What the World Can Learn About Effective COVID-19 Response from Rwanda, Kerala, and Germany
A comparative look at how three different parts of the world curbed an early spread of coronavirus.
Dayna Fischer
July 16, 2020
What do Rwanda, the small Indian state of Kerala, and Germany have in common when it comes to coronavirus? Although they are located on three different continents, differ in culture, population size, and economic wealth, they have succeeded on the global scale to contain the spread of COVID-19 in the first quarter.
However, it is how they are staying ahead of the curb that makes them similar. These three locations show that the success is arguably not related to GDP, urban versus rural, or small versus large populations. Instead, the common theme is the practice of universal and decentralized health care, public trust in government, and quick deployment of track, trace, test and support.
Rwanda
Rwanda, a country that was torn by genocide just twenty-five years ago has had a low number of infection and success in their response to coronavirus. Rwanda’s population of 12 million people earn an average of $801 USD per capita in 2019. The population is young and mostly rural; however, these factors have seemingly not had a large effect on the low rate of infection. Rwanda’s decentralized, community-based health care system has taken pressure off the hospital system, and instead, put the focus on prevention delivered through community health workers.
Rwanda’s program to train community health workers began in the mid-nineties as a part of the country’s development strategy. The program was initially created to deliver reproductive health services. By 2005, there were 45,000 community health workers, and by 2014 that number increased to 60,000. 80 percent of health care is delivered at the district level or below. Community health workers fill a significant gap in the health care workforce. They provide primary care services to the people that inhabit nearly 15,000 villages throughout Rwanda.
Each village has 3 to 4 community health workers, elected by their communities. CHWs have not only helped destigmatize the use of contraceptives, increasing use from 5.7 percent to 47.5 percent from 2000–2015, they played a significant role in decreasing the rate of maternal deaths by 84 percent, as well as increasing public confidence in the government to provide health care. In 2019, Rwanda ranked highest in a survey of 140 countries in trust in their hospitals, health clinics, and health care system.
When coronavirus broke out in Rwanda, the community health care system and infrastructure was ready, and public trust was in place. Aggressive testing and tracing was performed and facilities to self-quarantine and food were provided for those potentially at risk of infection.
The spread of the virus has largely been contained. In the first month, the rate of infection grew from two to 132. In June, the total number of reported infections was 582. As of July 14, 2020 the total number of confirmed coronavirus cases in Rwanda was just over 1,200, which is significantly lower than other places with a similar population size.
India
India also practices a decentralized health care system. States are mostly responsible for delivering health care, but are required to provide universal access to health care services. Kerala is a southern state with a population of 34 million people and a GDP per capita of $2,674 USD. The state is known for its high literacy rate, long life expectancy, and a properly funded public health system. Each of the 1,670 villages in Kerala have a health clinic, doctors, and paramedics.
The initial positive result in containing coronavirus transmission has largely been credited to the quick response of Kerala’s Minister of Health and Social Welfare, KK Shailaja. The former teacher successfully handled the Nipah virus in 2018, and acted immediately when she read about ‘a virus in China’ back in January. After seeking the expertise of the medical deputy about the likelihood of the virus reaching Kerala, she quickly gathered the state’s rapid response team for a meeting. Within days, a control room was set up in all fourteen districts in Kerala.
When the first case of COVID-19 appeared in the state seven days later from a passenger coming off of a flight from Wuhan the state had already adopted The World Health Organization’s process of test, trace, isolate, and support procedure. Each passenger’s temperature was taken as they got off the plane. COVID-19 pamphlets had been printed and handed out. People with a fever were taken to the hospital and quarantined.
Even when one family returning to Kerala from Italy in January refused to comply with health procedures, the state managed to stop an early outbreak. The family had been in contact with hundreds of others by the time they were tested and found positive for the virus. The response team acted immediately and manually traced the family’s steps and posted the results online. 300 people who had been in contact were tested and those infected went into quarantine.
Kerala’s Chief Minister, Piranyi Vijayan communicates current information through daily meetings and Twitter, and grassroots community health efforts play a large role in slowing the spread. Quarantine facilities are being provided in empty schools and houseboats. School children have continued to receive meals delivered to their homes throughout lockdown. The elderly and people living alone are checked on regularly. People in quarantine receive phone calls twice per day.
In April, Kerala had a total number of reported infections of 524. As of July 12, 2020 the total number of cases reached 7,873. Despite a low rate of infection in the first quarter, Kerala is seeing an increase in new cases as airports have reopened and possibly other factors, such as an increase in diseases that occur during monsoon season.
Germany
Germany has also received high praise for their initial response to COVID-19. A country with a population of 83 million people, and a GDP per capita of $46,258 USD in 2019 has a universal, multi-payer health care system. The federal minister of health credits the initial success to the strong health care infrastructure, quick response to the threat of the virus, and a large number of labs able to handle a high volume of testing.
The country saw what happened in Northern Italy and took the virus seriously. They began testing and tracing almost immediately after the virus became a threat. By early March, 2020 80,000 tests were administered per week. By May 1, 2020 400,000 tests were completed each week. According to the federal ministry of health, they will soon be able to perform around 1 million diagnostic tests per day and 5 million antibody tests per month.
Government and health officials earned public trust through transparent dissemination of information, and open discussion of how to best manage the social effect of the pandemic. When non-essential businesses, schools, and large gatherings were closed in March, people were willing to cooperate. Stay at home and physical distancing recommendations were followed. The country also has a well funded public health system with many labs able to perform testing, along with plenty of ICU beds.
However, Germany is also seeing new cases continue. Spikes have been seen, especially in some dense areas where physical distancing recommendations are not being adhered to. The number of reported infections was 6,933 in late March, 2020. As of July 12, 2020 the total number of coronavirus cases in Germany was 198,963.
Conclusion
Although it would be nice to tie a bow around the virus and say it is all under control, the reality is, COVID-19 is fast moving and is still not completely understood. It is not possible to draw conclusions at this point. It can be seen that even the best health care systems need to remain vigilant. Although these countries were successful in slowing the spread in the first quarter, they are dealing with the challenge of containing the spread as their societies reopen.
Key Takeaways
What can be learned is the effectiveness of community health systems in collaboration with government systems, as well as how public trust in government, and moving quickly to test and trace prevented an early surge in each of these areas.
For other parts of the world that are still trying to get to baseline, these examples show an effective course of action. For the general public, trust and cooperation with health guidelines for physical distancing, wearing a mask in public, and washing hands is key to slowing the spread as we move forward. The sooner we all get on board, the sooner things will get better.
In good health. MT
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