmacies,andFacebook.Thereasonswhytheymentionedthattheydonotbelieveintheseactorsareexplainedintheparagraphsbelow.

TraditionalhealersdonotprescribetabletsorexaminepatientsThecommunitymembersdonotbelieveintraditionalhealers.Duringan

interviewwithacommunitymemberthetranslatorstated:’Whenthepeoplecomehereathealthcentertheyaregivensometabletsastoreducefever.Thensuchtabletsarenotseenthereattraditionalhealers.Andinadditiontothisisthatthosetraditionalhealersdonotexaminethepeople.Whereashereathealthcenterpeopleareexaminedandcontrolledsoastotestifytheexamsfromsuchexamination.Thoseherbalistdonotexaminethepeople,sothatiswhytheydonotbelieveinthem’.

Thisexampleshowsthatthiscommunitymemberdoesnotbelieveintraditionalhealers,becausetraditionalhealersdonotexaminepatientsbeforesubscribingorsellingtablets.

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TraditionalhealerslieforsurvivalmeansDifferentactorsperceivedtraditionalhealerstotelluntrueinformation

forbusinesspurposes.Thetranslatorstatedthatacommunitymembermentioned:

’Thosetraditionalhealersspreadrumorssoastogetsurvivalmeans.Theydon’t,mostofthetimetheydon’ttalktheydon’ttellthetruth.Theywanttogainsomethingsoastosurvive.So,mostofthetimetheydon’ttellthepeoplethetruthasitis’.

Furthermore,theheadofthedistricthospitalalsomentionedtraditionalhealerswhenaskediftherearepeoplespreadinginformationaboutmalariathatisnotreliable.Hestated:

‘Fortunatelytheyarenotverymany,theyarenotmany.Butalthoughtherearesomefew,fewpersons.Notablythistraditionalhealers.Becausesomeofthemtheyneedmoney.Theydobusiness.Sotheymisleadpeopletellingthemthatisnotmalaria,itisanotherdiseasethattheycantreat.Ya.Buttheyarenotmany’.

Thesequotationsillustratethatsomeactorsthinkthattraditionalhealersmisleadcommunitymembersforsurvivalmeans.

CommunitymembersdonotbelieveinilliteratepersonsFurthermore,communitymembersmentionedthattheydonotbelievein

illiteratepeople.Theresearchassistanttranslatedthatacommunitymembermentioned:

‘Yeahbecausetheycan’ttrustwhattheyarespeaking.Theytrustinliteratepeople,arevillageadvisorsandthosewhoarehereathealthcenters.Theybelieveinthose,theybelieveinvillageadvisorsandthosethatareathealthcenterotherthanpeoplewhoarespreadingrumorsinruralareasandbeingilliterate’.

Thisstatementillustratesthatcommunitymembersdonotbelieveinilliteratepersons,becausetheythinkthattheyspreadrumors.

CommunitymembersdonotbelieveinuntrainedpersonsMoreover,communitymembersexplainednottotrustallinformation

fromneighborsorpeoplewhoareatthesamelevelasthem.Duringaninterviewwithacommunitymemberthetranslatorstated:

‘Webelievealsointhembutthepeoplewhowedon’tbelieveinarethosewhomareatthesamelevel.Forexamplemyneighbor.Hecomesandtalkstometotellmeaboutmalaria.IwillbecautiousIwillbeattentiveatwhatheorsheisspeaking.Becausetheremaybelies.Theremayberumors.Andhehasmentionedthatthosewhoarenotbelievedarethosepeoplewhoareatthesamelevellikelocalpeoples’.

Thisexampleshowsthatcommunitymembersarecarefulwithtrustinginformationaboutmalariareceivingfromneighbors.Anothercommunitymemberalsomentionedthatneighborsarenottrustedwhenitcomestospreadinginformationaboutmalaria,theresearchassistanttranslated:

‘SoifIgodirecttotheneighborssometimestheneighborwillthinkwhoareyoutalkingtome.Areyouatrainedcommunityhealthworker.Doyouhaveanyroleinthevillage?Butwhenthecommunityhealthworker,iseasyforhim’.

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Thesequotationsillustratethatcommunitymembersdonotbelieveininformationfromuntrainedpersons.

FacebookisnottrustedbecauseanyonecanpostinformationAcommunitymemberexplainedthatshedoesnottrustallthe

informationfromFacebook.Theresearchassistanttranslated:’Amongthosesocialmediasthatsheread,mostofthetimeshedoesn’treallybelieveinFacebook.ShehasmentionedwhyshehasnotbelievedinFacebook,becauseFacebookincludesthosepersonsfromdifferentfaroffareas.Andamongthosepersons,becauseFacebookdoesnotrequireusingsmartphonesandthosephoneswhichareexpensive.SoitmeansthatFacebookischeaperthanWhatsApp.Thenduetothefactthatthoseparticipants,thoseusersofFacebookarealsodifferentorarealsolowertocomparedto,socially,arelowersocially.Donotpossesmuchmoney,socially.Donothaveacapacityofusingthosesmartphones.Thepeopleamongthoseusersaresometimesofthefaroffareasincludingstreetchildren,includingrobbersandsoon.SotheymayposttheinformationwhichisnottrueatFacebook.Itisinsuchcase,itissuchreason,thatshedoesnotreallybelieveinFacebookbecauseFacebookincludesthosepersonsfromfaroffareas.Yawhocannotbetrusted’.

ThisexampleshowsthatthiscommunitymemberthinksthatFacebookcannotbetrustedwhenitcomestogettinginformationaboutmalaria,becauseanypersoncanpostinformationonFacebook.

PrivatepharmaciesdonotperformexaminationsandcanbeuntrainedInaddition,acommunitymemberexplainedhedoesnottrustsmall

privatepharmacies.Theresearchassistanttranslatedthathementioned:‘Theydon’tbelieveinthosepharmaciesinthoselittlepharmaciesbecausemostofthemrecruitpeoplethatarenotspecialized.Recruitpeoplewhoarespecializedwithinotherareas.Sobecauseofsuch,duetosuchtheydon’tbelieveinthoselittlepharmacies’.

Thiscommunitymemberdoesnotbelieveinsmallprivatepharmacies,becausethestaffcanbeuntrained.Anothercommunitymemberalsomentionedhedoesnotbelieveinprivatepharmacies.Theresearchassistanttranslated:

‘Hehasexplainedthathedoesn’tbelieveinthosepharmacies.Hehasexplainedthatthosepharmaciesaremostofthetimefightingfortheirprivateprofit.Hehasexplainedthatalsothattheseprivatepharmacies,wheneverpersonisenteringsoastotakesuchmedicaltreatmentwithinpharmacy.Theyunderstand,theyfirstlyunderstandsignsandtryandstartprescribingmedicalments.Beforeperformingexaminations.Theywrite,theyprescribemedicalments.Itmeansthattheywritemedicalmentsinsteadofperformingthoseexaminations,patientexaminations.Theydon’tperformpatientexaminations.Theyonlywritemedicalmentsthattheyunderstandthatsuchpatientisinneed.Theydon’tcarryouttheexaminations.Sotheydon’tbelieveinthisinformationgotfrompharmacy,becausetheythinkthattheydon’tperformexaminationsasherecomparedtothishealthcenters’.

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Thisexampleshowsthatthiscommunitymemberthinksthattheinformationfromprivatepharmaciescannotbetrusted,becauseprivatepharmaciessellmedicineswithoutperforminganyexaminations. Themostimportantfindingsinthissub-sectionarethatcommunitymemberstruststakeholderswhenitcomestospreadingreliableinformationaboutmalariawhentheythinkthattheseactorshavestudied,areliterate,orwhentheinformationissimilartotheactorsthattheytrust.Furthermore,communitymembersdonottrustsourcesofinformationwhentheactorsdonotexaminepatientsorprescribemedicines,areilliterate,untrained,orbecauseanypersoncanpostinformationonFacebook.FormyresearchthesefindingsmeanthatICTsbothhaveadvantagesanddisadvantages.Communitymemberscanmoreeasilyreachtrustedactorstoaskforinformationoradvise.Moreover,ICTsalsofacilitatethespreadofinformationaboutmalariafromthetrustedactorstothecommunitymembers.However,notalltheinformationthatissharedthroughICTsistrustworthy.

5.3.5SharedperspectiveoftheproblemThepreviouslyidentifiedactorshavetocooperateandworktogetherto

achieveasharedgoalofbattlingmalaria.Therefore,thissectionanalyzeswhetheractorshaveasharedperspectiveoftheproblemthatneedstobesolved.Furthermore,itanalyzestowhatextenttheseperceptionsaresharedbymultiplestakeholdergroups.ProblemsregardingmalariapreventionandcontrolinRuhuhathatwerementionedduringtheinterviewsareillustratedintable25.

Table25:WhatproblemswerementionedbywhichactorsProblems Mentionedbythefollowingactors StakeholdergroupsLackofmosquitonetswhicharenotavailableandmosquitonetswhichareexpired

Fivecommunitymembers,cooperative,healthcenterstaff,communityhealthworkers,CMAT,nationalhealthinsurance,headofthehealthcenter

-Communitymembers-Healthrelatedcommunitylevelactors

Tablets Fivecommunitymembers,cooperative,healthcenterstaff,communityhealthworker,healthcenterpharmacy,privatepharmacy

-Communitymembersandcooperative-Healthrelatedcommunitylevelactors

Notusingpreventivemeasuresproperly

Twocommunitymembers,communitymemberswithouthealthinsurance,healthcenterstaff,communityhealthworker,nationalhealthinsurancescheme,districthospital,privatepharmacy,headofthehealthcenter

-Communitymembers-Healthrelatedactorsfromalllevels

Poverty Twocommunitymembers,healthcenterstaff,communitymemberwithouthealthinsurance,districthospital,privatepharmacy,headofthehealthcenter

-Communitymembers-Healthrelatedactorsfromcommunityanddistrictlevel

Fumigationnotbeingcarriedout

Twocommunitymembers,healthcenterstaff,CMAT,RBC,nationalhealthinsurancescheme

-Communitymembers-Healthrelatedactorsfromcommunityandnationallevel

Beliefinbewitcheryandpoisonousactivities

Communitymember,healthcenterpharmacy,localleader,districthospital

-Variousactorsfromcommunityanddistrictlevel

Bedbugs Communitymember,MEPR,districthospital,headofthehealthcenter

-Communitymembers-Healthrelatedactorsfromcommunityand

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districtlevelRemovingplantationsaroundthehousewhiletheyareimportant

Twocommunitymembers -Communitymembers

Lackoftimelyresponseand(financial)resources

RBC,districthospital -Healthrelatedactorsfromnationalanddistrictlevel

Waterscarcity Healthcenterpharmacy -Healthrelatedcommunitylevelactor

Ascanbeanalyzedfromthetable,theproblemsaremainlymentionedby

healthrelatedactorsandbycommunitymembers.Problemsrelatedtotheavailabilityofmosquitonets,tablets,useofpreventivemeasures,povertyandfumigationaremostfrequentlymentioned.Moreover,problemsrelatedtotheavailabilityofmosquitonets,tablets,removingplantations,andwaterscarcityareonlymentionedbycommunitylevelactors.Furthermore,problemsrelatedtothelackoftimelyresponseand(financial)resourcesareonlymentionedbydistrictandnationallevelactors.Theproblemsinthetableaboveareperceptionsbyactorsandareexplainedinmoredetailbelow.

MosquitobednetsFurthermore,communitylevelactorsdescribedthatthereisalackof

availablemosquitonets.Thereareanumberofpeoplewhodonotsleepinbednets.Thenetscannotbeboughtanywhere.Thecommunitymembersexplainedthattheyarewaitingforthehealthcentertogetmosquitonets.Communitymembersarewonderinghowtheycangetmosquitonets.Onecommunitymembergaveanexamplethatithasbeentwoyearssincethegovernmentdistributedbednetsandcampaigned.Hesaidthatnowadaystheycannotevenfindwheretobuythem,butthathewouldbewillingtospendsomemoneytobuybednetsinsteadofwaitingtogetthemforfreefromthegovernment.TheRuhuhahealthcenterstaffmentionedthelackofbednetsasaproblemaswell.Duringthisinterviewthetranslatorstated:

‘Thesefumigants,theseproductsthatare,thesefumigationsinmosquitonetsisnotaccessible.Heiswonderingwhatcanwedo?Whatcanwedotopreventthosepeoplesufferfrommalariawhiletheysleepinthosehouseswithouthavingmosquitonets.Andwehavenocapacityofgivingthemmosquitonets.Whatwedohereiscuringthosepeoplewhohavebeenattackedorattacked,givingthemmedicalments.Butthematerials,thewayofgettingmaterials,thesupportofmaterials,thisexceedsourimagination’.

AnotherstaffmemberoftheRuhuhahealthcenteralsoexplainedtheproblemofbednetsnotbeingavailable.Theresearchassistanttranslated:

‘Whatisattherootofthisproblem,theincreasementoftheincreasingofthemalariaisthatpeoplearenowdonothavemosquitonets.Therearemosquitonetsthattheyusedtohave,buttheyarenowoldandtheyarenotfunctioning.Eventhegovernmentknowstheproblem.Buttheproblemhasnotyetgiventhosemosquitonetssoastohelpthem.Thosemosquitonetshelpthosenursesbecausewhenthereisavailability,whenthereisaccessibilityofmosquitonetspeoplearenotsufferingfrommalaria.Itmeans

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thatpeoplearenowstillsufferingfrommalariabecauseoftheirdiscusofthosemosquitonetsthatarenownotbeingavailable’.

Furthermore,acommunityhealthworkerexplainedthatbednetsarenotproducedinRwanda.Thetranslatorstatedthathementioned:

‘Mosquitonetsarefromabroad.Arefromforeigncountries.WherebyshehasemphasizedthatRwandahasnocapacityofproducingthosenets.Sothosenetsarefromoutside.Ya.Andaftergettingthosematerialsfromoutsidethecountry,Rwandaisinchargeofgivingthesematerialstopeoplesoastosupportthemtofightagainstmalaria’.

InadditiontheCMATrepresentativeexplainedthatthebednetsthatarecurrentlyusedareoldandthattheyhaveexpired.Theresearchassistanttranslated:

‘Wheneverpeoplefollowtherulesthatareregulatedsoastofightagainstmalaria,malariawillberemoved.Butexceptthetimewhenthesematerialsthatareusedtoprevent.Likemosquitonets,thosematerialsthatareusedtofightagainstmalaria.Wherethosematerialsarenotuptodate.Areold.Becausenowadayssomepeoplehavethosematerialsthatareold.Likemosquitonetswhichareold.Thismeansthattheywillnotfightagainstmalariabecausethematerialswhichistheretosupportthemisnotfunctioning’.

TheRwandanBiomedicalCenter,whoisinchargeofdistributingbednets,stated:

‘CurrentlyweareusingbednetsandlastyearinJanuary/Februarywedistributedthebednetsandcoveringthehouseholdbyhousehold.Butunfortunatelywehavenotfoundadeclineofmalariaafterthedistributionofbetnets.Wedon'tknowwhathappened.Resistancetoorinsecticideusedfortreatmentofbednet,wedon'tknow’.

ThisstatementillustratedthattheRwandaBiomedicalCenterdoesnotknowwhymalariadidnotdeclineafterthedistributionofbednets.TheheadofRuhuhahealthcenterexplainedthisinformationgapbetweenRBCandwhatishappeningonthegroundthatmalariaisnotdecreasing.Theresearchassistantstatedthatsheexplained:

’Governmentexpectthatmosquitonetshastobeexpiredintwoyears.Itmeansthatmosquitonetsisgivenonceeverytwoyears.Thenafterspending,becauseofthepovertyofthepeople.Andbecauseoftheconditionstheylivein,sheexplainedthisbygivinganexamplewherebysomepeoplearelivinginmudhouses.Wherebythereisnocementinthehouses,thereisnofloorandthehousesaresomehowinappropriate.Thenhavingthislifeconditions,thislifeconditionsthatisdifficultalsoisatthebaseofcausingthisproblemoflackingmosquitonets.Becausewheneverthispersonwholivesinthismuddyhouse,wheneverheisgiventhismosquitonets.Andwheneverthismosquitonetisgoingtobeestablished,isgoingtobeput,isgoingtobesetwithintheirhouseathisorherbed.Thereisnomattressthere,thereisnobedthere,therearesomegrassestherewherebysheorheorshespreadsthismat.Thenputtingtheremosquitonetisdifficultbecauseofsuchlifeconditions.Andwithin

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thesegrasses,withintheseleavesofthebananaswherebytheysleep,theremayalsoraisesomeotherinsects,bedbugs.Likebedbugsandsomeotherlikethoseofjiggas.Throughthesebadinsectsthisbadconditionthattheylivein.Theymaysaythatmosquitonetalsoincludeswithintheseisalsoatthebaseofthesebedbugs.Letmeputitasideorburnit.Thentheyburnitwithoutspendingtwoyearsexpected.Thenafterburningthismosquitonetearlier,comparedtothetimethathasexpectedbythegovernmentthemosquitonetisnotavailable.Mostofthepeopleperformthis,thenwithincertainperiod,ashortperiod,nottwoyears,thosemosquitonetsarenotaccessible.Itmeansthattheirlifeconditions,theirpovertyinwhichtheylivealsoisattherootofthesemosquitonetsgivenbythegovernment.Expectingthatthosemosquitonetsmayperpetuatemayhavedurabletimeoftwoyears.Itisimpossiblebecauseofthepovertythatpeoplearenowsufferingfrom’.

