Maintaining child health interventions in Rwanda during COVID

Context on the COVID-19 Pandemic

In many countries around the world, the COVID-19 pandemic and responses to it have disrupted the provision of essential health services (EHS)—including those critical for child health.

According to WHO Global pulse surveys in 2020 and 2021, more than 90 percent of countries reported some form of EHS disruption, particularly to primary-care services.¹

Countries attributed the EHS disruption they experienced during the COVID-19 pandemic to a variety of demand-side and supply-side factors. The significance of each of these factors varies depending on country and context: not every country we studied experienced the same disruptions in the same ways.

To understand Rwanda’s experience with disruption of evidence-based interventions (EBIs) known to reduce under-five mortality (U5M) during the COVID-19 pandemic, this study builds on earlier efforts to understand the strategies Rwanda used to reduce under-five mortality (U5M). It asks:

• How have EBIs to reduce U5M been disrupted or maintained in Rwanda during the COVID-19 pandemic?
• What strategies have Rwandan officials and health care providers used to prevent and respond to these disruptions?
• How have Rwanda’s previous efforts to reduce U5M affected its ability to weather EBI disruptions and maintain progress on implementing interventions known to improve health outcomes for children under five during the pandemic emergency?

Because Rwanda had already built a resilient health care system prior to the pandemic that could rapidly learn from and adapt to changing circumstances and system shocks, the country was better prepared to respond to the COVID-19 emergency and to prevent and mitigate the pandemic’s impact on the delivery of evidence-based interventions for child health.

Maintaining Evidence-based Interventions in Rwanda During the COVID-19 Pandemic

Rwanda did experience barriers to health service delivery during the early phase of the COVID-19 pandemic. However, because the country already had a resilient, adaptable health care system in place that could learn from past experiences and adapt and react rapidly to changing circumstances, it was prepared to bounce back from unexpected shocks. To surmount these new barriers, health officials continued to implement the strategies they were already using to reduce U5M.

KEY INSIGHTS

The system Rwanda built prior to the COVID-19 pandemic to respond to the everyday health needs of the Rwandan population and reduce U5M between 2000 and 2015 prepared the country to react quickly and comprehensively to the pandemic emergency, as well as to prevent and mitigate the impact of COVID-19 on the delivery of EBIs for reducing U5M.

Rwanda’s efforts to strengthen its primary-care system and coordinate its partners accordingly reduced under-five mortality in Rwanda by 67 percent between 2000 and 2015.

Five primary drivers contributed to Rwanda’s remarkable success in reducing U5M:

• Commitment to “horizontal” health system improvements

A crucial element of Rwanda’s progress against U5M was its consistent preference for policies and expenditures that would strengthen the overall primary-care system—instead of vertical, disease-specific interventions often favored by donors and foreign partners.

• Government-led coordination with donors and partners

Rwanda insisted that donors and nongovernmental organizations (NGOs) align their actions and expenditures with the country’s vision of a strong, unified, and national health system. A culture of including partners in the planning and design of health strategies facilitated this strong coordination.

• Strong community-based health services and facilities

By investing in its community health worker (CHW) program—and in the construction and renovation of health facilities in remote rural areas—the national government developed the human and infrastructural resources needed to serve its population and gather necessary data.

• Emphasis on evidence-based decision-making

The government invested heavily in building institutional capacities to generate and interpret data and other forms of empirical evidence. This strong data culture is sustained through performance-based financing and contracts, with negative consequences for low-quality or limited data.

• Commitment to decentralization and local empowerment

To maximize accountability, the national government devolved implementation capacity and responsibility to the district and local levels. The emphasis on local accountability has been accompanied by a commensurate expansion of local implementation authority.

The COVID-19 pandemic and the interventions put in place to control it did disrupt EBI maintenance between March- and May 2020.

Starting in March 2020, Rwanda began to adapt and implement the comprehensive epidemic preparedness measures it developed from its long experience with Ebola outbreaks. In part as a result, between mid-March and early May 2020 in particular, health care workers and officials in Rwanda reported transient disruptions in health service delivery.² HMIS data shows that vaccine coverage, outpatient department (OPD) consultations for non-severe illnesses, antenatal care (ANC) visits, facility-based deliveries (FBDs), growth monitoring, and appointments for non-communicable diseases (NCDs) were especially affected.

For instance, HMIS vaccination data shows missed doses of immunizations throughout the year. The above analysis from the Institute for Health Metrics and Evaluation shows the number of children who missed DTP3 doses each month in the different regions of Rwanda. (The expected number of missed doses is based on prior levels of missed doses for each month before the pandemic in 2019, extrapolated out to the pandemic months in 2020.) Overall, disruptions fluctuated by month and by region, but in general, immunization rates declined between March and June and began to recover from July through December. In addition, the data show periods when there were efforts to catch up on missed doses: for example, just after the first lockdown from March 21 to April 30, 2020, television and radio spots called on mothers to seek vaccines for children who had fallen behind on their shots. Likewise, a Maternal and Child Health (MCH) campaign in June 2020 targeted children for HPV vaccines. The graphs above show sharp reductions in the number of children missing doses in the months following these and other efforts.

The heat map above shows the cumulative disruption ratio for DTP3 over March through December 2020 for each district in Rwanda: the largest disruptions occurred in the Bugesera district, while the smallest disruptions occurred in the Rusizi district. (For context, the cumulative disruption ratio here refers to the ratio of the total number of doses from March through December 2020 compared to the same time period in 2019, normalized by the ratio of total doses from January through February 2020 compared to that time period in 2019.)

