10 Perspectives

Lessons for responding to COVID-19, from Exemplars in Under-five Mortality Reduction

COVID-19 is testing national health systems on an unprecedented scale. The response to the pandemic, including prevention, detection, and treatment, has placed difficult and often dangerous demands on frontline health care workers, health officials, and other essential workers, and has challenged policymakers around the globe.

Researchers are currently examining how the crisis and the response, including the diversion of resources, may indirectly impact other areas of public health. We believe one key area that should not be overlooked is the health of children.

Although the direct effects of COVID-19 on children seem to be less severe than on adults, it poses a significant indirect threat to children’s health by disrupting the delivery of routine health services such as immunization. We have seen this before. The 2013 and 2019 Ebola outbreaks resulted in decreases of key maternal and child health interventions, including ANC, vaccinations, and treatment-seeking for diarrhea and ARI. The result was an estimated increase in under-five mortality that ranged from 10-28 percent in affected countries.1 

Some are predicting similar consequences from the COVID crisis.2 Recent models predict disruptions that could potentially double malaria deaths in 2020 and lead to an excess of 500,000 AIDS-related deaths in sub-Saharan Africa by 2021.3 Specific to child mortality, other studies are already projecting reductions in coverage of key child and maternal health interventions (facility-based delivery, vaccinations, bed net distribution, and vitamin A supplementation)4 and a corresponding projected increase of over 500,000 child deaths in the next year.4 These sobering projections highlight the need to build resilient health systems capable of maintaining health interventions through strategies to adapt to COVID-related disruptions in demand and delivery, while integrating new services in response to new threats.

However, the aforementioned health impacts are not a foregone conclusion. The “Exemplar” countries of under-five mortality reduction (highlighted throughout this web platform) offer important insights which may help countries accomplish these aims. Countries such as Rwanda, Senegal, and Peru have demonstrated resilience through crises, and in doing so have leveraged certain key factors to their success. Which, if any, of those strategies might help countries trying to respond to the threat posed by COVID-19?

We focus on four strategies that stand out as especially important for achieving a resilient health system that is capable of responding to the current pandemic and maintaining coverage of key interventions known to reduce U5M.

Lessons from Exemplar countries

Lesson Exemplar Country Details
Clear national plan driving rapid response Rwanda Coordinating donors and partners towards a nationally-established vision of primary care and horizontal integration
Using data for decision-making and leveraging existing systems Senegal Using existing data systems to inform response to new diseases
Using community health workers to convey data-driven decisions to communities Senegal Senegal Leveraging community health workers to inform communities
Focus on equity to reach everyone and prioritize the most vulnerable Peru Addressing the multifaceted challenge of reducing inequity and improving access to care through the Juntos cash transfer program

A. Clear national plan driving rapid response

The first lesson is the importance of a well-coordinated and clearly articulated national plan for the rapid adoption of interventions, including nationally-led collaboration with partners and clear channels of communication.5 Among the Exemplar countries we studied, Rwanda demonstrated this effectively. After the genocide in the 1990s, Rwanda made a strong commitment to reducing U5M and established a clear vision for the health system, including an emphasis on primary health care and horizontal integration. The country aligned donors and partners with this vision, and ensured successful implementation at the local level through performance contracts to ensure accountability

Today, Rwanda has leveraged these capacities in their response to COVID-19. The government was successful in preventing two Ebola outbreaks in 2013 and 2019 and is applying learnings on multisectoral coordination and a national contact tracing program to the current pandemic.6 Rwanda took quick action in mid-January, implementing national policies to screen travelers for COVID and test suspected cases, in an effort to get ahead of the problem.6 After Rwanda’s first case of COVID was identified in mid-March, the government quickly launched contact tracing, COVID-19 testing, and declared a national lock-down.6 At the local levels, the country has established handwashing stations at transport hubs and strictly enforced national social distancing policies.7 Local officials have also been trained and equipped with fever scanners to monitor high-risk exposure areas.8

Rwanda’s success in reducing under-five mortality and their decisive action in response to COVID-19 show the importance of a clear national plan for rapid response, including alignment of international, national, and local stakeholders towards this plan. These learnings have enabled Rwanda to swiftly respond to changing circumstances in the interest of continuously improving quality of the response. These lessons can be applied by other countries looking to build a resilient health system that can manage COVID-19, continue delivering child health interventions, and minimize subsequent increases in mortality from other causes.

B. Using data for decision-making

A second theme from the Exemplars research is the importance of using data to inform the development and execution of a clear national plan for rapid response. In the context of COVID-19, this entails leveraging existing data systems (e.g. surveillance systems) to help identify where testing and other inventions are needed and to track changes in spread of the virus.

Senegal is one of the Exemplars that demonstrated this lesson effectively. In the 2000s, Senegal built upon their polio surveillance systems to monitor and respond to measles cases. Today, in their response to the pandemic, Senegal again has shown strength in surveillance, quickly establishing laboratories to conduct testing, and through developing rapid testing diagnostics.7 As a result, they have outpaced the testing rates of wealthier African countries like Morocco and Kenya.9

Senegal’s ability to repurpose existing data systems provides lessons that countries today can use to build a resilient health system that is capable of responding to COVID-19 and protecting the health of children.

C. Leverage community health workers to engage communities

In conjunction with using data for decision-making, it is important for countries to effectively disseminate these decisions to communities. This can be accomplished through community health workers.

Once again, Senegal demonstrated this effectively in their campaign to reduce U5M. The country recognized that data systems and data-driven interventions must be relevant and acceptable to local communities. Towards this end, Senegal mobilized the bajenou gokh community health cadre, comprised of older women who are respected by the community. The bajenou gokh cadre helped with promotion of maternal, neonatal, and child health, and provided antenatal care, postnatal care, and child immunizations. Moreover, much of Senegal’s monitoring and surveillance has also been done by trained community health workers, who report suspected cases of notifiable diseases to district nurses.

Senegal has continued this emphasis on community engagement in their COVID-19 response today. Together with their surveillance and testing efforts, the country has leveraged religious leaders to help reach and educate local communities, while simultaneously developing “evidence-based treatment guidelines and protocols” to improve quality of care provided.7

Senegal’s emphasis on pairing data use for decision-making with effective community engagement provides lessons that countries can use to build a resilient health system capable of more effectively responding to COVID-19 and protecting the health of children.

D. A focus on equity

Finally, another key theme from the Exemplar countries is the importance of a focus on equity, which can be assessed along many dimensions, including geographic, gender, ethnic, and wealth equity. In today’s context, equity is especially relevant. As an example of wealth equity, the shutdown of public transportation in response to COVID has made it challenging for both the poor and for healthcare workers to travel to health facilities, resulting in “dramatic reductions in essential public health and clinical interventions”, including a 69% reduction in measles, mumps, and rubella vaccination in children [and] a 21% reduction in institutional deliveries in some countries.10 In addition, early studies are finding that minority ethnicities have a higher risk of both COVID-19 case rates and mortality, showing an example of how COVID-19 is affecting equity among different ethnicities.11

Many Exemplar countries demonstrated how to account for equity, by adapting strategies to different groups based on the impact of diseases and corresponding health system responses on these groups. One example is Peru, which prioritized low-income areas for the initial rollout of key child health interventions, including rotavirus, HIB, and pneumococcal conjugate vaccines, rather than focusing on populations that were the easiest to reach.

Moreover, the country developed the Juntos conditional cash transfer program to address inequity and alleviate inter-generational transmission of poverty, by improving access to health services and education. The program, aided by strong data management systems, initially focused on low-income households, but later broadened its scope to consider equity along other dimensions, including households with lower women’s literacy and households with limited access to appliances, fuel sources, and public services.12 As conditions for the cash transfer, families were required to send their children to primary school and take them to routine health care visits, and pregnant mothers were required to attend six antenatal care visits. In this manner, Peru addressed a twofold challenge of reducing poverty and other inequities while simultaneously improving uptake of interventions to reduce under-five mortality.

