Stéphanie Maltais • Docteure en développement international et chargée de cours à l’Université Laval (Québec)
Resilience can emerge from fragility. This is what Stéphanie Maltais observed from her research conducted in the aftermath of the Ebola crisis in Guinea between 2013 and 2016. Lessons that can be applied to the current pandemic.
Health crises affect all countries around the world and the Covid-19 epidemic is the most patent example. There is always the fear that the impact of crises is more detrimental in fragile States because of the inefficiency of their institutions, the lack of resources, poor resiliency, and weak economies(1)OECD, “States of Fragility”, OCDE Publishing, 2016; WHO, “The state of health in the WHO African Region: an analysis of the status of health, health services and health systems in the context of the Sustainable Development Goals”, Regional Office for Africa, 2018.. In fact, from the onset of the current pandemic, the World Health Organization (WHO) has been dreading a catastrophe in Africa. Given the known weaknesses of the health systems of some African countries and the socio-economic conditions that the populations must endure, WHO’s concerns are well-founded. However, the proven experience that several African countries have gained in the fight against epidemics must not be discounted.
The Ebola epidemic that broke out in Guinea between December 2013 and June 2016 exposed the many shortcomings in the country’s health system that made the crisis difficult to control. However, with hindsight, Guinea has been able to recognise not only its past failures, but also the successes related to the experience that should lead the country to improve any future actions. Admitting that much has been learned from an epidemic like Ebola requires a good dose of humility, as well as a real capacity for gathering and transforming knowledge so as to generate stronger governance at the institutional level. Since the Ebola crisis, a major plan has been underway to strengthen the country’s health system, however, the prior experience that could have been used to fight the current pandemic has been underutilised. In this short article, we will review the knowledge acquired from the Ebola epidemic and look at how it can help to improve the management of Covid-19. We will also present some of the challenges still remaining in Guinea.
During our research in Guinea in 2017(2)This research was funded by the International Development Research Centre of Canada. For further information on this research, see: Stéphanie Maltais, La gestion résiliente des crises sanitaires dans les États fragiles : étude de la crise d’Ebola en Guinée, thèse doctorale, université d’Ottawa, Canada, 2019, http://dx.doi.org/10.20381/ruor-24094, we conducted 41 semi-structured personal interviews with more than 25 organisations involved in managing the Ebola epidemic and post-crisis recovery(3)This research would not have been possible without the participation of Guinean and international actors who warmly accepted our invitation to discuss their experience in managing the Ebola crisis and post-crisis recovery. We thank them sincerely..
Our data collection was complemented by in-depth document analyses and direct, non-participatory observations. During our stay in Guinea, a measles epidemic had broken out, and so epidemic control measures were already being implemented. In addition, the major work to strengthen the health crisis management system through the consolidation of the newly created National Health Security Agency (ANSS) was underway.
Beneficial operational structure
When the Ebola struck in Guinea, there was no effectively structured and adequately resourced coordination to handle health crises. Although Sidiki Diakité(4)Sidiki Diakité, “Ebola in Guinea: strengths and weaknesses brought to the fore”, Humanitarian Alternatives, inaugural issue, 2016, p.57-65, https://alternatives-humanitaires.org/en/2016/01/13/ebola-in-guinea-strengths-and-weaknesses-brought-to-the-fore refers to the presence of a unit that had managed health crises and disasters in Guinea since 2007, the results of our research revealed that its work had not been successful. At the start of the Ebola epidemic, an interministerial crisis committee was responsible for the response, but was later sharply criticised for having reacted poorly and for having been overly political. Subsequently, a completely new entity, the National Ebola Coordination and Control Unit, was set up to rectify the problems encountered during the early months of the crisis. This has proven to be more effective than the interministerial committee, and its personnel have acquired extremely valuable experience. Since epidemics spread without regard for administrative and political considerations, the value of maintaining an operational and ideally apolitical structure dedicated to the management of health crises had to be recognised. Lessons learned from the Ebola outbreak were therefore capitalised on, leading to the creation of the ANSS in its current form.
