Authored by: Gloria Ikilezi
At a time when COVID-19 has impacted health systems around the world, a few Exemplar countries have proven resilient by maintaining or quickly resuming the delivery of key health services despite lockdowns, supply chain challenges, and disruptions to daily life. Countries including Rwanda, Bangladesh, and Uganda have proven that during times of crises, the delivery of essential health care can be maintained. What’s more, our research on Peru and Nepal demonstrates that access to primary care can even be strengthened during crises.
To share lessons with countries as they recover from the pandemic, Exemplars in Global Health research partners presented lessons on building resilient health delivery systems at the Consortium for Universities of Global Health’s 2021 virtual conference on March 13, 2021.
The panel, which consisted of Drs. Rhoda Wanyenze (Makerere University), Nadia Akseer (Johns Hopkins School of Public Health), Agnes Binagwaho (University of Global Health Equity), and Mushtaque Chowdhury (Columbia University, BRAC University), discussed how Exemplars countries are maintaining health services during the current pandemic.
Dr. Agnes Binagwaho shared how Rwanda has delivered maternal and child health services during the pandemic by leveraging the same strategies it utilized to reduce under-five mortality (U5M) by 70 percent between 2000 and 2017. One of Rwanda’s key strategies, which has influenced multiple health outcomes is its decentralized health system, which promotes a geographically equitable response to health challenges. Also critical are the country’s single national health plan and its emphasis on equity, including offering free diagnostics and treatment for all.
Rwanda’s openness to innovative strategies and tools, including the use of drones to deliver critical health supplies, has contributed to U5M reduction and was key in their COVID-19 response. The country has also leveraged its community health worker (CHW) network (three CHWs for every village across the country) to compensate for shortages of trained health care workers and to provide health education, household screening, and patient care including referrals.
Finally, Rwanda’s leaders engage in clear and consistent communication. The country’s COVID-19 online portal is a great example of a trust-building communications tool.
Mushtaque Chowdhury shared insights from Bangladesh’s experience. During the country’s initial COVID-19 outbreak, delivery of antenatal care services declined by half. Since May 2020, the delivery of routine health services has slowly recovered, partly due to the efforts of Bangladesh’s CHW cohorts working in their own communities, growing trust, and rebuilding demand for health services.
CHWs have also been at the forefront of the country’s communication strategies to educate communities to accelerate the pace of COVID-19 vaccinations across Bangladesh. Thus far, the country has immunized 2.7 million people against COVID-19, ranking Bangladesh 17th globally in the number of people vaccinated and second in South Asia.
Bangladesh’s CHWs have a long history of supporting vaccination campaigns. In 1985, despite attempts to improve childhood immunization rates, Bangladesh’s BCG (tuberculosis), MCV1 (measles), Pol3 (polio), and TT2+ (tetanus) immunization rates were the lowest in South Asia.1 In response, the government launched an ambitious immunization program with CHWs from BRAC and CARE playing leading roles.2 CHWs traveled door to door to educate parents about the importance of immunizations against these diseases, a strategy which proved so effective, that 90 percent (24 million) of the country’s children were vaccinated in a single day.3
Uganda’s experience is like that of Bangladesh and many other countries. From March to May of 2020, childhood immunizations, outpatient visits, and in-facility deliveries declined significantly. There were disruptions in support supervision, fatalities among health care workers from COVID-19, and absenteeism for fear of contracting the infection.
Dr. Rhoda Wanyenze explained that the government’s response to these concerns was pivotal in improving both COVID-19 containment and mitigating further disruptions in delivery of essential health care. Health care workers were equipped with Personal Protective Equipment and were offered online training to learn how to minimize risk for themselves and their patients. Service delivery models have been adapted to minimize exposure including task shifting, telemedicine, and dispensing multi-month drug refills for patients with chronic illnesses.
Uganda’s delivery of health services has since rebounded. The government continues to use analytics to detect new or ongoing disruptions in critical health services, while the health system evolves to meet the challenges posed by the pandemic.
Maintaining primary health services is critical and must be an integral part of epidemic preparedness and response. Across the experience of Rwanda, Bangladesh, and Uganda and other geographies, Exemplars researchers have identified a few strategies that countries have used to build health systems capable of delivering primary healthcare during times of crisis:
- Community engagement and communications remain critical
- Data-driven solutions and real-time analytics can help guide decision making
- Governments can leverage their health system’s strengths, such as CHWs or data, to overcome challenges
- Stakeholders must be coordinated and existing partnerships should be leveraged
- Innovations can be adopted as is relevant to the country’s context
References
- WHO Reported Estimates of Coverage http://apps.who.int/immunization_monitoring/globalsummary/timeseries/tscoveragebcg.html
- Last Mile Health Interview (BRAC)
- http://www.who.int/pmnch/knowledge/publications/bangladesh.pdf