Working towards resilience in a long-suffering health system
Since the Ebola crisis, Guinea has taken steps to help its severely tried health system struggle back towards a semblance of normality. Important challenges remain and the existing gains are now threatened by the COVID-19 pandemic. German technical cooperation, with co-financing from the European Union, is supporting Guinea’s efforts to deal with this new crisis.
‘We are suffering more with this coronavirus than we did with Ebola!’ exclaims Amara Camara, a young nursing student in Faranah (a day’s journey from Guinea’s capital Conakry) whose studies were interrupted by the state of emergency declared on March 27. ‘At least with Ebola, people could still go out and work and go to the market.’ The barriers around Conakry, the epicentre of the epidemic, block farmers like his brother from sending their products to their principal market. At the same time, they prevent essential supplies from reaching the rest of the country. To make up for the loss in family income, his older sister, a seamstress, has taken up sewing cloth masks. She travels from village to village with her sewing machine over bumpy trails scarred from the last rainy season. Amara is using his involuntary vacation to work as intern in a health centre 40 km from Faranah.
‘It’s the malaria season, but people fear they’ll be infected by the virus if they come to the health centre. To reassure patients, one of us stands at the entrance, covered from head to toe with protective materials left over from the Ebola epidemic, and verifies the temperature of everyone who comes in with an infrared thermometer. We already lack protective equipment and are often obliged to reuse masks and gowns. We have a hard time telling the difference between malaria and COVID-19, since fever is a main symptom of both. If we suspected someone of having the virus, they would have to go all the way to Conakry to be tested.’
Guinea, like the rest of the world, was surprised by COVID-19
The virus most likely arrived in the country through visitors from abroad and Guineans who are in a position to travel internationally. The country’s first deaths included the Secretary General of the Government and the Director of the Electoral Commission, leading to a popular perception of the coronavirus as a ‘rich people’s disease’.
The authorities reacted by putting the Agence Nationale de Sécurité Sanitaire (ANSS), an emergency structure created at the time of Ebola, in charge of the response. The international borders – as well as gathering places such as mosques, bars and restaurants – were closed, and seven testing sites were established in Conakry. An overnight curfew was installed countrywide, masks were imposed as obligatory, and police started checking vehicles to make sure they were not transporting more than the allotted number of passengers. Roadblocks were set up in an attempt to keep the virus from spreading outside the capital city. In reality, however, those with the means to negotiate their escape have been scattering into the seven other regions, where they are feared to be disseminating the virus.
Tests and protective equipment for health personnel and the population are in short supply, and urgent attempts to procure them have been launched by the Government and its technical and financial partners. By the 6th of July, 34 people had succumbed to the virus in health facilities, while the number of confirmed cases has climbed to 5610 – and testing is not yet available outside the capital.
As time passes, it becomes increasingly difficult to enforce social distancing measures. As in other low-income countries with a majority of citizens earning their living in the informal sector, people cannot avoid crowding in markets and public transport, and social events such as baptisms, weddings and funerals, organised in bustling residential courtyards, take precedence over avoiding a disease that practically no one has encountered first-hand. People say that social distancing is ‘alien’ to their culture.
A second major epidemic in just four years!
West Africa’s Ebola epidemic raged from 2014 to 2016. In Guinea, whose health system was already severely impaired by years of political and economic instability, the disease killed over 2500 citizens and decimated its health personnel, forcing closure of 94 health centres and even one district hospital.
Guinea’s response to Ebola received strong support from international partners, and certain assets from that earlier epidemic – such as the ANSS and a network of treatment centres for epidemic diseases that were built in each district – are still available to strengthen the response to COVID-19. Another resource is the significant number of epidemiologists and laboratory technicians trained during Ebola who can now be enlisted to tackle the challenges of the new coronavirus.
