HealthManagement, Volume 20 - Issue 5, 2020

Burning Platform for Change: COVID-19 Experience in Ghana

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In mid-July, Ghana was among the African countries most affected by COVID-19. Infectious disease outbreaks are not uncommon here, and there has always been a critical need for the private and public sector to collaborate more. The situation is changing, however. talked to Dr Elikem Tamaklo, head of the oldest private group medical practice in Ghana, about his experience with COVID-19, the hardships his facility had to go through, and his struggle with the culture of stigma.

Our hospital was the first group medical practice in the private sector in Ghana. This year we celebrate 50 years, which is significant considering that independent Ghana is only 62. Back then, there weren’t a lot of specialised personnel in the country, and being a Ghanaian-owned company, we started to bring together specialists trained abroad. Over time, Nyaho has grown in terms of its place in the community and has become the first place people would come to if they need specialist care – even though there are, of course, tertiary public healthcare institutions.

This means that every time there are pandemics, such as Ebola, people tend to come to us for care. As a result, we have developed strong relationship with the Ministry of Health and the public health department in our local district, as well as established a public health unit in our facility. It is uncommon for private health sector players in developing economies to invest in a public health department. Still, we have one, because we know that if an outbreak happens, patients would be coming in. So, when COVID-19 started around the world, we were prepared; for example, we launched the necessary initiatives, such as personnel training, as early as January 2020.

In terms of our business continuity plan, we had to rearrange the whole organisation so that there was one single entry point, and triage happening at that entry point. If a patient fit the case definition, we would separate and isolate them, do the test and send it to the reference lab. At that time, there were only two reference labs in Ghana, one in Accra and one in Kumasi, and we could fast-track the testing because of our strong relationships with the district health authorities.

Early Issues

In the beginning, the government was mainly focussing on the public sector. However, the main threat was that of imported cases, and in Ghana, many people who travel tend to prefer the services of private facilities. Most of them do not utilise public faclities. This was something I believe the authorities had not considered back then.

With our facility being only 15 minutes away from the international airport, a lot of those who travel come to us. One of the first reported cases of COVID-19 was diagnosed at our hospital, and this was because of the rigorous processes we had implemented. We followed all the public health protocols and were able to ensure the safety of the patient and our staff until the test results came in, after which the required processes were followed through on the public health side. Retrospectively, that meant we prevented the spread.

The general challenge for healthcare in our country lies with the coordination of the private sector as there is much operational diversity. The public sector functions under the Ghana Health Service, so it is more centralised and thus more coordinated. When it became clear that COVID-19 was spreading in the community, we quickly realised that the private sector’s involvement in disease management is inevitable. We would ‘pick up’ positive cases just as any other facility would do – a frontline is a frontline regardless of whether it is public or private, this is just core health care. This is when we started engaging with the government to make sure that the private sector’s involvement was a key priority.

As cases in Ghana progressed from only imported ones to community spread, the laboratory testing turnaround times increased from 24 hours at the early stages to three days, five days, two weeks and then three weeks. This was, of course, unacceptable, and we started to explore testing capabilities internally. Through our partners that had access to supplies from China, we were able to bring in Polymerase Chain Reaction (PCR) equipment and test kits. To use them, however, we had to resolve numerous issues with the authorities regarding, for example, the patient data use in the private sector. Eventually, in early July, we became the first private hospital to be accredited to test for COVID-19 and provide care to patients who tested positive.

All this was possible through effective collaboration and engagement with all stakeholders and advocating for the development of a guideline on laboratory testing and reporting on respiratory infectious diseases in health facilities in Ghana. The document was released a couple of weeks ago, and now it is much easier for labs to set up their activities in a regulated manner and get registered. The same goes for hospitals in terms of which regulatory agency is required, how the data reporting is standardised and patients are managed.

Because of our reputation earned over the years and location, we were receiving many patients. However, there were challenges, such as shortage of personal protective equipment (PPE) and critical staff. Thanks to our growth plan, we had invested in an intensive care unit (ICU) with ventilators (we have 4 out of 60 in the entire country) and in an emergency team, our critical care nurses. It was clear that we were prepared to manage COVID-19 cases.

We reached out to partner with the district authorities and worked through a number of challenges to ensure the safety of patients and clinical staff. Through our initiatives, it was easier for the Ministry of Health, the Ghana Health Service, to understand what was required from the private sector. This has paved the way for more opportunities and for other players to operate within the stipulated regulation.

