Alemayehu Amberbir

Objectives The study aimed to evaluate the cumulative incidence of gestational diabetes (GD) among pregnant women receiving antenatal care at the King Faisal Hospital (KFH) in Kigali, Rwanda, using the criteria established by the International Association of Diabetes and Pregnancy Study Groups and endorsed by the WHO in 2013. Design Prospective cohort study. Setting KFH-Kigali, Rwanda. Participants A total of 284 pregnant women were enrolled between May 2023 and April 2024. Results The cumulative incidence rate of GD was 19.5% (95% CI 15% to 24.6%). Most participants (78%) were from Kigali City. Most participants belong to high-income households (96.5%) and were employed (85%). Risk factors associated with the development of GD included increased body mass index (adjusted relative risk (aRR) 3.2; 95% CI 2.02 to 5.3), a history of macrosomia (aRR 4.9; 95% CI 1.6 to 12) and family history of type 2 diabetes (aRR 4.6; 95% CI 1.3 to 14). Women diagnosed with GD had a significantly higher risk of adverse outcomes, including pre-eclampsia and gestational hypertension (aRR 6.7; 95% CI 1.7 to 26) polyhydramnios (aRR 6.4; 95% CI 1.94 to 8.9), postpartum haemorrhage (aRR 3; 95% CI 2.7 to 3.9) and caesarean delivery (aRR 4.9; 95% CI 1.6 to 9.1). Neonatal complications were also common in infants born to mothers with GD, including neonatal hypoglycaemia (aRR 2.2; 95% CI 1.2 to 4.5), neonatal intensive care unit admission (aRR 1.7; 95% CI 1 to 4.6) and macrosomia (aRR 2.3; 95% CI 1.01 to 3.5). Conclusions This study provides important data on the cumulative incidence of GD at the KFH in Rwanda and highlights the key maternal and neonatal factors and adverse outcomes associated with the condition. Given the growing global burden of obesity and diabetes, further research and public health education are essential for mitigating the double burden of GD on maternal and neonatal health.

INTRODUCTION: This protocol outlines the establishment and implementation of a Human Development and Demographic Surveillance System (HD2SS) in Butaro, Rwanda. The HD2SS will facilitate prospective, continuous monitoring of the population, tracking vital statistics, social events, and key health and demographic indicators in a defined population. The system will enable accurate and validated assessment of the impact of health and related population-level interventions, supporting evidence-based decision-making and data-driven improvements in healthcare and socioeconomic outcomes at a population level. METHODS: The HD2SS will be implemented in the Butaro sector, home to 38,013 individuals across 68 villages. The Butaro sector was purposively selected due to the existence of the University of Global Health Equity and Partners In Health-supported Butaro healthcare delivery. Data, including location, demographic, socioeconomic, and health-related variables, will be collected using the annual household census and stored using the Survey Solutions system for real-time electronic data capture, ensuring data quality, security, and confidentiality. Data analysis will enable the identification of emerging trends, the development of interventions, and the evaluation of related policies and programs. CONCLUSION: The HD2SS will provide currently limited but much-needed data to inform improvements in public health programming and socioeconomic development and strengthen local health research capacity. Regular dissemination of findings will ensure stakeholders, including local health authorities and development partners, are informed and able to use the results to improve health and social development outcomes in Rwanda.

Metabolic adaptations during pregnancy are essential for pregnancy maintenance and optimal fetal development. Substantial changes in glucose and lipid metabolism ensure maximum nutrient availability for fetal growth [1]. As the fetus depends on maternal glucose as the primary energy substrate, glucose homeostasis is maintained through compensatory changes in insulin secretion, insulin action and increases in […]

The global population of older adults (typically defined as individuals aged ≥60 years) is rapidly increasing, particularly in sub-Saharan Africa (SSA), where the number is projected to increase significantly due to declining fertility and increasing longevity [1]. These demographic changes in SSA have been attributed in part to advances in public health, medical interventions, and […]

