Overall, disruptions to EBIs were comparatively minimal, and Rwanda's health system bounced back quickly.
A critical theme that emerged from interviews with KIs and other data is that Rwanda was able to respond to the COVID-19 pandemic and prevent and mitigate its impact on EBIs because the country had already built a resilient health system to respond to the everyday health needs of its population. Consequently, it could quickly develop and implement a set of strategies designed specifically to stop the spread of the novel coronavirus and maintain EBI delivery in this pandemic context. Second, and more important, Rwanda could continue to implement and adapt the same strategies it was already using to maintain key health services—especially those aimed at boosting MCH. Together, these strategies enabled Rwanda to reverse initial EBI disruptions and keep delivering key services throughout the COVID-19 emergency.
COVID-19 response in Rwanda
Rwanda’s effective response to COVID-19 mitigated the impact of the pandemic and helped the country maintain EBI delivery by preventing the health care system from being overwhelmed by a surge in COVID-19 infections. For instance, officials provided CHWs and health facilities with PPE and other essential supplies so that they could safely continue to deliver evidence-based interventions. A toll-free telephone line provided accurate information about the novel coronavirus, reducing community fear and encouraging people to seek health care when they needed it. Finally, officials established command posts from the national level (the National Joint Task Force) to the cell level. These posts coordinated logistics, daily information-sharing, and community engagement to reduce barriers to COVID-19 prevention and treatment and enable the continued provision of EBIs.
The resilient health system Rwanda built prior to the COVID-19 emergency enabled the country to implement these responses to the pandemic itself. That system also gave officials and health care providers a battery of pre-existing strategies they could adapt (where necessary) to maintain EBI delivery and mitigate drops in coverage of EBIs, even when it was under unusual strain.
Most of the strategies Rwanda implemented to prevent or respond to COVID-related drops in EBIs coverage predated COVID-19 and were adapted to suit their new context, but a handful were new. All these interventions fall into three main categories: human resources for health, infrastructure, policy, and leadership.
Rwanda’s community health system has contributed significantly to the country’s rapid improvement in MCH outcomes over the past few decades.1 CHWs serve as a crucial link between communities and health facilities. CHWs also organize community outreach and education programs to reduce fear and encourage health-seeking behaviors, and they facilitate transportation for sick patients, via ambulances and public cars driven by local leaders. In addition, CHWs conduct home visits for newborn care, growth monitoring, deworming, and vitamin distribution, and to identify children who have missed their vaccines. Rwanda also has a strong emphasis on primary health care and community-based health insurance, which provide affordable health services close to home.
After the first lockdown from March through May 2020, these activities were maintained throughout the COVID-19 pandemic.
Mentorship and supervisionEarly in the pandemic, lockdowns interrupted onsite mentorship and supervision programs. However, once they were adapted to COVID-19 preventive measures (by reducing the number of participants at one time, for instance), mentorship and supervision continued to be critical tools that officials and health care providers could use to ensure the continuity and delivery of EBIs. Most informants reported disruptions and delays in regular, in-person supervision and meetings due to lockdowns and transport restrictions, but most supervision activities were moved to online platforms. For instance, CHWs were supervised via telephone when supervisors could not travel to their districts in person.
Strengthening human resources for healthCOVID-19 overwhelmed health workers and facilities, but Rwanda established a separate system of COVID treatment centers staffed by new staff and volunteers (using resources and staff support from partners) so that health service providers could continue their normal activities.2 For instance, one KI explained that nearly 400 “medical university students…were called upon and trained…to join [Rwanda’s] epidemiology teams” with financing from Rwanda Biomedical Centre and other partners.
Rwanda’s use of data is one of the key strengths of its health system. During the COVID-19 pandemic in particular, officials and health care providers used routine health facility data to identify disruptions to evidence-based interventions and implement interventions early. For example, electronic vaccine registers established in 2019 tracked missed children, and age-disaggregated data identified groups at high risk of infection.
Use of digital platforms, telemedicine, and e-healthDuring the COVID-19 pandemic, Rwanda used a number of digital-technology strategies to continue EBI delivery. For instance, officials used an existing WhatsApp group platform (established in 2014) to coordinate data audits and evaluation activities with data managers, community health workers, and supervisors. WhatsApp was frequently used when face-to-face meetings were restricted. Donors, partners, and stakeholders also used meeting platforms such as Webex and Zoom.
Provision of transportationLockdowns, mobility restrictions, and limits on public transportation initially made travel to health facilities difficult. Consequently, Rwandan officials and implementing partners provided transportation via automobiles and motorbikes to health centers to support vaccination programs. They also provided ambulances to patients headed to health facilities (particularly women in labor and patients referred from one level of the health system to another).
