Using Implementation Science to Understand Rwanda's Success in Dropping Under‐5 Mortality

Abstract

Research ObjectiveTo understand how and why Rwanda implemented Evidence‐Based interventions (EBIs) faster than similar countries to reduce amenable U5 mortality (U5M) and contextual factors which facilitated or hindered success.Study DesignExplanatory mixed methods study using an implementation research (IR) framework adapted from existing frameworks (Exploration, Preparation, Implementation, Sustainment expanded include Adaptation (EPAIS), and Consolidated Framework for Implementation Research) to guide literature and document review, and key informant interviews with health care managers and leaders, implementers and policy makers.Population StudiedNot applicable.Principal FindingsRwanda effectively used a 5‐step process to determine the need for and strategies to implement EBIs to address leading causes of death (Table). Critical strategies included rapid uptake of emerging EBIs, stakeholder engagement, donor, and partner coordination based on national plan, data use for decision making, including research when needed, and integrating into and building on existing systems and primary care. Facilitating contextual factors included leadership commitment to health and primary care, existing community health worker program, culture of data use and accountability, donor and partner resources, and national equity agenda. Rwanda was able to implement (feasibility) with high coverage (reach) key EBis including vaccinations, facility delivery, and PMTCT with high acceptability. U5M dropped by 74 percent, from 196 deaths per 1000 live births in 2000 to 50 deaths per 1000 live births in 2015.ConclusionsThrough strategic and stepwise process, Rwanda was able to achieve rapid and broad implementation of life‐saving interventions to reduce U5M. The lesson learned offer transferable knowledge to help other countries accelerate U5M reduction.Implications for Policy or PracticeUsing IR adapted to the study aims is effective in emerging generalizable lessons and knowledge needed for other countries to more effectively implement EBIs and reduce U5M.Primary Funding SourceBMGF and Gates Ventures.