LESSONS LEARNED FROM ETHIOPIA’S PREPAREDNESS AND INITIAL RESPONSE TO THE COVID-19 PANDEMIC

Abstract

Introduction Ethiopia reported the first confirmed case of coronavirus disease 2019 (COVID-19) on March 13, 2020. The novel pandemic has posed unprecedented challenges to the Ethiopian health, social and economic sectors. The socio-economic effects of the pandemic have been complex due to the presence of large, vulnerable populations, especially in urban areas. The health information system, unprepared to handle such a significant health crisis, faced additional challenges from the influx of information and misinformation, complicating response efforts. Dynamically monitoring the spread of the pandemic was, therefore, very difficult. However, the multisectoral coordination involving government and non-government stakeholders, including the diaspora, was unprecedented. In collaboration with the Ministry of Health (MoH), the Advisory Council decided to document the lessons learned during the initial phase of the pandemic to better prepare for future health crises. Objectives The study aimed to document the lessons learned from Ethiopia’s COVID-19 pandemic preparedness and response. Methodology The study utilized a qualitative approach, supplemented by a desk review of various documents related to the COVID-19 response, including guidelines and publications.  It was conducted at the national, regional, and facility levels. A total of 102 in-depth interviews were conducted with experts from all levels of the health system and among significant stakeholders, using semi-structured interview guides. The study period spans the initial detection of the pandemic through June 2021. A thematic framework analysis was performed based on the study's specific objectives, while a content analysis was conducted for the reviewed documents. The transcribed text was entered into Atlas ti 7 qualitative data analysis software. Ethical clearance was obtained from the EPHA’s Institutional Review Board (IRB) and informed oral consent was secured from each study participant. Results The findings of the study are organized under several themes below. These thematic areas reflect the diversity of the tasks implemented by various task forces to combat the pandemic. The task forces were based at either the Ministry of Health (MoH) or the Ethiopian Public Health Institute (EPHI) and included experts delegated by professional associations, non-governmental organizations, academic/research institutions, and diaspora professionals. A summary of the findings in each thematic area is presented below: Coordination and Multisectoral Collaboration: The Prime Minister's office led the entire government in national COVID-19 pandemic preparedness and response efforts through multisectoral coordination mechanisms across various ministries. The Ministry of Health (MoH) and the Ethiopian Public Health Institute (EPHI) were given technical responsibilities. Similarly, the highest administrative offices in most regions led the response coordination at subnational levels. The MoH coordinated the technical aspects related to the pandemic. The government took measures to protect the country and its communities by closing services and schools and implementing a state of emergency twice. The level of engagement in the multisectoral effort was unprecedented for a health-related crisis during the initial months of the pandemic. However, this engagement declined as the pandemic entered a protracted phase, influenced by other competing priorities, including elections and conflicts. The enforcement of non-pharmaceutical interventions was compromised by misinformation, the diversion of political leaders' attention, and the precarious living conditions of citizens, which were shaped by cultural, social, and economic realities. Risk Communication: Risk communication was initiated even before the first case of COVID-19 was reported, utilizing both public and private media outlets, including social media and billboards. Call centers were established in collaboration with the Ethio Telecom. Recognized social groups and individuals, including religious leaders, elders, public figures, and investors, actively participated in risk communication activities. Nevertheless, managing the volume of information and misinformation was a significant challenge, leading to public reluctance to fully adhere to scientifically proven prevention and control interventions. Surveillance: The surveillance system was enhanced following the World Health Organization’s declaration of COVID-19 as a Public Health Emergency of International Concern (PHEIC) to support case identification and contact tracing. Virtual training was provided to expedite the deployment of thousands of surveillance personnel. Relentless efforts were made to improve data management and contact tracing. However,  surveillance was inadequate due to the manual handling of data, a shortage of personnel for contact tracing, and many informal points of entry (PoE). Testing: The nation's zero-testing capacity was quickly enhanced to more than ten thousand daily tests by re-purposing public and private university facilities and laboratories. However, testing proved expensive, and large-scale testing was not sustainable for an extended period.   