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Preparation prior to the 2009 pH1N1 in Ghana evolved around risk assessment and communication regarding the pandemic. Early interventions, such as mounting surveillance to detect the threat or using surveillance data to determine human resource capacity,

including some of the operational activities, were in blueprint. The following quotation from a policymaker representing MOFA summarizes the surveillance preparations:

Prior to the pandemic, focusing on avian influenza, epidemiological and surveillance data was defined, tracked and shared among the developmental partners such as NADMO. (MOFA-Ghana-16)

As well as sharing surveillance data, a communication and reporting schedule was set up before the 2009 pandemic. This involved identifying leadership, partners and structures to implement the drafted plan. The process of implementing the new pandemic plan was centred on frequent interactions between lead agencies of the pandemic and stakeholders. A number of financial agreements with developmental partners were secured to help with strengthening capacity, such as influenza education and human resource laboratory surveillance. Non-health preparations, such as a business contingency plan and ethical plan (discussed further in Chapter 9), were not pursued.

The issue of research and development in the pre-planning stage is said to have been undermined during the drafting of the national plan, yet pandemic planners themselves knew it held the key to tackling the consequences of the pandemic. The lack of meaningful engagement with research and development was associated with the absence of research and leadership direction including a lack of resources and, in part, a lack of interest in pandemic preparedness.

The process of immunization in Ghana is practised regularly, but policymakers regretted not having launched similar campaigns for seasonal influenza which could have eased the pandemic campaign. In the UK, seasonal immunization targeting the elderly and vulnerable groups is taken seriously because it reduces morbidity and saves lives. There are no seasonal immunization campaigns in Ghana. Although, seasonal immunization was identified in the pre-planning stage of the pandemic plan as an important strategy, it was often overlooked including the process of ensuring vaccines are acquired on time. Even though the main beneficiaries (pregnant mothers and children) had been identified beforehand, there were no stockpiles of pharmaceutical products (including flu vaccines) for treatment of influenza in pharmacies in Ghana. A policymaker mentioned that there were no efforts to acquire vaccines

and antiviral drugs either for seasonal or pandemic influenza by buying or establishing vaccine and antiviral drug contracts and agreements with the pharmaceutical companies.

While the national plan considered various scenarios, policymakers were concerned that the planners did not consider specific issues, such as what would happen if there was a huge uptake of vaccines and antiviral drugs. In other words, what would happen if there was scarcity? Equally, there were no detailed plans for temporary health workers if needed. There was no consensus as to how the health care delivery systems would manage care in an extremely limited resource setting – for example, policymakers mentioned that it was not clear how they would maintain existing centres for immunization, especially when deciding when to close immunization clinics, since real-time information on supplies of and demand for vaccine doses was not available. Prevention and treatment guidelines were left open to the clinical judgment of the prescriber. For example, prophylactic use of antiviral drugs was allowed for health personnel in the pre-exposure stages of the pandemic, but this contradicted the policy that antiviral drugs were reserved for individuals with severe illness only.

6.3.3. Coordination

During my field visit, I was interested to know how responses to the 2009 pandemic were coordinated at the national, regional and local level. The findings suggest that coordination of roles and responsibilities to identify risks and implement mitigation strategies among stakeholder groups was deficient in many priority areas. The quality of support, according to most policymakers, exposed important structural weaknesses which seriously limited responses to the 2009 pandemic. Many policymakers mentioned that financial and technical support was mostly limited to a few PRPI entities, rendering governance of pandemic influenza inefficient, if not irrelevant.

Funders (appendix 13) frequently had the final say on what the money might be used for in PRPI strategies. Hence, gaining agreement on common multilateral approaches was beyond the control of key decision-makers. Development partners, predominately international donors, were reported to have had a greater voice on the role of PRPI in Ghana (GHS, 09).

Thus policy decision-making and priorities of PRPI had to be repositioned with this in mind.

This raises questions about who really was in control of PRPI. The playing field according to policymakers was complex, making it difficult to push forward any good PRPI policy

strategy against the proliferation of influential actors. The World Economic Forum⁸⁷ captures this shift by observing that collaboration is doctored by the corresponding interests of specialized agencies that are often segmented themselves.

Intergovernmental initiatives such as surveillance, communication and reporting were cited as being as highly prioritised on funders’ agendas; it is believed that this is so because these bring immediate, tangible benefits that are globally visible. Solving transborder problems related to pandemic influenza was therefore prioritised over local challenges. For example, the emphasis was placed on surveillance rather than revamping and strengthening the health service response. Consequently, the health sector is poorly connected with other sectors, with businesses and civil society, resulting in major missed opportunities to improve health outcomes (Piot et al., 2010).

Although NADMO had overseen planning and coordination, implementation of most activities remained unfulfilled. NADMO’s mobilisation of coordinated efforts was slow, raising huge worry about its capability to coordinate activities in the event there was a pandemic. Lack of communication about the disease among implementing agencies was singled out as a major barrier for initiation and coordination of influenza activities. However, the Ministries of Agriculture and Health provided timely critical political leadership that enabled execution of initial components of the pandemic plan (Republic of Ghana, 2006).

Leadership roles during the pH1N1 remained unclear. The GHS supported by USAID/Ghana took the lead in engaging the private sector. In Ghana the local offices of the WHO, USAID and FAO led the mobilization efforts among development partners (Republic of Ghana, 2006). The MOFA in collaboration with GHS and FAO continued to survey and monitor AI and PI while NMIMR provided laboratory support.