Rwanda’s COVID-19 response commendable but health information system needs improvement

Rwanda is consistently working to improve its health information system from many years. However, it is primarily dependent on the collection and reporting of health data on a monthly basis. Besides, evaluation studies on Rwanda's HIS published in 2020 have highlighted a couple of loopholes. As the East African nation has 90% broadband coverage and 75% of people use mobile phones, it's high time for a transition to a robust health management information system based on real-time geospatial data.

Rwanda reported the first case of COVID-19 on March 14 and over five months in the pandemic, the East African nation has reported a total of 3,537 cases and 15 deaths out of which the highest daily increase was on August 26 cases when 231 cases were reported. This is about 279 cases per million population in Rwanda which has a population of 12.9 million and a population density of 525 people per sq. km. In the first three months, the COVID-19 cases in Rwanda were below one thousand.

These achievements alone might not look impressive unless we have a thorough understanding of the healthcare system and health information system and COVID-19 response of Rwanda from a historical perspective. The success of Rwanda’s COVID-19 response is being credited to huge investment and dynamic political leadership which made healthcare a priority after the great genocide in 1994 which had crippled the healthcare as well as the economy of the country. 

Healthcare System in Rwanda

Rwanda has a referral healthcare system consisting of health posts (850) which act as primary healthcare centers, health centers (600), district hospitals (37), provincial hospitals (4), and national referral hospitals (7). The Community Health Workers (CHWs) play a crucial role in handling the burden of diseases in the concerned community and responsible for facilitating patients to the health posts who may be referred to the higher rank hospitals as per the requirement. The healthcare system in Rwanda is primarily funded by the government but there also exist private polyclinics and hospitals (7). Besides, innovative public-private partnership models (PPP) in healthcare such as telehealth, multispeciality hospitals, broadband services etc. have helped in the improvement of the healthcare information system.

Rwanda Biomedical Center (RBC) is the topmost medical body in the country which was constituted in 2011 through a merger of 14 key health institutions. The Ministry of Health through RBC implements healthcare policies and programs in the country. RBC is primarily responsible for conducting scientific researches, provide diagnostic services, and implementing innovative health interventions to protect the nation against diseases and other health threats.

Though Rwanda is a low income developing country, it has achieved Universal Health Coverage (UHC). Some of the landmarks achieved by Rwanda in the healthcare sector are - 93% of vaccination coverage rate, 90% institutionalized births, and 91% coverage of health insurance. These goals were achieved with sustained efforts of the political leadership in which long-term health policies played an important role. 

Vision 2020

Vision 2020, was launched in 2000 to achieve 44 targets across nine development sectors including 7 targets related to the health sector. In a mid-term evaluation in 2011, it was concluded that 6 health targets were on track while 'population control' was the most problematic sector as only one of its four targets were on track. The report further clarified that the country was on track to achieve the targets of life expectancy, children immunization, child and maternal mortality, HIV/AIDS and Malaria while the quality of healthcare services/ maternal health care, the sustainability of health insurance schemes, and eradication of Malnutrition were identified as areas of concern.

National e-Health Strategy Plan 2009-13

Rwanda is among the leading countries in Africa in e-health and launched an e-health plan as early as 2009. The National e-Health Strategy Plan 2009-13 is aimed at designing the architecture for an integrated e-Health system and setting standards for e-Health systems, setting strategies and evaluation measures for the e-Health Department, and making a governance and accountability model that would allow e-Health to be managed in a way that delivers on the government’s goals of transforming the healthcare system in a coordinated and integrated way. The services covered under the plan were – community health, primary healthcare, hospital care (diagnostic, surgical, emergency and tertiary care), population and public health, drug procurement tracking, blood bank, e-learning, healthcare financing, and integration of National Electronic Identity Card.

