Conclusiones

There are assumptions within the pandemic plans of Ghana and Malawi that seem to take the position that planned interventions will address the pandemic outbreak in a straightforward manner, yet there are great discrepancies at the level of intelligence and key issues associated with pandemic preparedness. Discrepancies are expected in any pandemic planning at the national or international scene due to the uncertainty associated with pandemics. However, it is important to have a consistent basis for planning, especially if it is to be applied at the local and national level alike.

Study of the deployment of influenza policies has revealed some good outcomes, for example, it was widely acknowledged in the interviews across Ghana and Malawi that public health authorities worked extremely hard to strengthen capacity through a number of public health initiatives. There were variations in the planning for, and responding to, pandemic influenza in Malawi and Ghana, as demonstrated in table 6, in terms of preparedness

activities, strengths and gaps in the major themes of preparedness. Both Ghana and Malawi developed communication strategies, strengthened influenza surveillance and updated overall goals in PRPI. However, most of the response actions addressing the 2009 H1N1 pandemic failed to achieve the important public health goals reflected in the national preparedness plans.

Malawi’s Ministry of Health and governmental policy structure for pandemic planning differs significantly from that of the Ghana Health Service, despite the fact that public health structures for Ghana and Malawi are both based on the PHC system delivering healthcare at the local level via health units. In Ghana, structures for PRPI were more organised, with the key scientific and professional organizations at the forefront of responding to the H1N1 pandemic influenza. For example, GHS took a leading role but worked closely with the NADMO, the MOFA/Veterinary Services, MLFM, FAO, WHO and USAID. In Malawi, similar structures were available, overseen by the DoDMA and the Ministry of Health as an implementing agency supported by key international partners (FAO, WHO and USAID).

Ghana performed comparatively well in PRPI (Table 6). Ghana spent more on health, with health expenditure per capita (USD) of $75, compared to Malawi who had an expenditure of

$31. The Commission on Macroeconomics and Health (2001) has concluded that US$ 34 per capita on health is the minimum required for providing basic curative services to reach health related MDG goals. Higher health expenditure does not necessarily lead to better health outcomes, but a minimum level of resources is needed for a health system to fulfil its essential functions adequately. Viewed as a share of GDP, Malawi contributed about 8.4% to the health service compared to Ghana, whose share of GDP was 4.8%, meaning that Malawi was very committed to health care in the overall economy.

NADMO and the DoDMA are arm's-length government organizations dedicated to disasters in the two countries respectively. In contrast to DoDMA, NADMO have the infrastructure and technical expertise to organize early warning information systems and manage emergencies. However, it was observed throughout the interview data that NADMO and the DoDMA were passive because they lacked the scientific expertise to assist health providers and public health partners to make informed decisions about PRPI. Comparing the two, NADMO was better-placed to assist because it had a permanent structure within the government dedicated exclusively to planning and leading a response to a public health

emergency. Similarly, the GHS was more prepared and responded far better than their counterparts in Malawi.

In Ghana and Malawi pandemic plans are not updated regularly because dedicated personnel with expertise in emergency management are rarely consulted. As a result of this, a pandemic advisory group was established within the emergency management structure which assisted in managing the training of staff and overall preparedness efforts. The pandemic roles and responsibilities for Ghana and Malawi were similar as both fell under the obligations of the WHO. Pandemic roles and responsibilities were based on the WHO pandemic phases. These guidelines were heavily criticized by policymakers from both Ghana and Malawi, particularly on the poor timing of the 2009 release of pandemic phases as these would not be applied in the current pandemic. Additionally, both the MoH in Malawi and the GHS, fell short of implementing drills or test plans for an imminent threat because of a lack of resources.

Neither Ghana nor Malawi did well in preparing for surge capacity. This was demonstrated by the clinical situation in the Ghana Health Service and Malawi’s MoH which lacked a good relationship with acute care and intensive care services. Similarly, there was a failure in engaging acute care units with PRPI. Because the pandemic was mild, preparation for acute care or procurement of intensive equipment was considered unnecessary – a sign that lessons have not yet been learnt. Looking at the broader picture, equipping intensive care units in the usual pathway of primary care is necessary for trauma care and treatment of other critical illnesses, and not only pandemic influenza.

Ghana had established Influenza Assessment Centres (IACs) at the national level supported by a laboratory unit, but there were doubts from policymakers in Ghana about how these would be operated. In Malawi, IACs were unavailable and influenza activities were dealt with by the Community Health Science Unit (CHSU), an epidemiological section of the MoH that handled influenza samples and made them ready to be tested abroad. Neither Ghana nor Malawi had ever considered establishing an ethical preparedness plan to support ethical considerations and there were no guidelines to support business continuity planning and surge capacity management with regard to local health organizations.

Table 6: Pandemic preparedness activities, strengths, gaps and comparison in which they are necessary, depending on major themes of preparedness