Subnational equity in the delivery of primary health care interventions during health shocks: lessons learned from an implementation research study in Rwanda

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 Rwandas 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. Rwandas 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. Rwandas 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 messagesO_LIIn 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. C_LIO_LIWe 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. C_LIO_LIRwandas 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. C_LIO_LIThe 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. C_LI