Today, Peru has adopted an equity lens in its response to COVID-19. Peru has given a voucher of 380 soles (~US$111) to those whose job and income have been adversely affected by COVID-19.13 In addition, Peru has approved loans to struggling businesses and spending programs totaling 12 percent of the country’s GDP, one of the largest in the world on a percentage basis.14

Peru’s example of focusing on equity and dismantling barriers to healthcare access are another key attribute of a resilient health system that can deliver essential services during and after times of crisis.5 An equity lens in responding to the current pandemic will ensure that vulnerable groups are accounted for and prioritized in the response, to improve their access to COVID-19 testing and ensure continued access to essential primary care services.

A call to action for the road ahead

At the moment, much energy is being spent on a direct response to the pandemic. At the same time, it is also critical to ensure that health systems maintain delivery of essential services, including key maternal and child health interventions, and that people are able to access these services.

To minimize the disruption to primary care caused during and after health shocks, countries can learn from the strategies we have highlighted.5 A number of these strategies link to domains that are hypothesized as integral to the resilience of health systems, namely integration across sectors and stakeholders, awareness of health threats and available resources, and an ability to adapt to meet population needs.15 While the examples shown here and throughout the EGH platform highlight how to build components of a resilient health system, we look to other work to define the full spectrum.5

Overall, the study of the Exemplars illustrates how to work towards resilient health systems in the midst of responding to COVID-19. Some of the most salient lessons include establishing a national plan for rapid response, leveraging data and community health systems, and accounting for equity; beyond this, the Exemplar country narratives offer both insights and nuances beyond those depicted here.

The challenge of responding to the pandemic while maintaining essential child health services is daunting, but learning from success stories can help smooth the road ahead.


1. Brolin Ribacke KJ, Saulnier DD, Eriksson A, von Schreeb J. Effects of the West Africa Ebola Virus Disease on Health-Care Utilization - A Systematic Review. Front Public Health. 2016;4:222. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5056406/. Accessed May 19, 2020.
2. Regan, L and Chi, Y. The Indirect Health Effects of COVID-19: Disrupted and Suspended Health Services. Center for Global Development; 2020. https://www.cgdev.org/blog/indirect-health-effects-covid-19-disrupted-and-suspended-health-services. Accessed May 12, 2020.
3. Pai, M. AIDS, TB and Malaria Set to Get Deadlier Due to Coronavirus. Forbes; 2020. https://www.forbes.com/sites/madhukarpai/2020/05/11/aids-tb-and-malaria-set-to-get-deadlier-due-to-coronavirus/#23c0ed1ed2fc. Accessed May 12, 2020.
4. Robertson, T, Carter, E, Chou, V, et al. Early estimates of the indirect effects of the Covid-19 pandemic on maternal and child mortality in low-income and middle-income countries: a modelling study. Lancet Global Health, 2020. https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(20)30229-1/fulltext. Accessed May 12, 2020.
5. Nuzzo, J, Meyer, D, Snyder, M, et al. “What makes health systems resilient against infectious disease outbreaks and natural hazards? Results from a scoping review.” BMC Public Health: 2019;19:1310. https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-019-7707-z. Accessed May 12, 2020.
6. Binagwaho, Agnes. We Need Compassionate Leadership Management Based on Evidence to Defeat COVID-19. International Journal of Health Policy and Management; 2020. https://www.ijhpm.com/article_3806_660d22b09ae2bcbbd5587188eb424672.pdf. Accessed May 12, 2020.
7. Lucero-Prisno, D.E., Adebisi, Y.A. & Lin, X. Current efforts and challenges facing responses to 2019-nCoV in Africa. Glob Health Res Policy 5, 21; 2020. https://doi.org/10.1186/s41256-020-00148-1. Accessed May 12, 2020.
8. Edwards, Neil. Rwanda’s successes and challenges in response to COVID-19. Atlantic Council; 2020. https://www.atlanticcouncil.org/blogs/africasource/rwandas-successes-and-challenges-in-response-to-COVID-19/. Accessed May 12, 2020.
9. Tests per thousand since the 100th confirmed case of Covid-19. Our World in Data; 2020. https://ourworldindata.org/grapher/total-tests-per-thousand-since-100th-case?country=ETH+GHA+KEN+MAR+NGA+RWA+ZAF+TUN+UGA. Accessed May 14, 2020.
10. Cash, R. & Patel, V. Has COVID-19 Subverted Global Health? The Lancet; 2020. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31089-8/fulltext#articleInformation. Accessed May 12, 2020.
11. Aldridge, R, Lewer, D, Katikireddi, S, et al. Black, Asian and Minority Ethnic groups in England are at increased risk of death from COVID-19: indirect standardization of NHS mortality data [version 1; peer review: awaiting peer review]. Wellcome Open Research; 2020. https://wellcomeopenresearch.org/articles/5-88/v1. Accessed May 18, 2020.
12. Gerard, F, Imbert, C, and Orkin, K. Social Protection Response to the COVID-19 Crisis: Options for Developing Countries. Economics for Inclusive Prosperity; 2020. https://econfip.org/policy-brief/social-protection-response-to-the-covid-19-crisis-options-for-developing-countries/. Accessed May 21, 2020.
13. Martín Vizcarra announces 380 soles bonus to families that depend on daily jobs. La Republica: 2020. https://larepublica.pe/economia/2020/03/16/martin-vizcarra-anuncia-bono-de-380-soles-a-personas-que-cumplan-trabajos-diarios/. Accessed May 12, 2020.
14. Hackett, D. “Peru’s ‘Toni’ Aggressively Confronts Coronavirus Economic Impact. Coronavirus Today; 2020. https://www.coronavirustoday.com/peruvian-government-took-ambitious-measures-maintain-its-economy-during-covid-19-pandemic. Accessed May 14, 2020.
15. Kruk, ME; Ling, EJ; Bitton, A, et al. “Building resilient health systems: a proposal for a resilience index.” BMJ (Clinical research ed): 2017;357. j2323. ISSN 0959-8138. https://doi.org/10.1136/bmj.j2323. Accessed June 12, 2020.

by Exemplars in Under Five Mortality Reduction Partnership

What can smallpox teach us about how we’ve managed our response to COVID-19?

For many global health decision-makers, COVID-19 has come to symbolize a failure to apply lessons from past experiences with infectious diseases and raised pressing new questions to be addressed ahead of the next pandemic.

I had the honor of being involved in the campaign to eradicate smallpox, a devastating disease whose historical names – pox, speckled monster and red plague – hint more clearly at the pain and suffering it caused hundreds of millions of people over centuries. After a decades-long fight to prevent transmission and inoculate people the world over, the last known case of Variola major was diagnosed in a three-year-old Bangladeshi girl named Rahima Banu, and the last case of Variola minor in October 1977, in Somalia. The World Health Organization, which estimates the disease killed 300 million people in the 20th century alone, declared in 1980 that it was the first – and so far only – human disease to be eradicated globally.

In light of COVID-19, it may be helpful to reflect on some of the lessons we learned during our campaign against smallpox to help address the current pandemic and better prepare for the next one.

1. Develop rigorous surveillance systems and relentlessly seek the truth

While conducting our smallpox eradication work, we constantly referenced a slogan from the American Management Association: “You get what you inspect, not what you expect.” It is important to continuously inspect and evaluate and, to do so, involve as many people as possible.

