COVID-19: What can we learn from previous lessons in responding to disease outbreaks in low-income countries?
Major disease outbreaks continue to be a significant risk to public health with serious economic repercussions. Across the world, we have seen a consistent rise of disease outbreaks in the past decade. Ebola, Zika, Nipah virus, Cholera, Yellow fever, Lassa fever, Severe Acute Respiratory Syndrome (SARS), H1N1 influenza, Middle East respiratory syndrome (MERS), to name just a few.
Start Fund, one of the fastest humanitarian financing mechanisms, has been instrumental in responding to disease outbreaks within 72 hours in low-income countries since its inception in 2014. For instance, it has responded to a range of disease outbreaks like Ebola in DRC, Lassa fever in Nigeria, Cholera in Zimbabwe and Cameroon, and Dengue fever in Nicaragua.
With the coronavirus pandemic sweeping across the world, Start Network has launched a new COVID-19 aid fund to anticipate and respond to critical virus-related humanitarian needs in low-income countries. The new fund, known as Start Fund COVID-19, is part of the Start Network’s existing funding mechanism, the Start Fund, which enabled the network to get the fund set up quickly. The fund has been kickstarted with a donation from IKEA Foundation for €1.5M and other donors are being sought.
At Start Network, we always aim to learn from our experience and draw on lessons learned from other sector players. So, we have endeavoured to analyse the data and information from past responses in order to present a set of lessons for COVID-19 projects. Looking at disease responses from 2018 and 2019, including project data and information from 12 activated Start Fund alerts and post-project learning exchanges, we’ve developed four disease-specific learning papers, and seven key lessons for COVID-19.
While some extremely useful and relevant lessons from the West Africa Ebola response have been documented and shared by major players in the sector, such as the importance of community participation, management of politics, strengthening of national health and emergency systems by ODI; building partnerships with religious leaders by Oxfam; good coordination among partners in countries and across boundaries by The World Bank; and the importance of effective communication, comprehensive care and the need to address community distrust and suspicion by Human Rights Watch. Our analysis provides some additional learnings, such as paying attention to child protection issues, maintaining flexibility and adaptability during the crisis emergency response and dealing with misinformation by working more closely with the anthropologists/epidemiologists from the beginning.
Seven key lessons
1. Coordination, collaboration and partnerships are key
Strong coordination with local and national response mechanisms, partnerships with ministries of health and education, as well as collaboration with other humanitarian actors involved in the response is important. Partnerships ensure that the response is built on more reliable demographic and context information (such as the capacity of the health structures) and mean people affected by an outbreak can be reached sooner. Coordination with other NGOs in the region are hugely important to avoid duplication, increase coverage and overall impact of the response in a relatively short timeframe to prevent the spread of the epidemic.
“Coordination with WHO, Nigeria Centre for Disease Control (NCDC) and the State governments when it comes to community sensitization and contact tracing proved to be very fruitful. Specifically, effective in using validated strategies and structures and national surveillance tools and community engagement checklists, including choosing which communities to target.” ALIMA, Lassa Fever response.
2. Deal with misinformation and work more closely with the anthropologists/epidemiologists from the beginning
Rather than just sharing information, it is important to address misinformation to avoid increasing anxieties around the disease outbreak. One of the unpredicted challenges reported in the Ebola response, for example, was the misinformation surrounding Ebola at the time of the outbreak. Community dialogue can help community leaders understand perceptions, tackle misinformation and adjust their approach accordingly. It can also help to reduce the stigma associated with the disease and post-traumatic stress disorder. In addition, some projects reported that working with anthropologists was helpful in terms of understanding the contextual nuances and adapting messages to better promote behavioural change (especially when it came to working with indigenous communities, and existing healthcare practices, myths and misconceptions). Similarly, working with epidemiologists ensured that only medically accurate information was distributed.
3. Be prepared for the political tensions and unanticipated conflicts
Developing a contingency plan is absolutely essential. For example, one of our member agencies working on Ebola response in the North Kivu region of DRC indicated that during their response, the Congolese government called for a ‘ville morte’ (or general strike) due to an attack, which impeded the project implementation. As a result, the projects were extended beyond the usual 45-day Start Fund timeframe in order to complete this important humanitarian response.
4. Community-led approaches, and strengthening trust and acceptance of different epidemic response pillars, is critical
Community-led prevention and control strategies where people participate in solving their own problems can be instrumental in the success of a programme. Communities play an important role in the support for screening, referrals of suspected cases, contact follow-up, monitoring of the outbreak, and communication initiatives. Sensitisation activities, which are proven to change attitudes toward and understanding of disease, are more effective when the community and local leaders are fully involved. For diseases like COVID-19, where communities are unfamiliar with what it is and how to prevent and treat it, it is important that the behaviour change messaging comes from a trusted source, either local leaders or community health workers (CHWs). Similarly, in the context of conflict and political crisis, communities can be sceptical of governmental or international non-governmental organisational (INGO) responses and may be more willing to trust local leaders. Therefore, developing trust in communities is paramount to the success of any sustainable intervention.
5. Training to prevent healthcare providers from contracting the disease
Protecting healthcare workers for their own safety and that of the affected community should be central to disease response strategy. Urgent provision of practical safeguards, particularly personal protective equipment and knowledge of how to use it, are key to safeguarding healthcare workers. For most of the Start Network disease response programmes, this was a priority. As a result, the knowledge and capacity of the government health ministries involved in the outbreak significantly improved, especially in terms of prevention and ensuring safe health facilities for the patients.
For the COVID-19 pandemic, where the available scientific knowledge and information is still quite limited and is evolving almost every day, national health professionals may have very limited knowledge and information. Therefore, prioritising their training and support needs to be central to any response plan. Also, it is worth noting that the response to a disease outbreak is multi-fold and includes many services to effectively prevent, contain the spread, and manage cases—medical care, surveillance, infection prevention and control (IPC), communication, logistic, psycho-social support, safe and dignified burials, vaccination, etc. Facilitating strong coordination between different response pillars is highly recommended.
6. Pay attention to child protection issues
Disease outbreak affects children directly (infection) and indirectly (risk of losing parents, family, homes, etc). It is therefore important to mainstream child protection across the project activities to reduce the risk of harm to children. Training and sensitising health workers, community leaders, community health workers, and other partners on child protection issues is critical.
7. Be flexible and adaptable
Disease outbreak trends change rapidly on the ground, so having the flexibility to modify and adapt project activities is important. For instance, when cases of Ebola were confirmed in a target city of one project, mass household WaSH kit distribution became impossible. As a result, the implementing agency had to adapt their activities, providing handwashing stations at key public places (market, entry points/ports) instead. Similarly, during project implementation, one of the cities lost its water supply, affecting the medical teams’ ability to respond to the outbreak. Subsequently, water trucking, emergency latrines and showers in health clinics and hospitals were provided to maintain medical operations.