ThisquotationshowsthataccordingtotheheadofRuhuhahealthcenterthereasonwhymalariadidnotdeclineafterthedistributionofbednetsisbecauseofpoverty,havingnobedstousemosquitonetsproperly,andbecausecommunitymembersburnthemosquitonetswhentheyfindbedbugs.

TabletsCommunitylevelactorsmentionedseveralproblemsregardingthe

tablets.Firstofallsomeactorsthinkthatthetabletsarenolongerabletocuremalariabecauseofdrugresistance.Communitymembersexplainedthattheythinkthatthemedicinesthattheyarenowadaystakingarenotabletocuremalaria.Thetabletsaresometimeschangedtonewones.Thecommunitymembersexpressedthatthecurrentmedicinesarenotcuringmalaria,becausemalariaattacksapersontwiceaweek.Therefore,theythinktheproblemiswiththetabletsandthattheyneedinnovationwithinmedicalproduction.Thecommunitymembersexplainedmalariahasbecomedrugresistant.Theythinkthatnowisthetimetochangethecurrenttabletsanduseanewdrug.Duringtheinterviewwiththehealthcenterstafftheresearchassistanttranslated:

‘Theydon’tconsiderthosemedicalmentsasrealmedicalments.Theyconsiderthoseseeds.Andtheysaythosemedicalmentsfromhealthcenterarenolongercuringus.Soitmeansthereisnoneedofgoingtherebecausetheirmedicalmentsaresomehowunabletocureelements’.

Thisstatementshowsthatthehealthcenterthinksthatitisaproblemthatthecommunitymembersthinkthatthemedicinesarenolongercuringthem,becauseinthesecasestheywillnotfeeltheneedtocometothehealthcenterforexaminationandtreatment.Othercommunitymembersalsomentionedthattheythinkthatthetabletsatthehealthcenterhaveexpired.

Moreover,actorsalsomentionedthattherearecommunitymemberswhosharetabletswiththeirchildrenathomeorwithneighbors.Theysharetabletsbecausetheyhavenocapacityormeanstoreachthehealthcenter.Thecommunityhealthworkersalsoexplainedthatthesharingoftabletsisaproblem.Thetabletsatthehealthcenteraregivenforfreewhenapersonhasahealthinsurance.Asthetabletsareforfreecommunitymemberssharethetabletswithfamilymembersathome.Whenpeoplegotoaprivatepharmacy

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theyarechargedforthetablets.Becausetheyarechargedarelativelyhigherpricecommunitymembersdonotsharethosetabletsfromaprivatepharmacywithfamilymembersathome.Therefore,thetabletsatthehealthcenterdonotcuremalariabecausetheyarebeingusedinanimproperwaycomparedtothetabletsboughtfromaprivatepharmacy.Recentlytherehavebeenrumorssayingthatthetabletsgivenathealthcenterarenotabletocuremalaria,whiletabletssoldat3500to6000RwandanFrancbyprivatepharmaciesareabletocurethedisease.Immediatelythehealthcentercalledthecommunityhealthworkerstoshowthemthatthetabletssoldattheprivatepharmaciesarethesamecomparedtotheonesatthehealthcenter.Accordingtothehealthcentertheproblemisthatpeoplegowithintheirlocalareaswiththetabletsfromhealthcenterandstartsharingthetabletswithfamilymembers.Afterwards,theyhavenottakenthenecessaryquantitytocuremalariaasexpected.Thisisthereasonwhyaccordingtothecommunityhealthworkerpeoplearenowspreadingrumorsandinformationregardingthetabletsthatisnottrue.

NotusingpreventivemeasuresproperlyRuhuhahealthcenterstaffmentionedthatoneproblemisthatthepeople

arenotawareofmalaria.Sheexplainedthatapatientmayreceivetabletsformalaria.Whiletakingthesetabletsshemaybestungbyamosquitoathomeagainwhilerecoveringfromthepreviousmalaria.Aftertakingthetabletsthepersonstartsthinkingthatthetabletsdidnotcuremalaria,whileactuallyheorshewasattackedbymalariaagainbeforebeingrecovered.Thenthepeoplecometothehealthcenterandreportthattheywerenotcured.Therefore,thehealthcenterstaffexplainedthattheyarenowadaysdealingwithpeoplewhoarenotawareoffightingagainstmosquitosandusingthepreventivemeasureswhileconsumingtablets.Thesecommunitymembersarenotawarethatmalariamayattackthemwhiletakingtablets.Thiswasalsomentionedduringtheinterviewwiththehealthcenterpharmacy,theresearchassistanttranslated:

‘Somemedicalmentsmaybetakenproperly,thenattheendtheremaybeasting.Themosquitomaystingsuchpatientagain.Thenafterbeingstingtheremaybeproposition,theremaybesomeideasthatpatienthasnotbeencured.Yathisisthecase’.

Thehealthcenterpharmacyalsomentionedthatpeopleconsumethetabletsbadly.Afternotbeingcuredtheystartthinkingthetabletsdonotfunction.Thehealthcenterpharmacistgaveanexample,thetranslatorstated:

‘Themedicalmentsthatareprescribedwithinmalariaareconsumedwithindifferenthours.Therearesomesteps.Thereisfirststepandsecondstep.Firststepisafterapatientispresumedtotakemedicalmentsaftereighthours,butmostofthepeopleunderstandthattheywillconsumemedicalmentsafter12hours,afteraday.Thenafterconsumingthesemedicalmentsbadlytheymaynotbecured’.

TheRwandanBiomedicalCenteralsostatedthattheknowledgeintermsofpreventionisstilllowbymentioning:

‘Theknowledgeisveryhighintermsofdiagnosticandtreatmentofmalariaandsymptoms.Butknowledgeisstilllowintermsofprevention.Thegooduseofbednets.Evenofspraying.Andalsoothermethodsforprevention.Becausetherearedifferentmethods

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forpreventionagainstmalaria.Buttheknowledgeisveryhighintermsofskillsintermsofhowtoknow,symptomsofmalaria,howtotreatmalaria,andsofort.Diagnosticofmalaria,butintermsofpreventionknowledgeisstilllow.Butecologyofmosquitos,knowledgeonmosquitosofthebreedingsites,mosquitolarvae,isstillverylowintermsofecologyofvectors.Knowledgestillverylow’.

ThiswasalsoconfirmedbytheheadofNyamataDistrictHospitalwhomentioned:

‘Andalsothelackofknowledgeofthepopulation.Aboutthepreventionagainstmalaria.Theydonothaveimportancetothisprevention’.

WhenaskedaboutthecauseoftheincreaseofmalariainRuhuhahesaid:‘Somecausesareduetolackofknowledgeofthepopulation.Theimportanceofsleepingundermosquitonets.Insteadofsleepingundermosquitonets.Theyusethesemosquitonetstofish,forfishing.Anduhmforotheractivities.Andothertheyrefusetosleepundermosquitonetspurposely’.

Theprivatepharmacistalsoexplainedthebaduseofpreventivemeasures.Duringthisinterviewtheresearchassistanttranslated:

‘Theunderstandingsofthepeoplearestillatlowlevel.Someofthemarenowstillsufferingbyarestillmeetingfacingthisproblemofnothavinggoodunderstandings.Wherebyilliteratebothilliterateandliteratepeopledonotusemosquitonets,someofthemdonotusemosquitonetsproperly.Hehasgivenanexamplewherebywifehiswifedoesnotusemosquitonets,whereasshereallyknowstheimportanceandtheroleofmosquitonet.Butthinkingthatthereishotnessandthinkingthatmosquitonetmaycauseotherrelatedproblemsshedoesn’tuseit.Itmeansthatthereislowunderstanding’.

Alltheseexamplesshowtheperspectivesofdifferentactorswhothinkthatmalariapreventionmeasuresarenotappliedproperly.

PovertyWheneverpatientsaresufferingfromseveremalariatheyare

transportedtothedistricthospital,buttherearepatientswhoescapebeforebeingtransportedbecauseofpoverty.Duringaninterviewwithahealthcenterstafftheresearchassistanttranslated:

’Wheneverpatientreacheshereandunderstandsthatheisorsheisgoingtobetransportedtohospitalshestartsthinking,Iamgoingtobetransportedtohospital,Ihavenofamilytocaremewhilebeingthereathospital,noonetobringmefood,noonetobringmeanythingsoastohelpmewhileIamthere,sowhyamIgoingtobetransportedthere.Thenafteranalyzingthissituationsheorheimmediatelyquitsthishealthcenter.Yathisispoverty’.Furthermore,somecommunitymembersalsohavenomoneytobuythe

communityhealthinsurance.Thetreatmentissomehowexpensiveatthehealthcenterwithouthealthinsurance.Forthisreason,thosethatdonothaveahealthinsuranceprefertogotoaprivatepharmacy.Ataprivatepharmacy,ifmedicinesare5000,acommunitymembercansayokformeIhave1000socanyougive

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methemedicinefor1000.Thisisnotforthewholetreatmentandthiswillnotcuremalaria,sothisisanotherchallenge.Acommunitymemberwithouthealthinsurancementionedthatwheneverthetimeofbuyinginsurancecardscomes,therearesomepeoplewhohavenomeansofbuyingtheinsurancecards.Oneperson’sinsurancecardcosts3000RwandanFranc.Thismeansifafamilyexistsoftenpersons,itmeanstheyneed30000RwandanFranctobuyinsurancecards.Accordingtothiscommunitymemberitisimpossibleforthisfamilytobuytheseinsurancecards.Forthisreason,theybuydrugsataprivatepharmacy.Duringthisinterviewtheresearchassistanttranslatedthathementionedthatwheneverapersonshowsupatthehealthcenterwithoutaninsurancecard:‘Theywillconsiderhimorherassomeoneforeign,thentheywillchargemuchmoney’’.Heexplainedfurtherthatinsteadtheyattendprivatepharmaciesbystating:

‘Hehasexplainedthathedoesn’tbelieveinthosepharmacies.Hehasexplainedthatthosepharmaciesaremostofthetimefightingfortheirprivateprofit.Hehasexplainedthatalsothattheseprivatepharmacies,wheneverpersonisenteringsoastotakesuchmedicaltreatmentwithinpharmacy.Theyunderstand,theyfirstlyunderstandsignsandtryandstartprescribingmedicalments’.

Thisstatementshowsthathedoesnotcompletelytrustprivatepharmacies,howevertheresearchassistantalsotranslatedthattheyattendthembecauseofthefollowing:

‘Buttheyfoundtheysometimesfoundthemselvesinmiserableconditions.Theygotheresoastogetmedicaltreatment.Theygotoprivatepharmaciesnotthinkingthattheremaybebadinformation.Butbecauseoftheirpoverty,theirmiserableconditionstheygothere.Theyhavenothingtodoapartfromgoingthere.Theygotherebecauseoftheirpoverty.Theywanttobeinpeacefulconditionsbutbecauseofmiserableconditions,miserableconditionsdonotallowthemtobeinsuchpeacefulcondition.Sotheygothereforpovertyreasons’.Inaddition,thehealthcenterpharmacyexplainedthatitisaproblemthat

privatepharmaciesdonotgivemanydetailsaboutthemedicationtopatients.Therefore,peoplemaynotgetcuredasplannedbecausetherewasnoeducationattheprivatepharmacy.Aftersomedaysofbeingsickthosepatientsreachthehealthcenterbeingsicker.TheheadofNyamataDistrictHospitalstated:

‘Itisnotagoodpractice.Sowearetryingtodiscouragethisandtosensitizepeopletogointhehealthfacilitytobetested.Iftheyhavemalariatheybegivendrugsthere.Itisnotgoodtogototheprivatepharmacywithoutpassingthroughthehealthfacility’.Moreover,theheadofthehealthcentermentionedthatpovertyis

atthecauseofmalaria,becausepovertydoesnotallowcommunitymemberstoapplysomeofthepreventivemeasures.Duringthisinterviewtheresearchassistanttranslated:

’Sotheconclusionisinshort,povertyisreallythemajorleadingcauseofmalariaincrease.Becauseifpeoplearelivinginsuchconditionthenoneoftherealityisthesebedbugs.Becausebedbugstheyfeedonandtheyreallyfeedonblood.Soiftheyhavethisinfectionofbedbugsandespeciallywiththemosquitonetsbecauseinthenightthebedbugsgoesinthemosquitonetsandthenwhen

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theyopenittheycomeandstarttofeedonthepeopleinthehouse.Thenpeoplearemore,theyremovequicklythemosquitonetandburnit.Sothatiswhytheydon’thaveanymoremosquitonets.Andthentheyarebecomingmoreoftentogetmalariafromthemosquitos’.

Theseexamplesshowthatanotherperceivedproblembydifferentactorsispoverty.

FumigationAccordingtodifferentactorsmalariaisincreasingduetothefactthatthe

actionoffumigationhasbeensuspended.Communitymembersgaveexampleswherebymalariahaddecreasedtwoyearsagowhentherewhereactivitiesrelatedtofumigationinhousesandswamps,butnowadaysitisnotbeingdone.AlsothememberofaCMATmentionedthatfumigationhasnotbeencarriedoutsince2016.ThetranslatormentionedthattheCMATmentioned:‘Thisfumigationtookplacewithin2016.Fromsuchyeartilltodayithasnotyettakenplace.Itmeansthatthislastyear.2017,theydidn’t.Tilltoday’.Communitymembersmentionedthataftersuspendingthoseproductsforfumigatingthehousesandswampsmalariahasincreasedatagreatnumber.ThestaffofRuhuhahealthcenteralsomentionedthisandtheresearchassistanttranslated:‘Thedecreaseorthislackoffumigationhascausedaproblemwherebymosquitosarenow,malariaisnowspreadingasaresultofusingthisfumigation’.Inaddition,theRwandaBiomedicalCenteralsomentionedthatmalariaincreasedsincefumigationhasstoppedbystating:

’IamnotupdatedaboutmalariainRuhuha.ButIknowthataftersprayingcampaign,wehavenotsprayedRuhuhaduringlastsprayingcampaignofSeptember.NowweareinJanuaryandwesprayedthereinFebruarylastyear,butSeptemberwehavenotsprayedthere.AndMalariaincreasedthere’.

ThepersoninterviewedattheNationalHealthInsuranceSchemewhowaspartoftheMEPRresearchprojectwithaBtiinterventionmentioned:

‘Thenweintroducedtheseapplicationoflarvaecide.Sowediditinjustonecultivationseason.Sothatafterthatcultivationseasonmalariamosquitosreduceddramatically.Butforaperiodaroundsixmonth.AndafterthatitwasabigproblembecausemosquitosstartedagaintoreproduceinmanynumbersthenIthinkwhenIwastherethelasttimeitwasabigchallengebecauseaftertheeffectsofBtithentheproblemofmalariabecameaseriousproblem’.

Theseexamplesillustratethatmultiplestakeholdergroupsperspectivesthelackoffumigationasaproblem.

BeliefinbewitcheryAnotherproblemthatwasmentionedbyseveralactorsisthebeliefin

bewitcheryandpoisonousactivities.Communitymembersexplainedthatwheneverapersonwhoisnotaccustomedtogettingmalariagetsmalariaheorshebecomesmad.Thenpeopleintheruralvillagesstarttalkingthatheorsheisbewitchedandimmediatelymovethispersontotraditionalhealers.Thelocalleadersaidthiscultureisnowuprooted,butgavetheexamplewhichthetranslatortranslated:

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‘Thereisacasewherebytwoneighbors.Onemaysuspecttheothertobewitchortopoisonhimorher.Thenafterawhile,asthereisapatient,asoneofthemissufferingfromelement.Hesheissufferingfrommalaria.Thenafteracertainperiod.Insteadofcominghereathospital,shegoestotraditionalhealer.Thentraditionalhealerstartsayingyouhaveanopponent.Youhaveapersonwhoisopposingyouinyourvillage.Hehasbewitchedyou.Youhavebeenbewitched,youhavebeenpoisoned.Wherebythistraditionalhealerislyingandthepersonissufferingfrommalaria.Thepersonissufferingfrommalariabuttraditionalhealerissayingthatpersonissufferingfrombewitcheryactivities’.