In India, we enlisted tens of thousands of watch guards to monitor the homes of people who had been infected and vaccinate visitors. We also enlisted thousands of contact tracers. As we built our team, we discovered that contact tracers preferred being called “disease detectives,” which conveyed a greater sense of prestige. We also motivated our team of contact tracers by constantly sharing our findings with the people who have provided the information. If people see the data is being used for good and are asked for their input, they are much more likely to continue sharing information and assist with the eradication effort.

Amid COVID-19, some have argued we should not conduct contact tracing until the number of new cases decreases significantly and the pandemic is “manageable.” However, our experience in India, which has a dauntingly large population, showed it can be done. In May 1973, we were discovering 1,500 new cases of smallpox a day just in Bihar state, which meant 1,500 new contact tracing events, including locating and vaccinating the contacts, and isolating those with symptoms until a we could make a diagnosis – all without computers or smart phones.

An excuse given now [for not conducting contract tracing] is that people won’t answer unknown callers on their phones. However, if people were told they would be receiving a call from a healthcare professional to inform them whether or not their test was positive and to discuss who else to test, and if they received a text message in advance giving the name of that healthcare professional, I believe many people would be eager to participate in contact tracing.

2. Data transparency and public trust are vitally important

To conduct proper surveillance and contact tracing, there must be a high level of trust between the people conducting the program and the public – a level of trust that does not exist today.

Our “disease detectives” had to stress to the public that no one would face repercussions for providing name of contacts. We also used incentives and offered rewards to report cases of smallpox – we started with 10 rupees, then 50 and 100 – and finally up to US$1,000 per case identified. A survey at the time showed that more people in India knew they could receive a reward for identifying someone with smallpox than knew the name of the prime minister, which indicated we had successfully communicated our message.

There has been a great deal of trust lost during this pandemic, including in both politicians and public health officials, some of whom have crossed the line between being public servants to becoming private servants. We must absolutely restore trust in the public health system and our pandemic response efforts. One way to do so is to enlist people who are already trusted by the public.

3. The importance of iteration

During our smallpox campaign, we did not have all the answers – nor do we this time. In India, we constantly adjusted our approaches, even up until the last month. Our Indian surveillance system required about four months to get right, while our contact tracing system needed six months. We are still early in the COVID-19 pandemic and it does not benefit us when our political or public health leaders act or communicate as if we have all the answers. We need to be honest about the fact that as the pandemic unfolds and evolves, our response will too.

4. Public health leaders and practitioners must learn from one another and share experiences

Despite the fact that many nations that have different political and governmental structures, health systems, and levels of economic development, they often still have similar pandemic surveillance and response programs and systems. This creates an opportunity to share experiences and learn from each other.

During smallpox, for example, we found that some healthy competition between Indian states was helpful to spurring progress. We would periodically have meetings between the different states, which were eager to demonstrate their progress and new approaches. We also held similar regional meetings in New Delhi involving Pakistan and Bangladesh so public health leaders could share their strategies and progress.

To this end, one of the most important things we learned in India was also the value of human connection in fighting a pandemic. Allow me to share an anecdote: one day, I was about to get on a plane in Patna and noticed the pilot was drinking beer, so I resolved to start taking the train. On these 12-hour train rides, I often found myself deep in conversation with my Indian counterparts and these conversations became far more important than weekly, hour-long meetings. Now, with meetings being conducted by teleconferencing, we should nevertheless take the time to develop personal relationships that are the key to productive partnerships.

Authored by: Bill Foege, Presidential Distinguished Professor Emeritus of International Health at Emory University, Emory Link to Bio

by Bill Foege

Finding Exemplars Among Those Who Restored Vaccine Confidence: a Pathway for COVID-19 Recovery

These are troubling times. We are in the throes of a hyper-infectious, disabling, and sometimes fatal COVID-19 pandemic, which has sparked a cascade of knock-on effects. Beyond health, efforts to control the spread of the pandemic have caused wider societal disruption, lost schooling, economic disasters, and exacerbated all of the pre-COVID fault lines of inequities, marginalization, and growing distrust in government. In the background of all these individual and collective disruptions, is the persisting uncertainty of: What’s next?

One antidote to the ubiquitous uncertainty around COVID-19, and waning trust in government guidance around the pandemic response, is to rebuild confidence with the public by recognizing their needs beyond COVID-19. Targeted efforts to start to normalize life by slowly reintroducing known and familiar health and development interventions in a hyper-uncertain environment can be a crucial means to rebuild trust and support an eventual post-pandemic recovery.

As the 2020 Goalkeepers Report called out, “we’ve been set back 25 years in 25 weeks.” Catching up on the millions of missed childhood vaccinations, for instance, is one tangible way to start to rebuild public confidence, while using the opportunity to talk with parents about other concerns they may have, including access to a possible COVID-19 vaccine.

Ten years ago, I founded the Vaccine Confidence Project with the ambition of trying to put some metrics around the complicated issue of public sentiments and emotions surrounding vaccines. We knew that these emotions, individually and collectively, were starting to take a toll on vaccine uptake and disrupting immunization programs in some settings. But we did not have a sense of the scope or scale of these disruptions, nor their impacts. Nor did we have a measure of public confidence in vaccines which we could track over time to anticipate changes in confidence before these sentiments influenced vaccine uptake. Such a metric provides an opportunity to understand what is causing drops – or gains – in confidence and inform appropriate interventions to rebuild public trust.

In 2015, we launched the Vaccine Confidence IndexTM initially investigating levels of vaccine confidence and reasons for low confidence in five countries which had a history of managing a vaccine crisis: Georgia, India, Nigeria, Pakistan, and the United Kingdom (UK). Based on this in-depth five-country analysis, we narrowed down the core questions that had the most influence on vaccine acceptance – including whether vaccines are important, safe, effective, and compatible with religious beliefs – to create the VCITM.

In the context of COVID-19, we incorporated COVID-related questions into our surveys and social media monitoring to explore the sentiment and emotions around governments’COVID-19 response more broadly and the public’s anticipated willingness to accept a COVID-19 vaccine.

This month, we published new research in The Lancet, “Global Trends in Vaccine Confidence,” mapping global trends in vaccine confidence across 149 countries between 2015 and 2019, based on VCI and other relevant data from over 284,000 adults (aged 18 years and older). We modelled the relationship between vaccine uptake in each country and demographics (i.e. age, sex, religious beliefs), socioeconomic factors (e.g. income, education), and source of trust (e.g. family, friends, health professionals).

The study showed that overall confidence in both the safety and effectiveness of vaccines was mixed – similar to the COVID-19 vaccine acceptance surveys (Fig 1). In the Lancet study, we found that vaccine confidence – including perceptions of safety, effectiveness, and importance – has fallen between 2015 and 2019 in Afghanistan, Azerbaijan, Indonesia, Nigeria, Pakistan, the Philippines, Serbia, and South Korea. It remains high in India and is growing in many European countries. Brazil showed a trend of slightly declining confidence. Together, these changes point to the need for trust-building to support not only routine vaccination but to also prepare for a potential COVID-19 vaccine across a wide number of countries. 

Surveys conducted by others on the anticipated willingness to accept a COVID-19 vaccine, have been generally consistent with our confidence mapping around vaccines more broadly. This suggests that our research could be a useful tool for identifying and mapping areas that need to be targeted for confidence building interventions in advance of a COVID-19 vaccine.