Besides, Rwanda also launched a couple of schemes to achieve Vision 2020 and improve e-Health in the country. An independent study published in 2018, has credited strong public sector leadership, investments in health information systems, equity-driven policies, and the use of foreign aid to invest in local capacity-building helped Rwanda achieve greater health gains compared to Burundi which passed through a similar political crisis in the 1990s. Besides several technological initiatives in healthcare such as routine reporting and data quality assessments (2008–2012), emphasis on research training for health professionals (2012), rapid mobile messaging for community health workers to report vital events (2010), early infant diagnosis via mobile phone (2008), the study also credits national stewardship of health policy, coordination of international partners and decentralized decision-making at the district level for Rwanda’s achievements in the healthcare.

Furthermore, the government is implementing several stakeholder-specific health policies, guidelines and regulations such as Health Sector ICT Security Policy 2016, National Community Health Policy, Health Sector Policy 2016, Rwanda Pharmacy Policy 2015. The ministry also publishes an annual Health Performance Report for the outgoing year and Forward-Looking Report for the upcoming years.

National Health Strategy Plan 2018-23

Rwanda is presently implementing a five-year long term e-Health plan entitled the National Health Strategy Plan 2018-23. The concept note of the plan also presents a SWOT analysis of of the existing HIS wherein low numbers of trained staff in some of the more specialized areas of systems analysis and software development (both in public and private sectors), insufficient back-up electric power, and limited numbers of staff and resources at the central level to support nationally deployed systems have been highlighted as major weaknesses. Besides, maintaining quality across all reporting systems has also been underlined as a challenge. Health facilities in Rwanda have been using electronic medical records (EMR) systems of one type or another for many years which results in interoperability challenges to HIS in Rwanda. 

The Plan has aimed to achieve 19 key e-health targets by 2022 which includes a National Health Information Exchange (NHIE), 100% health facilities (public and private) using integrated EMR, one lab system with interoperable medical records, 43 lab results available to facilities-connected Lab Information System (LIS), functional video conferencing facilities in all 48 hospitals, 30% citizens having access to individual medical information, 99% detection of disease outbreaks through eIDSR (Enhance Epidemic Diseases Surveillance and Response), 100% of public hospitals served with blood products and other urgent supplies using drones, supply chain management system connected through virtual platform e-LMIS and 100% use of tablets for data collection among others. 

Citizen Service Charter for the Ministry of Health

Rwanda is implementing an innovative Citizen Service Charter for public healthcare to improve the quality of service delivered to people. In addition, to provide time-bound healthcare services and grievance redressal system, the charter guarantees six rights to the clients - to be received, listened to and served with courtesy, promptness, and respect; to be served in a friendly environment; to be provided with clear information, to be given priority to satisfy her/his needs; to complain to higher authorities and to appeal administrative decisions. The charter also mandates the government to collect the feedback from the clients through the citizen feedback form, suggestion boxes at the entrance, outreach activities, hotline services, customer surveys, and complaints systems to make the healthcare system more responsive and friendly to the clients. 

Achievements and Challenges of E-Health and Health Information System in Rwanda

Rwanda’s Health Information System (HIS) is based on E-Health Strategy 2009-13 and Vision 2020. The country has achieved almost complete digitization of the healthcare sector but the reporting of health events/diseases is primarily on a monthly basis. The Ministry of Health has prescribed formats and deadlines for the collection of health data and its submission.

As per the guidelines, health data is recorded in registers and submitted digitally to the system on the 5^th of every month in the health information system. Thereafter, 10 days are provided for data validation, verification, and correction into HMIS without any request. The HIS is automatically locked on the 15^th of every month. This data is then centrally analyzed and published in the form of MOH Annual Statistics Booklet but the booklets are not available after 2016. Followings are the key achievements and challenges of Rwanda’s HIS: 

