The impact of Covid-19 on malaria services in three high endemic districts in Rwanda: a mixed-method study

Abstract

Background Rwanda has achieved impressive reductions in malaria morbidity and mortality over the past two decades. However, the disruption of essential services due to the current Covid-19 pandemic can lead to a reversal of these gains in malaria control unless targeted, evidence-based interventions are implemented to mitigate the impact of the pandemic. The extent to which malaria services have been disrupted has not been fully characterized. This study was conducted to assess the impact of Covid-19 on malaria services in Rwanda. Methods A mixed-methods study was conducted in three purposively selected districts in Rwanda. The quantitative data included malaria aggregated data reported at the health facility level and the community level. The data included the number of malaria tests, uncomplicated malaria cases, severe malaria cases, and malaria deaths. The qualitative data were collected using focus group discussions with community members and community health workers, as well as in-depth interviews with health care providers and staff working in the malaria programme. Interrupted time series analysis was conducted to compare changes in malaria presentations between the pre-Covid-19 period (January 2019 to February 2020) and Covid-19 period (from March 2020 to November 2020). The constant comparative method was used in qualitative thematic analysis. Results Compared to the pre-Covid-19 period, there was a monthly reduction in patients tested in health facilities of 4.32 per 1000 population and a monthly increase in patients tested in the community of 2.38 per 1000 population during the Covid-19 period. There was no change in the overall presentation rate for uncomplicated malaria. The was a monthly reduction in the proportion of severe malaria of 5.47 per 100,000 malaria cases. Additionally, although healthcare providers continued to provide malaria services, they were fearful that this would expose them and their families to Covid-19. Covid-19 mitigation measures limited the availability of transportation options for the community to seek care in health facilities and delayed the implementation of some key malaria interventions. The focus on Covid-19-related communication also reduced the amount of health information for other diseases provided to community members. Conclusion The Covid-19 pandemic resulted in patients increasingly seeking care in the community and poses challenges to maintaining delivery of malaria services in Rwanda. Interventions to mitigate these challenges should focus on strengthening programming for the community and home-based care models and integrating malaria messages into Covid-19-related communication. Additionally, implementation of the interrupted interventions should be timed and overlap with the malaria transmission season to mitigate Covid-19 consequences on malaria.

Impact of the COVID-19 pandemic on malaria cases in health facilities in northern Ghana: a retrospective analysis of routine surveillance data

“…As another consequence of the COVID-19 pandemic, the provision of rapid diagnostic tests for malaria was fragile, which may have led to under-diagnosis of cases [ 42 ]. The main explanation for the lower number of malaria cases seen in health facilities was limited access to health facilities – public transportations were unavailable or unaffordable, and health facilities were closed or only provided reduced services [ 43 , 44 ]. This is supported by findings from a study from Rwanda which showed that health facility visits for malaria decreased while community health services for malaria increased [ 43 ].…”

“…The main explanation for the lower number of malaria cases seen in health facilities was limited access to health facilities – public transportations were unavailable or unaffordable, and health facilities were closed or only provided reduced services [ 43 , 44 ]. This is supported by findings from a study from Rwanda which showed that health facility visits for malaria decreased while community health services for malaria increased [ 43 ]. Finally, reports of hesitancy to visit health facilities due to fear of getting infected with COVID-19 were common [ 37 , 42 ].…”

The COVID-19 pandemic in the African continent

“…In Kwazulu Natal, South Africa, there was a 36% decline in clinic attendance and 50% decline in hospital admissions of children in April–June 2020, although the changes were less for the hospital births and testing of HIV-exposed infants. Although short-lived, there was a 47% increase in neonatal deaths in May 2020 [ 202 ]. In Rwanda, there was a reduction in malaria testing in health facilities among patients by 4.32 per 1000 population while testing in the community increased by 2.38 per 1000 population monthly, due to challenges and delays in accessing care at facilities [ 203 ].…”

Sustaining surveillance as an intervention during the COVID-19 pandemic in Cabo Verde and implications for malaria elimination

“…Factors that may influence the likelihood of testing include symptom presentation, prevalence of the illness, availability of testing or treatment supplies, the ability of the health facility to manage COVID-19 as well as other common diseases, amongst others ( 9 , 10 ). A study in Rwanda found that there was a reduction in malaria testing at health facilities during the pandemic but increases in community-based testing ( 11 ). In contrast, a study in Uganda found that there was little impact on malaria testing early in the pandemic, but that there was a slight reduction in testing observed as the pandemic progressed ( 12 ).…”