According to the World Health Organization (WHO), infectious diseases are the leading cause of death worldwide [4]. The emergence and re-emergence of infectious diseases is a global challenge that affects all countries, including Rwanda [1]. Factors that contribute to the emergence and re-emergence of infectious diseases include virus mutations and recombination, population growth, urbanization, human population movement, hunting and pasture practices, agricultural practices and deforestation, globalization of commerce, human social behavior, and environmental factors such as global warming [2, 3]. The International Health Regulations (IHR) 2005 is a legally binding instrument whose purpose and scope are to prevent, protect against, control, and provide a public health response to the international spread of disease. It requires countries to have the capacity to detect, assess, notify, and report any events through the early warning, alert, and response (EWAR) function of a national surveillance system [4].
Effective surveillance systems are a vital component of a comprehensive public health infrastructure, as they act as watchful eyes and attentive ears of disease control efforts. These systems systematically gather, analyse, and interpret data to offer essential insights that can guide health policies and strategies. The importance of surveillance systems in the field of healthcare cannot be overstated. They provide timely information about disease trends and health-related events, which helps individuals respond quickly to public health threats. Additionally, they help in evaluating the effectiveness of public health interventions and monitoring the progress of health programs. As a result, they contribute significantly to global health security. The effectiveness of a health system in controlling disease and maintaining population health is largely dependent on the performance of its surveillance system. [6, 7]
There are two main approaches to health surveillance systems: indicator-based surveillance (IBS) and event-based surveillance (EBS). IBS is a traditional method that involves regularly collecting data on disease occurrence. Healthcare providers or labs often report specific diseases or conditions to track long-term trends, allocate resources, and measure performance. In contrast, EBS collects information about events that could indicate a disease outbreak or public health risk. These events are often detected from sources outside traditional health reporting channels, such as news reports or community rumours. The EBS is more sensitive and timelier, allowing for quicker responses to potential health threats. Many countries pursue a balanced approach to IBS and EBS, leveraging the strengths of both systems while mitigating their respective limitations. [8–9].
Rwanda faces a continuous risk of epidemic disease transmission. Factors contributing to this risk include its high population density (525 per km2), location in a region prone to epidemic diseases, and easy domestic and international travel or population movements, including tourism promotion, healthcare infrastructure, climate, and various socioeconomic factors. Rwanda is a landlocked country located in East-Central Africa. It is bordered by Uganda to the north, Tanzania to the east, Burundi to the south, and the Democratic Republic of the Congo to the west. In the near past, the region has been affected by the Ebola outbreak (DRC and Uganda), Marburg outbreak (Tanzania), cholera (Burundi), polio (Burundi and DRC), RVF (Rwanda and Tanzania), and other listed transmissible diseases [13, 14, 15, 16].
In Rwanda, the history of surveillance systems is closely tied to the country's progress in public health. After the genocide in 1994, Rwanda's health infrastructure had to be reconstructed from scratch. Despite this challenge, Rwanda achieved significant progress, including the introduction of an effective indicator-based surveillance (IBS) system. With help from international partners such as the WHO, Rwanda launched an electronic Integrated Disease Surveillance and Response (eIDSR) in 2012 that formed the foundation of the IBS system. The IBS is an intricate framework integrated into the broader DHIS-2 network, linking all health facilities across the country. It consistently gathers, consolidates, and examines data from numerous public health surveillance indicators, which aid in public health planning, monitoring, and evaluation.
Although IBS is well established in Rwanda, event-based surveillance (EBS) is still in its early stages. However, recognizing the importance of a comprehensive surveillance approach, there have been efforts to establish an EBS system to complement the existing IBS. By adopting EBS, the country's ability to detect and respond to new and emerging health threats in real time will be significantly improved. This will provide a strong early warning system for disease outbreaks.
While Rwanda has commendably implemented a comprehensive indicator-based surveillance (IBS) system, the public health landscape calls for constant evolution and adaptability. Despite the strengths of IBS, its limitations may hinder the country's ability to promptly detect and respond to new and emerging health threats. There is a growing recognition that for a surveillance system to be optimally effective, IBS should be complemented with event-based surveillance (EBS). However, in Rwanda, EBS has yet to be fully implemented and integrated into the existing health surveillance framework.
Therefore, the purpose of this study was to perform a robust evaluation of Rwanda's current IBS system based on key attributes such as completeness, timeliness, acceptability, simplicity, flexibility, representativeness, data accuracy, data use, usefulness, and feedback. By highlighting the challenges and gaps in the IBS system, this paper aims to underscore the need for a more balanced surveillance approach that integrates and strengthens EBS within the health system. Through such a blend of IBS and EBS, Rwanda can ensure a more responsive, comprehensive, and efficient surveillance system that is better prepared to safeguard public health in an ever-changing disease landscape.
The approval to conduct the study was obtained from the Rwanda Biodemical Centre as part disease surveillance evaluation. Informed consent was obtained from all subjects involved in the study. Data was de-identified to maintain confidentiality. The study adhered to principles of respect for persons, beneficence, and justice outlined in the Belmont Report.