Private testing centers provided the much-needed relief to the heavily constrained public facilities. These private centers received considerable government support to expedite the importation of machines and supplies necessary for COVID-19 testing. Over time, the private sector’s service expansions were increasingly driven by profit, resulting in unacceptably high service costs. The testing strategy and capacity were insufficient to understand the pandemic at a granular level and to implement timely interventions. Infection Prevention and Control (IPC): IPC was enhanced in all health facilities by revising protocols, training the health workforce, and procuring IPC materials. The COVID-19 pandemic created opportunities for innovation; locally produced items included face masks, hand sanitizers, automatic water and soap dispensers for hand hygiene, and area disinfection machines. Nevertheless, shortages of supplies and failure to adhere to IPC protocols remained severe challenges. A critical shortage of Personal Protective Equipment (PPE) was exacerbated by misuse and abuse. The scarcity of water and sanitary facilities at health institutions resulted in inconsistent IPC/WASH practices. Additionally, logistics and material shortages hindered the training and deployment of the necessary health professionals at the pandemic's start, presenting further challenges to IPC efforts. Case Management: Immediate actions were taken to free up COVID-19 treatment space in existing health facilities and temporary locations, such as the Millennium Hall, which served as treatment centers. Efforts to establish functional treatment centers were reasonably successful; the number of intensive care units (ICUs) equipped with mechanical ventilators increased, albeit grossly inadequate, due to the global shortage. In addition, the opening of private treatment centers helped manage more cases, although the cost of treatment was exorbitantly high. The protracted pandemic also caused fatigue and burnout among healthcare workers and severely constraining the provision of essential services. Initially, mental health and psychosocial support mechanisms for frontline health workers and individuals in isolation were lacking. They were later incorporated into the guidelines with the assistance of mental health professionals and their associations. The functionality of routine health services was restored relatively quickly after the initial interruption. However, the adverse effects of COVID-19 on certain routine services, such as immunization and care of patients on long-term treatment, remain unknown. Supplies and Logistics: This was a relatively well-organized component of the health system. Nevertheless, workforce shortages, dependency on the external market, and limited capacity for local production constrained the supply chain management system shortly after the pandemic began in the country. Regulatory flexibilities regarding the importation of medical supplies and successful efforts to boost domestic production of medical materials quickly increased the availability of Personal Protective Equipment (PPE). However, the government procurement system was not conducive to handling emergency procurements, a situation compounded by the lack of emergency funds. Additionally, the tendency for countries that produce supplies and equipment and those capable of paying higher prices to hoard these resources exacerbated global shortages, creating severe consequences for low-income countries. Conclusions and Recommendations Despite the concurrent challenges, including political, natural, and other man-made disasters, Ethiopia’s COVID-19 pandemic response was reasonable. The multi-sectoral efforts, domestic resource mobilization efforts, and innovations to overcome shortages of supplies and equipment were among the best practices. For instance, testing, isolation, and case management capacity were increased by repurposing existing lab machines, buildings, and health facilities.  However, the health system was overstretched in the first few months of the pandemic, and had it not been for the relatively mild nature of the pandemic in Ethiopia, the human losses could have been tragically high. The risk communication approaches failed to promote strict adherence to COVID-19 prevention and control efforts. The involvement of the private sector, professional associations, academic/research institutes, and non-governmental organizations was critical in strengthening the response efforts. Additionally, the Ethiopian diaspora made significant technical, logistical, and financial contributions to support these efforts. Establishing a standing professional advisory council must be seriously considered in preparing for and responding to future pandemics. Such a body can be engaged in revising strategies for risk communication, surveillance, management of essential medical services, and providing psycho-social support. In addition, strengthening the human resource capacity, improving the health information system, and establishing an emergency procurement system along with emergency funds are critical for future pandemic preparedness. A well-thought-out directive addressing the standards of care and pricing must guide the private sector's involvement in the pandemic response. Supporting efforts to produce essential medical supplies domestically should be given high policy priority. [Ethiop. J. Health Dev. 2024; 38(SI-1)]