Although not apolitical, this self-governing agency, notably autonomous in the disbursement of funds, is supervised by the Ministry of Health. Its structure fulfils the expectations of international partners in terms of operations and response. These partners wanted (i.e. demanded) that the agency work free from the political governance that had previously caused too much damage. The agency’s creation led to many internal discussions, but today, its existence and experience are assets in the management of Covid-19. It should be noted that it comprises an Emergency Operations Centre (EOC), which has, in turn, created decentralised EOCs across the country, thus facilitating the management of the outbreak. During our research, Guinean professionals confirmed that the ANSS has become “the control arm” of the Ministry of Health. Despite its strengths, its continuing financial dependence on international donors cannot be overlooked; the fact that it has taken over responsibilities previously held by other departments of the Ministry of Health and will continue to do so, and that it basically runs under very hierarchical and centralised decision-making and management.
A more responsive model
Our research uncovered one significant point resulting from the Ebola outbreak in Guinea, namely, the transition from a traditional crisis management paradigm to a more responsive model. Until the outbreak, even during epidemics, work was carried out at a so-called “normal” pace without giving any real attention to emergency interventions. Since the Ebola epidemic, Guinea has increasingly incorporated crisis management into its operations. One Guinean actor interviewed commented that the country had moved to a culture of emergency response. Although other interviewees mentioned that this culture needs to be amplified, there are areas where long-term developments can be made. Furthermore, some respondents also said that other skills and attitudes had to be developed and strengthened, such as openness to change (especially among senior staff), attention to detail, quick and automatic responses and diligence.
Improved resources and broader leadership
Since the Ebola outbreak, the skills of human resources have been enhanced through various types of professional education. Epidemiological surveillance has also been improved by providing both computer equipment and appropriate training on the use of various software applications. The lack of a computerised monitoring system was criticised by Diakité(5)Ibid and confirmed by our interviewees. Since the end of the Ebola outbreak, and during lulls in the epidemic, crisis simulations have been performed. However, keeping skills up to date and carrying out simulations remain highly dependent on financial constraints. Some organisations have stated that they want these activities to be more frequent, but without outside support, the required funds are lacking. In addition, the shortage of national funding is still a major challenge in strengthening the health care system. Even considering that the share of the national budget allocated to public health has grown in recent years from 1.5% of GDP in 2010 to 5.5% in 2016, according to information from Guinean Budget Unit(6)Some of the media in Guinea state it reached 8.8% in 2018, while the communication unit of the Ministry of Health stated on its social media in December 2019 that it was 8%., this percentage is a far cry from the 15% recommended in the Abuja Declaration and also far behind that of countries with comparable income(7)M. Diop et al., « Revue des dépenses publiques de santé – République de Guinée », République de Guinée, Banque mondiale, 2014.. This lack of financial resources greatly disrupts the country’s autonomous management approach since it always finds itself in need of support from international organisations.
Yet the Ebola epidemic led to the hiring of many young people in health care facilities and at the ANSS. The government has massively recruited health workers and deployed them to all reaches of the country with the help of the Assignment Commission(8)Ministère de la Santé, « Affectations au ministère de la Santé : De nouvelles dispositions », cellule de communication du gouvernement, Guinée, 2018.. At the ANSS, the need to train successive generations of staff has been recognised. Moreover, it must be mentioned that the country’s leadership greatly asserted itself during the Ebola crisis and has continued to do so since then. The ANSS receives greater international support than it gives. However, its leadership rests on the shoulders of specific individuals, which means that ANSS’ partners will perhaps lack confidence in the upcoming generation of leaders and may only want to deal with key decision-makers and managers. When all decisions are made by a sole person, there is the risk of running into other problems, because without that person’s approval, nothing happens.
The country’s leadership greatly asserted itself during the Ebola crisis.