Leveraging existing response systemsRwanda had systems of epidemic preparedness and response in place prior to the COVID-19 pandemic. This experience developing separate and parallel channels for epidemic response meant that officials were ready to establish a cross-sectoral National Joint Task Force even before Rwanda’s first case of COVID-19 was reported3 and could work as quickly as possible to make PPE available to health care workers after the initial PPE shortage was resolved.4
Strengthening the supply chainAccording to interviews with KIs, Rwanda has a strong supply chain system dating from the early 2000s that helped prevent stockouts of essential supplies and medicines even under periods of extreme strain such as the COVID-19 pandemic. Key implementation strategies include planning well in advance of supply shipments, redesigning the supply chain system for vaccines using a push system that distributes vaccines and supplies to districts using refrigerated trucks, and continuing to use local manufacturers to supply pharmaceutical products (such as PPE, sanitizers, perfusions, and new oxygen plants) to avoid international disruption of supplies. According to the head of the Rwanda Biomedical Centre, the emphasis on local manufacturing of high-demand supplies “halved the need for importation of such products.”
Particularly at the beginning of the COVID-19 pandemic, people often feared going to health facilities. To alleviate this fear and encourage health-seeking behavior and EBI continuity in Rwanda, officials used radio and public television to spread high-quality, accurate information. In addition, they empowered community health workers, local leaders, and church leaders to act as communication partners; organized community outreach and engagement activities; and integrated risk communication in all existing community education interventions. New community engagement strategies included SMS reminders to mothers regarding their children’s vaccines and telephone calls from CHWs to patients who missed family-planning appointments.
Policies supporting EBI maintenance The Rwandan government implemented policy guidance and principles to ensure EBI continuity during the COVID-19 pandemic. Some of these policy strategies are brand-new, such as a yellow paper prioritizing essential health care services during COVID-19, directives from the Ministry of Health instructing health workers to cancel vacations to avoid staff shortages, and directives instructing staff who lived far from their workplaces to move into nearby rental housing to ensure continuity of care. Others have been adapted from preexisting strategies, such as leadership performance contracts based on the Imihigo culture of accountability. These ensure communication and accountability at all levels. Donor and implementing partner coordinationRwanda has a long-standing system of collaboration with donors, implementing partners, and other stakeholders within the health system via the Ministry of Health’s National Joint Task Force. During the COVID-19 pandemic, KIs reported that regular partner-coordination meetings continued using virtual platforms, as did all technical working group meetings. This ensured the continuity of essential health and clinical services and facilitated decision-making aimed at maintaining those services.
Focus on equityRwanda’s focus on equity in its health systems has been a long-standing priority, maintained during the pandemic emergency—both in its direct response to COVID-19 and in its efforts to prevent EBI disruptions. For instance, officials redirected money to support vulnerable groups during the lockdown, such as by providing nutritional support in some parts of Kigali. Data review and analysis to locate and remedy equity gaps in programming, interventions, and outcomes are ongoing.
Disruptions by district
In partnership with the Institute for Health Metrics and Evaluation, we conducted an analysis of the disruption ratio of key EBIs. The monthly disruption ratio compares the coverage for a given month in 2020 to that same month in 2019, normalized by changes for that month relative to January and February of that year to account for seasonality. In addition, we calculated the cumulative disruption ratio over the full year, comparing the total disruptions from March to a given month in the year, and also normalized by comparing this to the same time period in 2019.
The heat maps below show both the monthly disruption ratios and cumulative disruption ratios over time, for DTP3 and measles first dose (MCV1). Disruptions were generally minimal in most districts, and recovery generally occurred within a few months. Ratios above 100 percent indicate that coverage was higher in 2020 than in the comparable month in 2019, indicating either variability or catch-up campaigns or both. This is especially significant when the ratio changed drastically from one month to the next (for instance, from March to April with the first dose of the measles immunization).
Monthly Disruption Ratio of Evidence-based Interventions in Rwanda, March to December 2020
Cumulative Disruption Ratio of Evidence-based Interventions in Rwanda, 2020
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1
World Health Organization (WHO). Rwanda: the beacon of Universal Health Coverage in Africa. WHO; 2019. Accessed February 15, 2022. https://www.afro.who.int/news/rwanda-beacon-universal-health-coverage-africa
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2
Karim N, Jing L, Lee JA, et al. Lessons Learned from Rwanda: Innovative Strategies for Prevention and Containment of COVID-19. Ann Glob Health. 2021;87(1):23. https://doi.org/10.5334/aogh.3172
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3
World Health Organization (WHO). COVID-19 in Rwanda: A country’s response. WHO Africa; 2020. Accessed February 15, 2022. https://www.afro.who.int/news/covid-19-rwanda-countrys-response
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4
Wanyana D, Wong R, Hakizimana D. Rapid assessment on the utilization of maternal and child health services during COVID-19 in Rwanda. Public Health Action. 2021;11(1):12-21. https://doi.org/10.5588/pha.20.0057