Genomic sequencing of SARS-CoV-2 in Rwanda reveals the importance of incoming travelers on lineage diversity.

COVID-19 transmission rates are often linked to locally circulating strains of SARS-CoV-2. Here we describe 203 SARS-CoV-2 whole genome sequences analyzed from strains circulating in Rwanda from May 2020 to February 2021. In particular, we report a shift in variant distribution towards the emerging sub-lineage A.23.1 that is currently dominating. Furthermore, we report the detection of the first Rwandan cases of the B.1.1.7 and B.1.351 variants of concern among incoming travelers tested at Kigali International Airport. To assess the importance of viral introductions from neighboring countries and local transmission, we exploit available individual travel history metadata to inform spatio-temporal phylogeographic inference, enabling us to take into account infections from unsampled locations. We uncover an important role of neighboring countries in seeding introductions into Rwanda, including those from which no genomic sequences were available. Our results highlight the importance of systematic genomic surveillance and regional collaborations for a durable response towards combating COVID-19.

Early changes in intervention coverage and mortality rates following the implementation of an integrated health system intervention in Madagascar.

INTRODUCTION: The Sustainable Development Goals framed an unprecedented commitment to achieve global convergence in child and maternal mortality rates through 2030. To meet those targets, essential health services must be scaled via integration with strengthened health systems. This is especially urgent in Madagascar, the country with the lowest level of financing for health in the world. Here, we present an interim evaluation of the first 2 years of a district-level health system strengthening (HSS) initiative in rural Madagascar, using estimates of intervention coverage and mortality rates from a district-wide longitudinal cohort. METHODS: We carried out a district representative household survey at baseline of the HSS intervention in over 1500 households in Ifanadiana district. The first follow-up was after the first 2 years of the initiative. For each survey, we estimated maternal, newborn and child health (MNCH) coverage, healthcare inequalities and child mortality rates both in the initial intervention catchment area and in the rest of the district. We evaluated changes between the two areas through difference-in-differences analyses. We estimated annual changes in health centre per capita utilisation from 2013 to 2016. RESULTS: The intervention was associated with 19.1% and 36.4% decreases in under-five and neonatal mortality, respectively, although these were not statistically significant. The composite coverage index (a summary measure of MNCH coverage) increased by 30.1%, with a notable 63% increase in deliveries in health facilities. Improvements in coverage were substantially larger in the HSS catchment area and led to an overall reduction in healthcare inequalities. Health centre utilisation rates in the catchment tripled for most types of care during the study period. CONCLUSION: At the earliest stages of an HSS intervention, the rapid improvements observed for Ifanadiana add to preliminary evidence supporting the untapped and poorly understood potential of integrated HSS interventions on population health.

In Madagascar, Use Of Health Care Services Increased When Fees Were Removed: Lessons For Universal Health Coverage.

Despite overwhelming burdens of disease, health care access in most developing countries is extremely low. As governments work toward achieving universal health coverage, evidence on appropriate interventions to expand access in rural populations is critical for informing policies. Using a combination of population and health system data, we evaluated the impact of two pilot fee exemption interventions in a rural area of Madagascar. We found that fewer than one-third of people in need of health care accessed treatment when point-of-service fees were in place. However, when fee exemptions were introduced for targeted medicines and services, the use of health care increased by 65 percent for all patients, 52 percent for children under age five, and over 25 percent for maternity consultations. These effects were sustained at an average direct cost of US$0.60 per patient. The pilot interventions can become a key element of universal health care in Madagascar with the support of external donors.

Baseline population health conditions ahead of a health system strengthening program in rural Madagascar.

BACKGROUND: A model health district was initiated through a program of health system strengthening (HSS) in Ifanadiana District of southeastern Madagascar in 2014. We report population health indicators prior to initiation of the program. METHODS: A representative household survey based on the Demographic Health Survey was conducted using a two-stage cluster sampling design in two strata - the initial program catchment area and the future catchment area. Chi-squared and t-tests were used to compare data by stratum, using appropriate sampling weights. Madagascar data for comparison were taken from a 2013 national study. RESULTS: 1522 households were surveyed, representing 8310 individuals including 1635 women ages 15-49, 1685 men ages 15-59 and 1251 children under age 5. Maternal mortality rates in the district are 1044/100,000. 81% of women's last childbirth deliveries were in the home; only 20% of deliveries were attended by a doctor or nurse/midwife (not different by stratum). 9.3% of women had their first birth by age 15, and 29.5% by age 18. Under-5 mortality rate is high: 145/1000 live births vs. 62/1000 nationally. 34.6% of children received all recommended vaccines by age 12 months (compared to 51.5% in Madagascar overall). In the 2 weeks prior to interview, approximately 28% of children under age 5 had acute respiratory infections of whom 34.7% were taken for care, and 14% of children had diarrhea of whom 56.6% were taken for care. Under-5 mortality, illness, care-seeking and vaccination rates were not significantly different between strata. CONCLUSIONS: Indicators of population health and health care-seeking reveal low use of the formal health system, which could benefit from HSS. Data from this survey and from a longitudinal follow-up study will be used to target needed interventions, to assess change in the district and the impact of HSS on individual households and the population of the district.

Managed care and private health insurance in a global context.

This article provides an overview of the current role of private health insurance and private care management organizations around the globe. We describe past experiences and challenges associated with the export of U.S.-style managed care. We provide a framework for understanding the potential opportunities within a national health system for expanding managed care approaches and also private health insurance more generally. This article is relevant to both the United States and members of the international community.