The COVID-19 pandemic has brought about significant disruptions to health care delivery worldwide, including in Rwanda. Countries experienced variable disruptions both at the national and the subnational level. Here we report results from mixed methods implementation research on lessons learned from Rwanda to mitigate inequity in the delivery of health care interventions during health shocks as in the COVID-19 pandemic. To estimate the coverage of primary health care interventions known to reduce under-5 mortality during the initial period of COVID-19 in Rwanda, we analyzed existing data from the health management information system. Using the available administrative health management information system data in Rwanda during 2019 and 2020, we calculated i) cumulative and ii) monthly disruption ratios of number of cases of facility-based delivery, number of four or more antenatal care visits, and number of diarrheal cases treated at health facility and community levels in 2019 and in 2020. We conducted key informant interviews between February to April 2021 with policymakers, donors, implementing partners, and direct health services providers to identify barriers and facilitators of subnational variability in the delivery of primary health care interventions, as well as implementation strategies, across Rwanda’s districts. We report district-level results of cumulative and monthly disruptions for three interventions. We found minimal disruption across most districts in Rwanda in the first phase of the COVID-19 pandemic (March to December 2020) and, furthermore, we found minimal subnational variability across districts. Implementation strategies such as community health worker interventions, community engagement and education, provision of transport, and command posts, were important in ensuring minimal disruption across most districts. Rwanda’s focus on equity likely helped to strengthen facilitating contextual factors including a culture of accountability and a strong pre-existing community health system and structure, which contributed to the low level of disruption and minimal subnational variability in the interventions studied. Rwanda’s experience offers potentially transferable knowledge for policymakers and decision-makers in other regions and countries to minimize disruptions at the subnational and national levels to essential health services during future health shocks. Key messages: In the first phase of the COVID-19 pandemic, we found minimal disruption across most districts in Rwanda, similar to previous findings of minimal disruption for the country as a whole and, furthermore, we found minimal subnational variability in disruption across districts. We found that implementation strategies such as community health worker interventions, community engagement and education, provision of transport, and command posts (the National Joint Task Force composed of multidisciplinary teams and supported by subnational task force from all 30 districts to ensure all the coordination around COVID-19 runs smoothly and supports health care delivery) were important factors in delivering minimal disruption across most districts in Rwanda during the first period of COVID-19. Rwanda’s focus on equity likely helped to strengthen facilitating contextual factors including a culture of accountability and a strong pre-existing community health system and structure, which contributed to the low level of disruption and minimal subnational variability in the interventions we considered. The capacity to conduct both national and subnational analysis of disruption and understand strategies which were applied is valuable for providing meaningful lessons learned for communities in other regions and countries.

Introduction Ageing is often accompanied by chronic diseases, multimorbidity and frailty, increasing the need for clinical and social care to support healthy ageing and manage these conditions. We are currently in the UN Decade of Ageing, and there is a growing focus on the need to prevent or delay some of these conditions through the ‘Healthy Ageing’ initiative of the WHO. However, there are limited data available to inform prioritisation of interventions, particularly for countries in sub-Saharan Africa. Methods and analysis This study will use a mixed-methods, stepwise approach to identify the current needs for older people in Rwanda, health system capacity and possible solutions to unmet need. First, we will conduct a household survey in the City of Kigali (predominantly urban) and Northern Province Burera district (predominantly rural) to determine the burden of multimorbidity, frailty, access to care, and experiences and responsiveness of care in older people. This work will be supplemented by secondary analysis of data from the Rwandan STEPwise approach to non-communicable disease risk factor surveillance (STEPs) survey of 2021. Second, we will conduct a health facility readiness assessment and healthcare provider survey to assess health system capacity and gaps to deliver effective primary care to older people in Rwanda. Third, to capture the voices of older people, we will explore the quality of healthcare as experienced by them using in-depth interviews. Fourth, we will synthesise data using mixed methods to understand barriers to access to quality of care among people of older ages based on a Three Delays framework (seeking, reaching and receiving quality healthcare). Finally, the project will culminate in a stakeholder workshop to ensure results are contextually appropriate and disseminated, and gaps identified are prioritised to design novel interventions to promote healthy ageing in Rwanda and the region. Ethics and dissemination The study has received ethics approval from the Rwanda National Ethics Committee, Northwestern University, USA, and the University of Birmingham, UK. This study will deliver impactful research by using multiple methodologies and working with in-country partners to develop a deep knowledge and understanding of healthcare systems experienced by older people in Rwanda. It will also provide a framework for sustainable healthy ageing research and policy engagement to benefit older adults living in Rwanda and inform similar work in low- and middle-income countries during this Decade of Healthy Ageing and beyond.