The Philippines provides some guidance on how this can be achieved. In 2018, a newly reported risk from a dengue vaccine (Dengvaxia), just over a year after its introduction, led to a dramatic drop in public confidence in vaccine safety and effectiveness and impacted the uptake of routine vaccines. The Philippines dropped from being in the top 10 countries with the highest overall vaccine confidence in 2015 (82% of those surveyed strongly agreeing that vaccines safe, 92% important, 81% effective), to ranking no higher than 70th in 2019 (58% those surveyed strongly agreeing that vaccines safe, 70% important, 57% effective). But, concerted efforts by the health authorities to rebuild trust through numerous outreach and engagement activities, including innovative on-line resources and opportunities for conversations – not just around the vaccine, but in the system more broadly – led to a rebuilding of confidence captured by the figures below. The Philippines example reflects a different kind of “exemplar” – an exemplar in recovering from a vaccine confidence crisis and building more resilience to potential future shocks. This renewed trust and confidence building will undoubtedly support the introduction and uptake of an eventual COVID-19 vaccine.

de Figueiredo A, et al. Lancet 2020

Indonesia was another country in our study that witnessed one of the largest falls in public trust worldwide between 2015 and 2019 (absolute difference in perception of safety fell 14% [from 64% to 50%], importance 15% [75% to 60%], effectiveness 12% [59% to 47%]). This was triggered by some Muslim religious leaders who questioned the safety of the measles and rubella (MR) vaccine and issued a fatwa (religious ruling) claiming that the vaccine was haram (forbidden) and contained ingredients derived from pigs, additionally local healers promoted natural alternatives to vaccines. In an effort to build confidence in the vaccine, the government and partners produced videos featuring Muslim leaders persuading parents to vaccinate their children, along with other targeted and nuanced communication efforts, including dialogue between political, health, and religious leaders.

Slides in vaccine confidence reflect changing relationships between the public and government, civil society, and religious authorities and point to the need for confidence building in immunization programs and health systems more broadly. The current COVID context is an opportunity to build trust by addressing public concerns, including and beyond vaccination.

It is vital with new and emerging disease threats such as the COVID-19 pandemic, that we regularly monitor public confidence in health and development interventions to help guide where we need to build trust to optimise uptake of not only life-saving vaccines, but health and development efforts more broadly. Trust will be fundamental if we are to regain the 25 years of progress lost in 25 weeks.

Dr. Heidi J Larson, PhD
Director, The Vaccine Confidence Project
Professor, Dept of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine
Clinical Professor, Dept. Health Metrics Science, University of Washington, Seattle

by Dr. Heidi Larson

Strong health care systems are key to deliver COVID-19 vaccines

During the World Bank’s 2020 Annual Meetings last month, we had our focus firmly on the coronavirus pandemic and how it’s affecting lives and economies around the world. During the Global Health Roundtable we discussed how the world can invest in COVID-19 vaccines as well as strengthen the health systems that deliver primary care.

As we met, there had already been more than 41 million infections and more than 1 million deaths worldwide and COVID-19 infections were on the rise again around the world. The World Bank estimates that the pandemic will push up to 150 million people into extreme poverty by the end of 2021.

Against this urgent backdrop, the roundtable convened more than two dozen government ministers from developing countries, along with heads of UN agencies and international health organizations. Participants agreed that the world’s most pressing immediate priority is to speed the development and delivery of vaccines that can control the spread of COVID-19. And we need to ensure that vaccines are available equitably to all countries – particularly the poorest, which have the least resources to procure and deploy them.

Helping the poorest countries to fight COVID and build resilience

People everywhere deserve access to health protections, and in a pandemic, no one is fully protected until all of us are protected. Everyone around the virtual table agreed on these points, but we also recognized that it will be an enormous challenge to ensure fair and equitable distribution to the countries and people that have few resources.

At the World Bank Group, we’re determined to do all we can. During the meetings, President Malpass highlighted the announcement of a $12 billion financing package – the largest health financing package ever provided by the Bank – to help countries purchase and deploy COVID-19 vaccines, tests, and treatments. In addition, the Bank has COVID-19 emergency operations underway in over 100 countries. Through the Bank, IFC, and MIGA, the World Bank Group expects to make $160 billion available through mid-2021 to help low- and middle-income countries mitigate the pandemic’s health, social, and economic impacts.

Beyond the urgent response to COVID-19, we need to help countries build resilience. Our new Health Emergency Preparedness and Response Trust Fund (HEPRTF), for example, can help developing countries prepare better for disease outbreaks, including when they can’t access our regular financing. The fund just made its first allocation to Sudan, and we’re grateful to our donor partners: Japan for leadership in establishing the fund and the United Kingdom for ongoing technical assistance.

Strengthening health systems and primary care

Delivering vaccines quickly and equitably will demand tremendous collaboration. Roundtable speakers highlighted the need for robust supply chain infrastructure – such as transportation systems, logistics, and ultra-cold freezers – to deliver vaccines and treatments, including by using new digital technologies and information systems. The aviation industry will be particularly important in distribution. As one speaker noted, “vaccines don’t deliver themselves.”

Strengthening primary health care systems has long been central to the World Bank’s work in developing countries. Resilient systems will now be key not only to distributing vaccines, but also to ensuring that other critical services, especially maternal and child health, continue during a pandemic. Early estimates suggest that child mortality could rise by 45% with health services curtailed and less access to food.

Ministers agreed that the COVID-19 response needs to prioritize health and community workers and other high-risk populations, and that it’s vital to ensure vaccines are affordable by addressing payment and access bottlenecks.

They also described the challenge of raising sufficient domestic financing both to tackle the huge cost of fighting the pandemic and to strengthen their health systems for future outbreaks. Through IDA, the World Bank is working to provide critical investments in the poorest countries, as well as technical assistance and public expenditure reviews to help improve spending efficiency. International donor cooperation will also remain important to ensure timely financing and support.

Participants noted that private sector collaboration will be crucial to vaccine manufacturing and delivery in developing countries. IFC, the Bank Group’s private sector arm, has announced a $4 billion global health platform to help ramp up production of COVID-19 vaccines and therapeutics in advanced and developing economies alike – and to ensure that emerging markets can access them. IFC is also working with the vaccine partnership, CEPI, to map vaccine manufacturing capacity and identify bottlenecks.

Debunking misinformation

The roundtable underscored concerns about the spread of misinformation, myths, and skepticism about COVID-19 vaccines and immunization generally. Participants agreed that national and community-based communication campaigns are needed to defuse growing vaccine hesitancy and educate people about protecting themselves and their families from the virus. This includes the use of community and religious leaders as trusted channels to communicate correct information.

Partnering and investing for resilient recovery

Strong partnerships and cooperation, within countries and across regions, are at the heart of effective action to combat the pandemic. The Bank Group is collaborating on an extraordinary scale with a diverse coalition of international partners, including bilateral donors, multilateral development banks, UN agencies, foundations, health organizations, the private sector, and civil society.

For example, we are partnering with the Access to COVID-19 Tools Accelerator (ACT-A), a global collaboration aimed at speeding the development and availability of COVID-19 tests, treatments, and vaccines and we support the COVAX facility led by Gavi, WHO and CEPI. We believe that benefits can be achieved through a pooled risk-sharing mechanism for accessing vaccines and we will continue to collaborate with Gavi and other partners in refining it.

The road to a resilient recovery will demand massive investments across countries, as well as sustained commitment and financial support from the international community. Rebuilding better will require bold reform agendas, with policies that create fiscal space and ensure more and better investment in health and pandemic preparedness. Given the unprecedented blow to countries’ human capital, we must also keep children learning, improve digital access, and speed up job creation.

The World Bank Group stands ready to support developing countries as they fight this crisis and work toward a more resilient and inclusive recovery.