TheheadofNyamataDistrictHospitalalsomentionedtheproblemofgoingtotraditionalhealersbysaying:

‘Andsometimestheyareill,insteadofgoingtothehealthfacilityorinsteadofgoingtothecommunityhealthworkertheyprefertogotolookfortraditionalhealer’.

Whenaskedaboutthereasonwhypeoplegotothetraditionalhealershementioned:

‘WhatIhaveseen,someofthemdonothavethiscommunitybasedhealthinsurance.Ya.Soiftheydonothavehealthinsurancetheyprefertogotothetraditionalhealerwholiveswiththem,nearbythem’.Thehealthcenterpharmacyalsoexplainedthataftergoingtotraditional

healerstogetcuredpatientstakelongtoreachthehealthcenter.Thenafterspendingalongtimeatthetraditionalhealerstryingtogetcuresinsteadofgoingtothehealthcenter,theyreachthehealthcenterbeingverysick.Inthesesituationsacommunitymemberisoftentakentothedistricthospitaltogetcured.

BedbugsDifferentintervieweesperceivedbedbugsanotherproblemregarding

malariapreventionandcontrol.Whenthecommunitymembersseebedbugsinthebednetstheyfearthembecausetheycauseaswelling.Theyprefertotakethewholebednetandthrowitawayorburnthenetsinsteadofremovingthebedbugs.Therefore,thebedbugsarealsoperceivedasaproblem.Itwasmentionedthatthecommunitymemberseitherneednewbednetsoranythingthatcankillthebedbugs,astheyarecommoninthisarea.

RemovingplantationsaroundthehouseCommunityhealthworkerseducatepeopleaboutthemalariaprevention

measuresincludingtheremovalofmosquitobreedingsites.Onecommunitymembergaveanexamplethatforthelasttwoyearstheyweretaughtnottoplantsorghumandmaizenearthehome,becausethisiswherethemosquitoscanliveandgrow.Anothercommunitymemberwonderedwhethertheyshouldremovebananaandsorghumplantationsnearbytheirhomewhiletheyareplayingagreatroleintheirlives.

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Timelyresponseandlackof(financial)resourcesTheRwandanBiomedicalCentermentionedthatanotherproblem

regardingmalariapreventionandcontrolinRuhuhaistimelyresponse.Heexplainedthisbysaying:

‘Causeforthefirstweekofeachmonthwehavenewdata.Buttheissuesometimesisresponse.Ourissueisresponse.Weknowthatthereisaproblemthere.Butsometimesifyouwanttosprayitisabigproblemtofindoutmoney.Becauseforonelitter,uhmnoonedosage.Foronesquarepointthereisaroundcurrentlywithoutsubsidyisaround7.34USD.Butyoudon’tknow,tosprayonehouseisaroundprobably20euro.Ifyouwanttosprayonehousefor20eurosisveryexpensive,isveryexpensive.Butwearetargetinghighburdenareas’.

TheheadoftheNyamataDistrictHospitalexplainedanotherproblemregardingmalariapreventionandcontrolinRuhuhawasthelackofRDT(rapiddiagnostictests).Hestated:

‘Othercausesuhmduetolack,theyhadinsomeperiodsastakeoutofRDT,rapiddiagnostictestinthecommunity.Anduhm,somebugsalso.Uuhm,andinordertocombatmalariawehavetocombatitatlocallevelinthevillage.Soifthesecommunityhealthworkersdonothavecommodities,donothavethisRDTordrugs,peoplehavemighthavechancetodieinthecommunity.Orifeveniftheydonotdieinthecommunitytheycometoolateatthehealthfacility.Theycometoolateatthehealthfacility.Theyhaveseveremalaria,becausetheyhavedelayedathome,soitiswhereitisimportanttohavetheseRDTordrugsinthecommunity,sowecantreatmalaria,wecombatitthereatlocallevelinthecommunityinthevillage’.

Thesequotationsillustratethattimelyresponseandlackof(financial)resourcesisanotherproblemperceivedbyactorsfromthedistrictandnationallevel.

WaterscarcityAnotherproblemmentionedbyhealthcenterpharmacystaffisthat

withinBugeseraDistrictthereisscarcityofwater.ThereislesswatercomparedtootherregionsinRwandaandgettingwaterisdifficult.Therefore,whenitrainspeopleputthiswaterwithindifferentmaterialsthinkingthatinsomedaystherewillbeashortageofwater.Withinthisprocessofputtingwaterindifferentmaterialsathomemosquitosareattracted.Mosquitosliveandproduceandpeoplewithinhouseholdsorthosethatcollectwatermaysufferfrommalaria.

Themostimportantfindingsinthissub-sectionarethatthemajorityofproblemswerementionedbycommunitylevelactors.Thedistrictandnationallevelactorsdescribedtimelyresponseandlackoffinancialresourcesasaproblemwhichwasnotmentionedbythecommunitylevelactors.However,thisproblemisrelatedtoissuesdescribedbycommunitylevelactors,suchaslackofmosquitonetsandnofumigation.Otherproblemssuchasthoserelatedtotabletsandbeliefinbewitchery,arerelatedtomisconceptionsonthecommunitylevel.Furthermore,notusingpreventivemeasuresproperly,poverty,andbedbugswerementionedbymultiplestakeholdergroups.Theseproblemsaresomehowrelated,forexamplebecauseofpovertyandbedbugsmosquitonetsarenotusedproperly.RBCmentionedthatthemosquitonetswerelast

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distributedin2016.Accordingtotheanalysisofthesituationregardingmalaria,andaccordingtoRBCmalariahasincreasedsincethen.Communitylevelactorsexplainedthatmanycommunitymembersdonothavebedstousethemosquitonetsinthewaytheyaresupposedtobeused.Inaddition,itwasmentionedthatsomecommunitymembersusethenetsforfishingandotherpurposes.Moreover,bedbugsareaprobleminRuhuhacausingcommunitymemberstoburnthemosquitonetswhentheyspotbedbugsinthenets.Nowthatmalariahasincreasedcommunitymemberswantmosquitonetsandseetheirimportance,howevertheyarenotavailable.Formyfindingsthismeansthatthereisamiscommunicationorlackofcommunicationbetweenstakeholderlevels,asforexampleRBCmentionedthat‘Butunfortunatelywehavenotfoundadeclineofmalariaafterthedistributionofbetnets.Wedon'tknowwhathappened.Resistancetoorinsecticideusedfortreatmentofbednet,wedon'tknow’,soapparentlytheyarenotawareoftheproblemsrelatedtopovertyandbedbugsidentifiedbycommunitylevelactorsthatexplainwhathappened.

Tosummarizethissection,firstofallactorsperceivedtheexaminationofpatients,teachingcommunitymembersaboutpreventionmeasures,facilitatingaccesstopastdataaboutmalaria,identificationofmosquitospecies,andabiggerroleofsocialmediaincommunicationregardingmalariaasfuturerolesofmobilephones.Furthermore,actorsperceivethesituationregardingmalariainRuhuhaasaproblemathighlevel,exceedinglimitscomparedtothepast,exceedinglimitscomparedtootherregionsinRwanda,andactorsexpressedthatmalariaincreasesduringcertainmonths.Moreover,regardingknowledge,myresultsshowthataccordingtotheperceptionofactorsthereareanumberofmisconceptionsaboutmalariainRuhuha.Thesemisconceptionsincludebewitcheryandpoisonousactivities,eatingmaizesticks,eatingsugarcanes,drizzleandnewlyharvestedbeans,medicinesatthehealthcenterdonotcuremalaria,andunbalanceddietorfoodthatisnotwellprepared.Inaddition,regardingtrustthecommunityhealthworkersandthenursesorstaffatthehealthcenteraremosttrustedwhenitcomestospreadingreliableinformationaboutmalaria.Traditionalhealers,illiteratepersons,neighbors,privatepharmacies,andFacebookaretheleasttrustedwhenitcomestospreadingorreceivingreliableinformationregardingmalaria.Lastly,perceptionsofproblemsregardingmalariapreventionandcontrolthatwerementionedbydifferentactorsarerelatedtofumigation,tablets,bednets,bedbugs,removingplantationsaroundthehouse,beliefinbewitchery,notusingpreventivemeasuresproperly,poverty,waterscarcity,andtimelyresponseandlackof(financial)resources.

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5.4MalariagovernancearrangementsIntheprevioussectionsIanalyzedtheinformationandcommunication

flowsbetweenactors,theroleofICTsinhealthsysteminRuhuharegardingmalaria,andwiderangeofactors’perceptionsregardingthefutureroleofmobilephones,thesituationregardingmalaria,knowledgeandmisconceptions.IidentifiedthatinformationregardingmalariainRuhuhaissharedviaface-to-facecommunication,SIScomandHMIS,mobilephones,radio,andvideoprojections.MyfindingshaverevealedthatapartfromthestrategicICTbasedhealthinterventionssuchasHMIS,mobilephonesalreadyplayacrucialroleinmalariaprevention,inparticularbyfacilitatingawarenessraisingandbyimprovinginformationflowswithinandbetweenstakeholdergroups.Contrarily,ICTscouldalsofacilitatethespreadofmisconceptions,asactorsfromalllevelsmentionedthatmisconceptionsaboutmalariastillexistinRuhuha.Myanalysispointedtotheroleoftrustinhowdifferentactorsassignlegitimacytotheinformationtheyreceiveaboutmalaria.Thisanalysisshowedthatcommunitymemberstrustinformationfromstakeholderswhohavestudiedhealthandwhoareliterate,opposedtoinformationfromactorswhoareuntrained,illiterate,orwhodonotexaminepatientsorprescribemedicines.Inaddition,therearenostrikinglydifferentviewsontheidentifiedproblemsregardingmalaria.However,differentproblemsdescribedbycommunitylevelactorsrelatedtotheapplicationofpreventionmeasuresaresomehowlinkedtoeachother.Thenationallevelisnotawareoftheseproblemsregardingthepreventivemeasuresdescribedbythecommunitylevelactors,thereforethereisalackofcommunication.

ThissectionanalyzesthemalariagovernancearrangementsandtheroleofICTsinestablishingandarrangingthem.Myinterviewsrevealedasetofrulesandregulationspertainingtomalariapreventionandcontrol.Theserulesandregulationsaremainlysharedbetweenhealthandnon-healthrelatedactorsonthecommunitylevel,howeverthedistrictandnationallevelaretosomeextentinvolvedintherulesaswell.Thisisespeciallyimportantfromthepointofviewofmytheoreticalframing:inherworkElinorOstrompointedtothefactthatdevelopingrulesandapplyingsanctionstorule-breakersisthefirststepineffectiveself-governanceofcommunities.Accordingly,IstartwithpresentinganoverviewofallthemalariapreventionrulesandregulationsobservedinRuhuha,includingthestakeholdersinvolvedintheircompliancemonitoringandthewaysinwhichtherulesareenforced.ThisisfollowedbyadiscussionofmalariaasapublicbadandcollectiveactioninRuhuha.Finally,Ilookatthedifferentlevelsofcompliancewiththerules,followingOstrom’sdesignprinciplesoneffectivegovernance,payingparticularattentiontotheroleofcommunication/ICTs.

5.4.1Preventionandcontrolmeasures

5.4.1.1RulesandregulationsThefollowingtable(table26)showstherulesandregulationsthatare

identifiedfromtheinterviews.TheserulesandregulationsarethepreventionandcontrolmeasuresthatareusedtofightagainstmalariainRuhuha.

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Table26:RulesandregulationsregardingmalariapreventionandcontrolinRuhuhaRuleorregulation ActorresponsibleTocutdowntreesandbushesaroundthehousewheremalariamosquitosmaylive.

Communitymembersandcommunityhealthworkers

Toremovestagnantwateraroundthehouse. Communitymembersandcommunityhealthworkers

Toreachhealthcenterontimewheneverapersonisshowingsomesignsofmalaria.


Indoorresidualspraying,alsoknownasfumigation. RwandaBiomedicalCenterUsinginsecticides,productsthatarespecializedatkillingsomeinsectsinthehouse.

Communitymembers

Tosleepinmosquitonetsandwheneveramosquitonetisexpiredornotfunctioningwellcommunitymembersareadvisedtoreporttogetanewone.

Communitymembers,communityhealthworkers,andRwandaBiomedicalCenter

Toclosewindowsanddoorsduringtheeveningandnight.Thecommunityhealthworkersalsotoldcommunitymemberstonotspendtheeveningornightoutdoors.


Tonothavebanana,sorghum,ormaizeplantationnearhomes,asthisisthelocationwherefemalemosquitosmayhidethemselves.


Tohavecleanlinessaroundandinhomes.Tobesmart,tohavecleanlinesswhilepreparingfood,cleanbodyandwashedclothes,andtoremovedirtandrubbisharoundtheplace.


Fumigationofswampsofricecooperatives. RicecooperativesResearchersusedtrapsandusedtofumigateswampsasinterventionsofaresearchprojectofthemalariaeliminationprogram.Howeverthoseinterventionsarenolongertakingplace.

ResearchersoftheMalariaEliminationProgram

Thelocalleadermentionedanelectronicdevicethatispluggedsomewhereduringthenightandthiselectronicdeviceplaysaroleinfightingagainstmosquitos.Heexplainedthatthiselectronicdevicefunctionsasamosquitonet.However,nootheractormentionedit.

Communitymembers

Tobuyandprovidehealthinsurances. Communitymembers,NationalHealthInsuranceScheme

Fromtable26canbeidentifiedwhichactorsareresponsibleforwhich

ruleorregulation.Thecommunitymembersarementionedtohavearesponsibilityforallrulesexceptforfumigation.TheRwandaBiomedicalCenterisresponsibletomakesurethatfumigationandmosquitonetsareavailable.Furthermore,fromthetablecanbeseenthatthecommunityhealthworkersalsohavealargeresponsibilityinmakingsurethattherulesandregulationsarefollowed.Moreover,theNationalHealthInsuranceSchemehasaresponsibilitybyprovidinghealthinsurances.Thefollowingsub-sectiondescribestherolesofactorsinensuringthatthemalariapreventionandcontrolmeasuresareinplaceinmoredetail.

5.4.1.2Whoensuresthesepreventionandcontrolmeasuresareinplace?Table26intheprevioussub-sectionshowsthemalariapreventionand

controlmeasuresandwhichactorisresponsibletomakesuretheserulesandregulationsarefollowed.Thissub-sectiondescribesinmoredetailhowthedifferentactorsrelatetotherulesandregulations.

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CommunitymembersTherulesandregulationsandpreventionmeasuresthatthecommunity

membershavetoperformthemselvesaccordingtotherulesandregulationsare:tocutdowntreesandbushesaroundthehousewheremalariamaylive,toremovestagnantwateraroundthehouse,toreachthehealthcenterontimewheneverapersonisshowingsomesignsofmalaria,tosleepinmosquitonetswhentheyareavailable,toclosewindowsanddoorsduringtheeveningandnight,tonothavebanana,sorghum,ormaizeplantationneartheirhomes,tohavecleanlinessaroundandintheirhomes,andtobuyhealthinsurance.

CommunityhealthworkersThecommunityhealthworkersareinchargeofcheckingwhetherthe

rulesandregulationstopreventagainstmalariaarefollowedbythecommunitymembers.Thecommunityhealthworkersvisithomestocheckifpeoplefollowtherulesandregulations,forexampleiftheyhaveproperhygienicconditionsaroundandintheirhomes.Thecommunityhealthworkersareinchargeofhelpingpeopleinlocalareas.Theycarryoutrapidtestsformalariatoreferpeopletothehealthcenterassoonaspossiblebeforeacommunitymemberbecomesaseveresufferer.Inaddition,thecommunityhealthworkersareinchargeofadvisingthecommunitymembersaboutmalariaandofgivingtabletstothosewhosufferfrommalaria.Furthermore,thecommunityhealthworkersaretheretoinvestigateandgatherinformationwithinlocalareastochecklivelihoodconditions.Theyreportthisinformationtothehealthcenters.Forexample,theyvisithouseholdsandcountandlistallpeoplewhoareinneedofmosquitonets.Afterwardstheyreportthisinformationtothehealthcenter.Thehealthcenterthenreportsthisinformationtothedistricthospital.

HealthcenterThehealthcenterisinchargeofcollectingdatafromlocalareasthrough

communityhealthworkers.Thisdatareportedbythedifferentcommunityhealthworkers(suchastheamountofmosquitonetsneeded)isreportedbythehealthcentertothedistricthospital.Also,wheneverthehealthcenterseesthatthereisaproblemrelatedtomalaria,theyreportthistothedistricthospital.

