La acción colectiva en la Unión Majomut

6.1.3. Structure of Relevant Authorities in Ghana and Malawi

The Governments of Ghana and Malawi were responsible for managing, updating and evaluating all aspects of PRPI through their Ministries of Health. Ghana and Malawi’s Ministries of Health (MoH) were lead by agencies on PRPI overseen by the National Disaster Management Organization (NADMO) and Department of Disaster Management Affairs (DoDMA) respectively. They monitored the spread of the disease and coordinated information with the WHO.

The Ministries of Health were supported by a number of key government departments at the frontline of PRPI. Tables 4 and 5 show the organizations involved in PRPI activities. The WHO recommends close collaboration with all relevant stakeholders to ensure strategic vision of response planning is achieved (WHO, 2005c). However, stakeholder representation from regional, district and local governments to aid in coordination of a national pandemic response was notably absent in Ghana and Malawi, thus weakening the command and management capacity.

In Malawi, preparations were led by a National Avian Influenza Task Force (NAITF) whose subcommittee constituted a Rapid Response Team (RRT). The RRT formed part of the National Avian Influenza Technical Committee (NAITC), drawing its participation at regional level with representation at the district level. The Office of the President (OP) had overseen NAITF and donor agencies (see appendix 8 for organizational and communication hierarchy in Malawi). In Ghana, an inter-agency Avian Influenza Working Group (AIWG) coordinated the development of the country’s plans and actions to address the pandemic.

Powers to develop core capacity for PRPI in Ghana and Malawi were conferred upon these committees, which primarily constitute policymakers representing governments, UN agencies and NGOs (Table 4).

During this study, I interviewed most of the officials and policymakers representing these governments, public and bilateral agencies, professional associations and intergovernmental international organizations. This involved technical experts, funders, advocates and those involved indirectly or directly in PRPI activities such as coordinating, updating and

Table 4: Authorities involved in PRPI by Organization, Position and Qualification

Source: Author's study of government authorities.

evaluating priority tasks and programmes. Policymakers held different positions. For example those I interviewed included veterinary officers, epidemiologists, laboratory technicians, medical or clinical officers, wildlife officers, UN representatives, politicians such as cabinet ministers and Principal Secretaries (PS) for Health and Agriculture and local NGO representatives such as the Red Cross.

The policymakers were drawn from national, regional and local level organizations to help provide performance insights into the public health functions of PRPI. As shown in table 4, Malawi’s preparations lacked highly trained experts such as ethical experts, economists, virologists and epidemiologists to make judgements and maintain the best use of limited resources. In Ghana, technical human resources within NCC/AIWG were excellent; this partly contributed to stronger pandemic preparedness. However, not all essential experts such as bioethicists, economists or local experts were engaged.

NAITF (Malawi) and AIWG/NCC (Ghana) led the coordination and leadership of PRPI, particularly in the early detection and rapid containment of avian influenza. Their roles changed as they moved from avian preparedness to human influenza preparedness prior to 2009 pH1N1. The controversy over the respective roles of PRPI and decision-making in NAITF (Malawi) and AIWG/NCC (Ghana) has contributed to the lack of clarity on their role in policy formulation. PRPI was inherently fluid and lacked policy framework. Policymakers at the macro level (constituting government authorities) failed to coherently articulate basic policy on PRPI and delegate roles to micro policymakers (WHO, USAID etc.) that would strengthen and implement PRPI. What we see in Malawi and Ghana is that PRPI is not a government initiative even though the government owns it. PRPI in Ghana and Malawi was initiated by the WHO and delegated to the governments. According to Brown (2003), where national policymaking requires technical expertise and nuanced shaping, governments should delegate to independent policymakers at the micro level for their contribution, regardless. The real question is who are the policymakers? Since PRPI is a national matter, the logical sequence in the policymaking process must be regulated adequately and so full government involvement is critical to control all elements of dictation of PRPI policy by interested parties.