Yaya Souaré of the Reproductive and Family Health Programme supported by Germany and the European Union summarises: ‘At the time of Ebola, district and regional teams for disease surveillance were set up and equipped. Many facilities were provided mobile phones and computers, and all hospitals were given ambulances. Any masks, gowns or other protective equipment now being used by health facilities in the regions have been left over from the earlier epidemic, while waiting for new supplies to arrive. Our programme is reinforcing mobility and communication of the district and regional health authorities with tires and mobile phones. Most health facilities have been able to revive the hand-washing facilities set up at their entrance at the time of Ebola and our programme is providing hygiene kits to 150 health centres.’
The Programme Santé de la Reproduction et de la Famille / Programme d’Appui au Renforcement du Système de Santé (PSRF/PASA2) is implemented by the Deutsche Gesellschaft für Internationale Zusammenarbeit GmbH (GIZ) on behalf of the German Federal Ministry for Economic Cooperation and Development (BMZ) with co-financing from the European Union. As part of ‘Team Europe’, GIZ’s contribution to Guinea’s overall response to COVID-19 is coordinated with the development agencies of the other EU member states, including France and Belgium. GIZ is focussing in its intervention regions on decentralised coordination of the response, health communication and infection control, including support to cross-border surveillance with neighbouring countries. This dimension, initiated by PSRF at the time of Ebola, is complementary to support being provided to ANSS through GIZ’s Regional Programme ‘Support to Pandemic Prevention in the ECOWAS Region’ based in Nigeria.
What changes have occurred since Ebola that can facilitate the response to the new epidemic?
A major change since 2016 has been an explosion in the use of mobile phones and people’s access to internet and social media. This has greatly facilitated communication among health professionals and with citizens. PSRF/PASA2 has been using classical means as well as social media to reach youth with messages on reproductive health. In response to COVID-19, the programme is promoting community initiatives to curb the spread of coronavirus in Guinea and debunk rumours about it. In addition, it has developed COVID-19 modules combining Frequently Asked Questions (FAQ) and information about the disease for health professionals and the general public. An online course for the francophone region is being developed for Atingi, a BMZ-supported e-learning platform.
The programme’s longstanding support to digitalising Guinea’s health information system and its human resource management is paying off in the current crisis. According to Dr Tidiane Barry, Deputy Director for Hospitals and Hygiene in the Ministry of Health, ‘Getting complete health data from the decentralised structures in real time will make all the difference when it comes to mastering the COVID epidemic. And the same goes for our new digital management of human resources: It gives us a clear picture of who is working where and with what qualifications. This is crucial for mobilising appropriate personnel in the response to COVID, for instance for the upcoming extension of testing to four regional hospitals.’ Guinea’s public health services have been reinforced through recruitment of some four thousand additional health staff since the Ebola epidemic.
The government sees continuity of healthcare as a priority
When planning the response to the looming COVID epidemic, the Ministry of Health remembered the catastrophic effects the Ebola epidemic had on the regular functioning of the health system. In the face of this new emergency, continuity of healthcare – despite COVID-19 – is therefore seen as a priority.
Dr Tidiane Barry is eager to preserve and extend the recent advances in the quality of healthcare delivery that have been achieved through the ‘Improved Monitoring’ approach which the Guinean-German programme has piloted in four districts, accompanied by sociological and economic research to ensure that the approach is adapted to the local context and sustainable in the long term. Inspired by the ‘Concours Qualité’ developed in the early 2000s under a predecessor project, this simplified approach harnesses the power of digital data processing and is planned to be interoperable with the Health Information System’s DHIS2. The idea is that health facilities use a specially developed app (MApro) to assess the quality of their work via a set of well-chosen indicators including inputs from patients, and are ‘counter-monitored’ every six months by the district and regional levels. MApro is to be upgraded to a national electronic web-based platform by the end of this year. The results of the pilot were to be officially presented just at the time that COVID struck, but there are strong indications that the Ministry plans to progressively roll out the Improved Monitoring as its new quality management system.