Major Outcomes

There are three broad areas. First is the development in the public-private partnership. Going through this helped to emphasise the importance of the private sector in a pandemic. It has always been recognised, but never been formalised. COVID-19 has become that burning platform for change.

There is now a momentum to consolidate private sector players together into an association, to have a unified voice. Previously, we were a solitary voice with no representative body for the private sector. As such, for the public sector it is difficult to take us on, because individually, we represent hospitals, not private healthcare as a whole. Now we have a coalition of some private sector players.

Second, this also helps us at the organisational level. The capacity constraints are huge, and there’s no way one sector, private or public, will be able to manage the pandemic alone, especially as the COVID-19 numbers keep increasing. We haven’t reached our peak yet, and it is good that now other players are getting more involved too.

Finally, for us as a company, deepening the relationship with key stakeholders was important and will make us better prepared for any future outbreaks in Ghana. The COVID-19 experience has really taught us a few lessons about the importance of stakeholder engagement. For example, we started the lab with official approval, and three weeks later, we were asked to suspend our services because we were doing too many tests more quickly than expected. This caused some friction, but it was a good lesson. Hopefully, we won’t make the same mistakes again.

Overcoming Fear

In the beginning, there was fear among the staff, fear of the unknown. When we started doing the trial runs and taking patients in, a lot of clinical staff, who should know better, actually were the ones most afraid because of the PPE challenges. We had stocked up what we thought was enough PPE based on our normal operations. But we hadn’t anticipated just how many and how quickly patients would be coming in. That meant we had to start rationing the PPE for our emergency teams. And the staff were scared for their own and their families’ health.

Notably, while the government gave us some incentives, we weren’t recognised as being part of the frontline – because we are the private sector. This raised a lot of questions from our public health teams. We engaged with government and gave them as much information about our actions as possible, being very transparent. This gave our staff the opportunity to question and challenge everything, and probably that had a therapeutic effect and enhanced the engagement. Yes, things were not perfect. But the staff were informed, hence engaged. 

Despite all the difficulties, they kept coming to work. This is testament of our people’s integrity, not just the clinical staff, but the support teams as well whose work encouraged the frontliners to keep showing up for work.

As such, we didn’t have a frontline worker saying, “I’m not coming to work.” We had, however, situations when due to exposure, about 30 of our employees, all in the ER, had to be isolated. As a result, those left on the ground were short-staffed and concerned about what was going to happen to them. That was a very stressful time.

We started rotating the staff, looking into how we could support them. If we hadn’t done that, a lot of our employees would be asking, “Why should we be doing this? Let’s leave it to the government to do!” But our stance is, what if that is your family member? How would you want them to be treated? “We’re doing this for ourselves,” “we are the patient.” As long as we have ventilators and an emergency service, the question always would be, have we done enough to ensure that each patient has the best chance at survival?

We owe a lot to the courage of our people because it was not easy in the early days. Now we have sorted out some of the PPE challenges, so there is some psychological safety. PPE was key to our operations team, and our public health team. The global supply chain was severely affected by the pandemic, and this affected us in Ghana. The cost of PPE and related consumables increased significantly, and access to equipment for testing and treatment was difficult due to the increased global demand. As a hospital, procuring on our own was a challenge as minimum order level from global suppliers were always too big for us. However, we were able to leverage our partnerships to get the needed supplies but at an additional cost.

In the early days, we found ourselves to be very constrained. Then the government launched some initiatives for local businesses to produce aqua gel, PPE, and so on. That helped, plus we were able to find some alternatives. Now our frontline staff have some guaranteed level of protection and feel more secure.

Fighting Against Stigma

My whole family got infected, but luckily it was relatively mild. Our children were asymptomatic, and my wife and I had the worst of the flu-like symptoms. There was about a week of fever and body aches; my wife lost her sense of smell and taste. Later on, I had fatigue hitting me at 11 am on most days, which is fine if you get to rest, but a challenge when you’re working. In any case, we seem to be in the majority of people who have recovered.

In Ghana, the virus is in the community. This is how we were infected too, despite all the precautionary measures we have been taking in our house. Then again, at home, you let your guard down and, ironically, are more exposed than if you are in a hospital with strict protocols and your PPE on.

The disease here is often accompanied by stigma, which stems from that fear of the unknown. It’s completely irrational. Unfortunately, people on the frontline are often met with reactions that are hurtful and separatist, even from those who you would expect to know better. But this is in our culture, so people follow.

