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detailed findings

The evidence from the literature review and qualitative interviews on each evidence-based intervention are shown in the table below against the implementation science framework used for the research.

REDUCTION IN UNDER-5 MORTALITY RATE (U5MR) FROM THIS CAUSE OF DEATH, 2000 - 2015 EVIDENCE-BASED INTERVENTION ACCEPTABILITY  FEASIBILITY FIDELITY  EFFECTIVENESS/REACH 

Malaria 88% decline in U5MR         

ITNs

 N/A Over 3 million ITNs distributed during 2006-2007 and 6.1 million distributed during 2008-2009.4 ITN utilization is approximately 10% less than ITN possession (KI). Percent of children under-5 sleeping under ITNs increased to 68% by 2015.5
  IRS General acceptability came about after seeing the lack of mosquitoes following the first round of spraying. In the districts chosen, 87-99% of targeted buildings are sprayed.6  N/A  Seven districts covered by IRS represent 70% of the malaria burden for the country.7
Lower Respiratory Infections 76% decline in U5MR    PCV The communities generally accepted the benefits of the vaccination because “[Rwanda’s] population trusts very much their government and what they are doing and that [the MOH’s] main interest is our beneficiaries” (KI). No stockouts occurred during the vaccine rollout.8 The roll out was completed as planned within 5 months. After introduction, PCV coverage quickly increased up to 97% by 2010 with a concurrent reduction in child hospitalization due to pneumonia of 53% between the periods of 2007-2009 (prior to introduction of PCV7) and 2010-2013 (after introduction of PCV7).9 
Diarrheal Diseases 86% decline in U5MR    Rota Vx High coverage rates reflecting community acceptance “it was very easy to administer the vaccine because mothers were not afraid of it.”
 Rotavirus vaccine was delivered nationally.
 Three doses of rotavirus vaccine are being given at 6, 10 and 14 weeks as recommended10 with the rollout completed as planned (partner engagement and coordination, community sensitization, integrated strengthening of supply and M and E systems).

Rotavirus vaccination in children under 1-year of age increased from 50% in 2012 and to 99% in 2013.11

Hospital admissions for diarrhea in children under-5 fell by 49% between 2011 and 2013.12 
HIV 93% decline in U5MR PMTCT  N/A Increased ANC services available led to increased availability of PMTCT (KI). The number of health facilities offering PMTCT increased from 53 in 2003 to 382 in 2010.  N/A

98% of women coming in for antenatal care are tested for HIV and 99% of HIV-positive pregnant women receive ART to reduce MTCT (KI).

MTCT rates have dropped from 9.7% in 2006 to 2.4% in 2010 and 1.8% in 2015.13

Adoption of improved treatments often prior to international recommendations by WHO and other bodies - most notably, Option B+.

In 2015, 92.2% of pregnant women received HIV testing during ANC, and less than 1% were HIV-positive.14

All Heath Centers by 2009 offered ART including PMTCT.
   ART   Turnaround time from collection of sample to receipt of results by the provider decreased from 144 days to 20 days.15  

Health facilities offering ART increased from 4 in 2002 to 465 in 2013.16

EID for infants born to HIV-positive mothers in 2011 was 72-94% 17

In 2013, 60% of HIV-positive children ages 0-14 years were receiving ART 16
Measles 97% decline in U5MR Measles vaccination Coverage with the MR vaccine estimated at 95% in 2015.18  Regular response to new needs and cases possible through leveraging of existing platforms. N/A Measles vaccine coverage was maintained above 80% from 2003 to 2009.19  In 2010, there was a vaccine coverage rate of 95% and 121 identified cases of measles nationwide.20 No extended outbreaks identified despite influx of new unvaccinated populations.
Nutritional deficiencies 81% decline in U5MR Severe acute malnutrition identification and monitoring       82% of children under-5 were screened for malnutrition in 2014.21 Wasting (low weight-for-height and therefore a marker for acute malnutrition) decreased from 6.8% of children under-5 in 2000, to 5% in 2005, 3% in 2010, and 2% in 2015.14  Note that similar success was not seen in markers of more chronic malnutrition including stunting.
Neonatal disorders 51% decline in U5MR Neonatal interventions
    

