Over the past nine months, COVID-19 has killed more than 1 million people. However, this is likely an underestimation; many countries do not count the deaths of older adults in nursing homes or individuals who may have survived if not for the disruption in health service delivery systems. For example, there have been instances in which people avoided care because of fear of contracting COVID-19, lack of transportation due to the lockdown, or lack of money due to partial or total job loss.
From our experience with previous outbreaks — such as Ebola in 2014 — we know that testing, contact tracing, isolation, quarantine, and other scientifically proven preventive measures, coupled with the continued use of primary and secondary care, are crucial to avoiding deaths caused by outbreak-related disruptions. Thus, it is clear that the direct and indirect causes of death due to SARS-CoV-2 were predictable and preventable through the application of previously tried and tested public health practices.
However, the COVID-19 pandemic has shed light on the systemic flaws within health care systems worldwide that have made these practices unachievable. In various countries, we have seen how the lack of resilient health care systems backed by policies, strategies, and programs centered on universal health coverage — or UHC — contributed to a failed pandemic response and a disruption in the delivery of existing health care services.
The state has an obligation to ensure UHC: the provision of affordable, accessible, and quality health services to all.
Take the example of Rwanda. Thus far, the country has recorded around 5,100 COVID-19 cases — significantly fewer than the 204,000 cases recorded by the similarly populated U.S. state of Pennsylvania. Examining Rwanda’s response to COVID-19 through the nation’s UHC program can provide key transferable lessons to countries seeking to achieve this same progress.
Here are four major facets of UHC that Rwanda leveraged to build and strengthen its pandemic response:
1. Solid primary care
"One million is a terrible number. And I think we need to reflect on that, before we start considering the second million," says Dr. Michael Ryan, executive director of the WHO Health Emergencies Programme.
It has now been 40 years since the 1978 Declaration of Alma-Ata , through which countries expressed their commitment to build proactive and resilient primary health care systems as the key pillar to UHC. Such systems serve as the bridge between the health care system at large and communities.
In Rwanda, the health system is decentralized to bring health care to where people live. Through the use of four community health workers, or CHWs, elected in each of the 15,000 villages, the government provides basic home-based preventive services, health education, and treatment for uncomplicated conditions.
When the pandemic emerged, CHWs were trained on COVID-19 and worked closely with districts and the national coordinating institution — Rwanda Biomedical Centre — to educate the public on measures to fight the coronavirus, consequently increasing adherence to prevention as CHWs work within their communities and are highly trusted.
CHWs also played an instrumental role in contact tracing and identifying potential COVID-19 cases, thereby allowing for a proactive response and, more recently, a well-accepted, home-based treatment for COVID-19.
2. Accessible, affordable care
The provision of accessible and affordable care ensures everyone has access to the necessary resources to implement preventive measures and get treatment in the case of infection. This is key to pandemic management, since universal access is the only way to ensure universal compliance. We will not be safe until everyone is.
Rwanda rooted every facet of its response in accessibility and affordability for all. Testing, isolation, and quarantine in the context of contact tracing were provided free of charge, allowing citizens who would not have been able to afford these services to protect themselves and their families. To ensure that a full lockdown was possible in a country where the majority of workers are in the informal sector — where people live hand-to-mouth — Rwanda provided food relief to tens of thousands of households.
It was in support of this solidarity movement that, on top of freeing up budgets, all Cabinet members gave up their April salaries. By providing the resources necessary to implement known evidence-based interventions, Rwanda was able to ensure a swift and successful response to this health crisis.
3. Protecting existing systems
Rwanda started doing temperature checks on each person stepping off a plane mid-January. Agnes Binagwaho, the country's former health minister, tells Devex President and Editor-in-Chief Raj Kumar more about the COVID-19 response.
In addition to the disease burden introduced by COVID-19, the pandemic also threatens to destroy existing health systems. For instance, Gavi, the Vaccine Alliance estimates that 13.5 million people will miss out on immunizations due to disruptions in health services.
To avoid such disruptions and prevent cross-contamination, Rwanda’s Ministry of Health requested that members of the public call a toll-free phone number if possibly infected, set up specialized COVID-19 treatment centers, and designated specific ambulances and personnel equipped with personal protective equipment to transport potentially infected people from their homes to a facility. This move preempted any reduction in health-seeking behavior for fear of contracting the virus in ordinary health facilities.
4. Good coordination of stakeholders
In Rwanda, collaboration between local and national leaders, community members, research institutions, and all sectors was central to effective response. The country’s coronavirus command post, which consists of 400 professionals from different sectors, was set up to guide the response. The government worked closely with scientists, pandemic management experts, and the transport industry to implement data-driven policies.
This collaboration was supported by the fact that the leadership provides daily updates and clear messaging on social media, backed by real data. This consistent information reinforced the community’s trust in the government, as well as its trust in the health system, which was previously identified as the highest in the world by a Wellcome Trust study.
Achieving UHC during a pandemic requires strong political will, collaboration between stakeholders, and a health care workforce trained in the principles of equity and evidence-based decision-making. This is what we are teaching at the University of Global Health Equity where we equip our students with the knowledge and skills needed to design and manage quality, accessible, and affordable health systems. It is only when we achieve such UHC that we can ensure safety for all.