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COVID-19 is testing national health systems on an unprecedented scale. The response to the pandemic, including prevention, detection, and treatment, has placed difficult and often dangerous demands on frontline health care workers, health officials, and other essential workers, and has challenged policymakers around the globe.

Researchers are currently examining how the crisis and the response, including the diversion of resources, may indirectly impact other areas of public health ¹ . We believe one key area that should not be overlooked is the health of children.

Although the direct effects of COVID-19 on children seem to be less severe than on adults, it poses a significant indirect threat to children’s health by disrupting the delivery of routine health services such as immunization. We have seen this before. The 2013 and 2019 Ebola outbreaks resulted in decreases in key maternal and child health interventions, including antenatal care, vaccinations, and treatment-seeking for diarrhea and acute respiratory infection ² . The result was an estimated increase in under-five mortality (U5M) that ranged from 10–28 percent in affected countries ² .

Some are predicting similar consequences from the COVID crisis ³ . Recent models predict disruptions that could potentially double malaria deaths in 2020 and lead to an excess of 500,000 AIDS-related deaths in sub-Saharan Africa by 2021 ⁴ . Specific to child mortality, other studies are already projecting reductions in coverage of key child and maternal health interventions (facility-based delivery, vaccinations, bed net distribution, and vitamin A supplementation) ⁵ and a corresponding projected increase of over 500,000 child deaths in the next year ⁵ . These sobering projections highlight the need to build resilient health systems capable of maintaining health interventions through strategies to adapt to COVID-related disruptions in demand and delivery, while integrating new services in response to new threats.

However, the aforementioned health impacts are not a foregone conclusion. The “Exemplar” countries of U5M reduction (highlighted throughout the Exemplars in Global Health web platform) offer important insights which may help countries accomplish these aims. Countries such as Rwanda, Senegal, and Peru have demonstrated resilience through crises, and in doing so have leveraged certain key factors to their success. Which, if any, of those strategies might help countries trying to respond to the threat posed by COVID-19?

We focus on four strategies that stand out as especially important for achieving a resilient health system that is capable of responding to the current pandemic and maintaining coverage of key interventions known to reduce U5M.

A. Clear national plan driving rapid response

The first lesson is the importance of a well-coordinated and clearly articulated national plan for the rapid adoption of interventions, including nationally-led collaboration with partners and clear channels of communication ⁶ . Among the Exemplar countries we studied, Rwanda demonstrated this effectively. After the genocide in the 1990s, Rwanda made a strong commitment to reducing U5M and established a clear vision for the health system, including an emphasis on primary health care and horizontal integration. The country aligned donors and partners with this vision, and ensured successful implementation at the local level through performance contracts to ensure accountability.

Today, Rwanda has leveraged these capacities in their response to COVID-19. The government was successful in preventing two Ebola outbreaks in 2013 and 2019 and is applying learnings on multisectoral coordination and a national contact tracing program to the current pandemic ⁷ . Rwanda took quick action in mid-January, implementing national policies to screen travelers for COVID and test suspected cases, in an effort to get ahead of the problem ⁷ . After Rwanda’s first case of COVID was identified in mid-March, the government quickly launched contact tracing, COVID-19 testing, and declared a national lock-down ⁷ . At the local levels, the country has established handwashing stations at transport hubs and strictly enforced national social distancing policies ⁸ . Local officials have also been trained and equipped with fever scanners to monitor high-risk exposure areas ⁹ .

Rwanda’s success in reducing U5M and their decisive action in response to COVID-19 show the importance of a clear national plan for rapid response, including alignment of international, national, and local stakeholders towards this plan. These learnings have enabled Rwanda to swiftly respond to changing circumstances in the interest of continuously improving quality of the response. These lessons can be applied by other countries looking to build a resilient health system that can manage COVID-19, continue delivering child health interventions, and minimize subsequent increases in mortality from other causes.

B. Using data for decision-making

A second theme from the Exemplars research is the importance of using data to inform the development and execution of a clear national plan for rapid response. In the context of COVID-19, this entails leveraging existing data systems (e.g. surveillance systems) to help identify where testing and other inventions are needed and to track changes in the spread of the virus.

Senegal is one of the Exemplars that demonstrated this lesson effectively. In the 2000s, Senegal built upon their polio surveillance systems to monitor and respond to measles cases. Today, in their response to the pandemic, Senegal again has shown strength in surveillance, quickly establishing laboratories to conduct testing, and through developing rapid testing diagnostics ⁸ . As a result, they have outpaced the testing rates of wealthier African countries like Morocco and Kenya ¹⁰ .

Senegal’s ability to repurpose existing data systems provides lessons that countries today can use to build a resilient health system that is capable of responding to COVID-19 and protecting the health of children.