Background Ageing is often accompanied by chronic diseases, multimorbidity, and frailty, increasing the need for clinical and social care to support healthy Ageing and manage these conditions. We are currently in the UN Decade of Ageing and there is a growing focus on the need to prevent or delay some of these conditions through the “Healthy Ageing” initiative of the World Health Organization. However, there are limited data available to inform prioritisation of interventions, particularly for countries in sub-Saharan Africa. Methods This study has five interlinked work packages (WPs), designed to understand the current needs for older people in Rwanda, health system capacity and possible solutions to unmet need. First, we will conduct a household survey in the City of Kigali (predominantly urban) and Northern Province Burera district (predominantly rural) to determine the burden of multimorbidity, frailty, access to care, and experiences and responsiveness of care in older people. This work will be supplemented by secondary analysis of data from the Rwandan STEPwise approach to non-communicable disease (NCD) risk factor surveillance (STEPs) survey of 2021. Second, we will conduct a health facility readiness assessment and healthcare provider survey to assess health system capacity and gaps to deliver effective primary care to older people in Rwanda. Third, to capture the voice of older people, we will explore the quality of healthcare as experienced by them using in-depth interviews (IDIs). In Fourth, we will synthesise data using mixed methods to understand barriers to access to quality of care in older agebased on a 3-delays framework (seeking, reaching, and receiving quality health care). Finally, the project will culminate in a stakeholder workshop to ensure results are contextually appropriate and disseminated, and gaps identified are prioritized to design novel interventions to promote healthy ageing in Rwanda and the region. Discussion This study will deliver impactful research by using multiple methodologies and working with in-country partners to develop a deep knowledge and understanding of health care systems experienced by older people in Rwanda. It will also provide a framework for sustainable healthy ageing research and policy engagement to benefit older adults living in Rwanda and inform similar work in Low- and Middle-Income countries (LMICs) during this Decade of Healthy Ageing and beyond. Strengths and limitations of this study Strengths of this study include our cross-disciplinary mixed methods health systems research, implementation research and a large population-based survey design; Our population-based study will cover over 127 villages in the city of Kigali (predominantly urban) and Burera district in Northern part of Rwanda (predominantly rural) covering a total sample size of 4280 increasing external validity of the study; It will provide, to our knowledge for the first time, a picture of public-sector health facility care seeking behaviors and health utilization experiences among older individuals in urban and rural Rwanda; Further strengths include our stakeholders’ involvement and engagement which will lead to strategies for translation of the findings in to practice and impact; Limitations of this study will include the cross-sectional nature of the study limiting our ability to assess a cause-and-effect relationship. Moreover, some of the chronic conditions (heart and respiratory disease, high cholesterol) and HIV in the study will rely on self-report of a diagnosis; Our study is further limited in that we will not collect all dimensions of the health systems responsiveness domains. Moreover, the study will not be representative of health centers and health care workers in private or higher-level health care facilities in Rwanda.

