THE LONG READ
Lilosa Muti’s 6-week old baby, Joshua, was due to have his rotavirus and Penta vaccine, which protects against diphtheria, tetanus, whooping cough, polio and other serious diseases. But Lilosa had no intention of taking him to his appointment at the health clinic at Bikita Rural Hospital in Masvingo Province, Zimbabwe.
“l was scared my son might be infected with COVID-19 if he visited the hospital. We have had 3 reported COVID-19 cases in Bikita and rumour has it one of the cases had visited the hospital before,” explained Lilosa.
Thankfully, a village health worker spoke with Lilosa and allayed her fears. Two days later, she visited the hospital where she was surprised to learn that all services were available. On arriving, Lilosa and baby Joshua underwent the COVID-19 pre-screening process before the appointment and then Joshua received all his vaccines.
Claretta Majova, a specialist in integrated management of childhood illness, was the nurse on duty. She followed the standard operating procedures during COVID-19, including Infection Prevention and Control (IPC), as prescribed by the Ministry of Health and Child Care (MoHCC). She also took the opportunity to disseminate messages to encourage behaviours that reduce the transmission of COVID-19. She expressed concern about the general lack of attendance.
“We have experienced a huge decrease of clients coming to the hospital for essential services such as vaccines. This has been due to the national lockdown, which restricted movements in March, 2020. In addition, the communication gap in Bikita was filled with misinformation, which led residents like Lilosa to not visit the hospital to vaccinate her baby,” said Claretta.
This situation is replicated right across Zimbabwe, with a decline in people accessing essential services in health facilities in all 10 provinces. Yet these are crucial for their health and wellbeing.
Lilosa Muti’s 6-week-old baby, Joshua, getting vaccinated at Bikita Rural Hospital, Zimbabwe. 2020
WHO, with support from the Universal Health Coverage Partnership, has worked closely with the MoHCC and provided technical assistance to strengthen the delivery of essential health services at rural, district and provincial health facilities prior to and during the COVID-19 pandemic. The MoHCC, with technical guidance from WHO, developed a tool to monitor disruptions of the delivery of essential health services caused by industrial action. The MoHCC conducted a field test and trained health workers to use the tool before it was adopted and implemented.
As a result of the routine monitoring tool, the MoHCC was able to receive data that enabled them to identify and address the challenges affecting delivery of essential health services. For example, they embarked on integrated outreach and ensured health care workers had access to much-needed personal protective equipment (PPE) according to the findings of the IPC assessment. The routine monitoring of health services report was used to inform the prioritization of fieldwork on the Rapid Assessment of continuity of essential services and to triangulate the results of the assessment.
Village health workers and primary health care (PHC) outreach efforts are communicating with communities to reassure them about the safety and need to access essential services.
“We envisioned having a system that gives us real-time data; a robust weekly routine monitoring system that rides on an existing system, in this instance the District Health Information System, forming part of the weekly disease surveillance report,” said Dr Kangwende, Director of Monitoring and Evaluation, MoHCC.
Zimbabwe is among the 115 countries and areas to which the UHC Partnership helps deliver WHO support and technical expertise in advancing UHC with a primary health care approach. The Partnership is funded by the European Union (EU), the Grand Duchy of Luxembourg, Irish Aid, the Government of Japan, the French Ministry for Europe and Foreign Affairs, the United Kingdom – Foreign, Commonwealth & Development Office and Belgium.
Chitse Clinic health care workers providing deworming pills during MoHCC National Mass Treatment Campaign for bilharzia and intestinal worms, also known as Mass Drug Administration, at Chitse Clinic in Mount Darwin. 2020
Protecting people and health workers
Providing essential health services during a crisis like the COVID-19 is a challenge, even in well-developed health systems. All countries deeply affected by the pandemic have struggled. For Zimbabwe, as elsewhere in Africa, the need to continue non-COVID-19 services such as immunization, access to medicines, sexual and reproductive health including treatment of HIV, and diagnosis and treatment of non-communicable diseases (NCDs) is vital.
“Equity is a key concern. COVID-19 has the greatest impact on communities that are already vulnerable and marginalized, especially those with high levels of diseases and which have less access to essential health services. The principles of UHC still hold in a pandemic. We must always meet the health needs of the most vulnerable at all times,” said Dr Alex Gasasira, WHO Representative in Zimbabwe.
Frontline health workers and patients also need to be protected in times of crisis but this is not an easy task. Providing safe health services during a pandemic requires PPE for health workers, proper entrance screening for COVID-19 and triage systems for patients. However, according to a survey WHO conducted in Zimbabwe, 22% of all health facilities did not have this screening point in place and 25% of facilities lacked an isolation room. Where facilities did have screening points, some were devoid of health workers or had inadequate supplies of PPE.
Even before COVID-19, the Zimbabwean health system already faced serious challenges with health workforce shortages, low staff morale and infrastructure in need of upgrading. The impact of COVID-19 was further compounded by protracted industrial action leading to the disruptions of primary health centre provision in Harare and some other provinces.