Moreover,thehealthcentermakesreportsofmedicinesneededandsendsthemtothedistrictpharmacyatthedistricthospital.AfterwardsthehealthcenterpharmacyreceivesmedicinesfromtheMinistryofHealthdistributedthroughthedistricthospital.Afterreceivingthemedicines,thehealthcenterisinchargeofgivingthesemedicinestothecommunityhealthworkers.Thehealthcenterisalsoinchargeofreportingtothedistrictwhenapersonreportshimorherselfatthehealthcenterfourtimesamonth.

DistricthospitalThedistricthospitalworkscloselytogetherwithadministrativeandlocal

leaders,communityhealthworkersandhealthcenterstoensurethatthepracticesregardingmalariapreventionandcontrolareinplace.ThedistricthospitalalsoworkscloselywiththeMinistryofHealthsuchastheRBCdivision.

Thedistricthospitalgathersinformationthatisreportedfromthehealthcentersatlocallevels.TheythenanalyzethisinformationandalsoreporttheinformationtotheMinistryofHealth.AfterwardsatthenationallevelsuchasatRBCtheydecidethematerialstobegivenandtobedistributed.Therefore,as

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healthprofessionalsthedistricthospitalisthelinkbetweenthecommunitylevelandthenationallevel.Theyhavemoreknowledgeaboutmalariathanthelocalauthoritiesandareinbetweentoworkcloselytogether.Furthermore,thedistricthospitalandthedistrictofficeareinchargeoftrainingnursesatthehealthcenteraboutmalaria.Inaddition,whenevermalariaissevere,communityhealthworkersandleadersfromdifferentlevelsarecalledtothedistrictofficetoattendameetingaboutmalaria.Therefore,thedistrictofficeandhospitalareinchargeoftrainingtherulesandregulationsandpreventionandcontrolmeasuresagainstmalariatoleadersfromsectors,communityhealthworkers,andvillagecommittees.Moreover,thedistrictpharmacyatthedistricthospitalhasthemandatetodistributedrugstosectors.Therearealsoprivatehealthspotsthatrequiredrugsfromthedistrictpharmacy.Lastly,thedistrictaskedthehealthcenterstoreportanycasewherebyapersonreportstothehealthcenterrepeatedly.Inthesecasesthedistricthospitalanalyzeswhethertherearenewspeciesofmalaria.

MinistryofHealth/RwandaBiomedicalCenterTheMinistryofHealthcreatesadvocacytothegovernmenttogetsupport

tofightmalaria.Thegovernmentisinchargeofspreadinginformationtoactorsondifferentlevelsandtomakethemhaveaccesstomaterialstofightagainstmalaria.TheMinistryofHealthadvocatesforsuchresourcestothegovernment.AdvocacyiscarriedoutbytheMinistryofHealthtothegovernmentwheneverthereisaspecialsicknessoralargeamountofpatientssufferingfromacertaindisease.Inthisprocess,forexampleregardingmalariapreventionandcontrol,theMinistryofHealthisresponsibletogivesupportbyprovidingfumigation,bednetsandmedicines.ThedifferentresponsibilitiesoftheMinistryofHealthandRBCregardingmalariapreventionandcontrolarenowexplainedinmoredetail.Firstofall,theRBCdepartmentoftheMinistryofHealthisinchargeofdistributingmosquitonetstothehealthcenters.Beforegivingthesemosquitonetstothehealthcenters,thecommunityhealthworkerscountpeoplewhoareinneedofmosquitonetsindifferentcommunalregions.Aftercollectingthisdatafromlocalareas,thehealthcenterreportsthecommunitymemberswhoneedmosquitonetstothegovernmentatnationallevel.Afterwardsthegovernmentsendsthesemosquitonets.AcommunityhealthworkermentionedthatRwandahasnocapacityofproducingbednetsandthenetsarefromabroad.AfterreceivingthenetsfromabroadtheMinistryofHealthisinchargeofdistributingthenetsinRwanda.RBCmentionedthatthemajorpartnersforbednetsareGlobalfundandUSAIDPMI(President’sMalariaInitiatives).RBCexplainedthatstartingfromthisyear2018,thedistributionofbednetswillnotonlybedonebythegovernmentbutalsobytheprivatesectorthroughSocietyforFamilyPlanning(SFH).Inaddition,fumigationisalsoanactivitythatiscarriedoutbytheMinistryofHealth.TheycurrentlyhavethreepartnersinsprayingwhichareGlobalFund,PMIandthegovernment.Furthermore,theMinistryofHealthwritesbooksthatareusedtofacilitatenursesaroundthecountrytoperformtheirprofessioncorrectly.TheMinistryofHealthisalsoinchargeofdistributingmedicinestodistricthospitals.Fromthedistricthospitalthemedicinesaredistributedtohealthcenters.ThegovernmentofRwandabuysthemedicinesfromwholesalersabroadsuchaswholesalersintheUnitedKingdom.Afterreceivingthesemedicinestheyaresuppliedthroughthepublicnetworkin

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Rwanda.PrivatepharmaciesinRwandacanalsobuymedicinesfromthesamewholesalerintheUnitedKingdom.Theysellthesameproductswithaprofitmarginandwithoutsubsidy.TheMinistryofHealthisincontactwiththeprivatepharmacistsastheysetregulationstobefollowedbyprivatepharmacies.Firstofall,theycheckwhetherprivatepharmaciesareequippedandeducated.Secondly,theMinistryofHealthlicensesprivatepharmacies.Theygiveoutcertificatestoprivatepharmaciststobeallowedtoengageintheactivityofsellingmedicines.Inaddition,theMinistryofHealthvisittheprivatepharmaciestocheckifthemedicationsthataresoldareonthelistofmedicinesthatareallowedtobesoldtocommunitymembersinRwanda.

OtheractorsFirstofall,theactionscarriedoutbythecommunitymalariaactionteams

arecontrolledandorderedbythepersoninchargeofsocialaffairsatsectorlevel.

Furthermore,thefumigationofswampsofricecooperativesiscarriedoutbythecooperativethemselves.Itisdoneperiodicallywheneverpeoplearegoingtoplantrice.Therearemembersselectedwithinthecooperativetofumigatetheswampbeforeotherscomeforplanting.Thisisdonetopreventmembersofthecooperativefromgettingattackedbymalariawhenworkingintheswamp.

Moreover,theMalariaEliminationProgramhadaninterventionwheretheysprayedswamps,howeverthisinterventionended.

Inaddition,studentsarebeingtaughtaboutmalariainschools.Theteachersalsogivethemexercisesandhomeworktoteachotherpeopleaboutmalaria.

5.4.1.3Aretheyenforced?Duringtheinterviewsactorswereaskedwhetherthemalariaprevention

andcontrolmeasuresareenforcedinanyway.Themajorityofactorsrepliedthattheyarenotenforced,howevertwocommunitymembersmentionedthatthepreventionandcontrolmeasuresaresomehowenforced.

NotenforcedThemajorityofcommunitymembersmentionedthattherulesand

regulationstofightagainstmalariaarenotenforcedinanyway.Someexamplesaregivenintable27.

Table27:ExamplesthatthepreventionmeasuresarenotenforcedActor Supportingquotation(translatedbyresearchassistantduringinterviews)Communitymember

‘Itisnotforced.Theyadvicethem.Thenafterthinkingaboutmalaria,theyonlytaketheirdecision.Theytaketheirdecisionofremovingthoseoftakingofusingthosemeasuresoffightingagainstmalaria.Itisnotforced’.

Communitymember

‘Itisnotenforced.Itisnotenforcedtogetthosemeasuresofpreventingagainstmalaria.But,mostofthepeoplebecauseofthinkingthathavingthosematerialsofhavingthosemeasuresoffightingagainstmalariaisveryimportant,mostofthepeopleneedmosquitonetsandtheyareusuallytalkingaboutmosquitonets,howdowegetmosquitonets.AndmostofthemneedmosquitonetsmostofthetimeandtheysayandIthinkhasitbeenexplained?’.

Communitymember

‘Thecommunityhealthworkersvisitthepeoplemostofthetime.Visiting,suchvisitisnotcarriedoutbyforce.Itisnotcarriedoutforcibly,itiscarriedoutwillingly.Andanytimeacommunityhealthworkerreachesthehouse,thepeoplefromsuchhousewelcomehimorher.Thentheygiveherorhimaservicethatheneedsorsheneeds.

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Thenacommunityhealthworkermaycomeintothehouseandcheckwhetherthereisabednet.Andwheneversheseesthatorheseesthatthereisnobednet.Heorsheadvisesthepeoplehowthewayofpreventingagainstmalariaandthewaytheymaypassthroughastogetbednets’.

Memberofcooperative

‘Asthepeoplehavebeeninformed,trained,taughtaboutmalaria.Thisactionthisactivity,thismeasuresoffightingagainstmalariaarenotdoneonforce.Peoplearewellinformed,arewelltrained,arewelltaughtaboutthisepidemic,malaria.Theythinkwheneverthereisanactionofmosquitonets.Hehasgivenanexample.Peoplestartsharing,startbeinghappy.Arethosemosquitonetscoming,letusgoforthem,letusgoandtakethem.Mosquitosarenowmakingusdieandarenowcausingusdifferentproblems,soletusgoandtakethem.Theyarehappy,theyarehappy.Theyarenotforcedatgettingmosquitonetsorbeinggiventhesemeasuresoffightingagainstmalaria.Theythinkthisistheirownaction.Tostayinmosquitonetsandtogetthemwhenevertheyareaccessible’.

Healthcenterstaff

‘Itisnotforced.Thepeoplearewillinglywishingthosemosquitonetsmostofthetime.Whenevernursepassesaroundtheroad,passesthroughtheroad.Andmeetingthosepeople.Thosepeopleareinquiringandaskinghimorheraren’ttheresomemosquitonets?Aren’ttheresomemosquitonets?Itismeansthatthepeoplereallyknowtheimportanceofmosquitonets.Andtheyreallyknowthatpossessingorhavingthosemosquitonetsisimportanttothem.Soitmeanstheyarenotforcedsoastogetthosemeasuresoffightingagainstmalaria’.


‘Thereisnoforcewithinthesewaysofpreventingagainstmalaria.Thereisnoforce.Peoplearewillingtousethosemosquitonets.Andsheisnowsayingthattheyarenowadaysmakingcensustheyarenowcountingbedswithindifferentlocalareas.Andpeoplearenowwaitingandsomeofthemarenowcomingwhenwillthosemosquitonetscome.Itmeansthattheyarewaitingeagerlythosemosquitonets.Theywanttogetthem.Becausetheyhavespendalongtimesufferingfromthiskindofillness.Theyarewaitingeagerlyandcheerfullythesemosquitonets.Itmeansthatthereisnoforceinthiswayofcontrollingthesewaysofpreventingagainstmalaria’.

Communityhealthworker

‘Noitisnotforced.Asthesecommunityhealthworkersaretogetherwiththesepeopledaytoday.Shehasgivenanexamplewherebytheygivethemmedicalmentsofdifferentelements,differentsicknesses.ShehasgivenanexampleofmedicalmentsofImonia,diarrheaandsoon.Thisfamiliarityforbeingtogetherwiththemdaytoday,thisfamiliarityhelpsthosepeopleandcommunityhealthworkersbecomefriends.Andthepeoplelovethosecommunityhealthworkersbecausetheyreallyknowthatthehealthcommunityworkersaretogetherwiththem,arealwaystogetherwiththem’.

Thequotationsinthetableaboveshowthattheseactorsfeelthatthe

rulesandregulationstofightagainstmalariainRuhuhaarenotforced.Thecommunitymembersexpressedthattherulesandregulationssuchasbednetsareimportanttothem,butnotenforceduponthem.Aswasanalyzedearlier,communityhealthworkersaretrustedbycommunitymembers.Moreover,theyalsohavealargeroleincompliancemonitoring.Thequotationofthecommunityhealthworkerinthetableabovealsoexplainedthatcommunitymembersdonotexperiencethattherulesandregulationsareenforcedbecausetheytrustthecommunityhealthworkersandbecausetheyarepartofthecommunity.

EnforcedAlthoughallotheractorsmentionedthatthepreventionandcontrol

measuresarenotenforced,therearetwocommunitymemberswhomentionedthatthemeasuresaresomehowenforcedinsomesituations.Duringtheinterviewwithoneofthemtheresearchassistanttranslated:

’Inadditiontothat,likewithinneighborhood,becauseinthecommunityhealthworkerstheyhavethisvisit.Iftheyget

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informationthataparticularhouseholdisnotusingthebednets,theygotheyvisittheysearchforinformationwhetherthehusbandandthewifecannotbeathome.Probablyintheplanation.Butwhenthekidistherethecommunityhealthworkercancome.Youknowmostthetimewiththekidheorshecandiscloseallinformation.Sothecommunityhealthworkercanaskthekid.Doyoueverseeyourparentssleepunderbednets,thekidsaysnoIhaveneverseen.Canyoucomeandseewherethebednetsprobablystoredsomewhere.Inthatcircumstancethecommunityhealthworkergetsinformationandthenheorshecandiscloseinthevillagethatok,certainhouseholddoesn'tusebednets.Sowithintheneighborhoodnowtheystartcriticismwhyareyounotsleepingunderbednets,canyouatleastifyoudon'tusejustgiveittootherswhoarewillinglytouseit.Sowithsuchacriticismofcoursepeoplearestartingtochangetheperceptionthentheycanuseit’.

Thisexampleshowsthatinsomesituations,whenthecommunityhealthworkersfindoutthatcertainhouseholdsarenotusingapreventivemeasure,thecommunityhealthworkerscaninformthevillageorneighborhoodthattherearepeoplewhoarenotusingthem.Inthiswaytheymakecommunitymemberstalkaboutittochangeperceptionsandtoincreasepressureonthesehouseholdstousethepreventivemeasures.Furthermore,thiscommunitymemberalsomentionedthatthecommunityhealthworkersaregoingtoensurethatthebednetsareusedproperlyinthefuturebyforce.Thetranslatorstatedthathealsoexplained:

‘Soheissayingthatnowhethinksthathecancontinuemobilizingforthosewhostillhavemisconceptionaboutmalariaaboutcleaningthismosquitobreadingsite.Andthenwhoeverstillhaveabednetssothattheycansleepunderthem.Buttheyarealsowaitingthehealthcentertogivethemthebednetsbecausetheystillhavefeworeveninsomehouseholdtheydon’thaveany.Sothecommunityhealthworkerspromisedthatoncethenewbednetscometheywillmakesureeverybodyuseit.Thosewhowillnotuseittheywillnotonlylikejustcriticizetheminthemeetingsbutsureprovidelikephysicalconditionsforthemsothattheymakesuretheywillnotuseforotheralternativepurposeslikeconstructingthischickenorfishingorwhateversotheygrantedthattheywilldolikeacloserfollowupforthem.-Interviewer:Sothenitisenforced?-Translator:Yeah.Tomakesuretheyenforcesothattheyarereallyused’.

Thisquotationshowsthatthecommunityhealthworkersplayanimportantroleincompliancemonitoringandmakingsurethatcommunitymembersfollowtherulesandregulations.

Furthermore,anothercommunitymemberalsoexplainedthattherulesandregulationsaresometimesforced.Theresearchassistanttranslatedanexamplethathegaveaboutfumigation:

’Aspeopledonothavethesamelevelofunderstanding.Therearesomepeoplewhounderstandthemeasuresoffightingagainstmalariaeasily.Andthereareotherswhoaresomehowrigid.Whoaresomehowdifficultatunderstandingthewayoffightingagainstmalaria.Hehasgivenanexamplewherebythisfumigationactivity.

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Thetimewhenitiscarriedout.Therearesomepeoplewhoclosetheirhouses.Andleavetheirhomessoastonotacceptthosepersonsfumigatingthehouses.Thenafterleavingtheplace.Afterquittingtheground.Thegovernmentmaynoticethatandanalyzeitandmayputthereforce.Whydon’tyouunderstandthiswhileitisimportantforyou,whywhat.Andasthetimegoesonthepeoplewhoareneglectingthisactivitythiseventsthatistakingplaceunderstandit.Ya.Butwhenthereapersonthepeopleareunderstandingthegovernmentstopsputtingthereforce.Itmeansthatpeoplewhoarenot,itmeansthatpeoplewhoneglecttotallythisactivityoffightingagainstmalariasometimesbutnotoftensometimesareforcedsoastounderstand’.

Thisexampleillustratesthatinsomesituationstherulesandregulationsaresomehowforceduponcommunitymembersbythegovernmentwhentheydonotfollowthem.Accordingtothiscommunitymemberthegovernmenttriestoputforcebymakingthesecommunitymembersunderstandtheimportanceofinthiscasefumigation.

