Maintaining Delivery of Evidence-Based Interventions to Reduce Under-5 Mortality During COVID-19 in Rwanda: Lessons Learned through Implementation Research

Existing structure and culture of collaboration between government/ implementing partners/donors/technical working groups/professional associations through the national strategic plan prevents duplication

Facilitates accurate decision-making by allowing for a holistic view

Strong facilitator of community level childcare and follow up as community health workers live within the communities

Responsible for communicating the continuation of health services to prevent stops in access (although some were overburdened during the pandemic)

Regular monitoring and evaluation supported identification of disrupted health services and informed decision-making at all levels

Continuous learning from global and local data

Ability and willingness to adapt based on emerging data

Availability of data through HMIS allows the Ministry of Health to follow the trend of service coverage during the pandemic to inform and facilitate the systems of learning and improvement

Centralized data reporting allows the government to make decisions with a holistic view of the situation in the country

The decentralized nature of the healthcare system increased access to health services before and during the pandemic

Use of separate COVID-19 treatment centers prevented cross-infection in hospitals and contributed to reduction of fear

The existence of one system instead of multiple, parallel systems prevents competition and allows the Ministry of Health to reach the whole population

Strong supply chain and stock of drugs that prevented stock-out of drugs and so reduced a cause of delivery interruption

Ability of the supply chain system to adapt to arising challenges (e.g., push rather than pull system)

Strong, centralized leadership that guides the involvement of donors and implementing partners

Leadership committed to investing in the health and well-being of its population

Strong inputs into the system that supported the continuation of health services: e.g., Mutuelle de Santé, strengthened healthcare capacity through HRH, cascade training/mentorship structure

Guidance provided from technical working groups and professional associations

Rwanda’s culture of coordination of partners with strong leadership at the central and local levels allowed the country to guide donor and implementing partners’ funding and project priorities towards the needs of the country

Despite fear, healthcare workers were committed to providing care

Commitment to serve the vulnerable, critical during COVID-19 as the vulnerable were most affected

Accountability beyond the health sector including the political leadership at district levels, e.g., imihigo contracts

Resulting trust increased adherence to public health measures and continued uptake of health services during the pandemic

The system was designed to adapt to the needs and behaviors of the population

The system that was built prior to the pandemic prepared the country to respond to COVID-19

Facilitating contextual factors such as strong leadership and the culture of collaboration existed prior to the pandemic

Many of the strategies such as community education and engagement existed prior to COVID-19 and support mitigated EBI drop

Lack of public transportation hindered population access to healthcare services and healthcare workers’ ability to reach their facilities

Increased costs of service delivery as adaptations were made to respond to this challenge

Challenged regular supervision and monitoring, shifting to virtual meetings

Fear of infection at facilities tackled through health communication

Report of community fear varied by district—regions with more COVID-19 cases more likely to report community fear of COVID-19

Novelty of the virus and lack of personal protective equipment contributed to healthcare workers’ fear of COVID-19

Training on COVID-19, reassurance from leaders and realization that COVID-19 patients were surviving helped prevent/address the fear of infection

Healthcare workers moved from their usual positions to COVID-19 treatment centers

Healthcare workers, overwhelmed with additional responsibility, received support from the government and partners

Overall, stock-out was not a challenge in Rwanda

Country prepared with one-year stock of vaccines and drugs

Technical mentorship using pediatricians to monitor neonatal care at districts to continue core activities during COVID-19 (A)

Supervision of community health workers via telephone as a response to COVID-related challenges to in-person monitoring and supervision (A)

Following COVID-19 prevention measures—e.g. limiting no. of supervisors per vehicle (N)

Use of data at the lower level of care including Data Quality Assessment, maternal death audit for local decision-making (E)

Partners use the same HMIS data platform, analyze and make decisions at coordination meetings and technical working groups (E)

Use of electronic register for vaccination to help track missed children (E)

Use of radio and public television to spread the right information, e.g., using community health workers, local leaders and church leaders (A), SMS message reminders to mothers in the vaccine program (N), integrated risk communication in all existing community interventions (A)

Educate the community to avoid fear, encourage health-seeking behavior, and facilitate transportation for patients (A)

Policy prioritizing essential healthcare services during COVID-19 (A)

“Imihigo” or leadership performance contracts—ensures accountability at all levels (E)

Directives from the ministry of health for health workers to cancel vacations to avoid staff shortage (N)

Staff who lived far from a health center had to relocate and move to a rental house closer to the health facility (N)

Provision of transport to patients and healthcare providers particularly during the lockdown (government + partners) (N)

Provision of vehicles and motorbikes to health centers to support vaccination programs (E)

Cross-Sectoral National Joint Task Force was established before the first case of COVID-19 based on experience with preparedness for Ebola (A)

Ebola preparedness and availability of personal protective equipment for COVID-19 response (N)

Planning well in advance of shipment of supplies to avoid stock-out

Redesigning the supply chain system for vaccines using push system, e.g., active distribution of vaccines and supplies to districts using refrigerator truck.

Using local manufacturers due to international disruption

Partner coordination meetings happening regularly using virtual platform (A)

All technical working group meetings continued to work virtually during COVID-19 and ensure continuity of EHS and clinical services (A)

Data analysis by geography to see if there is any equity gap (e.g., districts with low coverage supported) (E)

Redirect money from programs to support vulnerable population (informal sector) (N)

Support vulnerable groups during the lockdown (e.g., nutritional support) (N)

Using community health workers to identify children who missed vaccination; conduct house-to-house growth monitoring, vitamin, and deworming distribution; visiting schools; and organizing outreach campaigns (A)

Emphasis on primary healthcare and community-based health insurance—affordable health services (E)

WhatsApp groups with data managers, community health workers, and supervisors for data audit, discuss M&E activities, and maintain coordination (A)

WhatsApp group among professional members to discuss activities and exchange new information (E)

Webex and zoom virtual meetings with partners and stakeholders (A)

Remote mentorship using simulation-based training (less robust) and mobile phone consultations (A)

Safety: community health workers and health facilities were provided with personal protective equipment and other COVID-19 prevention measures; this supported EHS maintenance

Education: Toll-free number specific to COVID-19, also providing other EHS

Coordination: Establishment of command posts from national—the National Joint Task Force—to cell level to ensure all the coordination around COVID-19 runs smoothly

Health system support: Support logistics of COVID-19 response, information-sharing across the country and community engagement

Change in delivery: Additional under-5 vaccination days to respect social distancing and prevent spread of COVID-19 but also maintain vaccination

Reallocation of funds for the recruitment of new staff and volunteers (A)

Staff support from partners to ensure avoid pulling out of many healthcare providers from their normal activities to COVID-19 treatment centers (A)

Restructuring of staff from health centers to health post to increase outreach services for particularly for vaccination (A)

Strong motivation to adapt strategies to avoid negative health outcomes

Adaptation of service delivery to reach patients while abiding by COVID-19 guidelines

Task shifting and reallocation of budget to bolster healthcare worker capacity for COVID-19 response and to maintain EBIs

Aware of and well prepared for a potential disruption of health services during the pandemic

Awareness of the virus, protection methods, and trainings reduced fear among healthcare workers

Aware of drops in EBIs through the regular evaluation of data

Maintained core function through the prioritization of health services

Critical follow-up of patients with other diseases

Maintained straight lines of communication and referral between the different levels of the healthcare system

Coordination with trusted non-health actors for health communication

All service delivery activities continued with the support of leadership despite the threat of COVID-19

Multiple approach for EHS delivery