Also, in the country, there was silence around COVID-19, among the people and politicians alike, so when I became positive, I shared my story openly to help reduce stigma suffered by those carrying the virus. Such are my values. I posted a video on LinkedIn, which then went viral. A lot of the news channels picked it up because I was the first in the country to publicly talk about it. That video was based on our communication plan to spread the information beyond our staff only, thus modelling the behaviour on a larger scale. Being authentic is what’s required to build trust. I didn’t want this to be misconstrued, because I was infected not in the hospital but the community. This is the reality, and if we don’t talk about it, then we don’t empower ourselves with knowledge.

Two weeks later, we did another video, which hopefully helped people to recognise the symptoms they had. The issue of stigma has had a significant impact on containing the spread of the virus. The fear of a positive result has prevented a number of people from getting tested. They would rather say, “I have malaria or something else.” As a result of airing these videos and the engagement, the testing numbers have been increasing, and a lot more people have been taking it a bit more seriously, self-isolating. It has helped to reduce fear in our staff as well – there’s no need to stigmatise, it’s a normal disease, even if still unknown. Some people will be affected, but that’s the minority. 19 out of 20 will recover.

There’s a silver lining to my story. It was an opportunity to engage the staff more. We had multiple meetings afterwards, and from their feedback, I saw that they were empathetic. This gave me more context, not only at the hospital but on a country level. When we watch international news, we see a lot of negative stories and death reports, but none about people recovering. This sends the wrong message.

Story to Share

In the beginning, there were a number of false-negative cases, so by the time we had our first COVID-19 patient, the ER staff were really paying attention to the triaging. We had a doctor and a nurse at the entry point and security officers as the first point of contact. When this patient came in, they were generally fine, with mild symptoms. But the nurse doing the triaging strictly followed the protocol because of those previous false negatives that we had received. The patient was put into the isolation room, the test was done, and we called the district authorities. All our staff, including the security men, finally saw how that multidisciplinary approach should work, and that was just too good to be true. That first patient taught everyone that when we all play our part, we have the power. This was a long journey for all of us, full of mistakes, but we have learnt from them. That situation gave the right momentum to teamwork, and the patient was managed impeccably through all stages.

Another story is much sadder. A patient came in who was unwell, and there weren’t any beds available. Our ER staff were doing all they could for several hours, but the patient did not survive. The image of people trying their best and still failing to change the situation is heartbreaking. That was a very low moment for the organisation. As soon as I heard about it, I went to speak to everyone. But there are moments when it really hits you that a life is lost and there’s nothing you can say to lift people’s spirits.

That incident made me start questioning if we were doing enough. It also gave me a deeper level of motivation to keep pushing – for getting more ventilators, more PPE. At that time, I thought that it was someone’s mother. It could be my mum. Would I have felt satisfied? Would I have said I’d done my best? Surely, everybody was having such thoughts. And to everybody, this loss gave some momentum to keep pushing with their work.

Things to Learn from Africa

In some respects, African countries’ response was much more efficient than that of the West. We have to deal with infectious disease outbreaks often and are more aware of what needs to be done. At times, the decision-making in Western countries was confusing to us; many basic steps were ignored. For example, there was no testing or screening at airports, people were allowed to come in freely from anywhere. In Ghana, the authorities were really fast in implementing a travel ban. At all points of entry, incomers have their temperature checked, and have to fill out a form. These strategies, of course, do not give you 100% protection, but they are effective to a certain degree.

Another point is the agility of our thinking, especially when it comes to businesses. When you live in a low-resource environment, you have to come up with new ways of doing things. We saw companies, including ours, quickly rearrange to work remotely; restaurants close but offer delivery services; companies that used to make clothes produce scrubs for hospitals, and so on. This level of entrepreneurship is something I admire. We don’t have the capabilities to make, say, sophisticated devices like ventilators or scale up our production. But seeing local people sewing masks, I think that lack of resources sometimes sparks amazing adaptability and creativity.

Mantra of Hope

Reflecting on what we have done so far, I think that if there is one mantra I have, it’s about hope inspiring hope. There is a lot of mistrust in our health system, and this is being exacerbated by the crisis. There are fear and anger. Patients are being turned away because they might be infected. This is why we need more stories of people doing it right, and we need to encourage those doing it right. Without this, as a country, we will just demoralise everyone further. There are people who are choosing to come to their work at a hospital every day, but their efforts are still under-appreciated. So, the aim for us is to change this and focus on transparency and hope. 

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