Partographs, while available were not widely used completely.22

Only 7% of women getting active management of the third stage of labor (AMSTL) received all components.22

Rates of C-section increased from 2.1% of deliveries in 2000, to 2.9% in 2005, 7.1% in 2010 and 13.0% in 2015.23

Women having a post-partum checkup within the first 2 days following delivery increased from 2.9% in 2000 to 43% in 2015.24
  1. 1
    This analysis uses the Das Gupta decomposition method, which averages across the multiple ways in which each of the factors could combine to result in the realized changes in under-five mortality.
  2. 2
    The inputs to the decomposition are cause-specific mortality rate, age-specific population estimates, intervention coverage rates, and intervention effectiveness estimates. Cause-specific mortality and population estimates come from the Global Burden of Disease study and intervention coverage rates were estimated using multiple sources of survey data, including but not exclusive to DHS surveys. A literature review and synthesis were conducted to establish intervention effectiveness.
  3. 3

    The under-five mortality decomposition analysis breaks down changes over time for a series of factors that directly influence child-mortality levels. This figure assesses five-year intervals, presenting changes as percentages relative to the number of deaths in the first year of the time interval. Some factors contribute to increases (bars that are on the right side of the dotted line) in the number of deaths, while others contribute to declines (bars to the left of the dotted line) - the net of the two corresponds to the total change in deaths over the time period (represented by the black dot).

    Interventions and Risk Factors: Interventions and risk factors influence mortality rates through changes in the proportion of the population exposed to each, and through changes in the corresponding relative risk of mortality. Increased coverage of specific interventions is known to reduce mortality rates, whereas increased exposure to certain risk factors increases mortality rates.

    Health Care Access and Quality: The Healthcare Access and Quality index captures changes in 32 separate causes of death amenable to personal health care interventions. The impact of HAQ on under-five mortality rates was determined by regressing HAQ on risk-deleted mortality rates across locations and years. The bar representing HAQ can be interpreted as the effect of improved HAQ on mortality rates after accounting for risk factors and interventions.

    Population Change: The total number of deaths in a given year is a product of both age-specific mortality rates and the population size in each age group, so changes in population are factored into the decomposition. For example, if mortality rates are cut in half while the population size doubles, total deaths will remain the same.

    Other factors: After capturing all of the explainable changes in under-five deaths, there is often some remaining change that is unexplained by the factors included in the analysis. These can be thought of as indirect factors that ultimately affect child mortality through means other than the factors included in the analysis. For example, improvements in infrastructure may contribute to decreased mortality rates, but we were unable to incorporate a measurement of improved infrastructure - or the effect of any such improvement - into this analysis.