• Telehealth: Telehealth platform launched under a PPP model by Babyl in 2016 to book doctor’s appointments, pick up prescriptions, and access their medical records via an app that has crossed 2 million users in 2018. According to the report, Rwanda has become the first country in the world to have a digital-first universal primary care service. The mobile-based system Babyl has been upheld as a role model even on global platforms such as the World Economic Forum.
• Through its innovative information technology-based insurance scheme - ‘Mutuelle de Santé - Rwanda achieved 91% of insurance coverage.
• About 90% of Rwanda is covered with broadband infrastructure and about 75% of people have mobile phones in 12.5 million population of which 85% of people live in rural areas.
• Electronic Health Record was introduced in Rwanda in 2005 to control HIV/AIDS which is now being extended to all the health services.
• As per the Rwanda Health Sector Performance Report 2017-19, about 96% of facilities are connected with the internet. Besides, diagnosis, blood donation, testing and pharmacy facilities have also been integrated on the virtual platform through a health information management system. The efforts are also being made to make healthcare services on a real-time basis.

An evaluation study of Rwanda’s HIS titled ‘East African Community Digital Health and Interoperability Assessment 2020’ by Measure Evaluation has pointed towards deficiencies in the HIS of Rwanda. Some of the major loopholes highlighted in the report are as follows:

• Interoperability is a major challenge for Rwanda’s HIS. The e-health TWG (Technical Working Group) had not met for over a year. The key policy document – Digital Health Strategy and Policy 2018 – is in a draft form for about two years.
• Rwanda was one of the first countries to set up a National Health Information Exchange (HIE) under the Rwanda Health Enterprise Architecture project. Although the HIE technology for that project has been dormant for several years, the country is devising plans to revive certain pieces of the architecture as part of the Healthcare Digital Transformation Strategy. The development of the HIE has facilitated the coordination of systems and reduced many silos; however, the HIS still suffers from fragmentation, owing to a lack of data exchange standards and terminologies and uncertain funding for digital health initiatives.
• The shortage of trained human resources such as physicians and nurses is another major problem in the country. This has forced the country to rely on external assistance.

Similarly, an independent study of the HIS in four districts of Rwanda in 2020 has pointed out over-reporting for ANC (Anti-natal care)-related data requiring more complex calculations such as knowledge of gestational age, scheduling to determine ANC standard visits, as well as quality indicators in ANC. This challenge to accurate reporting has implications for decision-making on key interventions affecting maternal and newborn outcomes. Ongoing regular data quality assessments, promoting the use of HMIS data for quality improvement in health care delivery at the facility level, and training to address gaps could help improve HMIS data to be used in program evaluations, suggested the study.

COVID-19 Response of Rwanda

Experience in handling Ebola health warnings due to Ebola outbreaks in the neighboring Domain Republic of Congo (DRC) helped a lot in planning a synchronized COVID-19 Response in Rwanda. It is pertinent to mention that despite sharing terrestrial boundaries with DRC, Rwanda had successfully saved its people from the deadly Ebola epidemic of 2013-16, Ebola pandemic in 2019, and Ebola outbreak in 2020.

It was due to these previous experiences, Rwanda switched into action much before the World Health Organization (WHO) declared it a pandemic on March 11. By March 9, an inter-ministerial COVID-19 Joint Task Force (JTF) was constituted to implement decisions, about one week before the country reported its first case on March 14. This helped the country to communicate with the people efficiently, combat infodemic, and convince people to stay at home during lockdowns. Besides, social media campaigns such as #NtabeAriNjye - roughly translated as “Let it not be me” and #GumaMuRugo – 'a call to stay home' helped in raising awareness against the disease. 

Making the most out of its limited resources, Rwanda also used human resources and machines meant for HIV/AIDS for testing COVID-19. “The main machines we are using for COVID testing are the HIV machines that were (already) there," said Sabin Nsanzimana, Director General of the Rwanda Biomedical Center. “We are using the same structure, same people, same infrastructure and laboratory diagnostics, but applying it to COVID testing,” he added. Besides, the country also increased its testing capacity, contact tracing, and treatment by using health information technologies and availing new ones through international support. The technologies being used in the following four areas of COVID-19 response:

