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As the Director General of a provincial hospital, what is your experience on the frontline of the COVID-19 pandemic? 

Rwamagana Provincial hospital is in the Eastern Province of Rwanda and is located by the Rusumo-Kigali national road where a lot of truck drivers from Tanzania drive through. This traffic has contributed to the increase of COVID-19 cases in Rwanda and has put tremendous pressure on the hospital response team and the Rwamagana District COVID-19 Command Post. From 14 March this year, when the first case of COVID-19 was declared in Rwanda, every administrative district was requested to initiate the COVID-19 Command Post at hospital or district level for three main roles: 

• To ensure that every health facility has well-equipped and self-contained isolation rooms. 
• To design and follow up on COVID-19 mobilisation and prevention strategies.
• To facilitate the contact tracing as directed by the National Command Post.

The Command Post has five working cells that coordinate activities.

• Duty cell oversees both national and local calls (calls within the Rwamagana district). 
• Communication cell drafts and follows up the communication of COVID-19 messages to the population 
• Planning cell ensures daily and future organisation of the Command Post.
• Epidemiology and Operations cell is composed of doctors, nurses and lab technicians that constitute the Rapid Response Team (RRT). This cell is involved in all activities related to screening, contacts tracing, management of isolated/quarantined patients.
• Logistics and Administration cell avails the needed facilitation for command post activities such as transport.

Key recipes of success at hospital level were clarity of the mission as communicated by the Ministry of Health, committed local leadership, flexible financial management to accommodate unplanned expenditures and devoted healthcare workers. As a hospital director, leading in COVID-19 times was another learning experience. 

In your opinion, what are some of the main challenges healthcare workers in your country face in tackling COVID-19? 

COVID-19 is a public health emergency of international concern which surprised the healthcare system in Rwanda. When we were busy implementing the preventive measures against the Ebola virus that was ravaging the eastern part of Democratic Republic of Congo, COVID-19 came as a surprise without prior knowledge of its epidemiology, transmission mode, clinical presentation, and management as a novel disease.

The greatest challenge healthcare providers faced is misinformation, lack of information and conspiracy theories about COVID-19. The next challenge which later became somewhat of an opportunity was the confusion between Ebola and COVID-19 trainings. We thought that if you were trained to fight against Ebola it was enough to deal with COVID-19. It was true on one hand but not true on the other given the mode of transmission of COVID-19.

When the lockdown measures were implemented, most healthcare workers at hospitals were obliged to be accommodated near the workplace to be part of the rapid response team and the Command Post. This has affected the mental health status of some   healthcare workers. The workload has also increased while responding to the COVID-19 pandemic. In addition to routine work of the hospital, health workers were scheduled to participate in preventive measures such as temperature screening, facilitating hand washing practices, surveillance, information, behavior change and communication. As well as, organising the patients to ensure social distancing and to be part of the rapid response team.

At the beginning of the pandemic, medical supplies such as PPEs, face shields, test kits and masks were not enough which put a certain pressure on health workers when they were asked to respond. When the testing kits were only reserved for suspected cases, some healthcare workers who wanted to visit their families were afraid to go to their homes fearing that they may be infected and could infect their family members.  

How have you and your team adapted to manage this pandemic?

At the technical level, managing this pandemic was successfully facilitated by: 

• Early trainings of a critical mass of healthcare providers on Infection Prevention and Control measures, COVID-19 case definitions and Rapid Response attitude during an outbreak. 
• Joint coordination at district level between hospital leadership, local administration and security organs ensured smooth functioning of the COVID-19 Command Post.
• Clear communication of guidelines every two weeks from the Prime Minister’s office has ensured the entire country is fighting the same fight with the same methodology and at the same pace.
• Continuous engagement of the population via social media, radio and TV, and mobile megaphones has increased the population discipline to implement lockdown measures, social distancing, and the utilisation of masks.
• Free services (transport, accommodation, food catering, sample testing, sample transportation to National Reference Lab and treatment of other conditions) for all COVID-19 suspect cases have increased the confidence and acceptability of the population to be isolated at hospital premises.
• Every morning, there was a COVID-19 command post meeting at the district level where sitreps of coronavirus infection were discussed globally, nationally and locally at the district level. From deliberations at the meeting, followed the implementation of the meeting’s decisions. 

How can African countries work to strengthen their health systems in order to mitigate the impact of any future outbreaks? 

As highlighted by The Sustainable Development Goals Centre for Africa, even before COVID-19, many African nations reported incredibly low health indicators. The challenges were numerous such as poorly-equipped health facilities, shortage of human resources for health, inaccessibility of health facilities mainly in poverty-stricken rural areas, ineffective service delivery of essential interventions, lack of research facilities and inadequate health financing system. African leaders must design a new health model that answers the above challenges. 

As discussed by Bloom and Cadarette in ‘Infectious Disease Threats in the Twenty-First Century: Strengthening the Global Response’ - there is a need for  a new model because recent outbreaks such Ebola, Zika, dengue, Middle East respiratory syndrome, severe acute respiratory syndrome, and influenza have shown that current strategies do not  prepare the countries to effectively protect and promote the human health in case of outbreak. They further highlighted that, to damage the entire world, COVID-19 has benefited from urbanisation, globalisation, climate change, civil conflict, and the changing nature of pathogen transmission between human and animal populations. 

No health system was ready for COVID-19. In addition to COVID-19 challenges, some of leaders on the continent do not share the same vision to combat t COVID-19, and for those with an evidence-based mindset, they face challenges of limited resources. To mitigate the dangers of any future outbreak, the key word is leadership. Leadership that values people’s health. Leadership that gives room to research scientists and collaboration between peers on the continent. Well educated and informed population will ease public health interventions. If a leader can learn from the damage caused by Ebola in Guinea, Liberia, DRC and Sierra Leone, the current disaster brought by COVID-19, then he/she will design a new modus operandi that will protect  their people from any future outbreak. It all comes back to accountable leadership.

What are your hopes for the future of healthcare in Africa?

In Rwanda, the aftermath of the 1994 Genocide against the Tutsi was a challenging period. Rwanda was a failed state with hopelessness, with neither statehood nor nationhood. Had there not been selfless and strong leadership, Rwanda would have been a forgotten land.

To survive, Rwandans have chosen to be together, to be accountable and to think big. The aftermath of COVID-19 in the world is not different from the period after WWII or the Rwandan share of the period after the Genocide. The only hope for survival relies on the choices that will be taken by African leaders and the support of their people. COVID-19 has shown gaps in all sectors not only in healthcare. The education system in Africa could not easily continue at home using technology, the vulnerable people could not easily get food during lockdown periods and access to other basic needs was heavily affected. 

The future of healthcare will be seen in a mix of addressing other challenges left by COVID-19. During the pandemic, healthcare workers did a tremendous job. They risked their lives to save humanity. Their limited numbers and scarce resources put their lives and that of their patients in danger. As discussed by Dare and Buch in ‘The future of health care in Africa’, the budget allocated to health by African governments must exceed 15% of the total budget that was once agreed in Abuja in 2003. For African countries to build strong healthcare systems in the future they need to work together. They must build strong research centers where clinical trials for drugs and vaccines can easily take place without shipping the samples abroad. Regional centers of excellence would be a great idea to develop homegrown guidelines and protocols for African health challenges. Africans must think big in terms of investing in healthcare technology. After COVID-19 - medical tourism abroad was not possible during the pandemic - I am hopeful that our African leaders will make sure we have state-of-the-art health facilities well equipped and with well-trained doctors and other  healthcare providers always ready to respond to any health threat.