  4. 4
    Eckert E, Florey LS, Tongren JE, et al. Impact Evaluation of Malaria Control Interventions on Morbidity and All-Cause Child Mortality in Rwanda, 2000-2010. Am J Trop Med Hyg. 2017;97(3_Suppl):99-110. doi:10.4269/ajtmh.17-0281; Karema C, Aregawi MW, Rukundo A, et al. Trends in malaria cases, hospital admissions and deaths following scale-up of anti-malarial interventions, 2000-2010, Rwanda. Malar J. 2012;11(1):236. doi:10.1186/1475-2875-11-236.
  5. 5
    Rwanda - Demographic and Health Survey: 2014-2015. Kigali, Rwanda; 2016. https://dhsprogram.com/pubs/pdf/FR316/FR316.pdf. Accessed December 15, 2017.
  6. 6
    Karema C, Aregawi MW, Rukundo A, et al. Trends in malaria cases, hospital admissions and deaths following scale-up of anti-malarial interventions, 2000-2010, Rwanda. Malar J. 2012;11(1):236. doi:10.1186/1475-2875-11-236.
  7. 7
    Eckert E, Florey LS, Tongren JE, et al. Impact Evaluation of Malaria Control Interventions on Morbidity and All-Cause Child Mortality in Rwanda, 2000-2010. Am J Trop Med Hyg. 2017;97(3_Suppl):99-110. doi:10.4269/ajtmh.17-0281.
  8. 8
    UNICEF. Post-Introduction Evaluation of 7-Valent Conjugate Pneumococcal Vaccine (PCV-7) in Rwanda Report of the Post-Introduction Evaluation of PCV-7 in Rwanda.; 2010. https://www.unicef.org/evaluation/files/Rwanda_2010-10_Post_Introduction_Evaluation_Pneumococcal-PCV7.pdf. Accessed December 19, 2017.
  9. 9
    Karema C, Aregawi MW, Rukundo A, et al. Trends in malaria cases, hospital admissions and deaths following scale-up of anti-malarial interventions, 2000-2010, Rwanda. Malar J. 2012;11(1):236. doi:10.1186/1475-2875-11-236; Rurangwa J, Rujeni N. Decline in Child Hospitalization and Mortality After the Introduction of the 7-Valent Pneumococcal Conjugative Vaccine in Rwanda. Am J Trop Med Hyg. 2016;95(3):680-682. doi:10.4269/ajtmh.15-0923.
  10. 10
    Rwanda Biomedical Center Vaccine Preventable Diseases Division. Comprehensive Multi-Year Plan 2013-2017.; 2013. http://www.nationalplanningcycles.org/sites/default/files/country_docs/Rwanda/attachment_6_revised_cmyp_08.pdf. Accessed November 29, 201
  11. 11
    Ngabo F, Tate JE, Gatera M, et al. Effect of pentavalent rotavirus vaccine introduction on hospital admissions for diarrhoea and rotavirus in children in Rwanda: a time-series analysis. Lancet Glob Heal. 2016;4(2):e129-36. doi:10.1016/S2214-109X(15)00270-3.
  12. 12
    Tate JE, Ngabo F, Donnen P, et al. Effectiveness of Pentavalent Rotavirus Vaccine under Conditions of Routine Use in Rwanda. Clin Infect Dis. 2016;62(suppl 2):S208-S212. doi:10.1093/cid/civ1016.
  13. 13
    Rwanda Annual Report on HIV and Aids 2010-2011. Kigali, Rwanda; 2011. http://www.rbc.gov.rw/IMG/pdf/national_annual_report_on_hiv_aids_july_2010_june_2011.pdf. Accessed January 1, 2018; HIV/AIDS and STIs Unit Annual Report: July 2009 - June 2010. Kigali, Rwanda; 2010. http://rbc.gov.rw/library/sites/default/files/hiv_aids_and_stis_annual_report_2009_2010.pdf. Accessed May 17, 2018; Rwanda Country Operational Plan 2016: Strategic Direction Summary.; 2016. https://www.pepfar.gov/documents/organization/257633.pdf. Accessed January 1, 2018.
  14. 14