C. Leverage community health workers to engage communities

In conjunction with using data for decision-making, it is important for countries to effectively disseminate these decisions to communities. This can be accomplished through community health workers.

Once again, Senegal demonstrated this effectively in their campaign to reduce U5M. The country recognized that data systems and data-driven interventions must be relevant and acceptable to local communities. Towards this end, Senegal mobilized the bajenou gokh community health cadre, comprised of older women who are respected by the community. The bajenou gokh cadre helped with promotion of maternal, neonatal, and child health, and provided antenatal care, postnatal care, and child immunizations. Moreover, much of Senegal’s monitoring and surveillance has also been done by trained community health workers, who report suspected cases of notifiable diseases to district nurses.

Senegal has continued this emphasis on community engagement in their COVID-19 response today. Together with their surveillance and testing efforts, the country has leveraged religious leaders to help reach and educate local communities, while simultaneously developing evidence-based standards and guidelines for treatment to improve quality of care provided ⁸ .

Senegal’s emphasis on pairing data use for decision-making with effective community engagement provides lessons that countries can use to build a resilient health system capable of more effectively responding to COVID-19 and protecting the health of children.

D. A focus on equity

Finally, another key theme from the Exemplar countries is the importance of a focus on equity, which can be assessed along many dimensions, including geographic, gender, ethnic, and wealth equity. In today’s context, equity is especially relevant. As an example of wealth equity, the shutdown of public transportation in response to COVID has made it challenging for both the poor and for healthcare workers to travel to health facilities, resulting in “dramatic reductions in essential public health and clinical interventions”, including a 69% reduction in measles, mumps, and rubella vaccination in children [and] a 21% reduction in institutional deliveries in some countries ¹¹ . In addition, early studies are finding that minority ethnicities have a higher risk of both COVID-19 case rates and mortality, showing an example of how COVID-19 is affecting equity among different ethnicities ¹² .

Many Exemplar countries demonstrated how to account for equity, by adapting strategies to different groups based on the impact of diseases and corresponding health system responses on these groups. One example is Peru, which prioritized low-income areas for the initial rollout of key child health interventions, including rotavirus, Haemophilus influenzae type B, and pneumococcal conjugate vaccines, rather than focusing on populations that were the easiest to reach.

Moreover, the country developed the Juntos conditional cash transfer program to address inequity and alleviate inter-generational transmission of poverty, by improving access to health services and education. The program, aided by strong data management systems, initially focused on low-income households, but later broadened its scope to consider equity along other dimensions, including households with lower women’s literacy and households with limited access to appliances, fuel sources, and public services ¹³ . As conditions for the cash transfer, families were required to send their children to primary school and take them to routine health care visits, and pregnant mothers were required to attend six antenatal care visits. In this manner, Peru addressed a twofold challenge of reducing poverty and other inequities while simultaneously improving uptake of interventions to reduce U5M.

Today, Peru has adopted an equity lens in its response to COVID-19. Peru has given a voucher of 380 soles (~US$111) to those whose job and income have been adversely affected by COVID-19 ¹⁴ . In addition, Peru has approved loans to struggling businesses and spending programs totaling 12 percent of the country’s GDP, one of the largest in the world on a percentage basis ¹⁵ .

Peru’s example of focusing on equity and dismantling barriers to healthcare access are another key attribute of a resilient health system that can deliver essential services during and after times of crisis ⁶ . An equity lens in responding to the current pandemic will ensure that vulnerable groups are accounted for and prioritized in the response, to improve their access to COVID-19 testing and ensure continued access to essential primary care services.

At the moment, much energy is being spent on a direct response to the pandemic. At the same time, it is also critical to ensure that health systems maintain delivery of essential services, including key maternal and child health interventions, and that people are able to access these services.

To minimize the disruption to primary care caused during and after health shocks, countries can learn from the strategies we have highlighted ⁶ . A number of these strategies link to domains that are hypothesized as integral to the resilience of health systems, namely integration across sectors and stakeholders, awareness of health threats and available resources, and an ability to adapt to meet population needs ¹⁶ . While the examples shown here and throughout the Exemplars in Global Health platform highlight how to build components of a resilient health system, we look to other work to define the full spectrum ⁶ .

Overall, the study of the Exemplars illustrates how to work towards resilient health systems in the midst of responding to COVID-19. Some of the most salient lessons include establishing a national plan for rapid response, leveraging data and community health systems, and accounting for equity; beyond this, the Exemplar country narratives offer both insights and nuances beyond those depicted here.

The challenge of responding to the pandemic while maintaining essential child health services is daunting, but learning from success stories can help smooth the road ahead.

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