Ubudehe: Prevention, Intervention, and Social Stratification

By Maya Saint Germain
Dec. 19, 2019

All Maternal and Child Health Volunteers in Rwanda work on behalf of the First 1000 Days Program, which addresses the issue of childhood stunting that results from chronic malnutrition. This includes a wide umbrella of target areas such as preventing childhood illness, improving levels of nutrition, and increasing attendance levels of antenatal care visits.

A volunteer’s service is then further refined by their community’s needs. In partnership with their health center supervisors and counterparts, Health Volunteers in Rwanda develop site-specific goals to guide community-level initiatives.

PCV Maya, counterpart, and mother measure length of baby

One of the main goals my health center has asked me to work towards is improving levels of nutrition in our sector. Assisting our social worker Gaudence during distribution days is my most consistent responsibility at our health center, and one that contributes directly to our shared objective of reducing rates of malnutrition. Several times a month, Gaudence and I measure babies’ weight, height, and arm circumference to screen for and monitor cases of malnutrition, and then distribute nutrient-dense foods.

To understand the different food assistance programs available in Rwanda, you must first understand Rwanda’s system of Ubudehe (/OO-bOO-dAY-hˈe‍ɪ/). Rwandans are assigned to socioeconomic categories from 1 to 5, with 5 reserved for the wealthiest and 1 the poorest. Ubudehe categories are determined at the community level and remain relatively fixed unless circumstances change drastically. Ubudehe is a function of one’s income, personal possessions, and general quality of life. Households in Ubudehe 1 qualify for monthly government assistance – financial support, training, first consideration for some employment opportunities – and those in Ubudehe 2 also benefit from minor forms of assistance. I haven’t noticed any stigma associated with being in a specific category, with the exception of those in Ubudehe 2 eyeing the benefits of those in Ubudehe 1 and insisting they are miscategorized.

PCV Maya and two mothers wash their hands before preparing the group meal

SHISHA KIBONDO

Pregnant mothers, breastfeeding mothers, and children under two years old in Ubudehe 1 (and 2 in some districts) are eligible to receive Shisha Kibondo, a fortified porridge mix. This is a preventative program meant to target a demographic that is at a higher risk of becoming malnourished. Once a month, mothers come to the health center and receive several kilograms of Shisha Kibondo to help maintain good nutritive status throughout their babies’ earliest stages of life, giving them the best chance for full physical and cognitive development.

MILK, SOSOMA, RUTF

Cases of malnutrition in children under two years old are identified with information recorded during vaccination visits, sector-wide nutrition campaigns, and home visits by Community Health Workers. There are a few different tiers of nutritive status, or “zones”. By calculating different ratios of an infant’s height, weight, and age, they are assigned to either the green, yellow, or red zone. The measurement taken of a child’s upper arm circumference is useful in determining whether they are suffering from acute or chronic malnutrition. With a child’s color zone and case acuity in mind, Guadence gives each mother a different combination of supplemental foods. Bags of whole milk are distributed by the half liter. Most malnourished children qualify for 15 liters per month, or about two cups per day. SOSOMA is a fortified porridge mix high in protein and micronutrients, similar to Shisha Kibondo. It is made with soy, sorghum, and maize flower. RUTF (Ready-to-Use Therapeutic Food), or Plumpy Nut, is a nut paste high in fat and protein. Distributing these foods regularly helps us intervene in cases of malnutrition.

Group photo of mothers with babies, PCV Maya, and counterpart Gaudence

The act of regular monitoring in itself draws attention to the need for treatment and care. Cases that are extremely severe and cannot be treated with fortified foods alone are triaged to the local referral hospital to receive more intensive care. Integrating additional, more holistic forms of treatment such as home visits and counseling services is a priority for our sector-level social worker, Alice. This is especially helpful in cases of malnutrition that persist even after months of supplementary food assistance. Alice’s efforts to understand the unique challenges facing each household and develop solutions with them that suit their circumstances is a philosophy we hope to mirror with Peace Corps Rwanda site-specific goals. One-size-fits-all solutions often overlook nuanced challenges that can only be resolved with a closer look at a community or household.

Growth monitoring on distribution days is an activity many Peace Corps Health Volunteers in Rwanda have in common because all health centers partake in these government-supported programs. Distribution days are a great way for me to build relationships with a familiar group of mothers, and they give me an opportunity to teach basic lessons about hygiene and nutrition with Gaudence or my counterpart Damascene. These programs provide essential assistance to vulnerable groups, and I feel lucky to play a small part in Rwanda’s efforts to end food insecurity and childhood malnutrition.

PCV Maya with counterpart Gaudence and mothers with babies
Head shot of PCV Maya