Investing in preparation
The importance of preparation in managing health crises(9)Anne Fortin, Vroh Benie Bi et Abdelkrim Soulimane, « Les enseignements de l’épidémie d’Ebola pour une meilleure préparation aux urgences », Santé Publique, vol. 29 (4), 2017, p. 465‑475; WHO, “Report of the Ebola Interim Assessment Panel – July 2015”, 2015, https://www.who.int/csr/resources/publications/ebola/report-by-panel.pdf?ua=1 ; Système des Nations unies en Guinée, « Capacités nationales en matière de réduction des risques et de gestion des catastrophes en Guinée – Rapport d’évaluation », 2016. cannot be understated. Before the Ebola epidemic, such preparation was inadequate. In fact, International Health Regulations (IHR) set out the minimum capacities required to respond to health crises, but at the time Guinea did not have them. For example, there were gaps in terms of funding, coordination, monitoring, and communication about the risks, staffing, equipment, technical resources, etc. As for procedures and formal processes, there was a huge lack of managers, instruction manuals, and written protocols to help manage the country’s health crises. Even when some of these were available, they were incomplete, inadequate, or simply unknown. As for Covid-19, procedures and processes developed from the Ebola outbreak were tested in real time. The current epidemic alert has been very swift compared to that of Ebola. Monitoring and contact tracing have been tightly coordinated. Community health workers have been directly involved. Personnel have been quickly deployed at the country’s entry points, such as at the airport while community awareness has been raised through locally adapted information. The health system in general has developed its capacities across all areas (technical, logistical, human, etc.). Therefore, despite the weaknesses noted in IHR’s external evaluation(10)OMS, « Évaluation externe conjointe des principales capacités RSI de la République de Guinée : rapport de mission », 23-28 avril 2017. in 2017, there has been a marked improvement in response times and the implementation of interventions during the current pandemic.
Facing a variety of challenges
Before the Ebola epidemic, Guinea was struggling to handle multiple health issues and everything seemed to focus on one disease at a time as a matter of priority. Nine respondents in our study commented on the inability to maintain regular health services in their organisations during the Ebola outbreak. It appeared that for these entities, attention was focused solely on Ebola at the expense of other pathologies and regular health activities. It is now recognised that it is important to prioritise the monitoring of a greater number of diseases. During the Ebola epidemic, Guineans largely abandoned health facilities for fear of contracting the disease. They returned a few years later with their children who, for example, had not been vaccinated against measles. Nowadays, the problem that people who need health care not related to Covid-19 are staying away from health centres and hospitals persists(11)A. Sow et B. Criel, « Covid-19 en Guinée : mobilisation de la première ligne de soins au Sud et au Nord ! », Blog – BMJ GLobal Health, 12 mai 2020, https://blogs.bmj.com/bmjgh/2020/05/12/covid-19-en-guinee-mobilisation-de-la-premiere-ligne-de-soins-au-sud-et-au-nord.
In addition, Donka Hospital (the main treatment centre for Covid-19 patients) has exceeded its full capacity(12)Ibid.. Although there were more resources after Ebola and various structures, such as the Treatment Centre for Epidemic-prone Diseases (CTEPI), were built, the problem of centralised management and the lack of adequate hospital beds remains. Laboratory testing capacity, although improved after Ebola, is still limited.
As for Covid-19, procedures and processes developed from the Ebola outbreak were tested in real time.
Better communication about the risks
Poor real-time communication about the risks between experts, leaders, and the community that prevailed before Ebola has given way to improved processes for social and community mobilisation, mass awareness campaigns or use of traditional and social media. One of the best examples is ANSS’ proactive use of social networks and its website that is frequently updated to inform, educate, and carry out protective and preventive action. In addition, information about the number of confirmed cases, deaths, and recoveries is openly reported(13)As of July 14, 2020, the National Health Security Agency (ANSS) of Guinea reported 4,426 confirmed cases of COVID-19, 24 deaths associated with the virus, and 3,106 recoveries (https://anss-guinee.org)..
Furthermore, the lessons learned from the Ebola epidemic, such as the importance of adapting interventions to the local context and managing the community’s reticence have brought about good practices for the management of Covid-19. For example, awareness messages are adapted to the target audiences (radio messages in the local language, door-to-door canvassing, etc.). Local leaders and other authorities are involved so as to reactivate the reflexes that have lain dormant since the end of the Ebola crisis.
