Amelia VanderZanden

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.

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.

Rwanda has dramatically reduced child mortality, but the causes and sociodemographic drivers for mortality are poorly understood. We conducted a matched case-control study of all children who died before 5 years of age in eastern Rwanda between 1st March 2013 and 28th February 2014 to identify causes and risk factors for death. We identified deaths at the facility level and via a community health worker reporting system. We used verbal social autopsy to interview caregivers of deceased children and controls matched by area and age. We used InterVA4 to determine probable causes of death and cause-specific mortality fractions, and utilized conditional logistic regression to identify clinical, family, and household risk factors for death. We identified 618 deaths including 174 (28.2%) in neonates and 444 (71.8%) in non-neonates. The most commonly identified causes of death were pneumonia, birth asphyxia, and meningitis among neonates and malaria, acute respiratory infections, and HIV/AIDS-related death among non-neonates. Among neonates, 54 (31.0%) deaths occurred at home and for non-neonates 242 (54.5%) deaths occurred at home. Factors associated with neonatal death included home birth (aOR: 2.0; 95% CI: 1.4–2.8), multiple gestation (aOR: 2.1; 95% CI: 1.3–3.5), both parents deceased (aOR: 4.7; 95% CI: 1.5–15.3), mothers non-use of family planning (aOR: 0.8; 95% CI: 0.6–1.0), lack of accompanying person (aOR: 1.6; 95% CI: 1.1–2.1), and a caregiver who assessed the medical services they received as moderate to poor (aOR: 1.5; 95% CI: 1.2–1.9). Factors associated with non-neonatal deaths included multiple gestation (aOR: 2.8; 95% CI: 1.7–4.8), lack of adequate vaccinations (aOR: 1.7; 95% CI: 1.2–2.3), household size (aOR: 1.2; 95% CI: 1.0–1.4), maternal education levels (aOR: 1.9; 95% CI: 1.2–3.1), mothers non-use of family planning (aOR: 1.6; 95% CI: 1.4–1.8), and lack of household electricity (aOR: 1.4; 95% CI: 1.0–1.8). In the context of rapidly declining childhood mortality in Rwanda and increased access to health care, we found a large proportion of remaining deaths occur at home, with home deliveries still representing a significant risk factor for neonatal death. The major causes of death at a population level remain largely avoidable communicable diseases. Household characteristics associated with death included well-established socioeconomic and care-seeking risk factors.