Dr. Alemayehu Amberbir

The coronavirus disease 2019 (COVID-19) pandemic led to disruptions of health service delivery in many countries; some were more resilient in either limiting or rapidly responding to the disruption than others. We used mixed methods implementation research to understand factors and strategies associated with resiliency in Rwanda and Bangladesh, focussing on how evidence-based interventions targeting amenable under-five mortality that had been used during the Millennium Development Goal (MDG) period (2000-15) were maintained during the early period of COVID-19.

Background: The COVID-19 pandemic resulted in drops in access to and availability of a number of evidence-based interventions (EBIs) known to reduce under-5 mortality (U5M) across a wide range of countries, including Rwanda. We aimed to understand the strategies and contextual factors associated with preventing or mitigating drops nationally and subnationally, and the extent to which previous efforts to reduce U5M supported the maintenance of healthcare delivery. Methods: We used a convergent mixed methods implementation science approach, guided by hybrid implementation research and resiliency frameworks. We triangulated data from three sources: desk review of available documents, existing routine data from the health management information system, and key informant interviews (KIIs). We analyzed quantitative data through scatter plots using interrupted time series analysis to describe changes in EBI access, uptake, and delivery. We used a Poisson regression model to estimate the impact of COVID-19 on health management information system indicators, adjusting for seasonality. We used thematic analysis of coded interviews to identify emerging patterns and themes. Results: We found moderate 4% (IRR = 0.96; 95%CI: 0.93, 1.00) and 5% (IRR = 0.95; 95%CI: 0.92, 0.99) drops in pentavalent and rotavirus 2 doses vaccines administered, respectively. Nationally, there was a 5% drop in facility-based delivery (IRR = 0.95; 95%CI: 0.92, 0.99). Lockdown and movement restrictions and community and health-worker fear of COVID-19 were barriers to service delivery early in the pandemic. Key implementation strategies to prevent or respond to EBI drops included leveraging community-based healthcare delivery, data use for decision-making, mentorship and supervision, and use of digital platform. Conclusions: While Rwanda had drops in some EBIs early in the pandemic, especially during the initial lockdown, this was rapidly identified, and response implemented. The resiliency of the health system was associated with the Rwandan health system’s ability to learn and adapt, encouraging a flexible response to fit the situation.

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.