How Rwanda's and Bangladesh's long-term investments in resilient health systems paid off during COVID

Strengthening their health systems in the years before COVID-19 allowed Rwanda and Bangladesh to respond efficiently and effectively during the pandemic, and also resulted in an 'everyday resilience' that continues to boost the delivery of care and health outcomes, according to new research.

The study, recently published by Exemplars in Global Health research partner University of Global Health Equity (UGHE) in the Journal of Global Health, explored how countries have strengthened the resilience of their health systems over the years.

Specifically, the researchers examined how Rwanda and Bangladesh developed resilient health systems that maintained the delivery of critical interventions to prevent under-five mortality with minimal disruptions during the pandemic. Immunizations and health facility deliveries in both countries faced only minor disruptions in the pandemic's early stages. Within a few months, the provision of essential health care had nearly returned to pre-pandemic levels in both nations.

To learn more about the findings, Exemplars News spoke with Dr. Alemayehu Amberbir, chair of the Center for Population Health at UGHE, about what they learned about the importance of health systems resilience and how countries can build resilience and improve their health outcomes both during and outside of health crises.

You and your colleagues looked at health system resilience in Rwanda and Bangladesh and how those countries maintained interventions to support child health and reduce under-five mortality during the pandemic. Why look at those countries and why focus on resilience?

Dr. Amberbir: Our hypothesis was that countries like Rwanda and Bangladesh, which have been identified as 'Exemplars' in reducing under-five mortality, would maintain essential health services during the pandemic. Essentially, we posited that the same qualities that made these countries high performers when it comes to under-five mortality would make them resilient, high performers during a crisis.

Resilience is important because we know that health system shocks and crises are guaranteed. So, we need to be prepared for them. Our research showed that resilience during a crisis is built upon 'everyday resilience.' What we now understand is that less resilient countries have poorer health outcomes every day and had poorer outcomes during the pandemic.

You found that investments both countries made to support 'everyday resilience' long before the pandemic were key in helping both Rwanda and Bangladesh’s health systems adapt during COVID. What is 'everyday resilience?'

Dr. Amberbir: When we talk about resilience in the global health context, we are referring to long-term investments in health systems that are meant to provide equitable, quality care, whether during ordinary times or during crisis. 'Everyday resilience' is about investing in these most fundamental building blocks of a health system, which include at a macro-level: leadership, governance and accountability, and a culture of data use.

Investments in these building blocks long before the pandemic strengthen routine care every day and allow a health system to adapt efficiently and effectively during a crisis. For example, we can see strong leadership and governance in Bangladesh in the high levels of collaboration between government ministries during the pandemic. In both countries community health workers helped bridge care and minimize disruptions.

And in both countries, a culture of data availability and use allowed health leaders to track coverage of health care interventions such as vaccinations and make well-informed decisions. In Rwanda, a centralized data reporting system brought all governmental, non-governmental, and private facility reports into the health management information system. In Bangladesh, the government used data to track fluctuations in the coverage of evidence-based interventions and respond accordingly.

You cite cultures of collaboration and accountability as key factors of resilience in both countries. Why are these important and how can communities and governments nurture cultures of collaboration and accountability?

Dr. Amberbir: Collaboration and accountability are important for a number of reasons. Accountability to populations builds trust, which is critical during times of crisis. The higher the trust in the health system, the more likely a community is to listen to guidance from health providers. The higher the trust level, the higher the resilience of the health system and the lower the death rate during a crisis and the lower the disruptions to care. Conversely, research has shown that countries with lower trust within society tend to be less resilient and had higher caseloads and deaths during the pandemic.

Collaboration increases efficiency and reduces the likelihood of duplication. This is especially important during a crisis.

Developing cultures of collaboration and accountability takes time, commitment, and political will. There is no single or simple path to achieving it. The design of a health system influences this. Regular and clear communication up and down the chain of command is critical. Both Rwanda and Bangladesh offer examples of how health leaders are building trust and accountability from the grassroots, community level starting with community health workers.

How did long-standing investments in CHWs support resilience during the pandemic?

Dr. Amberbir: In both Rwanda and Bangladesh the strong community health systems depend on CHWs. During the pandemic and during ordinary times CHWs closely monitor and respond to community needs.

In Rwanda, CHWs were trained to provide services to help bridge gaps during the pandemic. When it was more difficult for patients to reach health care facilities during lockdowns, Rwandan CHWs were able to coordinate care and minimize disruptions. We see this in other countries too. For example, in Ethiopia, a strong community health strategy with a clear chain of command helped to ensure access to essential health services.

How did both countries’ use of investments in data support health system resilience and response during the pandemic?

Dr. Amberbir: Both countries invested in and built information systems to ensure the availability of quality data at all levels of the health system long before the pandemic.

Before the pandemic, for example, Rwanda had a centralized data reporting system using its HMIS platform and rapid SMS, which facilitated data use to identify and challenges and drive decisions.

Both Bangladesh and Rwanda leveraged this culture of data and data use for monitoring and decision-making during COVID. In fact, we noted that they ramped up the use of data during the pandemic. They used data, including at the community and facility level, to identify vulnerable populations and prioritize them for interventions. They used data for the training and monitoring of CHWs.

UGHE is closely involved in both researching and supporting the implementation of health system resilience. Can you talk more about the UGHE course that focuses on this topic?

Dr. Amberbir: To enhance the impact and uptake of the findings and transferable lessons from our health system resilience work, we developed a course for health system leaders and implementers from countries that did not recover as quickly or experienced more severe declines before recovery during the COVID-19 pandemic. These countries are interested in capacity building and learning from nations with more resilient health systems during the pandemic.

Over the past 18 months, we have worked with teams from two francophone African countries, Guinea and Chad, providing training and mentorship on how to identify and address gaps in their health systems' resilience. This includes strengthening existing strategies or introducing new ones tailored to their specific contexts. The training also disseminates the methodological approach, enabling health system leaders in other countries to apply it to advance their own programs.

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