Formyresearchthesefindingspointouttheimportantroleofcommunicationandtrustincompliancemonitoringoftherulesandregulations.Insection5.2wasidentifiedthatcommunitymemberscommunicatewithcommunityhealthworkersbothface-to-faceandviamobilephonesaboutmalaria.Communitymemberstrustthecommunityhealthworkersandthereforefollowtheiradvice.Furthermore,inthewaysinwhichrulesareenforcedcommunicationplaysanimportantroleaswelltomakecommunitymembersunderstandtheirimportance.

Communitymembersexpressedthatthesituationregardingmalariaexceedsitslimitandthatthepreventivemeasureslikebednetsareimportanttothem.Moreover,accordingtotheinformationillustratedintable27therulesandregulationsarenotforced,asthecommunitymembershaveahighwillingnesstofollowthem.However,inprevioussectionsmisconceptionsaboutmalariawereidentified.Inaddition,themajorityofactorsperceiveknowledgeaboutmalarianottobeenoughinRuhuha.Furthermore,communitymembersandhealthrelatedactorsfromalllevelsmentionedthatpreventivemeasuresarenotusedproperly.Anumberoftherulesandregulationssuchasclosingdoorsandwindowsduringtheevening,toreachthehealthcenterontimeandtohavecleanlinesscaneasilybefollowedbycommunitymembers.However,otherrulesandregulationssuchasbuyinghealthinsurance,removingtreesandplantationsaroundhomes,removingstagnantwaterandsleepinginbedswithmosquitonetsdependoncommunitymembers’financialsituation.Inaddition,mosquitonetsarenotavailableandthegovernmentdoesnothaveenoughfinancialresourcestofumigatehousesinRuhuha.Therefore,thecomplianceoftherulesandregulationsdonotonlydependonknowledgeandawareness,butalsoonotherfactorssuchasacommunitymembers’financialsituationorlackofresourcesandtimelyresponsefromhigherlevelactors.However,asearliersectionsinvestigatedpeople’sperceptionsaboutknowledge,beliefsandproblemsrelatedtomalariainRuhuha,itwasconcludedthatthemajorityofactorsperceiveknowledgenottobeenoughandthatmisconceptionsexist.Also,multiplestakeholdergroupsexpressedthatpreventivemeasuresarenotusedproperly.Evenifthousandsofmosquitonetsaredistributedtheywillnothelp

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unlessallcommunitymembersusethemefficientlyandconsistently.Forthisreason,non-compliancetotherulesbringsoncollectiveactionproblems.Sincemalariaspreadsinareaswheretherearemanyhosts,onerule-breakerendangerstheentirecommunity.

5.4.2MalariaasapublicbadEarlierinthischaptertherulesandregulationregardingmalaria

preventionandcontrolinRuhuhawereidentified.Theprevioussectionarguedthatnon-compliancetotherulesandregulationsbringsoncollectiveactionproblems.Onerule-breakerendangerstheentirecommunity.Therefore,thereisacollectiveresponsibilityinthepreventionofapublicbad.Allcommunitymembershavetofollowtherulesandregulationstofightmalaria,asindividualsarecapturedinaninescapableprocessfromwhichtheycannotremovethemselves.Duringaninterviewwithoneofthestaffmembersofthehealthcentertheresearchassistanttranslated:

‘Somepeoplearecuredforalongtimeandtheydon’tcomebacksoastogetthosemedicaltreatmentfrommalaria.Andotherscan’tspendtwoweeks,oneweekwithoutbeingbacksoastobecuredhereathealthcenter.Soitmeansthatmalariahasexceeded.Andhehasalsogivenanexamplewherebynohousehold,whenmalariahascomeandhasenteredhousehold,itcan’tgoawaywithoutmovingaroundallpersonsinhousehold.Allpersons,oneiscuredtoday,theotheroneisgettingsufferingfrommalariatomorrow.Thepeoplereplaceeachotherwithinhouseholduntilallareattacked.Yathatishowmalariaisnowcirculating’.

Thisquotationshowsthatwhenonepersoninahouseholdisattackedbymalariatheothermembersofthehouseholdalsogetit.Acommunitymemberalsogaveanexamplefromwhichcanbeunderstoodthatmalariaisapublicbad.Duringthisinterviewtheresearchassistanttranslated:

‘Hehasalsoexplainedthatmalariaiscausedbyfemalemosquito,wherebysuchfemalemosquitoisresponsibleforstingingaperson.Thenafterstingingapersonsuchfemalemosquitomayalsogowithindifferentpersons,spreadingsuchmalaria.Thenthosepersonsmaybeattackedatthesametimebeingstingedbythisbeingstangbythisfemalemosquito’.

Theseexamplesshowthatthereissomesenseamongcommunitymembersthatgettingmalariaisaninescapableprocessfromwhichonepersoncannotremovehimorherself.Allindividualshavearoleinincreasingtheefficacyofthepreventivemeasuresandrulesandregulations.Fightingmalariaasapublicbadisheavilyreliantonthecapacityandwillingnessofthecommunitymemberstocomplywiththerulesandregulationsintheirdailychoicesandactivities.Therefore,thefirstpartwithinthissectionanalyzeshowdifferentactorswithinthemalaria-affectedareaofRuhuhacooperateandworktogethertoachieveasharedgoalofbattlingthedisease.ThesecondpartprovidesexamplesofcollectiveactionproblemsinthefightagainstmalariaasapublicbadinRuhuha.

5.4.2.1CollectiveactionForeffectivecollectiveaction,theactorshavetocooperateandwork

togethertoachieveasharedgoalofbattlingmalaria.Thissub-sectionprovidesexamplesofhowcollectiveactionisusedtofightmalariaasapublicbad.These

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examplesincludecooperationbetweenactors,followingtherulesandregulations,tryingtobeanexampletoothercommunitymembers,andwillingnesstocontributetothecostsofBti.Theseexamplesareexplainedinmoredetailintheparagraphsbelow.

Cooperationbetweenactors Thereiscooperationbetweenactorstoachieveasharedgoalofbattlingmalaria.Table28presentsexamplesofactorsthatexplainedthatactorsworktogether.Table28:ExamplesofquotationsexplainingcooperationbetweenactorsActor Supportingquotation(translatedbyresearchassistantduringinterviews)CMAT ‘Alltheseteams.Communityhealthworkers.Thesecommunitymalariaactionteam

andalsohealthcenteranddifferentleaderswithinthesector,theyworktogether.Theyworkhandinhand.Andhehasmentionedthatwheneverthishealthcenterisanindicatorofmalaria.Itisanindicatorofmalariabecausethisistheplacewheretheleadersorotherpersonsmaycomeandnoticethatthereismalariathatisincreasing.Becausethisiswheremostofthepeoplesufferingfrommalariaareseen.Soitmeansthathealthcenterisanindicatorofmalaria.Andwhenevermalariahasbeenfoundhasbeenremarkedwithinthishealthcenter.Thishealthcentermaycallthosecommunityhealthworkerssoastoimpartthem.(…).Hereathealthcentertheworkersofthishealthcenterimpartthosecommunityhealthworkersthecurrentnewsaboutmalaria.Thenafterimpartingthemafterinformingthem.Thosecommunityhealthworkersalsogothereinthevillage.Andimmediatelytheyinformthesecommunityactionteamsworkers.Theyinformthem.Thenafterinformingthemthosethreepeoplewithincommunitymalariaactionteams.Theyalsoreachthepeople,immediately.Thentheyinformthepeoplethecurrentnews.Thisisthewayinwhich,thisistheprocessinwhichtheyworktogether’.

Communitymember

‘Butwhenyouobservelikeanymosquitobreedingsitewithinthevillage,notonlyforlikethecompoundorthehomeenvironment,youcancallthevillageleadersothattheycanorganizethecommunityworkthelastSaturdayofthemonth.Andthentheycancleantogetherforthevillage.Soheisleavinganexamplelikelastyearonmalariaday.ThatisinDecember,sotheygatheredtogetherinthewholecellandthentheywerejustcleaningthosemosquitobreedingsiteswherevertheywereinthewholecell’.

MEPR ’Andmostofthepeoplewereaccustomedtoburningthosemosquitonetsbysayingthosemosquitonetsarenowattractingbedbugs.Thenimmediatelytheycouldburnthosematerials.Andsisterstogetherwiththiscommunityofthishealthcentertheytrytomakepeopleunderstandwherethosebedbugscomefrom.Thenafterillustratingthesourceofthosebedbugstheyalsofacilitatethemtounderstandthatwhenthosebedbugsarenotavailable,theirmosquitonetswillnotbeburnedandthemosquitonestwillprotectthemfrombeingattackedbymalaria.Generally,theyadvicethosepeoplethewayofusingmosquitonetsandthewayofhavingtheseproperhygienicconditionsandtheyalsovisitpeople.Havinganambitionoftalkingtothosepeopleaboutmalaria’.

Communitymember

‘Thereisalsoacheckupofcommunityhealthworkerswherebythosepersonscheckwhetherallpeoplesleepinmosquitonets.Itmeansthatmostofthetimethosepersonsreachthegroundsoastocheckwhetherthepeopleareequippedandareimpartedaboutmalaria(…)InadditiontothatthelocalleadersandtheMinistryofHealthallhavestoodupsoastohelppeoplehaveknowledgeaboutmalaria.Andsoastohelppeoplepreventagainstmalariaasmalariahasbecomeaproblemintothecommunity(…)Thosepeoplewhoareinchargeoffumigatingthehouseadvisethehealthyadvisethehealthytofollowtherules.Andtheyalsoadvisethemtoreachclinicalcenterassoonastherearesomesignsthatthereissomethingnegativethatisgoingtooccur’.

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Thequotationsinthetableaboveshowthatthemultiplestakeholdergroupsofdifferentlevelsworktogethertofightagainstmalaria.Wheneverthereisameetingthatgatherspeopletogethertheyhavetotalkaboutmalariaandgetinformedabouttherulesandregulationsregardingmalaria.Moreover,duringpublicworkthecommunitiescollectivelycleanmosquitobreedingsitesinthevillages.Furthermore,thewayhowthehealthsystemisorganizedwithcommunityhealthworkersalsoenhancesthewayactorsworktogether.Duringaninterviewwithacommunitymembertheresearchassistanttranslated:‘Andmalariahasdecreasedduetothefactthatthevillageadvisorsarethereandtheyarealsoimportantatgivingtreatments’.Inthiscasewithvillageadvisorsthetranslatormeantcommunityhealthworkers.Theresearcherofthemalariaeliminationprogramalsoexplainedtheimportanceofthecommunityhealthworkersbystating:

’Ithinkiftheyareorganized,becauseatacertainperiodpeoplestartedtothinkthatthereisnoprobleminRuhuha,notonlyinRuhuhabutinRwanda.Peoplestartedtoneglectusingmosquitobednet,cleaningaround,orclosingtheirwindowseverynight.Sopeoplestartedtothinkthereisnoproblemaboutmalaria.Thenitbecameagainseriousproblemforthem.Andsomepeoplediedofmalaria.Whentheystarttothinkmalariaisstilltherethentheyalsoresumedtheorganizationofthecommunity,whattheycando.SowhatIthinkisthatlocalleadersandhealthprofessionalshavetocontinueremindingthecommunitythattheyhavetoalwaystakecareoftheirhealthusingthosepreventivemeasures’.

Healsomentionedthatcommunityhealthworkersareveryeffectiveinthecommunitiesbysaying:

‘Becausepeoplerelyonthecommunityhealthworkers.Theyareveryeffectiveinthecommunity.Sowehavethelocalleadersbutinadditiontothoselocalleaderswehavethecommunityhealthworkerswhohavetrainingsonspecificdiseaseslikediarrhea,malaria,orotherdiseases.Sotheyaretrainedonthatsothatwhentheygivereliableinformationandpeoplealsostartedtorelyonthem,becauseoncetheycamebackfromthosetrainingstheystartedtotreatmalaria,soifyougivemedicinesagainstmalariaoragainstotherdiseasesandyourfamilymembersiscuredthenyoustarttothinkthatheistherightpersontorelyon’.

Furthermore,anothercommunitymemberalsogaveanexampleoftheimportanceofcommunityhealthworkers,becausetheyaretrustedbycommunitymembers.Duringthisinterviewtheresearchassistanttranslated:

‘Sowewerewonderingwhetherifacommunityhealthworkercanentereasilyintothehouses.Sotheysaidevenawomanafterlikeoneweekofpregnantsohecandisclosetheinformationtothecommunityhealthworker.Soaslongasthesearetheirfriends,thesearetheirneighborsintothevillages.Sotheyarereallytrustableinthevillagessotheycanthideanyinformation’.

TheexamplesshowthatthereiscooperationbetweenactorsinRuhuhatofightagainstmalariacollectively.Furthermore,theyshowthatcommunityhealthworkershaveacrucialroleinthis.

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FollowingtherulesandregulationsAnotherexampleofcollectiveactioninfightingmalariainRuhuhaisfollowingtherulesandregulations.Severalactorsmentionedthatcommunitymemberscandosomethingaboutmalariathemselvesbyfollowingtherulesandregulations.Someoftheseexamplesareillustratedintable29.Table29:ExamplesofquotationsontheimportanceoffollowingtherulesandregulationsActor Supportingquotation(translatedbyresearchassistantduringinterviews)Privatepharmacy

‘Hethinksthatcommunitycandosomethingtopreventagainstmalariawherebyitfollowstherulesoffightingagainstmalaria.Hehasexplainedthatwheneverpeoplehavecleanliness.Thisproperhygienicconditionswithinthehousehold.Andusingmosquitonets.Throughthisway,followingtheregulationsandrulesthatareusedforfightingagainstmalaria,malariamaybeuprooted,maybe,maybemaybeputasside,maybecuredatagoodlevel’.


‘Peoplemayplayagreatroleatfightingagainstmalariawherebytheyfollowtherules,theregulationsthataregotfromhereathealthcenters.Throughthiswayoffollowingrulesthepeoplemayintervene,mayplayagreatrolewithinremovingorputtingasidethiskindofelement,malaria’.

Communitymember

‘Theyfollowtheregulationsasthoseregulationshelpthemsurvive.Forexampleshehasgivenanexamplewherebyshehasexplainedthatwhenapersonisattackedbymalaria,immediatelyahouseholdhomeissufferingfrompovertybecausesheorhemayspendtwodaysinbedwithoutworking.Sotheythinkfollowingtheregulations,followingtherules,isveryimportanttothemasithelpsthemtosurvive’.

Communitymember

‘Theythinktheyshoulddosomethingaboutmalaria.Whatevercost,whateverway,whatevercostthatmaybespendastofightagainstuprootingmalariamaybedone.Andwhattheydonowadaysisfollowingtherules.Followingtherulesthattheyaregivenfromdifferentpersons,fromdifferentareas,fromdifferentcommunityhealthworkersfromhealthcentersandfromleaders.Whattheydoisfollowingtherulessoastofightagainstmalaria.Butwhatevercoststhatmaybespend,whattheythink,whatevercoststhatmaybespendsoastofightagainstmalariamaybedonesoastosavethemselves’.

Stakeholderssuchastheprivatepharmacyandtheheadofthehealth

centermentionedthattheythinkthecommunitycanuprootmalariawhentheyfollowtherulesandregulations.Furthermoreasillustratedinthetableabove,communitymembersalsoexpressedtheimportanceforthemtofollowtherulesandregulations.

TryingtobeanexampletoothercommunitymembersAnotherexampleofcollectiveactioninfightingagainstmalariainRuhuha

isthatcommunitymembersexplainedhowtheycanbeanexampletoothercommunitymemberstoalsofollowtherulesandregulations.Severalexamplesofquotationsinwhichcommunitymembersexplainthisaregivenintable30.Table30:ExamplesofquotationsabouttryingtobeanexampletoothercommunitymemberswhenitcomestofollowingtherulesandregulationsActor Supportingquotation(translatedbyresearchassistantduringinterviews)Communitymember

‘Buthimselfalsocandosomething,likebeingarolemodel.Ifyouwerecleaningyourhomeandthenyoudon’thaveanymalariacaseinayeartheycanalsoseehow,justobserveandcanshowalsoyourexample,okIhavespendawholeyearmyhomeiscleanwithouthavingamalariacase,whycantyoudothesame’.

Communitymember

’Apartfromherselfshemayhelpherneighborsbyadvisingthem,byimpartingthemdifferentmeasures,differentwaysthatareusedsoastofightagainstmalaria’.

Communitymember

‘Whathedoesso.Inhisopinionwhathemaydosoastofightagainstthisproblemmalaria.Isfollowingtheregulationasorganizedaspreparedthoseleadersandalso

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helpingneighborswhodon’tunderstandtheroleoffollowingtherules,tounderstandtheroleofmosquitonets,becausetherearesomepeoplewhodon’tunderstandtheroleofmosquitonets.Andtheyconsidermosquitonets.Mostofthetimeheisattheleadingpositionleadingthosepeoplesoastounderstandit’.

