EBI Coverage in Rwanda during the First Year of COVID

Like most other countries in the world, Rwanda experienced some early reductions in EBI coverage because of the COVID-19 pandemic. Not all KIs reported disruptions in EBI delivery in the area they coordinated or at their level of the health system, but many reported disruptions to the following services during the initial months of the pandemic:

• Vaccine coverage
• Outpatient department (OPD) consultations for non-severe illnesses
• Antenatal care (ANC) visits
• Facility-based deliveries (FBDs)
• Growth monitoring
• Treatment for noncommunicable diseases (NCDs)

According to interviews with KIs, various supply- and demand-side barriers to EBI delivery contributed to this disruption. Some of these barriers, such as the fear of contracting COVID-19, were caused by the spread of the virus itself; others were the result of interventions implemented to control the pandemic, such as lockdowns and movement restrictions.

Lockdowns and movement restrictions

KIs report that the most significant demand-side barriers to EBI delivery in Rwanda early in the COVID-19 pandemic were the lockdowns and movement restrictions that prevented patients from accessing health care. This was especially true from March 21 until April 30, 2020, when Rwandan health officials imposed a strict lockdown to prevent the community spread of COVID-19.^{1, 2}

During this first lockdown, public transportation was disrupted, complicating travel to health facilities for patients and health workers without vehicles.³ For patients, getting from the community to health facilities for outpatient appointments or to pick up prescriptions was especially challenging. In many cases, ambulances and other vehicles were available to transport patients from one level of the health system to another, such as from district hospitals to referral hospitals—though one informant did note that some patients who had been referred to higher levels of care had to walk from the health center to the district hospital. As lockdowns were enforced, many people sought care closer to home, resulting in an increase in patients at community-level facilities and health posts. Health care providers likewise had difficulties transporting themselves to and from their workplaces, and some even moved to be closer to work. Community-level programs and interventions such as MCH Week were adapted to comply with lockdown rules and social-distancing guidelines.

The above figure shows bigger drops in treatment of diseases such as diarrhea and pneumonia than the preceding figure shows for vaccines, although the numbers began to recover toward the end of 2020. Moreover, diarrhea cases treated at the community level reached a lower level between April and July 2020 than diarrhea cases treated at the facility level, indicating shifting patterns in care seeking. Overall, diarrhea and pneumonia cases treated at the facility and community levels showed a marked drop (15–40 percent) during the COVID-19 pandemic, indicating a lower level of treatment-seeking behavior during this period. Some of this decline can also be attributed to a decrease in the incidence of these diseases, since KIs explained that COVID-19 prevention measures such as hand-washing, social distancing, and school closures reduced their transmission as well.⁴

Finally, the lockdowns and movement restrictions served as a barrier to supervision and mentorship activities for health care workers, interfering with the continued quality of care.

Staff shortages, redeployments, and heavy workloads in health care facilities

In Rwanda as elsewhere, KIs report that health care workers have been overwhelmed by the additional strain the COVID-19 pandemic has put on the system. As officials established separate COVID-19 treatment centers, for instance, some health care workers had to leave their regular posts and relocate; those who remained had to work overtime and forego vacations and leave. Task shifting was especially critical in places like Kigali that had a comparatively high number of COVID-19 patients.

This added burden had some negative effects. For instance, the restricted movement of technical teams and supervisors may have diminished oversight and therefore quality of care. Counseling and support groups for HIV patients were reduced. Community health workers, spread thin, had to focus on COVID-19 response at the expense of other key priorities. Finally, human and financial resources were further diverted from regular programs in favor of preparation for COVID-19 vaccine delivery.

Fear of COVID-19

As in most parts of the world, many people stayed away from health facilities in Rwanda during the early months of the COVID-19 pandemic because they were afraid of contracting the virus from sick patients or health care workers. This fear was especially pronounced in districts with high case counts, like Kigali. Community members were particularly wary of contact with community health workers, who did not have access to PPE at first. For instance, informants reported that pregnant women barred CHWs from entering their homes.

Health care workers, too, feared contracting COVID-19—especially at the beginning of the pandemic, when PPE shortages left many unprotected. However, once they had access to sufficient PPE from the direct COVID-19 response, as well as support, training, and reassurance (along with experience treating COVID patients who survived), this fear diminished.

Most of these disruptions resulted from the initial shock of the COVID-19 emergency and were concentrated in the early months (March–May) of the pandemic. This relatively short duration can be attributed to the ongoing resiliency of Rwanda’s health system: its ability to learn and adapt quickly, to deploy existing implementation strategies and develop new ones, and to take advantage of the presence of facilitating contextual factors when implementing strategies to address these barriers.