COVID19 –To Stay or Not to Stay at Home – Lessons from Managing Ebola in Sierra Leone

Introduction

As we strengthen the country’s capabilities to conduct more covid19 tests, the rate of infections will likely increase as more cases are confirmed. At the same time, this will understandably trigger more panic, fear and anxiety. I believe this period, on the contrary, requires cool heads to prevail especially at the level of the National Response team to ensure rational data driven decision making. During the 2014-2016 devastating Ebola virus disease (EVD) outbreak in Sierra leone, there were a series of “stay@ home measures”. As my contribution to the raging debate as to whether the President should or should not lock down the country, based on my “learning from the stay at home strategy in Sierra Leone’, I will argue that 4 key requirements must be in place for an effective stay@home policy namely; theory of change of the intended outcomes, rigorous surveillance approach, feedback mechanisms and a well-defined organizational model to ensure execution and measurement.

Theory of Change – For Stay At Home

The President of Sierra leone, ordered 3 stay@home measures in September 2014, in December 2014 and finally in March 2015. In simple terms, stay@home meant the entire Sierra Leonean population of more than six million people was obliged to stay at home for up to three days. The first intended outcome was to reach zero cases of EVD through surveillance that helped to identify people showing signs of illness or fever, test them for EVD. This had become necessary because stigmatization of EVD infected individuals had caused families/communities etc to with-hold information about potential and actual cases.

The second intended outcome was to trigger behavior change and address reckless behavior with basic hygiene practices ie soap and hand washing, reinforced with sensitization on the practice of safe burials and reporting illness. The lessons from the above is that any decision to implement “stay@home” in order to reduce spread of Covid19, must have a clear theory of change with measurable outcome supported by indicators to track and evaluate the effect at the end of the period. If the President of Ghana, decides to order a stay@home policy, that will require almost 30million Ghanaians to stay at home, the focus must be to strengthen surveillance in order to promptly detect new, suspected covid19 cases and deaths so as to trigger an appropriate response, including rapid diagnosis, case isolation and management, contact tracing and safe burial, and the identification of transmission chains through community engagement. The decision must have a clear theory of change and must not be done, out of emotional considerations, or pressure from the populace. A solid data driven risks assessment of the pros and cons must apply.

Surveillance Approach

A stay@home measure must be reinforced by a rigorous surveillance approach to promptly detect new, suspected covid19 cases and deaths. This is critical to trigger the right response, including rapid diagnosis, case isolation and management, contact tracing and safe burial, and the identification of transmission chains. An effective approach must balance the intensity of surveillance against reasonably acceptable risks. Covid19 survivors, must be involved in supporting surveillance and case investigations must be carried out in response to the discovery of new cases. The inherent risks of stigmatization must be managed and covid19 survivors should be cared for through a rights based approach that provides access to appropriate psychosocial, livelihood support. During EVD in Sierra Leone, surveillance was facilitated by the health services but success depended on community engagement and participation (e.g. via intel/alerts from community leaders and traditional healers to frontline health workers). https://web.ccsu.edu/afstudy/upd23-2.html. A surveillance approach for covid19 must aim to interrupt all chains of transmission from now to when it ends, reinforced by additional period of enhanced surveillance. Key elements of surveillance include community-based surveillance, active case search in the community, active case search in health facilities etc. This must be supported by screening of dead bodies for possible covid19 cases with identification led by community leaders.

Importance of Feedback Mechanism

During a stay@home policy, it is very important to have a network of informants who will provide alerts/intelligence etc to support the surveillance, isolations, contact tracing and testing strategy. During the EVD, youth reporters, information focal points and community reference groups were in action to gather information on sick people in the community in order to alert the district ebola response committees (DERC) which would then visit and line list, thus prompting the distributions of needed food and other basic supplies for quarantined households. In this era of technology and social media, this is an area that Government can leverage to ensure availability of real time data to guide decision making during this period. For example Government can engage the telecom companies to support this aspect of the response.

Organizational Model For Handling Crises

Management, coordination and logistics is very critical for responding effectively to covid-19. Clear definition of the organizational model for organizing leadership, management, professional, specialist , administrative roles, skills and expertise backed by a clear structure with emphasis on clarity of decision space and decision mandate by key state and non state actors played a major role to improve the leadership and management of the response during the EVD stay@home interventions. In addition coordination of the efforts of other stakeholders via subject matter technical pillars is very important to ensure synergy of efforts during this period. Logistics defined as roles that facilitate disaster risk response operations, including estimating equipment needs, procurement and distribution of supplies, transport of patients and samples and other response execution resources will be very critical during a stay@home policy and must be well planned and consistently monitored and evaluated in that regard.

In Sierra Leone, there were many instances when people ran away from quarantined communities to look for food. If you implement a stay@home policy and people don’t have access to basic needs ie food and water, they will adopt other measures to escape from their homes to attend to those needs.

In sum any decision by the President of Ghana to order a “stay@home” measure must be anchored on a clear theory of change of the intended outcomes, backed by an effective surveillance approach, reinforced by feedback mechanisms and framed by a cohesive organizational model that harnesses effective management, coordination and logistics.

Source: Casely Ato Coleman 

Author – Former Country Director, Plan International Sierra Leone, Fellow of IMANI Africa, Visiting Professor of HR, International School of Management, Senegal