How a Ugandan district is copying with a lockdown to deliver MNCH services
Support supervision for health services provision is part of the routine activities within the health systems strengthening to ensure effective and efficient health services delivery. The story has been different however during the COVID 19 pandemic. In Uganda, the first COVID-19 case was registered on the 21st march 2020, and since then, several rapid response interventions have been put in place to try and combat its spread. One of the restrictive measures put in place is the lockdown that has had several extensions since its inception catalyzed by the increased new cases especially from truck drivers discovered at the boarder points of the country.
The lockdown has had negative effects on an already struggling health system by creating physical barriers to access to health care facilities, in addition to the biting poverty and other contributors to poor health outcomes especially in regards to the three delays to health care services. The only window of opportunity that exists in the district however is that the health departments of districts by the leadership of the District health Officers have an oversight role of ensuring that those in need to health care services are supported to access them. Yet this has been misinterpreted by the general public to think that health facilities have been closed.
We therefore focused on identifying to identify the challenges in the provision of health care services in the district of Luuka in the face of COVID 19 Lockdown.
Communities in which Mothers and Newborns Thrive (COMONETH) through integrating COVID 19 into maternal Newborn and Child health with support from Makerere University school of public health under the leadership of Associate Professor Waiswa Peter and Elizabeth Ekirapa.
The project has built the capacity of the district health team through training on updates in maternal and newborn, hands-on mentorship and coaching in care for mothers and new born, as well as optimal delivery of routine care services like immunization, reproductive health, the health management and information system of timely data capture, as well as logistics and chain management of drugs and supplies for the health facility arm. Support to village health teams to conduct home visits for health education on antenatal care, health facility delivery and care after birth in the postnatal period has been an area of focus in the face of COVID 19.
What have been the disruptions and their consequences?
Evidence available suggests that in the first phase of the lockdown, decision to seek care at the health facilities at the community level was significantly affected as many individuals feared to travel to the health facilities, given the restrictions especially on the use of public transport. Some of the health workers likewise were trapped in their localities by the lockdown restrictions on movements especially for fear of being harassed, imprisoned by law enforcement officers along the transport routes. It is reported that a few available health workers at the health facilities are over worked, stressed, but also scared because of the epidemic for fear of contracting the disease from the patients whose status is not known. The health workers also express the fear for lack of personal protective equipment during their interaction with the patients that report for various medical conditions. No deliberate efforts have been made in the district either by the ministry of health or by development or implementing partners to formally orient the health workers on COVID 19. “We also just rely on the information from the radios and TVs mostly when the president is addressing the nation, we have not been oriented officially on how to manage the patients during the pandemic, it is God helping us” remarked one of the health workers in Luuka District.
There is reported reduction in the numbers of deliveries, antenatal care attendance, and also the postnatal as a result of the lockdown. This is attributed to the restrictions on public transport that has scared the mothers that are intended to attend these services.
Documentation for key interventions done at the health facilities has also reduced attributed to the workload at the health facilities. There is evidence that health workers are stressed and scared with the disease.
The COMONETH study continues to offer support to the health care system even during the lockdown. We facilitated a medical officer of the from Kampala and an anesthetic officer from Butaleja District at the We have procured and supplies emergency items to support the continuity of emergency and obstetric care services at Kiyunga H/C IV. We supplied examination gloves, Bupivacaine, Oxytocin, sutures, surgical masks, surgical gloves, Iodine, Gauze, cotton, Pethidine, spinal middles, Ketamine, safety glasses, theater caps. With these supplies and the presence of critical human resources at the highest level center IV supported by the study, caesarian sections continue for critical cases.
Phone interactions and follow ups with the village health teams were made to ensure that their work challenges including misconceptions on the COVID 19 are addressed in conjunction
What is being done?
The district health officer Dr. Wandira Christopher, during a debrief meeting with the COMONETH team emphasized that all health facilities are fully operational in providing all the services, although expressed fear that some health facilities in the district have been affected by the lockdown that found some essential staff off their duty stations and are currently unavailable. He remarked however that efforts are being made to facilitate the critical staff to travel from their locations to be able to provide care to the patients that need the services at the various health centers.