What did the key informants (KIs) say caused most of these disruptions?

• Lockdowns and movement restrictions resulted in patients missing scheduled appointments and delaying consultations for nonemergency health issues. Key community outreach events, such as the MCH Week, were initially cancelled, then rescheduled for after the lockdowns and adapted for door-to-door engagement.
• Staff shortages, heavy workloads, and the redeployment of health workers from their regular jobs to COVID-19 response interrupted delivery of health services.
• Fear of contracting COVID-19 among community members prompted many to avoid health care facilities and prevent community health workers (CHWs) from entering their homes.

At the same time, it is likely that widespread infection-control and social-distancing measures aimed at containing the spread of COVID-19 (such as school closures) also limited the spread of other infectious diseases, in turn decreasing demand for some evidence-based interventions.

The same interventions that Rwanda has utilized to reduce U5M also helped mitigate and respond to COVID-related drops in coverage of EBIs for reducing U5M.

Rwanda’s preexisting strong primary health care systems and accountable leadership made EBI delivery a priority—even as officials implemented necessary pandemic-control measures, such as lockdowns, that had the potential to undermine the delivery of those services. As a result, according to interviews with KIs, EBI delivery soon returned to normal.

Most of the strategies Rwanda implemented to prevent or respond to COVID-related drops in EBI coverage had been in place before the pandemic and were adapted to suit their new context. KIs report that these COVID interventions fall into three main categories—human resources for health, infrastructure, and policy/leadership—and include:

Human resources for health

• Leveraging community-based health care delivery

CHWs continued to identify children who missed vaccines and organize community outreach programs to encourage health-seeking behaviors. They also conducted house-to-house growth monitoring, deworming, and vitamin distribution.

• Mentorship and supervision

Most mentorship and supervision activities for health and community workers moved to online platforms.

• Strengthening human resources

Rwanda recruited new staff and volunteers and leveraged staff support from partners to prevent the diversion of health care providers from their normal activities.

Infrastructure

• Data use

The use of data for decision-making and learning is a key strength of Rwanda’s health system. Health care providers and officials continued to use data at the lower levels of care for early identification of disruptions to evidence-based interventions. They also continued to use existing electronic registers, implemented in September 2019, to keep track of children who missed necessary vaccinations.

• Digital platforms, telemedicine, and e-health

Health officials adapted existing WhatsApp group platforms for data managers, community health workers, and supervisors, for the purposes of data audit, feedback, discussion, and monitoring and evaluation. They also coordinated these activities using digital tools such as WebEx and Zoom.

• Transportation

Health officials ensured that transportation was provided to patients and health care providers during periods of lockdown and travel restrictions.

• Leveraging existing systems

Rwanda had already developed epidemic preparedness systems that it deployed in response to outbreaks of pandemic influenza (H1N1). Officials and health workers adapted these systems for the COVID-19 context.

• Strengthening the supply chain

Rwanda has a strong supply chain system that helped prevent stockouts of essential supplies and medicines and ensured the continuity of EBIs during the COVID-19 pandemic.

Policy/Leadership

• Community engagement and education

Officials used radio and public television to spread information, organize community outreach and engagement activities, and integrate COVID-19 risk communication in all existing community education interventions.

• Policies supporting EBI maintenance

Even during the pandemic emergency, Rwandan health policy continued to prioritize EBIs. For instance, ongoing Imihigo leadership performance contracts ensured accountability, communication, and support for EBI delivery at all levels of the health system.

• Donor and partner coordination

During the COVID-19 pandemic, regular partner coordination meetings continued using virtual platforms, as did all meetings of technical working groups.

• Focus on equity

In Rwanda as elsewhere, already-vulnerable people suffered most from the COVID-19 pandemic and its effects. Officials redirected funds to provide food and other support to especially vulnerable groups in Kigali during the lockdown.

According to interviews with KIs, Rwanda also implemented new strategies to prevent EBI disruptions during the COVID-19 pandemic. These include providing personal protective equipment (PPE) and other COVID prevention measures to the CHWs and facilities delivering EBIs; establishing separate COVID-19 treatment and isolation centers; establishing a toll-free information line to dispel the myths and rumors that lead to EBI avoidance; providing transportation (via ambulances and public cars driven by local leaders) to patients and health care providers; and setting up command posts at every level to coordinate pandemic response and support EBI maintenance.

Overall, early in the pandemic, Rwanda’s COVID-related EBI disruptions were small and transient. Its health system—and the system’s users—rebounded quite quickly.

Regarding maternal and child health (MCH) in particular, Rwanda saw an overall decrease in new antenatal care attendance in 2020 compared to 2019. However, despite this apparent disruption on the demand side, the assessment found that 97 percent of health facilities still provided facility-based delivery. All district hospitals continued to provide neonatal and pediatric care; 98 percent of health facilities maintained integrated management of childhood illness (IMCI) and immunization services; and 99 percent maintained prevention of mother-to-child transmission of HIV (PMTCT) service delivery.²

The visualization below shows the disruption ratio of select services over the course of 2020. (A disruption ratio less than 1 indicates lower observed coverage than expected, where expectations are set based on the previous year’s levels for that given month to account for seasonality; a disruption ratio greater than 1 indicates higher observed coverage than expected, potentially reflecting catch-up efforts.)

The above graph shows minimal disruptions to vaccinations and many facility-based services, such as ANC and in-facility delivery, and greater disruptions to services provided at the community level, such as diarrhea treatment, between March and September.