How Ghana maintained health services even during peak COVID

Like most countries, Ghana was hit hard by COVID. As of this April, the country had recorded more than 161,000 confirmed cases and 1,445 deaths. The pandemic also damaged its economy and strained its health services and budgets.

One area that Ghana excelled in, however, was maintaining the provision of essential health services (EHS), even during the peak of the pandemic. Soon to be published research by Exemplars in Global Health examines the decisions and interventions that allowed the country to do so.

Ghana, in February 2021, notably became the first country in sub-Saharan Africa to receive COVID-19 vaccine through the WHO's COVAX Facility. By March, the country had launched a relatively successful vaccination campaign using the 600,000 AstraZeneca doses. The country also quickly launched a fairly aggressive series of non-pharmaceutical interventions, including partial lockdowns, the closure of air, sea, and land borders, fumigations at marketplaces and schools, and the closure of schools, churches, mosques, bars, and other social venues.

The Exemplars study shows that all these strategies not only contributed to the reduction of new cases, deaths, and the socioeconomic impact of the pandemic, but also ensured the health care system was not overwhelmed.

We spoke with Dr. Duah Dwomoh, a biostatistician and a lecturer at the Department of Biostatistics at the University of Ghana, who helped lead the research, on the findings and lessons learned.

How did Ghana respond so effectively to COVID-19 and maintain essential health services?

Dr. Dwomoh: The government and other stakeholders adopted an integrated approach. There was no single intervention. It was integrated in terms of governance and the political will to fight COVID-19. You can have the best interventions when there is a pandemic, but if the leadership is not willing wholeheartedly to fight it head on then it becomes extremely difficult.

We also realized there was [already] an efficient surveillance system, which was how the country was able to capture data in real-time. Based on the data sets that were coming in they were able to make informed decisions as to where the disease was spreading or the cases were clustered, so interventions were tailored to those areas.

Another thing was the testing strategy and contact tracing the government used. At the beginning of the pandemic, basically what they said was "Well, we will test you, once you test positive, we trace you into the community, your household, and then we also test them. If they are positive cases, we treat them." We call it the three t strategy – you test, trace, and then treat.

But then when we started recording a higher number of cases, there was a change in strategy. We used a pooling system to test the number of blood samples that were coming in. Initially, we only had two recognized standard laboratories that were doing the COVID-19 testing. The number of samples that were coming in was quite high so they could not do individualbased testing. With pool testing they put all the blood samples together and determined whether there is a single blood sample from an individual testing positive. If there is one, then they test all the individuals again. If none of them tests positive, they are declared negative and we move on. We used the pooling system to fast-track the rate at which we're doing blood testing in Ghana.

The government of Ghana developed a COVID-19 strategic plan and then treatment guidelines purposely. We did not record a case in Ebola, but we had some experience [preparing for that disease]. We've also had a cholera outbreak in the country and we leveraged that experience to mitigate the effects of COVID-19. Basically, these were some of the things they did in terms of trying to mitigate the effect of COVID-19 and how it was also going to spread in the community.

In terms of the provision of essential health services, Ghana did not close any health facilities. The only thing they did was to suspend elective surgeries. All facilities were open 24 hours for services. Initially, people were a bit worried that they would go to the facility and get COVID. The government of Ghana quickly intensified education to [let people know] that once you get to the facility, you are safe because they also set up a triage station. Before you get services from any health provider, you are tested for COVID-19. Before you get access to the main facility, or before you see any medical doctor, nurse, or any other health professional, you are tested. It gave people some confidence, and most of them were able to visit these health facilities.

The government also created a shift system – they arranged the [incoming] patients in such a way that you only come to the health facility when your condition is severe. Otherwise, the health workers will visit you in your house. They also used telemedicine. They did that to reduce the number of people coming to the facility, but also to provide health services. The provision of essential health services was not just going to the health facility – it was also having nurses and medical doctors visiting patients in their respective homes. I think doing so contributed significantly to why we were able to maintain essential health services.

The incentives provided by the government of Ghana I think in my opinion, also helped. Initially, [health workers] were afraid, but the government came in and said 'we're going to increase your incentives,' and the zeal came back. People were willing wholeheartedly to work their heart out, especially the health workers.

Could you tell us about the interventions – or combinations interventions – that had a greater influence on the incidence of COVID-19 and deaths in Ghana?

Dr. Dwomoh: It's very difficult on a face value [to determine that], even after doing qualitative interviews. One policymaker will say "Oh, the closure of our international borders contributed significantly to reducing the burden of COVID19." Another policymaker will say that "Oh, the partial lockdown also contributed to reducing the burden of COVID-19." It was difficult trying to determine which non-pharmaceutical interventions contributed most significantly to reducing the burden.

The first thing I can say is the fact that all the interventions contributed one way or the other – the wearing of masks, partial lockdowns, the closure of our international airport, borders, the use of alcohol-based hand sanitizers, contact tracing. They all contributed. They all prevented new cases and averted a number of deaths. From the simulation, however, we did realize school closures and then the international travel ban during the peak phase of the pandemic contributed significantly to the number of cases and deaths averted.

We're especially curious about some of Ghana's innovations, such as the use of drones to transport test samples from remote areas of the country? Could you tell us how this program started and how it worked?

Dr. Dwomoh: It was extremely difficult for the government of Ghana to transport blood samples. Like I indicated, initially, we only had two labs doing all the testing. When the pandemic started, if you had somebody who lives in a remote area and then this person is suspected to have had contact with COVID-19 patients, it was difficult bringing the blood sample to Accra or Kumasi. Then drones bring the blood sample straight to [testing center] and then take it back to the health facility and then the results will be delivered to the patient.

I should also add that because of COVID-19 now we have new infectious disease centers just to accommodate people when there's an infectious disease outbreak, which is good, but we still need more. The government is now also planning what we popularly call Agenda 111 to build about 111 hospitals to complement the number of health facilities that we have in the country. COVID made us realize that we need more health facilities and more infectious disease centers and the government has started doing that.