This blog post was originally published on the World Bank’s Investing for Health blog.

by Muhammad Ali Pate

Electronic Immunization Registry in Pakistan - Using Big Data to Achieve pre-COVID-19 Routine Immunization Rates and Address Gender Disparities

By: Subhash Chandir and Danya Arif Siddiqi, Maternal & Child Health Program, IRD Global

The COVID-19 pandemic is rapidly unraveling decades of global progress towards improving public health. Especially impacted are childhood immunization rates. The 2020 Goalkeepers Report[1] revealed that over the course of just 25 weeks, COVID-19 pushed vaccination rates down to levels last seen 25 years ago. The pandemic cut the proportion of children around the world receiving all recommended childhood vaccinations from a record high of 84 percent back down to 70 percent – with immunization rates for children in vulnerable groups, including low-income populations, rural communities and girls, declining most.

Against this backdrop, organizations including WHO, UNICEF, and Gavi[2] have continued to highlight the need for maintaining routine immunizations during the pandemic. Countries around the world have taken innovative steps to maintain immunizations wherever possible, including mass immunization campaigns, extended hours at immunization centers to comply with physical distancing, and conducting immunizations through mobile vaccination centers, drive-through points, and schools.

One tool that has proved particularly effective in helping mitigate the impact of the pandemic is Electronic Immunization Registries (EIRs). Rwanda, Pakistan, Tanzania, and Zambia, among other countries, have successfully leveraged this tool to simultaneously monitor populations in real time, identify drops in immunizations, and the populations most impacted.

Pakistan’s Sindh Province is a powerful example of how EIRs can be leveraged during crises to monitor, maintain, and restore routine immunizations. The Zindagi Mehfooz (Safe Life; ZM) EIR is an Android-based application that allows vaccinators to enroll and track the vaccination status, geographic location, and biodata (e.g., name, sex, and date of birth) of children. ZM EIR was initially funded by the United Nations Innovation Working Group (IWG) in 2011. Over the last 10 years of implementation, ZM has evolved from a simple EIR based on Java code to an Android super-app that addresses both supply and demand side challenges. ZM EIR has not only enabled the collection of real-time data for the monitoring and evaluation of service delivery but also incorporates a host of innovative features to increase immunization uptake and timeliness.

Photo: IRD/Shehzad Noorani. A vaccinator using ZM EIR for locating child record and vaccination at a Basic Health Unit in rural Sindh, Pakistan

The Government of Sindh, supported by Gavi and WHO, scaled up ZM EIR in 2017 to bolster efforts to achieve universal, timely, and equitable immunization coverage in the province. From October 2017 to March 2021, more than 4.6 million children (aged 0–23 months) and more than 1.5 million women (aged 15–49 years) were enrolled, and more than 44 million immunizations have been recorded. Implemented across a province of 48 million people. The rapidly growing dataset generated through ZM has unlocked possibilities to instantly distill information and transform it into actionable insights for targeting pockets of unreached children, monitoring adverse events, and optimizing strategies to increase overall coverage. Within the COVID-19 context, the ZM EIR provides real-time, individual-level immunization data of children, enabling the Government and stakeholders to re-strategize and reprioritize policies for the COVID-19 era using data-driven decision making. 

Like many other countries, Pakistan entered a nation-wide lockdown last year to curb the spread of COVID-19. The lockdown was imposed on March 23, 2020.  Seven weeks later, when the restrictions were lifted, authorities had already measured a decline in the uptake and administration of routine vaccinations amidst movement restrictions, fear of infection, and suspension of mass immunization campaigns. In Sindh province, EIR data showed a 51 percent decline in the daily immunization visits during the lockdown compared to the preceding six months (baseline) with a growing number of children (estimated at 1,246,321) missing immunizations during the one year (March 2020-2021) since the onset of the pandemic. 

EIR data helped quantify the decline in immunizations in real-time and enabled health workers to track how many children were missed, providing their names, locations, and contact details. Data, assembled into defaulter lists, helped authorities trace and target hotspots of missed children and administer catch-up vaccinations through intensive outreach efforts and door-to-door vaccinations. As a result of this concerted effort, health authorities actually surpassed the pre-COVID-19 vaccination rates and increased vaccinations by about 40 percent over the baseline one year after the first lockdown. 

Of the 1,246,321 children who missed immunizations during the first year of the pandemic, 76 percent of these children were eventually, with the help of EIR, vaccinated by the end of March 2021. Similarly, of the 417,553 children in Sindh province who had missed life-saving vaccinations during the initial 7-week national lockdown (March 23-May 10, 2020), 79 percent of these were reached by March 2021 through diligent use of EIR data to proactively track these children.

Our analysis of EIR data shows that the catch-up and recovery of coverage rates has largely been driven through intensive outreach vaccination efforts as opposed to an increase in demand. Pre-COVID-19, fixed clinics accounted for 57 percent of all vaccines administered in the province, while the rest were delivered through outreach activities. One year since the onset of the pandemic, the average daily immunization doses administered through outreach increased by 121 percent above baseline estimates. In contrast, vaccines administered at immunization clinics were still 22 percent below baseline.

Photo: Crude M:F ratio of children enrolled in ZM EIR across Sindh province and Ghotki district, by enrollment (n=4,637,506), Oct 2, 2017 – Mar 31, 2021

While these positive findings from Pakistan illustrate how quickly routine immunization coverage rates can rebound to pre-COVID-19 levels even in LMICs, there is a need to ensure that efforts to recover coverage rates are guided by equity. Preliminary findings indicate that the COVID-19 crisis is deepening and perpetuating existing inequalities in the country. We observed that the lockdown affected routine immunization in rural areas more than in urban areas (54.9 percent decline vs 47.5 percent decline from baseline) and slums had a slightly larger decrease in immunization coverage than non-slum areas (53.8 percent vs 51.3 percent)[3]. Similarly, poor immunization coverage rates among girls seem to be a likely legacy of the pandemic in the absence of adequate remedial measures. For instance, in Sindh province, despite boys’ and girls’ coverage rates being seemingly equal at the provincial level, looking deeper, we see rural districts like Ghotki with areas where as many as 55 percent more boys getting immunized compared to girls. These are alarming findings that illuminate just how the pandemic is exacerbating far-reaching health and socioeconomic inequalities across countries. 

However, the experience of Pakistan demonstrates that with the right tools and strategies, LMICs can rectify routine immunization coverage and immunity gaps and rebound successfully to their pre-COVID-19 coverage rates. The regular collection and use of disaggregated data are vital to our understanding of who is most affected by COVID-19 and why, so that immunization-boosting efforts can be driven through an equity lens. As we recover from the pandemic, countries can adapt and adopt sustainable strategies to help vaccination rates rebound, with a focus on the following:

  • Reaching missed children and closing immunization gaps through tracing and vaccinating
  • Adopting strategies to rebuild trust and confidence in vaccinations, address vaccine hesitancy, mitigate misinformation, and work with local partners and communities on tailored approaches to increase immunization uptake
  • Leveraging real-time, robust data available through digital technologies such as EIRs for evidence-based decision making and tailored strategies to improve immunizations rates

The current COVID-19 crisis has demonstrated the value of EIRs. It should prompt LMICs to invest in this tool and other innovative practices to ensure childhood immunizations continue for all children, no matter the challenges.

[1] www.gatesfoundation.org/.../

[2] www.who.int/.../how-who-is-supporting-ongoing-vaccination-efforts-during-the-covid-19-pandemic

[3] www.ncbi.nlm.nih.gov/.../

by Subhash Chandir

Prioritizing those most at risk in the next push of vaccine rollout

By: Katie Bollbach, Director, U.S. Public Health Accompaniment Unit (U.S. PHAU), Partners In Health; Evrard Nahimana, MD, MMSc-GHD, Africa Regional Policy and Partnerships Advisor, Partners In Health

Last month, every adult in the United States became eligible for COVID-19 vaccination. In light of surging cases and evolving variants here and around the world, it was an important step forward. However, it is just as important to highlight that eligibility does not equal access. Throughout Partner In Health’s (PIH) work throughout the world, we have seen time and time again that simply making health care available without understanding and eliminating barriers to access perpetuates inequitable outcomes. And given the return to “normal” will only be achieved when we the entire globe reaches a 70 to 90 percent vaccination rate, an equity-centered approach is the most direct and just path to reach population immunity, ensuring no one – not in the U.S. and not elsewhere – is left behind. This means that even with open eligibility, epidemiologic evidence and justice both demand we build structures to ensure those most at risk get vaccinated. And learnings – whether they are from successes or failures – must be shared if we want a shot at bringing COVID-19 under control.