The coronavirus disease 2019 (COVID-19) pandemic disrupted health service delivery in many countries [1,2], as did the response measures implemented worldwide. The pandemic thus highlighted the importance of health system resilience, whereby countries lacking such health systems have had to deal with persistent challenges on both the demand and supply sides of health service delivery. […]

The COVID-19 pandemic posed unprecedented challenges and threats to health systems, particularly affecting delivery of evidence-based interventions (EBIs) to reduce under-5 mortality (U5M) in resource-limited settings such as Bangladesh. We explored the level of disruption of these EBIs, strategies and contextual factors associated with preventing or mitigating service disruptions, and how previous efforts supported the work to maintain EBIs during the pandemic. We utilized a mixed methods implementation science approach, with data from: 1) desk review of available literature; 2) existing District Health Information System 2 (DHIS2) in Bangladesh; and 3) key informant interviews (KIIs), exploring evidence on changes in coverage, implementation strategies, and contextual factors influencing primary healthcare EBI coverage during March–December 2020. We used interrupted time series analysis (timeframe January 2019 to December 2020) using a Poisson regression model to estimate the impact of COVID-19 on DHIS2 indicators. We audio recorded, transcribed, and translated the qualitative data from KIIs. We used thematic analysis of coded interviews to identify emerging patterns and themes using the implementation research framework. Bangladesh had an initial drop in U5M-oriented EBIs during the early phase of the pandemic, which began recovering in June 2020. Barriers such as lockdown and movement restrictions, difficulties accessing medical care, and redirection of the health system’s focus to the COVID-19 pandemic, resulted in reduced health-seeking behavior and service utilization. Strategies to prevent and respond to disruptions included data use for decision-making, use of digital platforms, and leveraging community-based healthcare delivery. Transferable lessons included collaboration and coordination of activities and community and civil society engagement, and investing in health system quality. Countries working to increase EBI implementation can learn from the barriers, strategies, and transferable lessons identified in this work in an effort to reduce and respond to health system disruptions in anticipation of future health system shocks.

Background: The Ethiopian government implemented a national community health program, the Health Extension Program (HEP), to provide community-based health services to address persisting access-related barriers to care using health extension workers (HEWs). We used implementation research to understand how Ethiopia leveraged the HEP to widely implement evidence-based interventions (EBIs) known to reduce under-5 mortality (U5M) and address health inequities. Methods: This study was part of a six-country case study series using implementation research to understand how countries implemented EBIs between 2000–2015. Our mixed-methods research was informed by a hybrid implementation science framework using desk review of published and gray literature, analysis of existing data sources, and 11 key informant interviews. We used implementation of pneumococcal conjugate vaccine (PCV-10) and integrated community case management (iCCM) to illustrate Ethiopia’s ability to rapidly integrate interventions into existing systems at a national level through leveraging the HEP and other implementation strategies and contextual factors which influenced implementation outcomes. Results: Ethiopia implemented numerous EBIs known to address leading causes of U5M, leveraging the HEP as a platform for delivery to successfully introduce and scale new EBIs nationally. By 2014/15, estimated coverage of three doses of PCV-10 was at 76%, with high acceptability (nearly 100%) of vaccines in the community. Between 2000 and 2015, we found evidence of improved care-seeking; coverage of oral rehydration solution for treatment of diarrhea, a service included in iCCM, doubled over this period. HEWs made health services more accessible to rural and pastoralist communities, which account for over 80% of the population, with previously low access, a contextual factor that had been a barrier to high coverage of interventions. Conclusions: Leveraging the HEP as a platform for service delivery allowed Ethiopia to successfully introduce and scale existing and new EBIs nationally, improving feasibility and reach of introduction and scale-up of interventions. Additional efforts are required to reduce the equity gap in coverage of EBIs including PCV-10 and iCCM among pastoralist and rural communities. As other countries continue to work towards reducing U5M, Ethiopia’s experience provides important lessons in effectively delivering key EBIs in the presence of challenging contextual factors.