6.2.0. Planning for and Response to Pandemic Influenza in Malawi 6.2.1. Overview of the National Preparedness and Response Plan

The pandemic contingency planning process in Malawi began in 2006 after outbreaks of highly pathogenic avian influenza (HPAI) in poultry that began in Asia in mid-2003. The Malawi Pandemic Plan was developed by NAITF in collaboration with NAITC/RRT, a multi-sectoral team chaired by the Ministry of Agriculture (MoA), with the support of the Ministry of Health (MoH). Three Rapid Response Teams (RRTs) were put in charge of verifying and dealing with all aspects of suspected bird influenza outbreaks. An RRT was

established in the south, the centre and the north of the country and each had access to existing infrastructure, such as laboratories and the IDSR. The RRT members were predominantly MoA staff trained in all aspects of future rapid response at the national level so that they could also train trainers.

Preparedness in Malawi mainly involved active surveillance of animal diseases by monitoring animal traffic in and out of the country at the borders. Southern African Development Community (SADC) regulations require that movement of animals must be accompanied by legitimate permits, but stopping illegal transportation is impossible because of weak border controls and illegal animal trade in the region. The Malawi government attempted to deal with this problem by increasing human capacity at the borders and speeding up monitoring mechanisms of disease reporting. This exercise was accompanied by training that enabled the National Avian Influenza Technical Committee (NAITC) / RRT including Veterinary Assistants (VAs) and Health Surveillance Assistants (HSAs) to identify cases, conduct rapid tests and report all cases through the Integrated Disease Surveillance and Response (IDSR) system. Appendix 9 shows the disease reporting and coordinating system deployed to monitor disease outbreak.

As part of its preparations, the Malawi government established animal contact tracing and an animal identification system at the national level to aid track-back activities. Laboratories to aid active surveillance were identified. The Central Veterinary Laboratory (CVL) in Lilongwe and two satellite laboratories in the northern and southern parts of the country were identified to perform rapid tests. Through the Department of Animal Health and Industry (DAHI), a free animal vaccination campaign was carried out to tackle renewed concerns about Newcastle Disease (ND) and HPAI. ND is not considered a serious disease by smallholder chicken farmers, yet it cannot be clinically distinguished from HPAI without rapid tests. This has implications for public health considering the seriousness of HPAI.

The majority of these preparations were accomplished under the authority of the MoA and on a temporary basis. The contribution of the IDSR under the authority of the MoH extended preparedness for HPAI to humans. The MoH strengthened its capacity by integrating HPAI into the IDSR system. MoH sensitized all its health authorities on the method of implementing the IDSR using the simplified tools and response actions adopted in the resolution of IDSR (WHO, 1998). In addition to the IDSR providing timely information for

decision-making regarding HPAI, the Malawi Government signed an agreement of partnership with Kenya Medical Research Institute (KEMRI) to assist with laboratory confirmation of HPAI. Surveillance systems at international airports were set up, although these were not sensitive enough to pick up human cases.

Two points are observed from the preparatory activities in Malawi. First that although there was strong evidence to suggest the threat of the disease might be carried by migrating flocks, most of the work that was done in the first part of preparation was relevant to animals and only in the second part of the preparations was it relevant to humans. Second, preparations for the pandemic were unclear. It remained difficult to judge whether preparations were based on the influenza specific subtype H5N1, H1N1, both or others.

The Malawi Plan was ill prepared to respond to a modest influenza pandemic. Most respondents (N=22) cited the lack of planning in terms of surveillance, case management, infection control, social mobilization, communication and logistics. This lack of planning is believed to have affected the effectiveness of the response measures necessary to detect, manage and control the pandemic. As will be described in more detail in later sections, most public health activities were instigated during a relatively short period of time between April and May 2009. These mainly involved the conversion of the existing avian communication plan into a human pandemic plan. This suggests that more time was deployed putting together the plan than utilizing it to respond to the needs of the 2009 HIN1 pandemic influenza. More importantly, it raises important questions about whether such responses are effective without influenza drills, exercises and simulations.