Communitymember

‘Whattheymaycarryoutasthecommunitytofightagainstmalariaisremovingthisbadunderstanding.Misunderstandingisaproblemwithincommunity.Wheneverpeoplehaveunderstoodsomethingcollectivelytheywillpracticeit.Butwhenevertheymisunderstandittheywillperformsuchthingbadly.Itmeansthattheyneedtochangetheirunderstanding.Andalsoafterchangingsuchunderstandingtheywillfollowandusethoserulesregulationsthataretheresoastofightagainstmalaria.Throughthisoffollowingtherulesthatareusedtofightagainstmalariatheythinkthattherewillbesomethingimportantwhichtheymaycarryoutsoastofightagainstthisepidemic’.

Communitymember

’Whathethinksaboutthismisunderstandingofthepeopleandthiswayofnotgivingvaluethiswayoffightingagainstmalariatosomepeople.Hethinksthathehastoreach.Hastogotherenearbythem.Hastogoandapproachthosepeoplewhodon’tunderstanditwellandwhodon’tgivevaluetothiswayoffightingagainstmalaria.Andteachthemaboutthiswayoffightingagainstmalaria.Andalsoinadditiontothatthosepeoplearerequiredtoattenddifferentmeetingsthatarebeingdonewithindifferentlocalareas.Thenafterattendingthesemeetingshethinksthatthosepeoplewillgetinformationaboutmalariaandtheirunderstandingwillbechanged’.

Communitymember

‘AfterreceivingtheinformationfromWhatsApporFacebookshetriesimplementingtherulesandthewaysofpreventingit.Shehasgivenanexamplewherebyshemaymeetapersonsufferingfrommalaria.Andshegoestohishomeorherhomeandadvisetogotothehospitalintimesoastobecured.Andsheadditionallyaddedthatwheneversheseesapersonorneighborhavingsomestagnantwaterattheoutside,notcuttingthetrees,busheswhicharearoundthehouse,shemaygoandadvisehimtoadvisetheneighbortoremovetheunwantedbushessoastofightagainstmalaria’.

Asillustratedinthetableabovecommunitymembersexpressedthey

couldbeanexampletoothercommunitymemberstofollowtherulesandregulations.Someofthemmentionedthattheyhelpneighborstoremindthemtofollowtherulesandregulations.Inaddition,anothercommunitymemberexplainedthathethinksthathehastoexplaintherulesandregulationstofightagainstmalariatocommunitymemberswhoarenotawareofthemorwhoignorethem.Duringtheinterviewscommunitymemberswerealsoaskedwhattheydowiththeinformationthattheyreceiveaboutmalaria.Severalcommunitymembersansweredthattheyteachthisinformationtoothersinthecommunity.

WillingnesstocontributetothecostsofBtiAchallengeregardingthefightagainstmalariaasapublicbadinRuhuha

isthefactthatthereisalotofricefarminginRuhuha.Theresearcherofthemalariaeliminationprogramexplainedthisbysaying:

‘Ricefarminghaspositivebenefitsfromricefarming.Ricefarmersbenefitdirectlyfromtheirricefarmingactivities.Butatthesametimetheycreatenegativeimpactonothercommunitymembers,becausetheconditionswherericeiscultivateditsincleanandstagnantwaterwhichisafavorableenvironmentformosquitotoreproduce.Ononesidepositiveimpactforthericefarmersbutnegativeimpactfortheentirecommunity.Thenwehadtothinkabouthowfromtheseeconomicbenefitsfromthefarmers,ifasmallportioncanbeusedtomitigatetheriskcausedbytheiractivities.Thenwecarriedoutwillingnesstopaystudy.Thenattheendwe

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foundthatthericefarmerswerewillingtocontributeupto25%ofthetotalcostsofBti.Thenafterthatweneedtoinvolvealsoothercommunitymembersandthegovernment.Thenweinvolvedriceconsumers.Soinvolvingthericeconsumersistoseeifriceconsumerswerewillingtopayanadditionalamountabovethecurrentpriceoftherice.SothattheadditionalamountcanbeusedtosupplyBti.Sowearebuildingamodelwherericefarmerscouldcontribute,riceconsumers,thenoncethereisagapthegovernmentcancontribute.Butitisbetterifthegovernmentcantopupinsteadofcomingandpay100%,thiscannotbesustainable.Butifthegovernmenttocontribute10%,15%thiscanbeunderstandable’.

ThisquotationillustratesanexampleofhowcollectiveactioncouldbeusedtofightmalariabycontributionsofricefarmersandriceconsumerstoBtitofumigateswamps.

5.4.2.2CollectiveactionproblemsIntheprevioussub-sectionexamplesweregivenonhowmalariaisfought

collectivelyinRuhuha.However,therearealsocollectiveactionproblemsinRuhuha.Asexplainedearliercollectiveactionproblemsoccurwhenforexamplethereisnon-compliancetotherulesandregulations.Whenoneindividualdoesnotfollowtherulesandregulations,thisisatreattotheentirecommunity.Thissub-sectionprovidesexamplesofcollectiveactionproblemsinbattlingmalariainRuhuha.Theseexamplesarethatfumigationandbednetsarenotavailable,thatmalariaknowsnoboundaries,thatsomecommunitymemberscannotfollowtherulesandregulationsbecauseofpoverty,andthattherearecommunitymemberswhodonotfollowtherulesandregulations.Alltheseexamplesarecollectiveactionproblemsandareexplainedintheparagraphsbelow.

Fumigationandbednetsnotavailable OneofthecollectiveactionproblemsisthatbednetsarenotavailableandthatactivitiesoffumigationarenottakingplaceinRuhuha.Forthesereasonscommunitymemberscannotcomplytotherulestosleepunderbednetsandhousesarenotfumigated.Actorsexplainedthatmalariacannotberemovedbycommunitymembersthemselvesifthesepreventivemeasuresarenotcarriedout.Forexample,duringaninterviewwithacommunitymembertheresearchassistanttranslated:

‘Ashehasmentionedabove,teachinginendlesswayinendlessprocess.Theyarerequiredtogoaheadtocontinueteachingthepeoplesoastobeawareofit.Andwhattheymaycarryoutsoastosupportthepeoplesoastopreventagainstmalariaisthattheyhavetobeawareofthis,Malariawillalwaysbetherewithinthecommunity.Whattheymaycutoutisthattheywillgoaheadinpartingthecommunitysoastoknowmoreaboutmalaria(…)Malariawillnotberemovedtotallytherewithinthecommunity.Unlesstheproblemsthattheyencountersuchastohaveprotectionagainstmalaria,unlessthoseproblemsareunavailable’.

Thisstatementshowsthatthiscommunitymemberthinksthatitisnotpossibletouprootmalariaunlessproblemsrelatedtomalariapreventionmeasuressuchastheavailabilityofbednetsandfumigationarenotthere.Thememberofthe

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CMATalsoexplainedthatitisnotinthecapacityofcommunitymemberstouprootmalariacompletelywithouthelpfromsupportfromhigherleaders.Theresearchtranslatedthisexamplebysaying:

‘Thereissomethingthatcanbedonewithinthecommunitysoastoremovesoastopreventagainstmalaria.Wherebywheneverthosepeoplearefollowingtheregulationsproperly.Malariawillbediminishedatagreatlevel.Butitwillnotbeuprooted.Becausethereissomealsotherearesomealsosomethingsomethingsthatcanbedoneapartfromtheirmeans.Apartfromtheircapacity.Itmeansthattheymaydosomethingaboutmalariathemselvessoastoremoveit.But,itisnot,malariacannotbetotallyremoved.Interviewer:Whynot?Translator:Becausetheirmeans,theirmeansareallowingthemremovepartofmalaria.Butnotwholepart.Yaitmeansthattheremustbealsosomeotherpeople.Someotherleaders,somesupportfromoutsidewhichwillhelpthemsoastoremoveittotally’.

Thisquotationalsoillustratesthatcommunitymemberscanfollowtherulesandregulations,butthatthisalonewillnotuprootmalariacompletely.Accordingtotheseactorsoutsideassistancefromforexamplehigherlevelsareneededtouprootmalariacompletely,suchasassistancebyhigherlevelstoprovidemosquitonetsandfumigation.Moreover,theheadofthemalariadepartmentofRBCalsomentionedthatmalariaeliminationisnoteasyandstated:

‘Beforewehadagoalforelimination.Upto2017.Nowwiththenewstrategicplanfrom2013upto2020wechangethegoalformalariacontrol.Welikenowtoreducemalariaburdenthanelimination.Becausewefoundthateliminationisnoteasy.Weneedtostrengthenourcapacityandalsotogomobilizemoreresourcesfromhealthsectorsandnon-healthsectors.Becausewefoundisnoteasywork’.

ThisquotationexplainsthatforthenationallevelitisdifficulttomobilizemosquitonetsandfundstofumigateallhighburdenareasinRwanda.Therefore,theychangedtheirobjectivefrommalariaeliminationtoreducingthemalariaburden.Thisexplainswhybednetsandfumigationarenotavailableatthecommunitylevel.Duringaninterviewwithanothercommunitymembertheresearchassistanttranslated:

‘Theyhavetriedalltheirbestsoastofightagainstmalaria.Soastopreventthismalaria.Theyhavefollowedallregulationswhichhavebeenregulated,whichhavebeenorganizedbythegovernmentbythenursestellingthepeopleaboutmalariaprevention.Andwhattheyhavedoneisenoughbuttheproblemthattheyarenowadaysencounteringthattheydonothaveenoughmosquitonets’.

Thiscommunitymemberalsoexplainsthatthecommunitymembersfollowtherulesandregulationsbutthattheproblemthattheyarenowadaysfacingisthatmosquitonetsarenotavailable.Thisisacollectiveactionproblem,becausefumigationandbednetsaretwoveryimportantpreventivemeasurestofightagainstmalaria.

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Malariaknowsnoboundaries Anothercollectiveactionproblemisthatmalariaknowsnoboundaries.Duringtheinterviewwiththemalariaeliminationprogramtheresearchassistanttranslated:

‘Shethinksthatwheneverpeoplefollowtheseregulationsasorganizedshethinksthatmalariawillbediminishedbutitwillnottotallybeended.Becausesheisnowgivingexamplesbysayingthatmosquitosareelsewherearewithindifferentareas,arethroughoutdifferentareas,sothesemosquitoscannotberemovedwithinallareas.Peoplehavenocapacityofremovingallmosquitosaroundallareas’.

ThisexampleshowsthatpeopleinRuhuhamayfollowtherulesandregulations,butmosquitosarealsoinneighboringareas.Thisisacollectiveactionproblem,becausecommunitymembershavenocapacitytoinfluencemalariapreventionandcontrolinneighboringcommunitiesandcountries.

SomecommunitymemberscannotfollowtherulesbecauseofpovertyPovertyisanothercollectiveactionproblem.Becauseofpovertysome

communitymembersarenotabletocomplytotherulesandregulationsofbuyinginsurancecards.Moreover,communitymembersmightnotsleepinbedsbutontheground,whichmakesitdifficulttousemosquitonets.Inaddition,therearecommunitymemberswhowonderwhethertheyshouldfollowtherulesandregulationsregardingtheremovalofplantationsaroundhouses.Theseplantationsareimportantforcommunitymembers.Acommunitymembergaveanexampleofthisandthetranslatorstated:‘Theyaskthemselveswillwecutdownthosebananaplantationswhiletheyareimportantforus.Whatwillwedo’.Anothercommunitymemberalsowonderedwhytheyneedtoremovetheplantationswhiletheyareimportanttothem.Duringthisinterviewtheresearchassistanttranslated:

‘Theproblemisbecausemostofpeopleinthevillageorinacelltheyattendmeetingswherethesecommunityhealthworkerssharethemalariapreventionandcontrolmeasures,orevenmalariarapidinformation.Butthemainproblemisputtingintopracticethisinformationshared.Heisgivingmoreinformation,theexamples.Likethefirstwhere,rememberabovewetalkedaboutnotplantingthissorghumnearthehome.Butnowadayspeopleyoucanobserveevenhouseholdswhichhavesuchplantationbecausetheysay,okwhyaretheypreventingussuchforplantingsuchasorghum.Whycanttheyletusplantandthenworryaboutmosquitos’.

Thesequotationsshowthatcommunitymembersdonotalwaysfollowtherulesandregulations.Therearecommunitymemberswhochoosetohaveplantationsaroundtheirhomestoproducefoodinsteadofremovingthemtogetridofmosquitobreedingsitesaroundtheirhomes.Thisthreatensthehealthofothercommunitymembersinthecommunityastheseplantationsattractmosquitos.

Communitymemberswhodonotfollowtherulesandregulations Communitymemberswhodonotfollowtherulesandregulationsisanothercollectiveactionproblem.Asdescribedinearliersections,theremightbeseveralreasonsforcommunitymembersnottofollowtherulesandregulations,whichincludelackofknowledge,misconceptions,poverty,andthe

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unavailabilityofmosquitonetsandfumigation.Intheprevioussub-sectiontheimportanceofcommunityhealthworkersinfightingagainstmalariaandinmakingpeoplefollowtherulesandregulationswasexplained.However,communitymembersalsomentionthatitisachallengethattheythemselvesmayfollowtherules,butneighborsmightnotfollowthem.Duringaninterviewwithacommunitymembertheresearchassistanttranslated:

’Butwhenitcomestotheprevention,Iwaswonderingwhetherthey,becausehesaidthathehaslikesixkids,canyouensureeverybodyinyourhouseholdsleepunderbednets.Sohesaidbeforehegoestosleephehastomakesurethateverybodyisunderbednets.Buttoensurewithinthewholecellissomehowdifficult.Becausefewpeoplemaynotsleepunderbednets.Butheisarguingthatcomparedtotheprevioustimeduetotheincreaseofmobilizationofcommunityhealthworkersatleasttheperceptionhasimproved’.

Thisexampleshowsthatthiscommunitymemberexplainsthathishouseholdcanfollowtherulesandregulations,butthathecannotensurethatallpeoplewithinhiscellsleepinmosquitonets.Anothercommunitymemberalsotalkedaboutneighborsnotfollowingtherulesandregulations.Duringthisinterviewtheresearchtranslatorstated:

’Sohestartedmentioningthathefeelsthattheyaredoingtheirbest.Intermsofputtingintopracticethisinformationbeingreceivedbythecommunityhealthworkers,especiallyusingbednetsandcleaningthehomeenvironment.Byaddingtothatwewerewondering,ifhishomeenvironmentisclean,buttheneighborshasbushesandwaterstagnantwateraround.Ofcoursethemosquitoswillflytohishouse.Sointhatcasehesaidsoforhimitisdifficulttoconvincetheneighbors.Butwhatisthebestishecancommunicatewiththecommunityhealthworkerssothatthecommunityhealthworkercangoandeducatethatneighborwiththosemosquitobreedingsites.Butweemphasizethatalthoughofcoursethecommunityhealthworker,ifnotthere,ofcourseasaneighborhecandosomething.Soheagreedatthattimeofcourseifaneighborisdoingsomethinggoodsootherscanalsotakealookandsay,oknow,atleastithasbeenoneyear,ourneighbordoesn’thaveanymalariacasebecauseofsleepingunderthebednetsorcleaningthehomeenvironment.Whynotus.Ifwehavelikeeachmonthwehaveamalariacasebecauseofthismosquitobreedingsitesaroundus,whycantwecleanthemandshowlikeanexampletoothers.Sohesaysthatoknowwecanalsoprayaroundtothosewhohavemosquitobreedingsitesaroundorprobablywhodon’tusethebednets’.

Thesequotationsshowthatcommunitymembersareawarethatitisacollectiveactionproblemwhenneighborsdonotfollowtherulesandregulations. RegardingtheroleofICTsincollectiveactionandincollectiveactionproblems,theroleofmobilephonesextendsbeyondtargetedinterventionsbecausetheycan(toapoint)facilitatecollectiveactionamongconcernedpopulations.Mobilephonesfacilitateincreasedadherencetotherulesandregulations.Whenrulebreakingoccurs,communicationviamobilephonesallowsformoreeffectivereportingofrule-breakers.Forexample,communitymembersmentionedthatwhentheyobservethataneighborisnotfollowinga

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certainrule,heorshecallsacommunityhealthworkertoreportthissothatthecommunityhealthworkercancometoadvicetheneighbor.Anotherexamplethatwasgivenbycommunitymembersisthatwhenevertheyobservemosquitobreedingsiteswithinavillagetheycallthelocalleadertoschedulepublicworktocleanthem.Moreover,mobilephonesalsoenabledifferentactorsandstakeholdergroupstoeffectivelycommunicate,negotiateanddiscuss.Formyresearchtheseexamplesmeanthatimprovedcommunicationviamobilephonesfacilitatemoreeffectiveapplicationandmonitoringoftherulesandregulations.