In the U.S., based on risk, transmission, and equity, there is a clear case for prioritizing vaccination efforts on older adults, communities of color, and essential workers.

From an epidemiological perspective, vaccination serves two main goals: directly protecting those at highest risk of severe disease outcomes (“risk-based vaccination”) and reducing transmission among those who are most likely to acquire and spread illness (“transmission-based vaccination”). Risk-based data dictate that we must prioritize groups that have experienced higher death and hospitalization rates. In the U.S., this includes those over 65 who have born more than 80% of COVID-19 deaths, and Black, Indigenous, and Latinx adults, who have experienced two- to three-fold higher hospitalization and death rates from COVID-19 than their white counterparts. Frontline essential workers are also at heightened risk of both contracting and transmitting COVID-19 based on the nature of their work, making them a clear priority for vaccination. The intersection of these groups compounds the risk of poor outcomes.

Racial and social injustice reinforce this epidemiological challenge: historically marginalized groups have disproportionately suffered from COVID-19 and therefore deserve priority protection. In particular, the burden of disease born by communities of color is a pervasive feature of U.S. systems. Our institutions are deeply infiltrated by systemic racism that continues to ensure these communities remain underfunded and undervalued. Additionally, they are further excluded by a lack of recognition of demographic and structural barriers. For example, a focus on mass vaccination sites fails to consider transportation challenges, while strict universal age-based prioritization during the initial vaccine rollout excluded many members of high-risk communities of color who have shorter life expectancies due to baseline health inequities. The consequences have been measurable: by May 17, 2021, among 41 reporting states, white people had received at least one COVID-19 vaccine dose at a rate 1.5 times higher than Blacks and 1.4 times higher than non-white Hispanics. Whites also received a higher share of vaccinations as compared to their overall share of cases and deaths.

While these challenges can seem insurmountable, it is both possible and vital to concurrently combat the COVID-19 pandemic and the U.S.’ structural inequities. To do so, vaccination programs should focus on three key areas, each of which is more successful if done in concert with the others.

First: Improving vaccine demand through community engagement

Community engagement is an essential and crosscutting part of vaccine programs built on bidirectional communication and collaborative decision-making informed by a nuanced understanding of community needs. Vaccine programs should work with trusted partners who are representative of the communities they serve and who are empowered to openly communicate needs. In the U.S. and internationally, many communities and partners have been hosting informational events (town halls, door-to-door outreach, etc.) aimed primarily at addressing vaccine hesitancy. However, engagement must go further: community members must be able to influence and inform policies and programs, to speak and to be heard, and to make informed decisions regarding vaccination. 

  • Exemplar: in Chicago, bolstered by the Chicagoland Vaccine Partnership – a community coalition formed to aid the push for equitable vaccination – the city launched an initiative to dedicate vaccine resources to 15 vulnerable neighborhoods. As part of the Partnership, PIH developed a training program to equip local leaders with resources for engaging community members in dialogue, ensuring relevant vaccine information reaches everyone, including public health planners. Thus far, over 113 organizations and 266 members have become a part of the initiative, a diverse and adaptive community network with broad health and social aims and a mandate for long-term system improvement that will last beyond the pandemic.

Second: Ensuring adequate vaccine supply through equitable resource allocation and site operations

In order to achieve coverage for all, but especially disadvantaged people who are most in need, we must ensure priority communities have an adequate supply of vaccines when and where they are needed. As such, vaccination programs must collect disaggregated coverage data to grasp the full extent of the local landscape. But many communities continue to lack this information. As of May 19, 2021, the CDC reported that race/ethnicity was known for only 56.1% of those who had received at least one vaccine dose.. To understand disparities in access, innovate and operationalize “last mile” strategies, and monitor progress toward outcomes, this data must be available so vaccine allocation and distribution can break down common barriers to access: limited hours of operation, complex scheduling and registration systems, inaccessible sites, and language barriers. Equity demands that instead of blanket tactics like mass vaccination, which may be less resource intensive but are also less effective in reaching historically oppressed communities, we invest in strategies that reach those most in need.

  • Exemplar: in Ohio, using collaborative spatial mapping, community, government, and academic partners comprehensively document and visualize available resources and vaccination needs of communities most vulnerable to COVID-19. Through census tract-level analysis, the team identifies gaps in coverage and insufficiencies in public transportation. Four major health systems and two local health departments are now using recommendations based on this mapping to place mobile and pop-up clinics. The mapping will also inform the deployment of Community Health Workers (CHWs) to provide vaccine education, assist clients to locate and register for appointments, and furnish transportation assistance.

Third: Leveraging this opportunity to invest in long-term public health systems

COVID-19 is only one disease among many that disproportionately disadvantage certain communities. The programs we put in place now are foundational to functional, effective, and equitable health systems beyond the pandemic. This longer-term work includes standing up a community health workforce that is critical to the recovery and rebuilding of our public health systems. In particular, we must invest in care resource coordination, taking a lesson from global community health playbooks and connecting those in need with care and support programs that address social determinants of health. We now have an opportunity, with vaccination, to link individuals into such support structures that can improve pandemic response as well as community well-being, as we move forward.

  • Exemplar: in Rwanda, CHWs are trusted community members who bring access to health care, social supports, and information to those hardest to reach: the elderly and immobile, communities in remote areas, and high-risk groups. CHWs will continue to play an important role in the COVID-19 vaccine rollout, building upon the nation’s workforce and supply chain investments over the past two decades to drive demand and promote both a smooth rollout and a high uptake when supply is more widely available. Already, CHWs are being deployed to identify, support, and facilitate vaccine access for priority populations including those with underlying medical conditions. While in many places in the U.S. CHWs are contributing to local COVID-19 response, we can learn from places like Rwanda how to best execute larger scale community-driven approaches to achieving coverage and equity.

If we work together to understand and increase vaccine demand, to allocate resources equitably, to break down barriers to access, and to invest in the long-term health of our communities, we can stop COVID-19 and, at the same time, reduce health injustice. With a concerted and collaborative effort and a strong commitment to justice, we can protect ourselves and one another, save lives, and build a more sustainable future that creates access – not just eligibility – for all.

View our full white paper, “Eligibility Is Not Access: Prioritizing those most at risk in the next push of vaccine rollout” to learn more about our efforts to support equitable access across our partner sites.

About Partners In Health and the U.S. Public Health Accompaniment Unit

Partners In Health is a social justice organization that responds to the moral imperative to provide high-quality health care globally to those who need it most. In May 2020, PIH launched the United States Public Health Accompaniment Unit (USPHAU) to help states, cities, and communities rapidly scale up a more equitable and comprehensive public health response to COVID-19. Building on PIH’s 30-plus year track record of fighting epidemics and strengthening health systems around the world, the USPHAU is working shoulder-to-shoulder with partners around the country to advise, implement, and troubleshoot new strategies and initiatives to combat COVID-19, while preparing for the recovery and rebuild efforts that we know must urgently follow. The USPHAU is committed to building and strengthening resilient and responsive health systems in the U.S. that are rooted in access and equity for all.