From fragility to resilience
In light of the research carried out in the post-Ebola period in Guinea, we have been able to draw a picture of the country’s resilience to health crises. After the Ebola epidemic in Guinea, there was an awareness of the shortcomings of and the need for a robust health system. Several projects were set up that have today made it possible to avoid massive deaths from Covid-19. Rapid interventions and physical distancing measures were set up to avoid overloading the health care facilities, even though some are now overwhelmed. Our research has demonstrated that, since the Ebola crisis, although the country still clearly depends on its bilateral/multilateral and technical/financial partners, it now has policies, procedures, and practices in place that can provide a better response to health crises. These include the massive recruitment of personnel into the health system (including more than 4,000 health workers) and the establishment of the ANSS, eight regional multi-tasking teams and 33 local community teams to alert and respond to epidemics. There is also the development of an epidemiological surveillance system, the creation and refinement of crisis scenarios and written procedures, the construction of 38 treatment centres for epidemic-prone diseases, the supply of equipment and technology, and the mapping of entry points into the country. Clearly, resilience, on an individual as well as on community and systemic levels, has emerged from fragility. This can only lead to the improved management of Covid-19.
Translated from the French by Alan Johnson
|Biography • Stéphanie Maltais
She has a Ph.D. in International Development from the School of International Development and Global Studies at the University of Ottawa. Her thesis focused on managing health crises in fragile States with a case study of the Ebola epidemic in Guinea. Stéphanie is a lecturer at the Faculty of Business Administration at Université Laval where she teaches the Management of International Development and Humanitarian Action in the Master’s degree programme. She also works as a research professional at Université Laval, the National School of Public Administration and the University of Ottawa on various projects, notably on Covid-19, women’s careers in international development and humanitarian action and neutral assessments in the Canadian federal public service. She is the Editorial Coordinator of the Canadian Journal of Program Evaluation.
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|￪1||OECD, “States of Fragility”, OCDE Publishing, 2016; WHO, “The state of health in the WHO African Region: an analysis of the status of health, health services and health systems in the context of the Sustainable Development Goals”, Regional Office for Africa, 2018.|
|￪2||This research was funded by the International Development Research Centre of Canada. For further information on this research, see: Stéphanie Maltais, La gestion résiliente des crises sanitaires dans les États fragiles : étude de la crise d’Ebola en Guinée, thèse doctorale, université d’Ottawa, Canada, 2019, http://dx.doi.org/10.20381/ruor-24094|
|￪3||This research would not have been possible without the participation of Guinean and international actors who warmly accepted our invitation to discuss their experience in managing the Ebola crisis and post-crisis recovery. We thank them sincerely.|
|￪4||Sidiki Diakité, “Ebola in Guinea: strengths and weaknesses brought to the fore”, Humanitarian Alternatives, inaugural issue, 2016, p.57-65, https://alternatives-humanitaires.org/en/2016/01/13/ebola-in-guinea-strengths-and-weaknesses-brought-to-the-fore|
|￪6||Some of the media in Guinea state it reached 8.8% in 2018, while the communication unit of the Ministry of Health stated on its social media in December 2019 that it was 8%.|
|￪7||M. Diop et al., « Revue des dépenses publiques de santé – République de Guinée », République de Guinée, Banque mondiale, 2014.|
|￪8||Ministère de la Santé, « Affectations au ministère de la Santé : De nouvelles dispositions », cellule de communication du gouvernement, Guinée, 2018.|
|￪9||Anne Fortin, Vroh Benie Bi et Abdelkrim Soulimane, « Les enseignements de l’épidémie d’Ebola pour une meilleure préparation aux urgences », Santé Publique, vol. 29 (4), 2017, p. 465‑475; WHO, “Report of the Ebola Interim Assessment Panel – July 2015”, 2015, https://www.who.int/csr/resources/publications/ebola/report-by-panel.pdf?ua=1 ; Système des Nations unies en Guinée, « Capacités nationales en matière de réduction des risques et de gestion des catastrophes en Guinée – Rapport d’évaluation », 2016.|
|￪10||OMS, « Évaluation externe conjointe des principales capacités RSI de la République de Guinée : rapport de mission », 23-28 avril 2017.|
|￪11||A. Sow et B. Criel, « Covid-19 en Guinée : mobilisation de la première ligne de soins au Sud et au Nord ! », Blog – BMJ GLobal Health, 12 mai 2020, https://blogs.bmj.com/bmjgh/2020/05/12/covid-19-en-guinee-mobilisation-de-la-premiere-ligne-de-soins-au-sud-et-au-nord|
|￪13||As of July 14, 2020, the National Health Security Agency (ANSS) of Guinea reported 4,426 confirmed cases of COVID-19, 24 deaths associated with the virus, and 3,106 recoveries (https://anss-guinee.org).|