Rwanda's Enabling Environment

Because Rwanda has built a resilient health system over the past two decades to respond to the everyday needs of the population, it was prepared to respond to COVID-19—and prepared to prevent and mitigate the impact of COVID-19 and the pandemic response on the delivery of ordinary EBIs.

According to interviews with KIs, many of the same enabling environmental factors that enabled Rwanda’s exemplary reduction in U5M between 2000 and 2015 also made it possible for the country’s health system to respond to and recover from disruptions to EBI coverage during the early part of the COVID-19 pandemic.

Key facilitators that predated the pandemic emergency include:

In Rwanda, different stakeholders in the health sector have long collaborated with one another. This collaboration continued during the COVID-19 pandemic: the Ministry of Health oversaw policy and oversight at the highest levels; the Rwanda Biomedical Centre was in charge of implementation and service delivery (including diagnostics, vaccinations, and field operations); and implementing partners worked on the ground as well as on scientific-advisory and technical working groups. These stakeholders met regularly using digital platforms to develop plans for COVID-19 response as well as EBI maintenance. These existing relationships and structures for stakeholder collaboration prevented the duplication of efforts and maximized scarce resources.

At the beginning of the pandemic, the Rwandan government created the multisectoral National Joint Task Force, which exemplifies this culture of collaborative decision-making.

Rwanda’s community health system—and especially the CHWs who are its engine—has been celebrated for its contribution to the country’s rapid improvement in MCH outcomes in the past few decades. Since task shifting, training, and mentoring programs have empowered CHWs to perform many jobs formerly reserved for professional health care workers, CHWs provide a wide range of services and play a critical role in increasing community access to health services. They play an especially key role in patient follow-up, for example with children who have missed vaccinations. Finally, because CHWs are trusted and respected members of their communities, they are crucial partners in community education and information campaigns.

During the COVID-19 pandemic, CHWs adapted the way they delivered services, providing more door-to-door and in-home care. They also helped provide food to Rwanda’s most vulnerable families, performed follow-up visits to COVID patients who were self-isolated in their homes, and provided household-based health education about COVID prevention measures. Officials provided PPE, hand sanitizer, face shields, and masks so CHWs could perform this work as safely as possible.

Rwanda has a strong culture of data use that emphasizes learning from the past to improve programs for the future. This flexibility and openness to adaptation served the country well during the COVID-19 crisis: it enabled health officials and providers to use HMIS and survey and research data to identify the pandemic’s impact on EBIs and adjust their strategies accordingly.

The availability of quality data is essential to this culture of learning and improvement. In Rwanda, all governmental, nongovernmental, and private health care facilities report their data to a centralized HMIS, which incorporates data from CHWs and data managers at every level of the system. Monthly data-quality assessment meetings allow for localized feedback and improvement; they also help health care workers identify the most prevalent burdens of disease and respond accordingly. Meanwhile, daily reviews of data on maternal mortality, neonatal mortality, U5M, and road accidents help detect emergent situations in particular areas or across the country.

During the COVID-19 pandemic, pre-existing digitized HMIS data allowed the Ministry of Health to follow trends in health-service coverage and track the impact of the pandemic on EBI delivery. Rwanda did not need to change any of its monitoring, evaluation, or reporting tools in response to COVID-19; existing systems, with the addition of COVID-19 indicators, were sufficient.

In Rwanda’s decentralized health system, each successive level of the system provides more comprehensive care than the one (or ones) below it. Health posts in rural or remote areas (many of which have existed for more than 15 years) expand the system’s reach and ensure that it serves as many people as possible. This decentralized, hierarchical approach to health care prevents competition and eliminates redundancies.

During the COVID-19 pandemic, chronic-disease patients who would normally go to higher-level health centers were able to visit their local health care facilities to receive essential care. Their normal provider could connect to local providers to guide treatment.

Rwanda’s centralized, digital supply chain system functioned even during the COVID-19 pandemic, supporting EBI delivery. For instance, CHWs ordinarily provide a monthly report to health centers showing the medications they used, the medications that remain, the medications that had expired, and the medications they need for the following month. This data is entered into the HMIS and other systems and helps determine drug and vaccine procurement, allowing Rwanda to avoid both stockouts and expirations. This system functioned as usual during the pandemic.

Likewise, because Rwanda prioritized the continuation of EBI delivery, health officials used an electronic logistics management information system (eLMIS) to keep track of drug supplies and review stock data regularly. The eLMIS also made it possible to rapidly adapt the supply chain system to emerging needs. Health officials were able to arrange for emergency deliveries of medication and essential goods like oxygen, making it possible for patients to get the supplies they needed even during periods of lockdown or movement restriction. This in turn facilitated the strong supply chain noted above.

With its strong central government, Rwanda can implement interventions at all levels of the health care system: for example, one of President Kagame’s goals was to build a health center in each of the 416 sectors, and this goal has nearly been accomplished; by 2019, the country had 509 health centers. The inclusion of health indicators in the Imihigo leadership-performance contracts that mayors sign with the central government is a demonstration of this top-down commitment to Rwandans’ health and well-being.

During the COVID-19 pandemic, the Rwandan Ministry of Health clearly established EBI delivery as a common objective. It steered funding and efforts from donors and implementing partners to the country’s main health priorities, including EBI maintenance.

This top-down structure enables adaptability and flexibility in challenging circumstances. For instance, EBI disruptions during the first lockdown led to an official assessment, a recommendation from the Ministry of Health, and concrete changes to the health system; partially as a result, service coverage soon returned to normal.

The Rwandan health system is set up to deliver primary health care to as many people in as many places as possible. The Human Resources for Health program boosted the number of well-trained medical staff in the country, brought specialist staff to remote areas, and dispatched pediatricians to regional health facilities. Likewise, the cascade training system for neonatology strengthened that capacity for health workers and hospitals across the country.

During the COVID-19 pandemic, health officials used familiar, accessible technologies to support EBI delivery. Community radio stations played public health messages tailored to their audiences; people could use text messaging to report emergencies and get support; and local health posts brought services and goods such as fortified foods into the communities where they were needed most. Mutuelle de Santé community health insurance also increased community access to critical health services.

Rwanda’s strong culture of accountability and commitment to the community facilitated the maintenance of EBI delivery during the COVID-19 pandemic. Health workers were afraid of contracting the novel coronavirus in health facilities and other workplaces, but they overcame this fear because they were committed to providing care—especially emergency care—for their neighbors. Rwanda’s leadership also encouraged health facility staff to organize and solve problems in their own districts.

Imihigo contracts at all levels also contributed to this culture of accountability by holding mayors responsible for the health of their communities—and for performance on individual EBI indicators such as stunting and ANC visits.

Finally, this sense of community ownership has built enduring trust in the public-health system—trust that was maintained throughout the COVID-19 pandemic.

Rwanda’s experience with preparations for possible outbreaks of Ebola virus disease in 2018 and pandemic influenza in 2009 meant that health officials were ready to develop and implement a pandemic response plan even before the country’s first case of COVID-19 was diagnosed. This plan prioritized pandemic monitoring and evaluation; protection of health care workers and patients; and, critically, the maintenance of evidence-based interventions for child health.