Five Questions With…Dr Yoseph Mamo and Momoh Jimmy
4 August 2020
This month we caught up with Dr Yoseph Mamo, THET Country Director for Ethiopia, and Momoh Jimmy, THET Country Representative for Sierra Leone, to find out more about the short and long-term challenges that stem from COVID-19 and the lessons that can be learnt from pandemics to build more resilient health systems.
What are the particular challenges faced in your country in relation to COVID-19?
YM: From low testing per capita due to the expensive nature of PCR testing – antibody testing would have been cheaper but this is not yet widely available – to PPE shortages at health facilities, the challenges in Ethiopia are many. Social and physical distancing is a big problem, particularly in big cities and towns where many people live and interact in physically intimate environments. Lockdown is also difficult to implement because a large proportion of the population work in the informal sector where their income is daily. Ethiopia has a very weak health system that is already overwhelmed due to a high demand for health services and a lack of human resources, medicine and other supplies. COVID-19 has compounded this by draining the health budget, with funds being used to source PPE and mechanical ventilators, to set up COVID-19 isolation wards, train staff and paying hazard allowances to staff.
MJ: Sierra Leone has a number of challenges that confronts the nation in dealing with COVID-19. First of those challenges is that we have a weak health system with some of the worst health outcomes in the areas of maternal mortality (1360 /100,000 LIVE BIRTHS (WHO, 2015) and child mortality (Under five 105/1000 live births). This means that referral systems – though recently boosted by the launch of the National Emergency Services – still need to be upgraded as we have weak lab facilities with few PCR machines and limited RDTs for testing. We also have less than 23 Trained Doctors, Nurses or Manpower for every 10,000 of the population. The Health System is therefore weak and under motivated with limited capacity in terms of manpower/staff, supplies and national resources to cover the COVID-19 response. The Government of Sierra Leone (GOSL) has largely depended on donors and other international bodies like the World Bank, GF and the African CDC to support with sourcing test kits, PPE and general logistics. This kind of supply chain is unreliable in a global pandemic such as COVID-19. The country also has a workforce with over 50-60% in the informal sector and this makes it incredibly difficult on the economy to fully comply with lockdowns and such measures needed to stem the spread of the virus. The country should, however, be commended for its swift action to close port entries, initiate state of public health emergency, activate the emergency response structures and commit its meagre resources to the initial response in April 2020. This has helped in stemming the geometric progression in the rise of COVID-19 cases, though it can be argued that more testing needs to be done.
What impact has COVID-19 had on other health services and what sort of impact could this have in the long term?
YM: COVID-19 has had a significant impact on how health services are delivered, much of which is here to stay. For example, staff training mechanisms will become increasingly virtual and there will be greater use of virtual technology for meetings and consultations. COVID-19 has also impacted staff turnover and retention mechanisms and changed protocols for managing all kinds of emerging diseases. The pandemic has improved Ethiopia’s intensive care services and increased the local production of mechanical ventilation and other supplies through frugal innovation. Finally, we have seen a more pronounced involvement of volunteers in the health system, with 12,000 recruited so far.
MJ: COVID-19 has indeed had an impact on other health services. For example, according to outpatient records, there was a 30-40% reduction in the use of secondary and tertiary facilities by mid-June. This meant that possible TB patients and patients with respiratory illnesses similar to the presentation of COVID-19 were not picked up for treatment. The Government also had to divert resources that could have been used in treating malaria, for instance – one of the leading causes of child mortality in Sierra Leone – to the fight against COVID-19. Nurses and doctors who would have been working in hospitals have had to be moved to treatment centres and isolation centres and this has caused even further stress on the country’s health system.
How has COVID-19 affected the most vulnerable?
YM: The poor have been hard hit due to the slowing of the economy, their income has declined and their supply of food and other basic necessities has decreased. Child and domestic abuse has reportedly increased due to greater time being spent in the home and increasing levels of stress and tension. Additionally, the quality of care provided to patients with non-communicable diseases (NCDs) and other chronic disease has decreased due to competition for human resources for health, along with logitistical and supply challenges.
To find out more about the impact of COVID-19 on NCD care in Ethiopia, catch up on the following webinars:
Leaving No One Behind – Essential Services for NCD Patients in Ethiopia during COVID-19
COVID-19 and NCDI Poverty Knowledge Exchange.
MJ: This is a country where 60% of the population live on less than 2$ a day and 60% of the total population live in rural areas where there is the lowest concentration of trained medical professionals. The most vulnerable population groups, such as the homeless and people living on less that one dollar a day, and those with special health conditions found it difficult to survive during the inter-district lockdowns from May – June 2020 since movements and business activities were limited. The Government, however, did roll out a National Commission for Social Action (NACSA) program funded by the World Bank to provide Le 1,300,000 (130$) for vulnerable populations and this has helped to lessen the impact of COVID-19 on the poorest of the poor.
How can we use past and current pandemics as an opportunity to build more resilient health systems?
YM: The current pandemic has highlighted the importance of establishing early warning and reporting systems on a national and international level, setting up community level early warning and tracing systems, and training and deploying more community health agents as mechanisms for building more resilient health systems as we move forward.
MJ: The Ebola pandemic was the first public health tsunami that tested the very weak health system in Sierra Leone, resulting in thousands of deaths because the country was unprepared for an outbreak of this nature. These pandemics have influenced the way I work in the sense that I have advocated for a more holistic approach to Resilient Health Systems Strengthening (RSSH). I now advocate for more investments in cross cutting RSSH issues, such as having and investing in a Health Emergency Directorate, investing in Human Resources for a well-motivated health sector, proper labs and testing facilities, community health systems, strong and responsive supply chain systems, mental health and psychosocial support systems, social support systems that take care of the most vulnerable, and strong co-ordination systems. In addition, the current pandemic has shown us how to work remotely and virtually and has made clear that strong communication facilities are essential in responding to health emergencies.
What more needs to be done to support health workers now and in the future?
YM: In addition to providing adequate personal protective equipment (PPE) to keep health workers and patients safe, we need to increase access to psychosocial support, such as stress management and self care techniques for frontline staff, while also working to minimise stress and prevent burnout at the institutional level by limiting hours of work, implementing duty rotation and providing counselling services. Providing a special hazard allowance, nutritional support and financial or guest house expenses for those who want to decrease the risk of exposing family and loved ones to COVID-19 and other contagious diseases are also key steps.
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