More information: Partners In Health’s U.S. Public Health Accompaniment Unit | Partners In Health (www.pih.org)

by Katie Bollbach

Fighting Future Pandemics… Today

By: Dr. Saadiq Kariem, Chairperson, Director General, Specialist & Emergency Services in the Western Cape Department of Health

There is an old South African proverb I have come to enjoy: the best time to plant a tree is 20 years ago; the next best time is now. During COVID-19, these words have become emblematic. Perhaps even prophetic.

The pandemic that shook our planet in 2020 came slightly late to South Africa but made up for its tardiness in intensity. The Western Cape became the continent’s first epicenter of COVID-19, with the first case being identified on March 11 having turned into 4367 deaths just six months later.

In South Africa, and particularly the Western Cape, we have extensive experience fighting endemic diseases like TB or HIV. But this was not the same. By December, when hospitals were topped out at 100 percent capacity, we found ourselves staring at an incoming second wave, barreling towards us aggressively and threatening to vanquish systems that were already at the brink.

In public health, certain tools are proven. Good primary care and hospital systems allow us to respond quickly and effectively. Good data helps decision makers allocate resources for impact, triaging them strategically to thwart a crisis. And demand-driven innovation accelerates the pace in which solutions come to life. But to fight COVID, we would need more. We did not know much about this disease but like the rest of the world, we were certain that we were before a new kind of fight. Facing it would take amplifying every tool we had and leading with unrelenting will. It would also take collaborating in ways that had we had not before.

Our first challenge with COVID-19 was that it required us to test large swaths of the population. But as that was the entire world’s challenge, supply chains became constrained and for South Africa, this meant we would not have access to the tests we desperately needed. But we did have something homegrown that could help us – and that was data. So, we used it to create real time dashboards that would tell us who had symptoms and comorbidities. Some dashboards were public facing, and others were internal, but all of them helped inform a strategy of rationalized testing, which – as unpopular as we knew it would be, given it wouldn’t allow all to be tested – allowed us to start saving lives by prioritizing scarce testing resources for those with diabetes and hypertension.

With one hurdle cleared, we quickly saw another one as processing the crushing volume of tests began strangling our labs. So, we looked to universities and the private sector. We even enlisted the help of agricultural labs. They had no experience with human diagnostics, but they did have something we might be able to use – equipment that could be adapted for COVID-19 assays. We created a simplified online checklist to facilitate rapid accreditation of these labs within one week – a process that typically takes several months. Within weeks of enlisting the help of these most unusual suspects, our test processing capacity increased by 18 percent.

Once we knew the rates of infection for at-risk populations, we could model and prepare for the inevitable. Hospital beds would need to be available to treat a percentage of those we knew would become gravely ill. But all our hospitals together could not accommodate the flow of patients that was imminent. So, we created a field hospital that would. The Cape Town Convention Center was retrofitted with beds, each of them with corresponding electricity, water, oxygen, pharmacies, and everything required by a functioning hospital and all its clinical disciplines. In 14 days, we were ready to treat 200 patients.

With each step forward we took, we had to continue feeding the logistical operation we had just created just behind it. Testing had to continue, test processing had to continue, hospital management had to continue. And with that, we had to evolve our systems simultaneously.

Tracking the available bulk oxygen supply to see where the deficits would likely cause treatment gaps, tracking healthcare workers’ own health to manage personnel shortages looming on the horizon, tracking data correlated to alcohol restrictions and lockdowns to see where points of alleviation would allow us to bring in more COVID-19 patients, tracking available beds, repurposed beds, admissions for non-COVID issues, and were the only service in South Africa to track the trauma admission before, during and after lockdown, to help determine how quarantine was affecting violence, domestic and otherwise.

Our multiple dashboards acted like sophisticated air traffic control tower, showing us what was around the corner, what was coming at us from all sides, and what was further ahead. They allowed our managerial staff to act with precision, opening call centers where non-medical but trained personnel would reach out to at-risk adults to check in on their daily wellbeing and screen for symptoms. They allowed us to source oxygen from neighboring provinces that had a surplus before we ever ran out. And they allowed us to manage against the increasing burden of COVID-19, the de-escalation of normal services, and the mitigation of medical interventions and surgery.

Our data-led strategy was critical to our response and propped up our entire operation. It also allowed us to effectively inform the general public and in doing so, alleviate the general anxiety that befell Western Cape, but also, promote the importance of non-pharmaceutical interventions like social distancing, mask wearing and the washing and sanitizing of hands.
As we pressed on, we captured the attention of those who started looking to tus for guidance on their own province’s COVID-19 battle. We invited them into our circle, so they could learn from us, but also, so we could keep learning ourselves. We knew this was not over.

When our numbers began coming down, we had earned political will, legal will and perfected our technical skill to partner with almost all major private hospital networks across the country, national groups that at times used our public hospitals to treat their patients. Regulatory and financial frameworks were negotiated, and MOUs came to be, with the public and private sector working in tandem towards a common goal, improving our joint stewardship practices and sharing our insights along the way.

Even though the pandemic is still very much here, we have learned quite a bit from the COVID-19 experience, warranting an assessment of our landscape. We are looking at our newly formed partnerships to see if our collaboration frameworks can prop up future universal health coverage or provide a contracting basis for strategic purchasing across our entire healthcare system. We are also working with new partners to see how we can leverage supply chains to reduce our collective costs. And we are continue improving our data to better understand crises, and in doing so, reduce their negative impact.

This education, while invaluable, has been hard won. COVID-19 has placed an enormous toll on all of us and the enormity of what has happened here in the Western Cape and around the world continues to weigh on us. It is why we took a piece of our tradition with truth and reconciliation and entered a deliberate healing process. Since March 4, 2021, our Department of Health has been holding reflective sessions in which we share our personal experience with the trauma that we too had been experiencing, honor colleagues that have died, and think of the ones who are ill. Responding to a crisis of this magnitude rarely gives you the opportunity to sit back and reflect. When everything – or certainly the most important thing – is on the line, time becomes your most valuable commodity and often, the one that is most scarce.

When the pandemic is finally behind us, I presume we will look back at this time and have much to say about it. But today, even as I know that 20 years ago was the best time to have prepared for this precarious moment, I am consoled by the fact that we took the next best time. That has been my biggest lesson, and perhaps my silver lining. The work we have done and will continue to do now will help us be ready when the next global crisis comes our way.

by Saadiq Kariem

Implementing digital health to transform primary health care in LMICs

In 2021, McKinsey & Company partnered with Exemplars in Global Health to research the success factors that can drive effective, widescale implementation of digital tools across health care systems in LMICs. The findings resulted in potential pathways to drive the implementation of digital health care in a manner that has the potential to transform primary health.

Read the full paper here: Unlocking digital healthcare in lower- and middle-income countries.

The COVID-19 pandemic has both highlighted and exacerbated the gaps in access to health care around the world, but particularly in lower- and middle-income countries (LMICs). Prior to the pandemic, almost a third of the population in LMICs already lived more than two hours away from essential health services, and the ratio of health care workers to population was typically well below the minimum recommended by the World Health Organization. But in the last year, the loss of health care workers to COVID-19 and the disruption of transport systems due to lockdowns have likely made that access – or lack thereof – even worse.

However, during this difficult time, a silver lining has surfaced to benefit those most in need: the growth in digital tools. Digital technologies, like those highlighted in Exemplars in Global Health case studies, have unmatched potential not only to improve countries’ responses to infectious diseases, but to strengthen their primary care systems. And with companies reporting an unprecedented acceleration in the adoption of digital technology, digital health tools used to address COVID-19 may pave the way for a transformation in primary health care systems well beyond the pandemic.

