La teoría del oligopolio cooperativo y la colusión en precio

The response to the 2009 pH1N1 in Malawi was reflected in the level of communication of information about the disease. Several policymakers interviewed noted that unprecedented communication efforts were implemented during the H1N1 2009 pandemic. However, several other policymakers admitted that little was actually done to cover a large audience.

Policymakers felt that the government and concerned organizations could have done more by explaining how the disease is caused, its pattern of transmission and its impacts. Officials never sufficiently stressed the likely nature or duration of the pandemic, its spread, its peak and decline, nor did they sufficiently inform the public on these issues. The message regarding ethical issues, such as who is eligible for limited vaccines and when a case can be quarantined, was not clearly defined or transmitted to the public. With regard to vaccine availability and efficacy, for example, officials were unclear as to how soon vaccines would be made available or how effective they would be against the virus. According to Kotalik (2005), more information on the benefits and burden of vaccines and antiviral drugs would set the stage for a more successful voluntary vaccination programme and thus avoid an ethically problematic mandatory programme. This also corresponds to the ethics of prevention that was presented in Chapter 4. On the other hand, an influenza vaccine offered too late in a post or free pandemic period does provide some benefits in terms of reducing illness, absenteeism, hospitalizations and deaths. The benefits will not be the same as they would have been had the vaccines been offered much earlier in the pandemic period. As such immunizing late would raise genuine ethical concerns because of the little achievable benefits and lost opportunities for disease prevention during the pandemic outbreak. There is a lot of demand for influenza protection during an outbreak and equally are more opportunities to mitigate and control the disease had the vaccines been used early enough than later.

There is evidence that offering the vaccine well after the 2009 pandemic could provide some

benefit to individuals against influenza A virus (pH1N1) that caused the 2009 pandemic because this virus is now circulating as seasonal influenza. Thus, individuals who have not previously been infected with pH1N1 may have achieved personal protection. As will be discussed in Chapter 9, the public in Ghana and Malawi may have been right to be less than enthusiastic to receive a vaccine in March/April 2011 that was most needed in 2009.

However, it important to remember that the 2009 (pH1N1) virus that caused the pandemic is now circulating and is considered seasonal influenza.

The MoH sensitized the public to the risks of influenza and the means of prevention through national radio adverts and the use of Information Education and Communication (IEC) materials. Despite the controversy over whether the MoH performed the task well, it is evident in the interviews that the MoH and its implementing partners were committed to public awareness on pH1N1.

Those who criticized the handling of communication and messaging proposed new ways to improve IEC. For example, some policymakers suggested the use of multi-media communication, including newspapers, radio, TV, posters, magazines and social networking sites such as Facebook and Twitter. These methods of communication could be used to develop a key message and deliver it through other channels, such as press briefing or press releases, or through social mobilization campaigns at the local level. The role of two-way communication was emphasized, especially as pandemic influenza was a sensitive and controversial subject requiring consistent and carefully designed communicative strategies.

According to one policymaker (USAID-MW-41), vaccine uptake could have been improved if people had been assured that vaccines were safe to use. Providing information explaining inconsistencies could also have clarified the perception of the vaccines; for example, information could have been provided as to why the authorities took a long time to implement the vaccine strategy. The WHO delivered doses of A(H1N1)pdm09 vaccine to Malawi in November 2010 and implementation took place a couple of months later. While it took a few months for the government of Malawi to vaccinate, what is more shocking is that the WHO could not deliver vaccines until November 2010, arguably well into the post pandemic period. It could be argued that it was not morally right for the WHO to dump vaccine stocks on Malawi well beyond the pandemic period, and pressurize the Malawian Government to vaccinate when the rationale and time for immediate benefits to prevent

and mitigate the 2009 pandemic influenza had passed. As was noted earlier, immediate benefits in terms of managing the pandemic were no longer possible. If unvaccinated individuals who have not previously been exposed to 2009 pH1N1 (now circulating as seasonal influenza) become infected with the same strain they will not be protected. Only individuals vaccinated against 2009 pH1N1 without previous exposure after the pandemic outbreak may be protected from the current seasonal strain (2009 pH1N1) because they will have developed immunity from the vaccine.

Policymakers also noted that the communication strategy was restricted only to communicating with the public and it did little to establish links with its implementing partners inside and outside the health system. For example, one policymaker stated that:

There were no better linkages among structures at the national, regional and local level or between primary and acute care systems. (COM-MW-04)

The lack of coordination in the communication process caused conflicting messages, especially within the media. The reasons most policymakers gave for this discrepancy was embedded in the lack of Public Relations (PR) within the PRPI lead agencies.