5.4.3Ostrom’sdesignprinciplesTheprevioussub-sectionanalyzedhowcollectiveactionisusedin

Ruhuhatofightagainstmalariaasapublicbad,thecollectiveactionproblems,andtheroleofICTsincollectiveactionandcollectiveactionproblems.ThissectionanalyzesthecompliancewithOstrom’sdesignprinciplesofeffectivelypreventingapublicbad.Asexplainedin3.2Ostrom’sdesignprinciplesweredesignedtounderstandtheimportantconditionsoftheinstitutionalarrangementsthatattainedgoodoutcome,oppositetogroupswhoseeffortsfailed(Wilsonetal,2013).Ostrom(1993)describesthat:

‘’By‘designprinciple’ismeantacharacteristicthathelpstoaccountforthesuccessoftheseinstitutionsinsustainingthephysicalworksandgainingthecomplianceofgenerationsofuserstotherulesinuse’’.Section5.4.1.1identifiedtherulesandregulationsthataretheretofight

againstmalariaasapublicbadinRuhuha.Thedesignprinciplescanbeusedasapracticalguidetonearlyanygroupwhosemembersmustcooperateandworktogethertoachieveasharedgoal(Wilson,2013).Aswasexplainedinsection3.2,ICTscanfacilitateinthebuildingofcollectiveactionbyincreasingflowsofinformation,socialnetworking,participation,transparency,andinteractionsamongcommunitymembersthatfacilitatemaintainingtrust,acceptanceandalignmentnecessaryforsuccessfulcooperation(Thapaetal.,2012).Therefore,thissectionalsoanalyzeswhetherICTshaveaparticularroleinthecompliancewithOstrom’sdesignprinciples.

Thefollowinglistanalyzesthecomplianceofactorsfightingagainst

malariainRuhuhawithOstrom’sdesignprinciplesandtheroleofICTs.1) Clearlydefinedboundaries

Itisimpossibleforactorstodefineboundariesofthehealthsystemandtocloseitofftooutsidersortomosquito’sfromotherareas.WithinRwandamobilephonesandHMISplayaroletoreportincidentstothenationallevel.Thenationallevelusesthisinformationtomonitorwheremalariaincreasesanddecreases.AfteramalariaoutbreakisobservedthenationalanddistrictleveltogetherwithactorsonthecommunitylevelcaninitiateactionswithinRwandatoactupontheseobservationsthataremadeavailablebyICTs.However,RuhuhabordersLakeCyohohaandtheBurundianborderinthesouth.Ingabireetal.(2014)describe‘’LakeCyohohaisamajorcorridorforuncontrolledpopulationmovementsbetweenRwandaandBurundi’’.Therefore,boundariesarenotclearlydefined.TheactorsinvolvedinmalariapreventionandcontrolinRuhuhacannotenforcepeoplewholiveontheothersideofthelakeinBurundito

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followtheirrulesandregulations,astheydealwithanotherhealthsystem.Forthisreasonthereisnocompliancewiththedesignprincipleclearlydefinedboundaries,astoclearlydefineboundariesthefightagainstmalariawouldneedaregionalapproachthatinthecaseofRwandaalsocoversborderingcountries.

2) ProportionalequivalencebetweenbenefitsandcostsOstrom(1993)states‘’Differentrulesareusedinself-organizingirrigationsystemstomobilizeresourcesforconstruction,formaintenance,andtopaywaterguards’’.Therearedifferentruleshowthehealthsystemisorganizedtomobilizeresourcesformalariapreventionandcontrol.Forexamplethereisthehealthinsurance,whicharepaidbycommunitymembersthemselves.However,afterpayingthelowersocialclassesgetmorereimbursedbythehealthinsurancecomparedtothehighersocialclasses.Furthermore,thegovernmentprovidesbednetsandsubsidizesmedicines.

Inaddition,wetlandsagricultureandricecultivationareacommonpracticeinRuhuha.Theseswampsattractmosquitos.Abenefitcostchallengethatthecommunityisfacingiswhethertheyshouldcontinuegoingintoswampsbecauseofthehighriskofgettingmalaria.Themalariaeliminationprogramdidresearchandfoundthatriceproducersarewillingtopayforthesprayingofswamps.Theyarewillingtopaybecausetheybenefitfromriceproduction,whilethewholecommunityhasabiggerriskofsufferingfrommalariaastheswampsattractmosquitos.Intheexamplesofthesebenefitcostchallengesmobilephonesplayaroletoremindcommunitymemberstopayforhealthinsurance.Moreover,startingthisyearcommunitymemberswillbeabletopayfortheirhealthinsuranceusingmobilemoney.

3) Collective-choicearrangementsOstrom(1993)states:

‘’Theproblemofgainingcompliancetorules,nomatterwhattheirorigin,isfrequentlyassumedawaybytheoristspositioningallknowingandallpowerfulexternalauthoritiesthatenforceagreements.Inthecaseofmanyself-organizingsystems,noexternalauthorityhassufficientpresencetoplayanyroleintheday-to-dayenforcementoftherulesinuse’’.

However,inthecaseofmyresearch,externalauthoritiesthatmakerules‘’thehigherlevel’’areabletoplayaroleintheday-to-dayenforcementoftherules.Theyareabletoinfluencethisbecauseofthewaythehealthsystemisorganizedwithcommunityhealthworkers.ThecommunityhealthworkersreportseverecasesofmalariaviaSMStextmessagestothenationallevel,copiedtothedistricthospitalandthehealthcenter.Furthermore,communityhealthworkersreportweeklytothehealthcenterhowmanypatientsofmalariatheytreated.ThehealthcenterusesHMIStoreportthesecasestothedistricthospital.ThedistricthospitalusesHMISaswelltoreporttothehigherlevel.ForthesereasonsthehigherlevelknowswhatisgoingonregardingmalariainRuhuha.Whentherearemanycasesofmalariatheyworktogetherwiththedistricthospitaltointerfereandtoensurethatthehealthcenter,localleadersand

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thecommunityhealthworkersraisemoreawarenessabouttherulesandregulationsandthattheyfollowupmorecloselywhethertherulesandregulationsarebeingfollowed.Furthermore,thecommunitymembershavetemptationsnottocomplytherulesandregulations.Thesetemptationsincludehotnesswhilesleepinginbednets,violationofprivacywhenfumigatorsenterthehousewhenspraying,togrowplantationsaroundthehouseforincomeorownfoodconsumption,tosharetabletswhenotherfamilymembersalsosufferfrommalaria,andbedbugs.Wheneverthehealthcenteridentifiesthatcommunitymembersdonotcomplytotherulesforspecificreasonstheytrytogiveexplanationswhenpeoplearegatheredandordercommunityhealthworkerstomakecommunitymembersawareoftheimportanceoffollowingtherulesandregulations.

4) MonitoringOstrom(1993)describes‘’Monitors,whoactivelyauditphysicalconditionsandirrigatorbehavior,areaccountabletotheusersand/oraretheusersthemselves’’.Inthecaseofmyresearchthecommunityhealthworkersaremonitorsandusers.Theymonitorwhethercommunitymembersfollowtherulesandregulationsbyvisitingtheirhomestoassesswhethertheysleepinbednets,havehygienicconditionsinandaroundtheirhomes,andwhethertherearemosquitobreedingsitesorstagnantwateraroundthehouse.ICTsareusedintwowaysregardingmonitoring.Firstthecommunitymembersgaveexamplesthatwhentheyseethattheirneighborsdonotfollowtherulesandregulations(forexamplewhentheyhavestagnantwaterorbushesaroundthehouse)theyuseamobilephonetocallacommunityhealthworkerwhocancometoexplaintherulesandregulationstotheneighbor.Secondly,mobilephonesareusedtoreportseverecasesofmalariatothenationallevel.CommunityhealthworkerssendSMSmessagestothenationallevelincasetheymeetaseverecaseofmalaria.WithinthreedaysthecommunityhealthworkerreceivesaSMStextmessagefromthenationallevelaskingwhetherthemalariapatienthasimproved.

5) GraduatedsanctionsOstrom(1993)states:

‘’Userswhoviolateoperationalrulesarelikelytoreceivegraduatedsanctions(dependingontheseriousnessandcontextoftheoffense)fromotherusers,fromofficialsaccountabletotheseusers,orfromboth’’.

Violationstotherulescanbeprovenwhencommunitymembersforexampledonotallowfumigatorsintheirhomes,whentheydonotsleepinmosquitonets,orwhentherearebushesorstagnantwateraroundhouses.Thecommunityhealthworkers,whoareparticipantsandcommunitymembersthemselves,undertakemonitoring.Inthecaseofmyresearchtherearenoenforcedsanctions.However,thereissocialpressure.Communityhealthworkerscanvisithomeswhentheparentsareawaytotrytogetinformationfromchildren.Afterwards,ifthechildrensaytheydonotseetheirparentssleepinbednets,thecommunityhealthworkersmentioninthevillagemeetingsthatthereare

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somepeoplewhoarenotusingthebednets.ICTsplayaroleinmonitoring,butdonotplayaroleinsanctioningcommunitymembersfornotfollowingtherulesandregulations.

6) ConflictresolutionmechanismsOstrom(1993)describes:

‘’Ifindividualswhomakeanhonestmistakeorfacepersonalproblemsthatpreventthemfromfollowingarulecannotfindmechanismstomakeuptheirlackofperformanceinanacceptableway,rulescanbeviewedasunfairandconformanceratesdecline’’.

InthecaseofmalariapreventionandcontrolinRuhuhathereareseveralexamplesofthis.

Firstofall,inthecaseofmalariapreventionandcontrolinRuhuha,theruleofsleepinginmosquitonetsisnotfollowedproperly.Manycommunitymemberssleeponmatsonthegroundanddonothavebeds.Thissituationmakesitdifficultforthemtousemosquitonetsproperlyanddeclinesconformanceratestothisrule.Moreover,atthemomenttheresponsibleactorsdonotprovidemosquitonets.Thislackofavailabilityalsodecreasesconformancerates.

Furthermore,becauseofpovertysomecommunitymemberscannotcomplywiththerules.Somehouseholdsdonothaveenoughmoneytobuyhealthinsurancesortablets.Thislackofmoneymightalsomakesomecommunitymemberssharetabletsathomewithotherfamilymemberswhosufferfrommalariaandtheydonotfinishtherequireddozetogetcured.

Inaddition,communitymembersexpressedthattheywerewonderingwhethertheyshouldreallyfollowtherulesofnotplantingbanana,sorghumormaizeplantationsneartheirhomeswhiletheyareimportantforthem.Theseplantationscouldgivethemincomeorfoodtoeat.Communitymemberscouldperceivethisruleasunfairanditwasmentionedthatnowadaystherearemanyhouseholdsthathaveplantationsaroundtheirhomes.ICTsdonotplayaroleinconflictresolutionmechanismsinthecaseofmyresearch.

7) MinimalrecognitionofrightstoorganizeTheactorsinRuhuhaaregivensomerightstoorganizebythegovernment.Forexample,thereisarulethatpeoplewhoshowsignsofmalariashouldreachthehealthcentertogettreated.However,therearealsoprivatepharmaciesthatarelicensedbythegovernmentwherecommunitymemberscanbuymedicineswithoutanyexaminations.Severalactorsmentionedthisasanegativedevelopment.However,thecommunitymembersandallactorsarerecognizedbythenationalgovernmentaslegitimateformoforganization.Nexttothepublicactors,alsothetraditionalhealersandprivatepharmaciesarelicensedbythegovernment.Itisdifficultforcommunitylevelactorstoenforcerulesasfundsforfumigationandbednetsareunavailableatthenationallevel.TheactorsthatareincludedinRuhuha’shealthsystemdohavetherighttoorganizebyauthoritiesfromhigherlevels,buttowhatextentisdifficulttodetermineasthegovernmentsomehowcontrolshowthe

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healthsystemisorganizedthroughthepublichealthandnon-healthrelatedactorsatthecommunitylevel.ICTsdonotplayaroleintherecognitionofrightstoorganize.

8) NestedenterprisesOstrom(1993)states

‘’Irrigatorscantakeadvantageofmanydifferentscalesoforganization.Small-scaleworkteamsareaneffectivetechniqueforovercomingfreeriding.Everyonemonitorseveryoneelseinsituationswhereshirkingisobvious.Large-scaleenterprisesallowsystemstotakeadvantageofeconomiesofscalewheretheyarerelevantandtoaggregatecapitalforinvestment’’.

Thisisalsothecaseinmyresearch.Everyvillageorcellhastheirownsmallgroupsofcommunityhealthworkers,communitymalariaactionteams,localleaders,andpublicworkonasmallscale.Therearemeetingsonallthesesmalllevels,aswellasmeetingsondifferentlevelssuchasthedistrictbecausemalariaisaregionalproblem.Thereforethiscasealsohasscalesoforganizationfromvillage,cell,district,tothenationallevel.However,RwandaasacountrymightnotevenbebigenoughasascaleformalariapreventionandcontrolinRuhuha,becausetheborderwithBurundiisclose.ICTsplayaroleininformationandcommunicationflowsbetweenactorsondifferentscalesandbetweenactorsofthesamescale.

5.4.4TheroleofICTsinthemalariagovernancearrangementsTheprevioussub-sectiondescribedthatICTsplayaroleinfacilitating

communitylevelstrategiesof‘publicbad’governance.WhenanalyzingthecompliancewithOstrom’sdesignprinciplesitwasidentifiedthatmobilephonesplayaroleinthedesignprinciplescollectivechoicearrangements,monitoring,andnestedenterprises.ThissectiondescribedtheroleofICTsinthemalariagovernancearrangementsinmoredetail.

TheemergenceofICTsinRwandasomehowchangestheroleandlegitimacyofactorsinmalariapreventionandcontrolinRuhuha.Regardingmalariaasapublicbad,ICTsplayaroleineffectivelymanagingcollectiveaction.Firstofall,onthecommunitylevelcommunitymembersusemobilephonestocalllocalleaderstoinformthemaboutmosquitobreedingsitesinvillagesthatneedtobecleanedduringpublicwork.Anotherexampleisthatcommunitymembersusemobilephoneswhentheirneighborsdonotfollowtherulesandregulations.Inthesecasestheycallacommunityhealthworkertocomeandtoexplaintherulesandregulationstotheneighbor.Theadviceofcommunityhealthworkersismorelikelytobefollowedupcomparedtoifacommunitymemberwouldtrytoexplaintherulesandregulationstohisorherneighborbyhimorherself.Moreover,onthenationallevelICTsareenablingthenationalactorstogatherdataformonitoringandevaluation.TheyareusingtheICTsSIScom(CommunityHealthWorkerInformationSystem)andHMIS.Furthermore,ICTsenablequickinformationsharingacrosslevelsandbetweenthestakeholdergroups,whichenhancesquickactionincaseofanincreaseofmalariapatients.

IntermsofwhethernationalICTpoliciesandstrategiesarerelatedtolocaloutcomesinICTuseandmalariaprevention,thenationalICThealth

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initiativesSIScomandHMISarefunctioningandareusedonthelocallevelandtoreportacrosslevels.Onthenationallevel,theRwandaBiomedicalCenterusesSIScom,rapidSMS,andHMISforreportingandmonitoringpurposes.However,accordingtotheRwandaBiomedicalCenterresponsetothedatagatheredisaproblem.Hestated:

‘Timelyreporting.Causeforthefirstweekofeachmonthwehavenewdata.Buttheissuesometimesisresponse.Ourissueisresponse.Weknowthatthereisaproblemthere.Butsometimesifyouwanttosprayitisabigproblemtofindoutmoney.Becauseforonelitter,uhmnoonedosage.Foronesquarepointthereisaroundcurrentlywithoutsubsidyisaround7.34USD.Butyoudon’tknow,tosprayonehouseisaroundprobably20euro.Ifyouwanttosprayonehousefor20eurosisveryexpensive,isveryexpensive.Butwearetargetinghighburdenareas’.

Thisquotationshowsthatforexampleknowledgeisavailableatthenationallevel.Theyareawarethatthehousesneedtobefumigated,buttherearenofinancialresourcestosupporttheserulesandregulationsregardingmalariapreventionandcontrol.TheRwandaBiomedicalCenteralsohasknowledgethatpreventionmeasuresarenotusedproperly.Recently,therehasbeenaresurgenceofmalariainRuhuha.Therefore,national(ICT/malariaprevention)policiesdidnotresultinalocaloutcomeofmalariaprevention,eliminationorreduction.However,ICTsarealsonotdeadpiecesofpaperthatareirrelevantforcesatthelocallevel.Althoughmalariaincidentshaveincreased,thenationalICThealthstrategiesandpolicieshavebeenimplementedandareusedatthelocallevel.ThecommunityhealthworkersreporttothehealthcenterusingSIScom.Furthermore,thehealthcenterandthedistricthospitalreportusingHMIS.TheseICTsspecificallydesignedforthehealthsystemplayaroletomakedataandknowledgeavailableformonitoringandevaluation,asRBCisawarethatthefollowuponthisdatatopreventmalariaatthecommunitylevelisanissue.

