The impact of COVID 19 Pandemic on the vulnerability of Ghana’s Health System: A Personal Reflection on aspects of the testing process by a frontline worker.

Author: Alexander Omari K. Yeboah
For the past 9 months, the whole world has been engulfed by the threat of a novel coronavirus disease (COVID-19). The disease which started in a single city in China, Wuhan, spread rapidly to other parts of the world and it was declared a pandemic by the World Health Organization (WHO) on March 11, 2020. The disease is virtually in every country of the world now and as at August 1, 2020, there were 17,405,103 confirmed cases of COVID-19 with 675,085 deaths (1). In Ghana, the case count reached 38,501 with 191 deaths as at August 1, 2020 (2). The rapid spread of the disease vis-à-vis its management has exposed the vulnerabilities of the health systems of several countries in the world including Ghana.
Vulnerability, as defined by the WHO, is the degree to which a population, individual or an organization is unable to anticipate, cope with, resist and recover from the impact of certain exposures or disaster (3). Within the health system also, certain health interventions, if poorly managed, could have unintended consequences and could equally maintain, and unintentionally create, vulnerabilities among certain groups. With respect to COVID 19 in Ghana, one good intervention whose implementation has inadvertently resulted in several challenges within the health system is the enhanced testing regime. Source: Times Magazine – https://time.com/5878732/covid-19-testing-delays/ One of the best ways found to limit the spread of COVID 19 is testing and isolating those who test positive from the general population. The implementation of the principle of ‘test, trace and contain’ is reported to have contributed to the rapid decline in the spread of COVID 19 in South Korea (4). Reporting their first positive case on January 20, 2020, South Korea had tested more than 270,000 people by the middle of March with as many as 20,000 tests performed on certain days and results were being obtained in less than 24 hours for planning purposes. By the time the WHO informed their member states to test, test and test (5), the disease was already on the decline in South Korea (4). Ghana began tracing contacts for testing immediately after the first two cases were recorded on March 12, 2020. The tracing of contacts for testing was enhanced when the country started experiencing community spread of the virus and as at August 1, 2020, Ghana had performed a total of 402,564 test making it the 4th country in Africa with the highest number test performed after South Africa, Morocco and Ethiopia (2,6). Despite the apparent success of this testing policy in Ghana, the intervention is not without challenges. Source:https://qz.com/africa/1832066/coronavirus-covid-19-testing-in-south-africa-leads-continent/The main challenge of the enhanced testing policy is the delay in releasing the results which can partly be attributed to the few centres involved in testing the numerous samples being taken daily. On a personal level, I had my first sample taken on April 10, 2020 (insert photo) within the regional hospital where I work but received the results after 2 weeks. At that time, only the Noguchi Memorial Institute for Medical Research (NMIMR) and the Kumasi Centre for Collaborative Research (KCCR) were performing the test in the country. By the end of May 2020, there were 9 testing centres (8 public, 1 private) in Ghana performing the test with 4 of these facilities located within the Greater Accra Region where I work and yet for my last test on May 27, 2020, I received the test results after 72 hours. Since then, the 72-hour window has now become the norm in my institution. Colleagues of mine who work remotely from the major cities in Ghana are still receiving results more than a week after samples are taken.
The delay in releasing results has several unintended consequences. First, it leads to delays in instituting the appropriate therapy. This was the case in our first positive client in May, 2020, who was 41 weeks pregnant. After the initial assessment which gave an indication of a healthy baby in an asymptomatic client, the team had to wait for 5 days to receive the results before the appropriate management for the pregnancy at that gestational age was instituted. Secondly, the delay in releasing results also lead to delays in tracing individuals who had come into contact with the client. This has the potential of resulting in large numbers of people being exposed. One of our doctors who had attended to our first positive client was found to have also tested positive one week after diagnosing the client. The news of our colleague testing positive brought a lot apprehension among the health care workers as many of us had interacted with our colleague for a whole week and several clients that our affected colleague had seen and cared for could not be traced. This, indeed was a sad reality!