6.3.0. Planning for, and Response to, Pandemic Influenza (PRPI) in Ghana 6.3.1. Drafting of the Pandemic Response Plan

As of 2006, Ghana had set up the Avian Influenza Working Group (AIWG) to be in charge of pandemic preparation needs and the delivery of public health and health promotion services at a national level. The drafted national pandemic plan was approved in December 2005 and revision of the second draft was completed in February 2006 with a great deal of involvement from the National Coordinating Committee (NCC). The draft of the plan was based on three hypothetical scenarios developed from the AIWG needs assessment, taking into consideration various factors such as the timing and the geography of the disease. The purpose of the draft was to identify any risks that needed to be addressed, and generally assist the country with PRPI.

According to the Ghana pandemic plan (Republic of Ghana, 2006), the first scenario in the AIWG needs assessment is a situation where Human and Avian Influenza (HAI) is brought

into the country either by migratory birds or humans and then quickly spreads between both groups. The second scenario depicts pandemic phase 4, where human-to-human transmission is declared, resulting in geographically localized clusters of human cases. The third scenario is phase 4 of the pandemic, progressing into phase 5, where the virus is capable of rapid and effective human-to-human transmission.

The course of action for each scenario was based on the six WHO pandemic response phases.

Experts involved in the design of the national preparedness plan were aware of the implications of each pandemic scenario, but setting up a course of action that corresponded to the scenario of a modest pandemic was problematic. The pandemic plan and its subsequent revisions were not piloted to verify the appropriateness of identified actions, responsibilities, logistics and communication for different severities of the outbreak.

The New Zealand pandemic plan, for example, requires ongoing testing through exercises to ensure the plans will be effective when activated (Ministry of Health, New Zealand, 2010).

According to the policymakers interviewed, exercising pandemic actions for each scenario demanded additional resources and infrastructure and thus was unrealistic and costly if applied under different scenarios of occurring pandemic influenza. Planning assumptions are not the prediction of what exactly will happen during the pandemic. They should be indicators of what could happen. Drawing on UK pandemic preparedness, lessons can be learnt that planning assumptions that are reasonable yet not clear may not be well understood.

Pandemic influenza is unpredictable as such scenarios should be flexible and adaptable to a wide range of potential scenarios. The UK plan suggests that planning assumptions should be updated regularly in light of emerging evidence about the range of likely assumptions about the pandemic (Department of Health, 2011). Interestingly, the UK Department of Health plan developed in 2011 draws on lessons learned in 2009, but the 2009 plan was not so flexible or proportionate in its approach even though CEAPI had pointed this out to the UK Government before 2009.

Many policymakers recognized that the drafting of a national plan using a modest pandemic scenario would be the appropriate thing to do if Ghana was to prepare effectively for facing and containing the danger of an emerging pandemic. They made it clear that there was a need to consider implementing response actions that were reasonably proportionate to the threat of the pandemic. For example, wave 1 response and inter-wave planning phases would have

their own courses of action and budgets which would be implemented accordingly.

However, most policymakers, especially those with economic backgrounds, could not agree on courses of action for different pandemic phases.

For most policymakers, plans that were being developed were inflexible. The interview data suggests that plans should include measurements of severity that could reflect escalating changes in the pandemic. The lack of a severity index in the pandemic plans may be justifiable on the basis of financial resources. There is no money to conduct influenza research that might determine a suitable severity index in the context of Ghana. Even if a severity index was determined, developing and using such an index is not straightforward and would demand an efficient operational health system that is practical. For example, would Ghana have the surveillance or patient data to make an accurate assessment of severity?

Rapid research in this area of concern is needed to improve understanding of the level of planning and inform resource allocation.

Policymakers interviewed in Ghana appear to agree that the scenarios used in Ghana were lacking in various aspects, especially in clearly expressed assumptions about clinical attack rates, hospitalisation and death rates. For example, the National framework for responding to an influenza pandemic gave a range of case fatality of between 0.4 and 2.5%, for which the UK should be prepared (Department of Health, 2011), while the New Zealand preparedness plan prepares for up to 2% case fatality rate (Ministry of Health, New Zealand, 2010). One policymaker wondered how Ghana could claim full preparedness when its drafting of the national plan was inadequate and tabletop exercises that drew on these scenarios were not systematic. Notably, the drafting of the Ghana Pandemic Plan (GPP) did not fully acknowledge the processes involved in mobilizing resources, or scrutinize issues of resource allocation and priority setting, or the associated logistical challenges such as business continuity, surveillance, case examination, case management, disease prevention, monitoring and mitigation of the diffusion of the disease in the community.