WHO Country Representative, Dr Alex Gasasira (right) handing over clinical equipment to support the COVID-19 response from the African Development Bank to MoHCC Deputy Minister, Dr John Chamunorwa Mangwiro (left). 2021
Preparation and response to COVID-19
Zimbabwe reported its first case of COVID-19 on 20 March 2020. Within one year, the country has recorded 36,717 cases and 1,516 deaths as of 23 March, 2021.
For a country like Zimbabwe, which had a weakened health system, the public health response was a challenge. The COVID-19 pandemic exposed gaps in even the most advanced economies, demonstrating even more how the resilience of all countries to cope with emergencies depends heavily on the strength of their health systems. WHO supports countries to strengthen health emergency preparedness capacities before a crisis even occurs.
Zimbabwe, under the International Health Regulations (IHR) 2005, had reported on its capacities to develop and maintain core public health capacities by completing the State Party Self-Assessment Annual Report in both 2018 and 2019. In 2018, the government also conducted a simulation exercise to help develop, assess and test its capabilities to respond to outbreaks or public health emergencies and conducted a multi-sectoral Joint External Evaluation to identify critical gaps in the health system.
When COVID-19 arrived in Zimbabwe, the government developed an emergency response and preparedness plan comprising 8 pillars, one of which was case management and continuity of essential health services. It aimed to ensure that essential service delivery did not grind to a halt as a result of the pandemic.
To support Zimbabwe on this front, WHO, through the UHC Partnership, collaborated with a range of Global Health Initiative partners including UNICEF, UNFPA, UN Women and Africa Centres for Disease Control and Prevention.
“To mitigate the impact of COVID-19, the MoHCC with support from UNICEF, WHO and other partners have developed and rolled out service continuity guidelines which include integrated outreach services across all 10 provinces to compliment community-based services offered by village health workers. The integrated outreach activities use the primary health care approach to bring services closer to people. It is anticipated that owing to the scale up of integrated outreach services (commencing September 2020 as a COVID-19 response measure) the essential services indicator coverage will continue to improve to pre-COVID-19 levels,” said Dr Paul Ngwakum, UNICEF Zimbabwe Chief of Health and Nutrition.
In October 2020, with support from the UHC Partnership and other partners, the MoHCC conducted a national rapid assessment of the continuity of essential health services in all 10 provinces of Zimbabwe.
The assessment sought to identify the state of service delivery in communities and any bottlenecks to effective service provision for both COVID-19 cases and other essential services. It also reached out to provincial and district implementers with technical support to solve the related problems they were experiencing.
The assessment found a decline in access to essential health services in all 10 provinces as a result of COVID-19. Overall, 6% of all health facilities were completely closed, and 86% reported a decline in attendance. Reasons for the decline of service use included the general situation of the national lockdown and the spread of misinformation, along with fears of catching COVID-19 at health facilities circulating among community members. Health workers were also afraid of contracting COVID-19, exacerbated by a lack of PPE and information. Inadequate capacity and a failure to provide outreach services to the population also heightened the problem.
A woman getting her family planning pills at Mpilo Hospital in Bulawayo. 2021
Information-driven systems help improve access to essential health services
In August 2019, prior to the pandemic, WHO, through the UHC Partnership, worked with the MoHCC to develop a tool for the weekly routine monitoring of health services. This was a means to track the continuity of essential health services. WHO trained MoHCC staff at central, provincial and district hospitals and at primary care facilities on how to use the weekly routine monitoring tool.
When the COVID-19 outbreak began, the MoHCC, with support from WHO, updated and adapted the tool to the new context. This followed requests from several partners for rapid assessments. However, the MoHCC needed a robust and sustainable system, building on the existing system. The tool collects information from all primary and secondary health facilities nationwide including data on work attendance by health personnel, patients visits to outpatient and casualty emergency departments, patient admissions to hospitals, major operations, renal dialysis sessions, family planning services, postnatal care, institutional and complicated deliveries and antenatal care attendance. It further collects data on institutional and community deaths, immunization and vitamin A supplements, tracer medicines status and tuberculosis diagnosis. It also finds information on HIV testing and viral load, COVID-19 testing and availability of PPE.
Ideally, the weekly routine monitoring of health services report forms part of the weekly disease surveillance report and meetings that are conducted to help identify disruption in service provision and appropriate interventions that can then be instituted with examples of good practice shared across health facilities. On a quarterly basis, in-depth explanatory and exploratory analysis is done.
WHO supporting MoHCC National Mass Treatment Campaign for bilharzia and intestinal worms, also known as Mass Drug Administration (MDAs) at Chitse Clinic in Mount Darwin. 2020
Life-saving decisions rely on robust and timely data
COVID-19 is a strong reminder that the continuity of essential health services needs to be part of a pandemic response and ensuring health security. Protecting the most vulnerable in times of calm or crisis is one of the core principles of UHC, and relies on equitable and resilient health systems. People having the right information at the right time makes all the difference in saving lives, providing treatment and preventing disease. Monitoring and analysis of health systems functions followed by practical support is crucial to the decision-making process across the health system.