Thirdly, the delay can result in wastage of personal protective equipment (PPE) used to care for such patients, if the report comes out as negative. In one of our patients whom we suspected to have COVID 19, the health personnel had to use full PPE anytime they attended to her. This went on for more than 5 days. After a lot of PPE had been used, the test result came out as negative. All over the world, shortage of supply of PPE had been reported. In fact in Germany, there had been reports of physicians posing naked on social media to protest against shortages of PPE (7) and therefore any practice which promotes inappropriate use of PPE must be discouraged. Again, the delays in the release of results also causes a lot of psychological trauma to the client as he/she has to wait for several days in anticipation of a report that could cause his/her detention in a facility for weeks. Tied to the psychological stress on the client, is the apprehension on the part of her relatives. In one instance, this led to verbal assaults on some of our staff as relatives could not contain the long separation from their relative who had been kept in quarantine for several days waiting for her results. In another instance, a suspected client who was in quarantine awaiting her results, came out of her room without a mask to the nurses’ station complaining of loneliness and the desire to see her family. She said, “I have not tested positive yet, and I don’t have any symptom so why are you treating me this way”. The frustration was obvious but that act of hers had the potential to expose the staff and other clients on the ward to the disease. Lastly, the delay in receiving the results contributes to fuelling the stigma associated with the disease. A case in point was a client who had to wait several days to receive the report. Even after the results came out as negative, some staff were still reluctant to attend to her and relatives were also not comfortable approaching her. Source: Alexander Omari K. Yeboah
Without any interventions to address these challenges in the testing process, our objective of preventing the spread of the disease will not be realised and the incidence of the disease will continue to increase. In addition to the social distancing policy, use of face masks in public places and appropriate hand hygiene practices, countries who have been successful in reducing the negative impact of COVID 19 on their economic and sociocultural lives have strict testing regimes with results made available within 24 hours of testing. This early release of results ensures that those infected are ‘removed’ from the communities for treatment and contacts can be traced immediately for testing. This will also ensure that health care personnel and scientists involved in the fight against the disease will have access to real time data for planning purposes.
In light of the benefits that early release of test results bring to our collective fight against COVD 19 and the negative consequences of delays, I will recommend that in addition to the existing testing facilities, the ministry of health, and its implementing agencies, should ensure that all regional health facilities are equipped to enable them test clients who meet the criteria for testing. Most of our regional hospitals have standard laboratories and therefore will require minimal support to upgrade them. This will reduce the load on the existing testing facilities and ensure that results are received early. Also the government must support the private sector to get involved in the testing as we have a disease that threatens our national security. Currently, there is only one private facility in the country, located in the capital, involved in the testing and this is woefully inadequate.
While waiting to have more centres for testing to be created, motivation of staff directly involved in the testing and other areas must be looked at. Even though the income tax waivers for all health workers has been implemented, some frontline workers (most of whom are in the testing and treatment centres) are yet to receive the 50% increase in the salaries promised by the central government. Also, managers of the various health facilities must build strong networks with these testing centres to ensure that they receive results, particularly for suspected clients who are in detention in their facilities to prevent the drama that characterizes these delays.
In the meantime, the public education must be intensified. The national commission for civic education (NCCE), the information service department (ISD), public and private media must be involved in educating the populace on their rights, responsibilities and the issue of stigmatization as far as COVID 19 is concerned. This will help reduce the incidence of unhealthy interactions that occur between health care workers, clients and their relations at the level of the health facilities. Lastly, the clinical psychology and mental health units of the various health facilities must be given a central role in the care of patients not only in those who have tested positive but also within the facilities in dealing with the anxieties and apprehension of clients who are waiting to receive their test results.
In conclusion, the vulnerabilities of most health systems has been exposed by the COVID-19 pandemic. The enhanced testing policy adopted by the Ghanaian authorities, though a very good intervention, has come with several unintended consequences. All efforts must be made to deal with such drawbacks to enable the country realize the full benefits of the policy.
Key lessons:
• Evidence exists for the effectiveness of the enhanced COVID-19 testing policy in contributing to the decline in the spread of the disease.
• Implementation of the policy without ensuring that the test results are released on time to aid in case management and planning will result in consequences that have the potential to derail the country’s effort at curtailing the spread of the disease.
• Policy authorizers can make a difference in ensuring that the necessary infrastructure are put in place to give true meaning to the enhanced COVID-19 testing policy in Ghana.
References:
1.WHO Coronavirus Disease (COVID-19) Dashboard. Covid19.who.int. Assessed August 6, 2020.
2.COVID 19 update. Ghana health Service. 2020. https://ghanahealthservice.org/covid19/archive.php Assessed August 1, 2020.
3. WHO. Vulnerable groups: Environmental health in emergencies. 2002. https://www.who.int/environmental_health_emergencies/vulnerable_groups/en/. Accessed on June 4, 2020.
4.Murray J. Test, trace, contain: How South Korea flattened its coronavirus curve. April 3, 2020.https://www.theguardian.com/world/2020/apr/23/test-trace-contain-how-south-korea-flattened-its-coronavirus-curve. Assessed on June 4, 2020.
5.WHO Director-General’s opening remarks at the media briefing on COVID-19 – 16 March 2020. https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19—16-march-2020 Assessed June 6, 2020.
6.Worldometer. COVID-19 coronavirus pandemic. https://www.worldometers.info/coronavirus/. Assessed August 6, 2020.
7.German doctors pose naked in protest at PPE shortages. https://www.theguardian.com/world/2020/apr/27/german-doctors-pose-naked-in-protest-at-ppe-shortages. Assessed June 5, 2020.

The Centre for Health Systems and Policy Research (CHESPOR) at GIMPA:
This Blog Series is compiled and edited by Dr. Gina Teddy, Coordinator as the Centre for Health Systems and Policy Research (CHESPOR). It is part of a Special COVID-19 Edition to explore issues of health systems vulnerabilities and resilience compiled by the Centre for Health Systems and Policy Research (CHESPOR). The COVID-19 Edition is a series from the GIMPA MPH 2019/2020 Cohort working as frontline workers in various sectors of the health system to enable them to share their experiences and perspectives on the impact of COVID-19 Pandemic on Ghana’s Health System. However, the views expressed herein are those of the author and do not necessarily reflect those of CHESPOR or the Ghana Institute of Management and Public Administration (GIMPA)