Category: Add Resources – Research & Development

Rwanda has raised the bar in using digital tools to scale up community-based testing in its COVID-19 response. 

A national Joint COVID Task Force, established in February 2020 before the first case was confirmed, led the pandemic response of this African country. The team gave both high-level strategic guidance and day-to-day operational support. 

This had, however, been preceded by years of investment in the broader digital health infrastructure, where digital technologies were expanded to support service delivery – a longstanding government priority.

Institutions in Rwanda were therefore able to combine resources and capacities to respond to emerging problems.  Adopting a multi-sectoral approach from the start has allowed rapid deployment of interventions and more efficient troubleshooting.

It also helped the country to build COVID-specific digital systems to strengthen the areas of testing, contact tracing, patient support and surveillance. 

Rwanda’s numbers

First registered COVID-19 case: 14 March 2020
14 March 2021: more than 20 000 cases diagnosed, with mortality rate of 1.4%

Sharpest peak in cases: late 2020 and early 2021. This prompted stringent restrictions on movement that led to a rapid decline in new cases.

Testing the toolbox

Rwanda has used District Health Information Software (DHIS-2) to survey and monitor disease since 2011 and, in early 2020, this system was adapted to capture data on COVID-19 diagnosis and case management. 

DHIS-2 is integrated with the laboratory information system which allows for automated transmission of data. 

COVID-19 Command Posts, the sub-national operational centres of the Joint COVID Task Force, receive and analyse surveillance data from these different systems to inform policy and programme decisions. 

Rwanda also devised a stringent port of entry system to avoid importing COVID-19 cases. 

Other technologies were deployed in selected settings, including the internal Visitor Tracking Record and the e-ASCOV pilot, a locally developed application to help give access to rapid antigen testing.

Patient-facing tools

• WhatsApp help line 
• Unstructured supplementary service data (USSD) platform, which provides basic information on COVID-19 on any phone with no data or airtime requirements
• WelTel app, where patients can report symptoms
• Standard electronic medical record (EMR) system 
• Online results portal
• Open Data Kit (ODK) application which captures data for targeted surveillance activities outside of health facilities, particularly in hotspots. 

Impact of digital tools 

The use of digital tools in Rwanda has had a significant impact.  For example, through integrating laboratory and health management information systems, the testing process is now paperless. All facilities capture data in the same central system. 

Patient unique health codes (UHCs) also allow data transfer between different digital solutions. This cuts down the time taken by health care workers to record and report data, as it is captured in real-time at the point of care. 

Application programming interfaces have also been developed for a number of tools to enable interoperability. 

Mobile-data collection tools for community-based surveillance have generated valuable insights to inform timely responses to outbreaks. 

Monitoring cases and contacts remotely using digital tools has reduced the burden on the health system. This has allowed the country to focus limited capacity on delivering services to the most at-risk individuals, while consistently monitoring other patients.

Key success factors in Rwanda

• Pre-existing digital infrastructure  
• Political will, with digital infrastructure bolstered by political commitment at the highest levels of government
• National ownership of systems, minimising the challenge of isolated pilots, duplicate interventions and “data fog”
• Building on existing tools
• Multisectoral collaboration
• Providing patients with direct access to results. 

Challenges

The lack of readiness of health care workers to adopt new digital tools can be a barrier to successful implementation. 

This is worsened in a crisis such as COVID-19, where systems are already overwhelmed with new protocols and interventions. 

Resource requirements are also unpredictable due to the rapidly evolving nature of the pandemic. 

It is important to coordinate decisions on selection of digital tools from among numerous vendors.

KEY INSIGHTS

• Ensuring integration of national COVID-19 data (public and private sector) into one platform enhances understanding of the pandemic and simplifies data management. 
• Leveraging databases in other areas can minimise the time and effort required for individual data capture. 
• Digital tools, particularly on mobile devices, are key in providing decentralised testing services. 

While Rwanda is still in the early stages of rolling out its approach, it shows potential to expand and standardise testing outside of health facilities. 

India’s digital ecosystem for COVID-19 management has centred around Aarogya Setu – Sanskrit for “Bridge to Health” – a public-facing mobile application designed in response to the pandemic. 

Software engineers, epidemiologists, statisticians, social scientists and legal experts from across India started to work with the Indian government to develop a digital response to the pandemic in March 2020.

The resulting systems, new digital tools as well as adapted existing tools, aimed to help test-trace-isolate (TTI) programme activities, predict emerging hotspots and identify high-risk individuals in need of targeted testing. 

This case study examines how India leveraged these digital solutions in their COVID-19 response.

India’s numbers

First confirmed COVID-19 case: 28 January 2020.

1 March 2021:  11-million cumulative cases detected from 227-million tests. 

15 March 2021: 2,19,262 active cases, a cumulative recovery rate of 96.7% and death rate of 1.4%.

The digital backbone of Aarogya Setu 

Aarogya Setu, the backbone of India’s COVID-19 management strategy, is a mobile application launched on 2 April 2020. By November 2020, it had 170 million registered users, or 13% of the country’s population.

Users download the app free and register using their mobile number, following which a de-identified identification (DID) is generated to enable anonymised transfer of their data in the system. It captures two key sets of data:

• Self-reported symptoms – for case management and hotspot mapping 
• Location (via Bluetooth) for contact alerts

Aarogya Setu then scores user risk based on exposure to confirmed cases to determine who is at high risk of infection and should be prioritised for testing. Based on this, follow-up actions are recommended: Caution, Quarantine or Test.

Information on high-risk individuals is also transmitted to the Ayushman Bharat call centre, which follows up with them by phone to support linkage to testing and care.

Within the first eight weeks of the app’s introduction, more than 900 000 users identified through the algorithm had been contacted. 

India’s response also leveraged the pre-existing electronic infrastructure of Ayushman Bharat, the National Health Authority (NHA) scheme to provide free healthcare to 500-million citizens. 

The IT-enabled Integrated Hotspot Analysis System (ITIHAS) uses syndromic data submitted by Aarogya Setu users to map future hotspots. This in turn informs targeted testing strategies.

ITIHAS also generates hotspot predictions using the historic location data, based on cell phone tower signals, of confirmed positives diagnosed in the Indian Council of Medical Research (ICMR)’s network of approved labs. 

Digital tools: the benefits 

Digital health solutions can help address high-priority gaps, particularly in India, which has high overall digital maturity and a rapidly evolving digital health landscape. 

Digital solutions tailored to support the integration and/or bundling of tests provide an opportunity to identify at-risk patients earlier and intervene faster. 

Practical ways to scale

India’s government has established a positive and enabling environment for ICT intervention in health. 

In August 2020 the country launched the National Digital Health Mission, in which every Indian was due to receive an electronic health account in the form of a mobile application.

Challenges

Despite its digital maturity, India’s health system is underfunded, with government healthcare spending only 0.96% of its GDP. 

This is lower than spend in other low- and middle-income countries (1.3%), and BRIC countries (3.0%). It contributes to a lack of adequate public health services, especially in rural areas. 

India’s population relies heavily on private health providers, in the face of an under-resourced and unregulated health system, skilled staff shortages and disparate management systems.  

KEY INSIGHTS

India has an increasingly low-cost and fast digital infrastructure, with high mobile phone penetration and growing smartphone penetration. This has enabled extensive use of the Aarogya Setu mobile app.

As mobile penetration and ICT literacy in India is growing rapidly, scale-up of digital health tools will be necessary to optimise the nation’s limited resources, bridge inequity in healthcare access and strengthen the availability of quality diagnostics.