What needs to be done as of now?
- The office of the district health officer has arranged focused emergency meetings with all the in charges of all the health facilities to orient them on COVID 19 in accordance with the COVID 19 guidelines.
- Continuous support for struggling health facilities in documentation is a priority to the DHOs technical staff of the HMIS focal person in ensuring that accuracy and consistence of data is maintained.
- The missing staff from the health facilities are being supported with transport to their duty stations from their current places of lockdown and services provision shall continue even in the face of accommodation challenges at some of the health facilities. Other staff have been granted travel permits from the RDC through the DHOs office.
- The DHO shall engage the RDC’s office to produce a document directing all the TBAs to stop their operations of delivering mothers as it has been reported by the VHTs. The DHO however indicated that there is no policy document that mandates his office to stop their operations as some of them claim to have been trained and authorized by passed leadership and with certification of operation. This makes it hard to stop them without any legal backing.
- The next supplies requests to be done in liaison with all the health facility in charges during the ordering of drugs and supplies to be clear on the stock that they need. Emergency requests shall as well be made in consideration of the wage bill for drugs
- Continuous onsite hands-on mentorship is critical in skilling and confidence building for critical frontline health workers especially for correct triage, diagnosis and prescription of treatment in addition to proper records keeping and reporting for all procedures done.
- Focused referral system, while adhering to referral protocols is critical based on the condition, but also the pre-referral treatment given to patients. Availability of ambulance services for critical cases is a requirement where the cases are escorted by a qualified staff. The district task force is facilitating ambulance referrals for critical cases, although some patients are meeting the costs of fuel.
- Use of the already available protocols for emergencies obstetric conditions for better management of patients is critical by all the health care workers.
- Ensure that all maternal and newborn deaths are notified and audited in accordance with the MOH guidelines. The audit books to be availed to all facilities from the district stores.
- VHT’s to continue with home visits to educate families on maternal and newborn care plus COVID 19 sensitization messages while observing COVID 19 guidelines with close support from the health facilities.
Lessons learned from the lockdown intervention
Frontline health care providers are motivated by close support from their superiors and they feel protected to continue to provide care even in the hardest times. The availability of essential commodities for use at the health facilities where care is sought breaks barriers to care as the patients are assured of continuity of care services and therefore they continue to seek care as lockdowns may not necessarily hinder the needy to seek care.
The lockdown increased workload on the health facilities. Reports from the catchment facilities indicated increase in numbers of ANC, malaria caseload, HIV/AIDS refills due to relocation/migration of some clients during the looming lockdown.
Accommodation for health workers at the health facilities enables presence and consistence/continuity of care especially the routine services, the health facilities with relative accommodation reported continuity of services as health workers were locked down at their work stations.
Communities care systems are interconnected and interlinked in ensuring that services continue. Community support systems when strengthened complete the chain of access to care from the health facilities in rural areas. The community has ably mobilized local resources to support themselves to access care even in the absence of public transport as bicycles and even walking has been adopted to reach care facilities.
At the community level, there is no clear information about COVID in regards to its cause, spread, signs and symptoms as well as prevention and therefore preventive measures are not implemented accordingly; say social distancing at staying at home. People are still found in trading centers loitering and going about with their routine work as though there is to disease
The community health workers’ activities have been slowed down as they no longer interact with the households are often and as free as before for the fear of the spread of the COVID disease; and therefore there is fear danger signs in mothers and newborns go unnoticed and may lead to negative outcomes. But also there is a possibility that mothers are going elsewhere for delivery and other service4s and therefore a threat
Integrating Village health team members is still pivotal in linking health facilities to the communities where the actual beneficiaries come from.
Special thanks go to Comic relief for the unwavering support through their funding support to Makerere University the school of public health to COMONETH.
Authored by: Rogers Mandu- Quality improvement specialist, maternal Newborn care, Makerere University school of Public health.