1. Contact tracing: Data Kit Mobile Apps have been made available to collect and analyze mobile-based data to identify high-risk areas.
2. Surveillance: Digital reporting surveillance system is used to screen and monitor the influenza-like illness. Besides, free COVID testing facilities are available throughout the country. The government has also installed ‘walk-in’, and ‘drive-in facilities at the airport and important stations. Besides, Mobile Labs are also conducting random tests of the population. 
3. Awareness: In addition to various media-based activities, Drones have been deployed to commend radio and television messages related to the pandemic to increase awareness.
4. Infection Prevention: Rwanda is among a few countries to install handwashing facilities at public places such as bus stations at the very beginning of the COVID-19 outbreak. Besides, robots were deployed in healthcare settings for contactless temperature monitoring and work as nurses to help spread of the viral disease.
5. Data visualization: Geographic Information System (GIS) is also being used with the help of mobile app data to monitor COVID-19 cases and plan interventions to control the outbreak.

Sharing his experiences of COVID-19, the Health Minister of Rwanda Dr Ngamije M Daniel emphasized comprehensive surveillance strategy and testing facilities including ‘drive-through’ and ‘walk through’ campaigns for random testing. Besides, international help such as PPE Kits and logistics from Dubai and ventilators from the US also helped in boosting the COVID response of Rwanda.

Conclusion and Agenda for Discussion

Rwanda has witnessed a sudden surge in COVID-19 cases during the past few days. It has reported more than 200 cases per day for three consecutive days on 24, 25, and 26 August. This is alarming for the country where COVID-19 cases breached the 100-mark only once on July 1 before the recent spike in mid-August.

Surgo Foundation has ranked Rwanda among ‘very high vulnerable’ countries under its Africa COVID-19 vulnerability index. The country is also ranked poor under UNDP Preparedness Dashboard for having a low number of hospital beds (16), physicians (1.3), and nurses (8) per 10,000 population. These resources are very close to the UNDP standard for a least developed country i.e. 7 hospital beds, 2.5 physicians, and 6 nurses. The number of physicians in Rwanda is 1.3 per 10,000 population which is less than the least developed countries of 2.5 physicians. Besides, the WHO Country Cooperation Strategy Report 2014-18 of Rwanda had also highlighted concerns related to lack of resources, malnutrition among children, up to 70% of malaria burden in eastern border areas, infant mortality among maternal mortality, regional disparity (concentration of health professionals and services in urban areas), and a high burden of HIV/AIDS among others. The WHO has also ranked Rwanda below 75 marks in all the IHR Capacity Progress Report of 2019.

These issues are also being raised by local media. According to a report, the country had only 50 Intensive Care Unit (ICU) beds across the hospitals out of which 14 ICU beds were in the country’s best King Faisal Hospital. The report also highlights a lack of COVID-19 testing and diagnostic facilities. Though the local reports appreciate the efforts of government but highlight that, so far, COVID-19 was limited to the capital city of Kigali and some other urban areas. As Rwanda has limited medical resources for the treatment of high-dependency patients, the country needs to focus on infection prevention. Besides, it also needs to ensure that loads of other diseases such as HIV/AIDS, malaria, cancer, diabetes, typhoid, and immunization of children are not ignored.

Though the health information system is the top priority of the country, the basic data related to the healthcare system are not updated after 2015-16 while key health indicators were not updated after 2016-17 on the website of the Ministry of Health. Besides, MOH Annual Statistics Booklet is not available after 2016.

Shortcomings of Rwanda in data collection, processing, and publication highlight the need for a robust and integrated health management information system (HIMS) which is based on real-time data. This entire system should be integrated through a virtual platform equipped with AI (Artificial Intelligence) technologies, which can enable an automatic system for judicious filtration of data and information at each level. Besides, the decision-makers in Rwanda also need to realize that a health information system needs regular maintenance, up-gradation, training of the human resource, infrastructure support, quick action teams, and integrated supporting supply chain system.

VisionRI's Centre of Excellence on Emerging Development Perspectives (COE-EDP) aims to keep track of the transition trajectory of global development and works towards conceptualization, development, and mainstreaming of innovative developmental approaches, frameworks, and practices.