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6.ConclusionThehealthsystemregardingmalariapreventionandcontrolinRuhuha

consistsofhealthandnon-healthrelatedactorsfromthecommunity,district,andnationallevel.Informationandcommunicationflowsbetweenthesedifferentstakeholdergroupsarefacilitatedbyface-to-facecommunication,SIScom,HMIS,mobilephones,radio,andvideoprojections.Firstofall,SIScomandHMISareinitiativesspecificallydesignedforthehealthsystemandfacilitatethesharingofinformationfromcommunitytothenationallevelformonitoringandevaluationpurposes.Secondly,face-to-facecommunicationandmobilephonesfacilitateinformationandcommunicationflowswithinandbetweenallstakeholdergroups.Lastly,radioandvideoprojectsfacilitateinformationflowsfromthenationaltocommunitylevel.

MalariaisconsideredagrowingprobleminRuhuhaandawarenessishigh.However,themajorityofactorsperceiveknowledgeaboutmalarianotenoughinRuhuha,whileotheractorsexplainedthatknowledgeisenoughbutthepreventivemeasuresarenotappliedproperly.Intheanalysishasbeenidentifiedthatreasonsfornotapplyingthepreventivemeasuresarerelatedtopoverty,misconceptions,andthelackofmosquitonets.Ifacommunitymemberdoesnotapplythepreventivemeasuresproperly,heorsheisarule-breakerandthisendangerstheentirecommunity.Forthisreason,non-compliancetotherulesandregulationsthatareinplacetofightmalariaarecollectiveactionproblems.AccordingtotheanalysisofcompliancewithOstrom’sdesignprinciples,thesecollectiveactionproblemsincludenoclearlydefinedboundaries,lackofgraduatedsanctionsandthelackofconflictresolutionmechanisms.DespitethesecollectiveactionproblemstherearealsoexamplesofhowmultiplestakeholdergroupstrytocollectivelygovernmalariaasapublicbadinRuhuha.Thecommunityhealthworkersplayanimportantroleinthiscollectiveaction.Thecommunityhealthworkersmonitorwhethertherearerule-breakersandgiveadvicewherenecessary.Communitymemberstrusttheadviceandinformationthatisspreadbycommunityhealthworkers,becausetheyarepartofthecommunity.

ICTsplayaroleinthesegovernancearrangementsofactorsthataredealingwithmalariaasapublicbadinRuhuha.Firstofall,theadvantagesofICTsarethattheyfacilitateinformationandcommunicationflowsthatarerealtime,lowcost,overlargedistanceandacrossstakeholdergroups.ApartfromthestrategicICT-basedhealthinterventions,mobilephonesplayacrucialroleinmalariapreventionbyfacilitatingawarenessraising,improvingtheinformationflowswithinandbetweenthestakeholdergroups,andbystrengtheningtheimplementationofcommunitylevelmalariapreventionrulesandregulations.However,stakeholdersalsopointedoutthattherearemisconceptionsaboutmalariainRuhuha.Therefore,notallinformationistrustworthyandmobilephonescouldalsoincreasethespreadofmisconceptions.Despitethisdisadvantage,mobile-basedinformationandcommunicationflowsimprovethecollectivegovernanceofmalariaasapublicbad.

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7.Recommendations1.MyresultsshowthatthereisnocompliancewithsomeofOstrom’s

designprinciples,whicharenoclearlydefinedboundaries,lackofgraduatedsanctionsandthelackofconflictresolutionmechanisms.Thisanalysiscanbeusedbyactorsfromthevariouslevelstogovernmalariaasapublicbadmoreeffectivelybylookingforpossibilitiestodefineboundaries,graduatedsanctions,andconflictresolutionmechanisms.

2.TheanalysisinmythesisidentifiedthatactorsperceivethatknowledgeaboutmalariaisnotenoughinRuhuhaandthatmisconceptionsexist.Thesefindingscouldbeusefulforthehealthrelatedactorsandlocalleaderstoimprovecommunicationflowsandinformationprovisiontoincreaseknowledgeandtodissolvemisconceptions.Thefindingsofmyresearchshowthatcommunityhealthworkersandhealthcenterstaffaretrustedactorswhenitcomestospreadinginformationaboutmalaria.Therefore,theycouldplayanimportantroleinchangingperceptions.

3.Furthermore,myresearchprovidesinsightsinhowICTsareusedinmalariapreventionandcontrolinRuhuhaacrossandwithindifferentlevelsofthehealthsystem.Actorsfromthevariouslevelsandstakeholdergroupscouldusetheseinsightstoimprovetheirinformationandcommunicationflows.Inaddition,theinsightsofthisanalysiscouldbeusefultoincreasetheeffectivenessanduseofICTinterventionsthatwillbeimplementedinthefuture.

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Appendices

Appendix1–OverviewofintervieweesNumber Actor Position Amountfor

travelexpensesDate EndTimeof

InterviewDuration

1 Communitymember(above50yearsfemale)

Farmer 2000RWF 08.01.2018 10.03 45:44minutes

2 Communitymember(above50yearsfemale)

Farmer 2000RWF 08.01.2018 10:50 42:46minutes

3 Communitymember(above50yearsmale)

Farmer 2000RWF 08.01.2018 15.13 50:08minutes

4 Communitymember(above50yearsmale)

Farmer 2000RWF 08.01.2018 16.27 01:07:18minutes

5 Communitymember(above35-50yearsfemale)

Farmer 2000RWF 09.01.2018 10:47 01:29:01minutes



7 Communitymember(above35=50yearsmale)


8 Communitymember(above35-50yearsmale)

Farmer 2000RWF 09.01.2018 16:07 53:44minutes


Studentorunemployed

2000RWF 10.01.2018 10:19 01:03:06minutes


Studentorunemployed

2000RWF 10.01.2018 11:35 01:08:56minutes

11 Communitymember(above Farmer 2000RWF 10.01.2018 15:25 01:19:04

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18-35yearsmale) minutes12 Communitymember(above

18-35yearsmale)Farmer 2000RWF 10.01.2018 16:51 01:16:48

minutes13 Cooperativesfemale Farmerofrice

cooperative5000RWF 11.01.2018 10:23 01:34:03

minutes14 Cooperativesmale Farmerofrice

cooperative5000RWF 11.01.2018 11:54 01:10:42

minutes15 Schoolteacher Teacherat

G.S.Butereri5000RWF 11.01.2018 14:55 33:06minutes

16 NonCommunityhealthinsurance(sendtheirchildwhoisastudent)

Studentofprimaryschool

2000RWF 11.01.2018 15:37 26:58minutes

17 StaffofRuhuhaHealthcenter(male)

Ruhuhahealthcenterstaff

5000RWF 12.01.2018 10:10 01:00:57minutes

18 StaffofRuhuhaHealthcenter(female)

Ruhuhahealthcenterstaff

5000RWF 12.01.2018 11:36 01:05:11minutes

19 Communityhealthworker(female)

Communityhealthworker(RuhuhaH.C.)

2000RWF 12.01.2018 15:07 01:09:12minutes

20 Communityhealthworker(male)

Communityhealthworker(RuhuhaH.C.)

2000RWF 12.01.2018 15:51 35:33minutes

21 CMATs CMATS(CommunityMalariaActionTeams)

2000RWF 15.01.2018 10:23 55:20minutes

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22 Pharmacy Pharmacy–Ruhuhahealthcenter

5000RWF 15.01.2018 11:36 48:37minutes

23 Localleader Localleader 5000RWF 15.01.2018 14:55 52:30minutes24 MEPR Assistantof

MEPR–RuhuhaHealthCenter

5000RWF 15.01.2018 15:51 42:32minutes

25 Traditionalhealer Traditionalhealer

5000RWF 15.01.2018 17:02 40:56minutes

26 NonCommunityhealthinsurance

Non-healthinsuranceperson

2000RWF 16.01.2018 10:26 01:23:03minutes

27 NMCP-RBC Directorofvectorcontrolunit–Rwandabiomedicalcenter

5000RWF 17.01.2018 11:43 40:10minutes

28 NationalHealthinsurancescheme-RSSB

Headofcommunity-basedhealthinsurancedepartmentCBHI-RSSB

5000RWF 22.01.2018 16:06 35:33minutes

29 Nyamatadistricthospital DirectorofNyamatadistricthospital

5000RWF 24.01.2018 09:23 30:46minutes

30 Religiousleader Priest 5000RWF 24.01.2018 11:11 25:08minutes

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31 Privatepharmacy Privatepharmacy

5000RWF 24.01.2018 12:33 01:08:08minutes

32 HeadofRuhuhahealthcenter

LeaderofRuhuhaHealthCenter

5000RWF 24.01.2018 13:49 01:04:14minutes

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Appendix2–Topiclistoftheinterviews

2.1Interviewtopics–community

1. Doyouevertalkaboutmalariainyoureverydaylife?(ifnot–whynot?)Onwhatoccasion?Towhom,howface-to-face/phone/other,whatdoyoutalkabout.

2. Doyouthinkthereisknowledgeinyour(community,regionetc.)aboutmalaria?Istheknowledgeenough?Arethereanymisconceptions?Why?Howdotheyspread?

3. Whatmalariaprevention/controlmeasuresdoyouknow(liketraps,nets,

repellant,stayingoutsideafterdark,removingstagnantwatervesselswheremosquitosbreedetc.)?Whatdoyouthinkabouteachofthem?Doyouevertalkaboutthem?Withwhom?

4. Wheredothesemeasurescomefrom?Whoensurethattheseprevention

andcontrolmeasuresareinplace?Isitenforcedinanyway?Why,how,howdoyoufeelaboutit?

5. DoyoureceiveinformationaboutMalaria?E.g.radio,tv,socialmedia,churchservices,advertisements(fromwhom,howandwhatinformation,whatdoyoudowiththeinformation).

6. Whomdoyoutrustthemostwhenitcomestogettingreliable

informationonmalaria?Whomdon’tyoutrust?Why,whynot?

7. Whatisthesituationrightnowinyour(community,region,etc.)regardingmalaria?Whatdoyouthinkaboutit?

8. Doyoufeellikeyoucandosomethingaboutthemalariaissueyourself?How/why/whynot?Howdoesthatmakeyoufeel?

9. Recently,IhaveheardthatanumberofpeopleinRwandaareusing

mobilephonesmoreandmore.Doyoueveruseyourphonetocommunicateorreceiveinformationaboutmalaria?Doyouthinkmobilephonesplayaroleinbattlingmalariainthefuture?How,why,whynot?Canyougivemeexamples?

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2.2Interviewtopics–actorsinhealth/policylevel

1. Onwhatoccasion(s)doyoutalkaboutmalaria?Towhom,howface-to-face/phone/other,whatdoyoutalkabout.

2. Whatisthesituationrightnowinyour(community,region,etc.)regardingmalaria?Whatdoyouthinkaboutit?

3. Whoensurethatpracticesregardingmalariapreventionandcontrol(like

traps,nets,repellant,stayingoutsideafterdark,removingstagnantwatervesselswheremosquitosbreedetc.)areinplace?Isitenforcedinanyway?Why,how,howdoyoufeelaboutit?

4. Aretheretrainings,programsorawarenessraisingtopreventandcontrol

malaria?Whoensuresthattheseareinplace?Isitenforcedinanyway?Why,how.

5. Doyouthinkthereisknowledgeinthe(community,regionetc.)aboutmalaria?Istheknowledgeenough?Arethereanymisconceptions?Why?Howdotheyspread?

6. Whichactorsdoyoutrustthemostwhenitcomestospreadingreliable

informationonmalaria?Whomdon’tyoutrust?Why,whynot?

7. Doyoufeellikethecommunitycandosomethingaboutthemalariaissuethemselves?How/why/whynot?Howdoesthatmakeyoufeel?

8. Recently,IhaveheardthatanumberofpeopleinRwandaareusing

mobilephonesmoreandmore.Doyouthinkmobilephonesmayplayaroleinbattlingmalaria?How,why,whynot?Canyougivemeexamples?

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Appendix3–OverviewofcodesCode ExplanationTalkaboutmalaria-occasion,whom Whenintervieweestalkabouttalking

aboutmalariaandtowhomTalkaboutmalaria-what Whatintervieweestalkaboutwhen

theytalkaboutmalariaSituationregardingmalaria Whenintervieweesmentioned

somethingaboutthesituationregardingmalaria

Knowledge-isitthere?enough? Whetherintervieweesthinkthereis(enough)knowledge

Knowledge-misconceptions Whensomethingaboutmisconceptionsismentioned

Preventionandcontrolmeasures-whichonesandinfotheytell

Whenintervieweesmentionedaboutmalariapreventionandcontrolmeasuresandwhattheytalkaboutit

Preventionandcontrolmeasures-whoensurestheyareinplace

Whenintervieweesmentionedwhoensurespreventionandcontrolmeasuresareinplace

Preventionandcontrolmeasures-enforced?

Whenintervieweesmentionorexplainaboutmalariapreventionandcontrolmeasuresbeingenforcedornot

Receivinginformation-fromwhom,how

Whenisbeingmentionedthatthepersonreceivesinformationfromwhomandhow

Receivinginformation-whatinformation

Whenapersonmentionedaboutwhatinformationheorshereceives

Receivinginformation-whatdoyoudowithit

Whenisbeingpersonwhatthepersondoeswiththeinformation

Trust-actorsthataretrusted Whenactorsthataretrustedarementioned

Trust-actorsthatarenottrusted Whenactorsthatarenottrustedarementioned

Cando-feellikecandosomethingyourself?

Whentheintervieweementionsorexplainswhetherheorshefeelsthecommunitymemberscandosomethingaboutthemalariaissuethemselves

Cando-whatshouldbedoneaboutmalaria

Whentheintervieweementionssomethingrelatedtowhatheorshefeelsthatshouldbedoneaboutmalariatosolveitorfutureactions

ICTs-roleofmobilephones Whentheintervieweementionssomethingabouttheroleofamobilephone

ICTs-roleofotherICTs WhentheintervieweementionssomethingabouttheroleofotherICTs

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ICTs-futurerole WhentheintervieweementionsorexplainsaboutthepossiblefutureroleofmobilephonesorotherICTsinthefuture

Healthinsurance Whensomethingabouthealthinsuranceismentionedbyaninterviewee

Problems-->regardingmalaria Whenanintervieweementionsorexplainsaproblemregardingmalaria

Publicbad-rulesandregulations Whenanintervieweementionssomethingrelatedtorulesandregulationsregardingmalariapreventionandcontrol

Roleofclubandcare Whenanintervieweeexplainstheroleofcluband/orcare

RoleofCMATs WhenanintervieweeexplainsormentionsabouttheroleofCommunityMalariaActionTeams

Roleofcommunityhealthworker Whenanintervieweeexplainsormentionsabouttheroleofcommunityhealthworkers

Roleofcooperative Whenanintervieweeexplainstheroleofcooperatives

Roleofhealthcenter(staff) Whenanintervieweeexplainsormentionsabouttheroleofthehealthcenter

Roleofhealthcenterpharmacy Whenanintervieweeexplainsormentionsabouttheroleofthehealthcenterpharmacy

Roleoflocalleader Whenanintervieweeexplainsormentionsabouttheroleoflocalleader

RoleofMEPR WhenanintervieweeexplainsormentionsabouttheroleoftheMalariaEliminationProgram

RoleofNyamatadistricthospital Whenanintervieweeexplainsormentionsabouttheroleofthedistricthospital

RoleofRBC WhenanintervieweeexplainsormentionsabouttheroleoftheRwandaBiomedicalCenter

Roleofresearchers Whenanintervieweeexplainsormentionsabouttheroleofresearchers

Roleofteacher Whenanintervieweeexplainsormentionsabouttheroleofteachersandschools

Roleofthechurch Whenanintervieweeexplainsormentionsabouttheroleofthechurchandpriestsandotherreligiousleaders

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Roleoftraditionalhealers Whenanintervieweeexplainsormentionsabouttheroleoftraditionalhealers

Sendinginformationorsharinginformation

Whenanintervieweementionsaboutsendingorsharinginformationwithotheractorsrelatedtomalariapreventionandcontrol

Trainings,programsorawarenessraisings

Whenanintervieweementionsaboutatraining,programorawarenessraising

The role of ICT in public bad Ruhuha, Rwanda

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