Strained relations between population and health personnel
Despite the Ministry’s objective of maintaining continuity of care, use of health services has plummeted by 50% since the start of the epidemic. As in other countries, fear of contamination keeps patients from coming to health facilities for essential curative and preventive care. In Guinea, however, problems between health personnel and community can run deeper. According to a doctor in charge of a health centre near Conakry, ‘With the coronavirus, we health workers don’t dare venture out into the community, even to do vaccinations, let alone awareness-raising. It’s too dangerous: people think that we have come to infect them, like at the start of the Ebola epidemic, when eight of our colleagues were killed in Nzérékoré.’
The tragedy of Nzérékoré, which got international media attention, was not an isolated incident. A number of health providers were attacked by the population, and their health centres demolished – the expression of a long-smouldering fury against the Government. Although the population’s cooperation was crucial for mastering the Ebola epidemic, in many cases those in charge of the response did not communicate with them as essential partners, but rather obliged them to conform to measures whose relevance was not explained to them.
It is possible that a similar dynamic might be playing a role in the current ‘disappearance’ of many people tested positive for COVID-19. Reputedly, some give false telephone numbers and subsequently cannot be traced, which also makes it difficult to trace the people they have been in contact with. Time and improvements in the health system do not yet appear to have healed the population’s distrust of their health personnel. This should be of vital concern for both the management of the epidemic and the future of the health sector.
Partnering with local and traditional resources to promote health
Where they mistrust their government structures, the population lends all the more credibility to traditional networks and resources. The current and previous German-supported programmes have therefore not just worked with health service providers but also with communities and their traditional leaders. PSRF has been a major supporter of the Government’s new policy on Community Health, and since April has massively enlisted different types of community health workers to spread information on COVID prevention in over 30 rural districts. Religious leaders join with health professionals to reinforce the message via interactive radio broadcasts.
A GIZ advisor who during the Ebola epidemic was part of a mission to Guinea, recalls how traditional healers were trained on the virus and on effective outbreak containment measures. ‘The healers beamed with pleasure as they received their certificates, but above all they appreciated being treated as capable resource persons. Following that training they started to use their community networks to share correct information about the epidemic. They were no longer competitors but became reliable partners in the fight against Ebola.’
In the same spirit, the German-supported programme has been working with a collective of singers (Collectif Africa Stop COVID-19) for its current awareness-raising campaign. Griots – traditional singers, historians and news broadcasters – are a dynamic institution in Guinea. Their art is passed on from generation to generation within certain families. When the PSRF/PASA2 team was contacted by the group, including some heirs of the griot tradition, the programme seized the opportunity. The video and sound clip, which includes the participation of Miss Guinea 2019, is being broadcast over a variety of public and private TV and radio channels. Using beloved traditional rhythms and melodies to promote COVID-19 prevention is likely to echo and bring the message home.
Hope and determination despite an uncertain future
ANSS is embarking on an ambitious community response plan for Conakry: ‘Stop-COVID-19 in 60 days’. The Ministry also knows it cannot keep the virus from spreading to the interior – some cases have already been confirmed far from Conakry. With the recent co-financing of the European Union, the German-supported programme is now active in five of Guinea’s seven rural regions. Building on its longstanding approach of working simultaneously at central, regional and grass-roots levels, the programme is determined to pull its weight in mobilising communities and Guinea’s health services to muster a comprehensive response to COVID-19. Dr Tidiane says, ‘I know we can count on German development cooperation, our historic partner, to continue to support the quality and security of our health services.’
For Amara and his family there have been some changes. So many free masks have meanwhile been distributed by NGOs and the authorities, that Amara’s sister stopped producing them and returned to generating a small income with sewing jobs for her neighbours. Amara has found it difficult to survive in the health centre, which has no budget to compensate him and his fellow volunteers for their work: ‘I prefer to return home to Faranah and hope my school reopens soon. I want to become a good nurse and contribute to better health in my country.’
Dr Mary White-Kaba, July 2020