KIGALI – When COVID-19 started going global in the early months of 2020, developed countries struggled to keep the virus at bay, and many began to worry about the ability of African countries to withstand the pandemic. Experts from around the world issued dire predictions, warning that the region’s weak health systems would be decimated. Yet as we look back on the first nine months of the pandemic, it is clear that African countries have not only survived, but also offered lessons about how to manage similar crises in the future.
Here in Rwanda, our health system had to be completely rebuilt after the 1994 genocide against the Tutsi, when one million people were murdered. Just 26 years later, the country is widely seen as a world leader in responding to the pandemic. Projections for January 1, 2021, have the COVID-19 death toll in the United States surpassing 330,000 (out of a population of around 330 million), while Rwanda’s stands at just 62 (out of a population of 12.3 million).
Rwanda’s success in fighting COVID-19 should lead us to rethink many assumptions about what it takes to build a strong health system. For example, Rwanda does not have an abundance of ventilators or intensive-care-unit beds, but it does have a system built on equity, trust, community participation, and patient centrism. By making evidence-based decisions, learning from the lessons of our past, and following the example of other successful countries, Rwanda has defied expectations and shown that any country can keep its citizens safe with the right strategies and leadership.
The pandemic has reinforced an idea that we teach at the University of Global Health Equity (UGHE): that an equity-based approach to health care is the best way to ensure public health more broadly. When the Rwandan national government instituted a countrywide lockdown in mid-March, it coordinated with village leaders to distribute essential foodstuffs to tens of thousands of households in need. Because those who could not work did not face the prospect of hunger, they were able to abide by the lockdown, thus keeping themselves, their loved ones, and the rest of us safe from the virus.
The government also took steps to ensure that the most vulnerable populations were tested, quarantined, and treated free of charge. And those who tested positive could rely on public support, including food and lodging.
Rwanda’s health system follows a decentralized model that emphasizes prevention and care at the community level, thus ensuring geographic equity and access. Each village has a team of elected Community Health Workers who understand the specific needs of their constituencies. Since the pandemic emerged, the country’s 60,000 CHWs have assisted the Rwanda Biomedical Centre, the institution leading the nationwide response, in educating citizens on prevention measures, identifying vulnerable populations in need of support, conducting contact tracing, and following up on discharged patients who have received two negative test results.
This decentralized yet integrated approach has helped Rwanda achieve the highest level of public trust of any health system in the world. Nearly all Rwandans are confident that vaccines guaranteed by UNICEF and the World Health Organization are safe and effective. As a result, since 2011, the country has nearly eliminated the risk of cervical cancer among Rwandans aged 12 to 23 by administering the HPV vaccine to girls.
Meanwhile, some Western countries have struggled to get their citizens to abide by public-health guidelines as basic as wearing a face mask in public, owing to a widespread loss of trust in institutions and expertise. If the COVID-19 pandemic has shown anything, it is that public trust is a strong determinant of public health. A country can have the most advanced medical technologies in the world, but if its people do not have faith in their government or public-health institutions, the value of these assets will be squandered.1
As climate change and human encroachments continue to disrupt natural systems, the risk of another zoonotic disease outbreak will only increase in the years and decades ahead. It is therefore critical that we learn from the mistakes and the successes of the COVID-19 crisis, in order to be better prepared for future prevention and treatment needs.
In Rwanda, we used what we learned from the 2014 and 2018 Ebola outbreaks in neighboring countries, and the steps we took to prevent the epidemic from entering our country, to guide our response to COVID-19. Hence, there was a rapid push to train CHWs and educate the public on basic sanitation and hygiene. But since every epidemic is different, this is an ongoing process. With each new challenge comes new innovations, knowledge, and strategies to strengthen the existing system and prepare for the next outbreak.
Moreover, training and public education must be refreshed and updated with each new generation of disease detectives and global health experts. That is why we at the UGHE are training students from around the world in epidemic and pandemic preparedness and response, and in managing outbreaks equitably through a “One Health,” community-based approach. By aligning education with health-sector demand, we can ensure that health professionals are providing the services their communities need, and that they are graduating with the leadership skills, knowledge, and entrepreneurial drive to innovate and adapt.
As Rwandan and other African health leaders reflect on the lessons of the COVID crisis thus far, so, too, should their Western counterparts. The countries that have struggled to contain the virus and its economic effects should reorient their health systems to serve their communities’ needs. All countries should be thinking critically not just about available resources and technologies, but also about issues of equity, access, and public trust.
The pandemic is yet to be defeated. But while many Western publics are succumbing to skepticism and doubt in themselves and their own leaders, Rwanda has protected the vast majority of its citizens from the virus and built up even more trust in its health-care model. The same principles underlying that model could help to save lives in better-resourced and wealthier countries, both today and in the future. The hope now is that all other countries will adopt a Rwandan-style approach, for we are all only as safe as our most vulnerable neighbors in the global community.