As with all things COVID-19, the world has seen firsthand that merely discovering a solution – like a vaccine – only begins to solve a problem. In the equation of Research, Development and Implementation (RD&I), implementation is often the most beleaguered of steps. For digital health tools, the very same applies. Merely discovering digital tools and technologies only begins to solve a problem. For them to be truly impactful, they must be enabled within a national health ecosystem that has effective national governance, sustainable financing, a strong regulatory environment, health data interoperability, digital readiness, and multi-sector engagement.

Click here to view larger image.

Of all of these, governance and digital readiness are the essential differentiators, if a country is to experience implementation success.

Countries with a government-led digital health effort and those with strong digital foundations tend to prioritize digital health strategies through data exchange and interoperability at national level. They also tend to intervene directly by creating dedicated teams responsible and accountable for implementing digital health strategies, ensuring capability building to support. And finally, they tend to develop mechanisms for sustainable financing of the digital health infrastructure, beyond donor funding.

Our research found that in Rwanda, a country that, thanks to its strong political will and partnerships, is becoming a digital health success story. Through its national growth strategy and its 90 percent universal health care coverage, the Rwandan government produced an environment that was ripe for improving its digital readiness. By ensuring over 90 percent of the population had access to broadband, Rwanda was then able to focus its digital capabilities on HCWs to scale telehealth, and the adoption of drone delivery for essential medical products.

We also saw this in India, where a flourishing digital health private sector, coupled with strong political will, has greatly contributed to a more powerful national health ecosystem. The country’s flourishing digital health start-up landscape is buoyed by investments (between 2014 and 2018, health-tech start-ups raised a total of US$504 million), and strengthened by the government’s commitments to improving a digital infrastructure that enables interoperability.

And in Ethiopia, we saw the country accelerate its digital journey, leapfrogging some of its LMIC peers, thanks to strong government leadership and co-creation and co-funding partnerships with donors. The country prioritized its digital health strategy, adopted best practices in IT, and fostered a culture of data use at all levels of the health system. It then invested in end-user training and created the Digital Health Innovation and Learning Center to foster innovation.

Implementation success can lead to expanded health care coverage, allowing broader reach of health care delivery through technological solutions. Whether it is through triaging at the right levels to ensure equitable care, or greater and faster patient access to health information, or more effective disease prevention and treatment, or using telemedicine for remote monitoring and diagnosis, well-implemented digital health tools can expand coverage for all.

Where there is a commitment to implementation, there tends to exist better quality of care. By supporting improved data sharing and analytics for evidence-based guidelines to improve outcomes, allowing health care workers to focus more time on patients, or even educating both through e-learning platforms, countries are improving the kind of care available to those who did not have it in the first place.

And finally, by enabling earlier risk-detection through predictive analytics and enabling long-term cost management, strong implementation can have a lasting impact on efficiency. By allowing increased division of labor and improved utilization through centralized, coordinated, real-time management of patients, supplies, and workflows, it can optimize resources, enabling lasting change.

If necessity is the mother of invention, this last year has generated enormous demand for innovative solutions that have saved lives. Through effective implementation of digital tools, many countries have paved the way for impactful innovations that will endure beyond COVID-19.

by Contributors

How Did Senegal Mitigate the Impact of COVID-19 on Routine Childhood Immunizations?

By: Dr. Moussa Sarr: PI & Head of Development and Cooperation Group and Mr. Daouda Gueye: Project Manager – The Institute for Health Research, Epidemiological Surveillance and Training (IRESSEF)

Over the last 20 years, Senegal has made significant investments in improving child health outcomes – cutting under-five mortality by more than half. COVID-19 has threatened to undermine that progress, including progress on routine childhood immunization. Senegal’s creative and evolving response to this challenge provides lessons for how health systems can respond to current and future health crises.

During crises, health systems face two simultaneous challenges: they must respond to the unanticipated crisis (in this case, COVID-19), while also maintaining the delivery of essential health services, including immunization services.

In the context of the COVID-19 pandemic, health leaders around the world met these challenges by implementing Infection Prevention Control protocols, while adapting the delivery of essential healthcare to maximize safety and confidence for patients and providers alike. These adaptations took the form of conducting childhood vaccine services outside or in a separate tented area from the rest of the health facility; reducing patient loads per hour to ensure sufficient time for sanitation and ventilation; and conducting drive-through or walk-up services in open spaces with clearly marked distancing areas.

Yet amid these adaptations, lockdowns still interrupted vaccine supplies and distribution. PPE shortages left health workers unprotected, and misinformation tempered demand for health services. As a result, the World Health Organization estimates 80 million children under the age of one were affected by disruptions to immunization services by May 2020.

These challenges held true in Senegal as well. Interviews with health leaders in Senegal revealed that COVID-19 impacted both the supply of and demand for routine childhood vaccinations.

Despite Senegal’s history of high acceptance and uptake of childhood vaccines and strong trust in community health workers, fear of infection and misinformation reduced demand for immunization services dramatically. “Patients had deserted the health centers for fear of being infected…we could stay for a week without receiving a patient,” said one health provider.

In mid-March 2020, the government of Senegal prohibited large public gatherings and suspended all in-person instruction at schools in response to the pandemic. This meant that outreach-based services and community mobilization activities such as those conducted by the Badiènou Gokh, community health workers who promote vaccination through music and in-person communication campaigns, were postponed. And since schools are typically the main platform for HPV vaccination in Senegal, HPV vaccinations were interrupted.

Senegal’s efforts to address these challenges demonstrates how countries can develop more resilient immunization delivery systems. The key is quickly recognizing the emerging challenges and leveraging existing programmatic strengths to adapt accordingly.

For example, clinic staff use existing childhood immunization records to identify children who are missing vaccinations and send text message reminders to their families. And, as community mobilization resumes, Senegal is leveraging its extensive and trusted cadre of community health workers, for both outreach and service delivery, including going home-to-home to provide vaccination visits. Moreover, as clinics and outreach programs restart immunization activities, they are providing greater flexibility (in terms of location and timing) for scheduling catch-up doses.

Senegal has also launched media campaigns disseminated through local TV channels and radio spots to remind the public of the importance of childhood immunizations and to correct misinformation.

These insights and others are included in preprint paper currently under peer review. The paper examines how three countries identified as Exemplars—Liberia, Nepal, and Senegal—responded to the pandemic, and the findings provide guidance on how leaders can adapt and adopt these countries’ successful strategies to strengthen the equitable and sustainable delivery of childhood immunizations.

Our key findings on how countries can mitigate COVID-19’s effects on routine immunization include:

  • Prioritizing continued services with strengthened infection prevention control
  • Identifying alternative locations and approaches to providing vaccine services (e.g., conducting door-to-door vaccination if facility-based services are not possible)
  • Engaging in effective communications and mobilization activities, especially to offset misinformation about COVID-19 and vaccines
  • Setting up systems and strategies for reaching children who missed doses amid periods of disruption
  • Conducting catch-up campaigns as soon as COVID-19 transmission is under control

We recognize that COVID-19’s impact on routine immunization services varies across settings, and that there is no one-size-fits-all implementation strategy that will solve this challenge for all geographies. At the same time, Senegal and other countries, now one year into the pandemic, have demonstrated lessons for how countries can maintain routine immunization services and develop strategies for more resilient health systems in the future.

For the latest WHO guidance on immunization activities during COVID-19 click here.

by Moussa Sarr

Mitigating Maternal and Child Health disruptions during the COVID-19 pandemic: Lessons from Rwanda, Bangladesh, and Uganda

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


1. WHO Reported Estimates of Coverage http://apps.who.int/immunization_monitoring/globalsummary/timeseries/tscoveragebcg.html 

2. Last Mile Health Interview (BRAC)

3. http://www.who.int/pmnch/knowledge/publications/bangladesh.pdf 

by Gloria Ikilezi