    Rwanda - Demographic and Health Survey: 2014-2015. Kigali, Rwanda; 2016. https://dhsprogram.com/pubs/pdf/FR316/FR316.pdf. Accessed December 15, 2017; Rwanda Annual Health Statistics Booklet - 2015. Kigali, Rwanda; 2015. http://www.moh.gov.rw/fileadmin/templates/hmis_reports/2015_20Annual_20Statistical_20booklets_20V13_20Signed.pdf.
  15. 15
    Binagwaho A, Mugwaneza P, Irakoze AA, et al. Scaling up early infant diagnosis of HIV in Rwanda, 2008-2010. J Public Health Policy. 2013;34(1):2-16. doi:10.1057/jphp.2012.62.
  16. 16
    Rwanda Global AIDS Response Progress Report (GARPR) 2014. Kigali, Rwanda; 2014. http://www.unaids.org/sites/default/files/country/documents/RWA_narrative_report_2014.pdf. Accessed December 1, 2017.
  17. 17
    Binagwaho A, Mugwaneza P, Irakoze AA, et al. Scaling up early infant diagnosis of HIV in Rwanda, 2008-2010. J Public Health Policy. 2013;34(1):2-16. doi:10.1057/jphp.2012.62; Rwanda Global AIDS Response Progress Report (GARPR) 2014. Kigali, Rwanda; 2014. http://www.unaids.org/sites/default/files/country/documents/RWA_narrative_report_2014.pdf. Accessed December 1, 2017.
  18. 18
    Rwanda: WHO and UNICEF Estimates of Immunization Coverage: 2016 Revision.; 2017. http://www.who.int/immunization/monitoring_surveillance/data/rwa.pdf. Accessed December 9, 2017.
  19. 19
    Seruyange E, Gahutu JB, Mambo Muvunyi C, et al. Measles seroprevalence, outbreaks, and vaccine coverage in Rwanda. Infect Dis (Auckl). 2016;48(11-12):800-807. doi:10.1080/23744235.2016.1201720.
  20. 20
    Seruyange E, Gahutu JB, Mambo Muvunyi C, et al. Measles seroprevalence, outbreaks, and vaccine coverage in Rwanda. Infect Dis (Auckl). 2016;48(11-12):800-807. doi:10.1080/23744235.2016.1201720; Rwanda Health Statistical Booklet 2010.; 2011. http://moh.gov.rw/fileadmin/templates/HMIS_Docs/MOH_Annual_booklet__2010.pdf. Accessed December 1, 2017.
  21. 21
    Rwanda Annual Health Statistics Booklet - 2014. Kigali, Rwanda; 2014. http://www.moh.gov.rw/fileadmin/templates/hmis_reports/Rwanda_Annual_Health_Statistics_Booklet_2014_.pdf.
  22. 22
    Zoungrana J, Favero R, Ngabo F, Rosen H, Levine R, Arscott-Mills S. Postpartum Hemorrhage Prevention and Management Require Strengthening: Findings from a National Quality of Care Assessment in Rwanda. In: MCHIP, USAID, Jhpiego. https://www.mchip.net/sites/default/files/Zoungrana_FIGO_Presentation.pdf. Accessed December 31, 2017.
  23. 23
    Enquête Démographique et de Santé, Rwanda 2000. Kigali, Rwanda and Calverton, Maryland, USA; 2001. https://www.dhsprogram.com/pubs/pdf/FR125/FR125.pdf. Accessed December 20, 2017; Rwanda - Demographic and Health Survey: 2014-2015. Kigali, Rwanda; 2016. https://dhsprogram.com/pubs/pdf/FR316/FR316.pdf. Accessed December 15, 2017; Rwanda Demographic and Health Survey 2010. Kigali, Rwanda and Calverton, Maryland, USA; 2012. https://dhsprogram.com/pubs/pdf/FR259/FR259.pdf. Accessed November 30, 2017; Rwanda Demographic and Health Survey 2005. Kigali, Rwanda and Calverton, Maryland, USA; 2006. http://www.measuredhs.com/pubs/pdf/FR183/FR183.pdf.
  24. 24
    Enquête Démographique et de Santé, Rwanda 2000. Kigali, Rwanda and Calverton, Maryland, USA; 2001. https://www.dhsprogram.com/pubs/pdf/FR125/FR125.pdf. Accessed December 20, 2017; Rwanda - Demographic and Health Survey: 2014-2015. Kigali, Rwanda; 2016. https://dhsprogram.com/pubs/pdf/FR316/FR316.pdf. Accessed December 15, 2017.
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