A review of Ghana's 2009–2013 integrated strategic response plan for pandemic influenza: illustrative study of the perceived adequacy of preparedness for the pandemic influenza of sub-Sahara Africa
- 1Department of Biological, Environmental & Occupational Health Science, School of Public Health, University of Ghana, Accra
- 2Department of Health Policy Planning and Management, School of Public Health, University of Ghana, Accra
- 3School of Public Health, University of Ghana, Accra
- 4African Association of Public Health Schools
- 5Department of Biostatistics, School of Public Health, University of Ghana, Accra
- Correspondence to Dr Ishmael D Norman, Department of Biological, Environmental & Occupational Health Science, School of Public Health, University of Ghana, Accra;
Contributors IN did the primary research and drafting. MSKA did the review and corrections. FNB took part in the discussions leading to this topic selection and generation of the tables used in this paper. AG revised the tables after the first submission.
- Accepted 6 May 2012
- Published Online First 26 July 2012
Objectives To review the National Integrated Strategic Plan for Pandemic Influenza for 2009–2013 and assess whether it is in congruence with the nation's emergency preparedness status.
Method The authors examined the National Plan ‘as is’ and evaluated it against the ‘State and Local Pandemic Influenza Planning Checklist’ of the Department of Health and Human Services and the Centers for Disease Control and Prevention. The authors matched the activities in the National Plan apropos the national emergency response capabilities. From the legal framework, published studies and other grey literature on the thematic areas of the Plan, the authors developed key items found in response programmes and drew a 5-point Likert-type scale for assessment. The authors analysed the results in relation to WHO's framework for hospital emergency preparedness, and conducted two-sample non-parametric Wilcoxon rank sum (Mann–Whitney) tests.
Results/discussion The result showed that Ghana's health emergency preparedness is in disarray. About 75% of the health facilities lack emergency preparedness plans, surge capacity planning, triage for mass event and mutual aid agreements.
Conclusions The authors concluded that the Plan is incongruent with Ghana's public health emergency preparedness. The evaluation is important for Ghana and the subregion.
- National integrated strategic plan
- emergency preparedness
- pandemic influenza
- first responders
- risk management
- mass incidents
We proffer that the response modalities in the National Integrated Strategic Plan for Pandemic Influenza for 2009–2013 (NISPPI) is incompatible with the national programmes for mass health emergency preparedness and response. Due to this, the goals stated in NISPPI would not be achieved and may fail if there is a pandemic in Ghana. We also assumed that in comparative terms, the preparedness statuses for all-risk emergencies among sub-Sahara African nations are relatively the same. Ghana has had a formal agency for disaster risk reduction and management since 1996, whereas many of the nations in the subregion do not have such institutions. We further assumed that given their similar emergency preparedness statuses, the evaluation of Ghana's preparedness plans would serve as a credible case-study for sub-Sahara Africa.1
The white paper put out by the NISPPI confirmed that ‘even the most conservative model/scenario (attack rate = 15%, case death rate = 0.6%) shows the potential for significant mortality (21 600 deaths) in the face of the influenza AH1N1 pandemic, given the current Ghana's population of 24 million vis-à-vis the situation of the national healthcare delivery system’.2 This is not an acceptable risk.
Ghana's response for the pandemic influenza was developed based on the recommended framework of WHO and the Food and Agriculture Organization. It focuses on five key themes: Planning and Coordination; Surveillance, Situation monitoring and Assessment; Prevention, Containment and Management; Communication s; and Social Mitigation. The objective was to ‘improve on existing preparedness and response mechanisms established for SARS and Avian Influenza pandemic threats to effectively detect and manage any pandemic influenza in the country’.2 It seems the NISPPI had assumed the existence of a plan. To assess the improvements contained in the NISPPI, it is required to review the historical plan and then determine if any improvements had occurred to meet WHO/the Food and Agriculture Organization benchmark or that of the Department of Health and Human Services (HHS) and the Centers for Disease Control and Prevention (CDC).3
Ghana's Act 517 of 1996 provides for the establishment of the National Disaster Management Organization (NADMO). Under Part 1 section 2(d) of Act 517, it is expected from the national organisation to prepare the nation for an anticipated emergency. However, from the disaster risk management view, there is a systemic lack of clear understanding of what the duties and responsibilities of the first responders ought to be.
A study by the UK Joint Civil Military Co-operation Group and NADMO found that 'out of 72 critical organizations assessed only 24 had the capacity to provide ‘capable effect’ in risk mitigation'.4
Again, a recent (2010/2011) evaluation of 22 hospitals' emergency preparedness and response to a mass casualty event revealed that many of Ghana's hospitals did not possess realistic capacity to manage a mass casualty event. The evaluation demonstrated that 75% of the hospitals did not have basic operational tools like emergency preparedness plan, surge capacity planning, off-site triage, and simulation exercises for the training of hospital staff and management. That evaluation used WHO's 2007 Field Manual for Capacity Assessment of Health Facilities, but modified for the national situation. There appears to be a general national malaise regarding emergency response. This calls into question the seriousness of the National Strategic Integrated Response for the Pandemic Influenza.4
We reviewed the National Plan ‘as is’ without embellishment from the organisations involved in pandemic control and management. We matched the activities in the NISPPI apropos the national emergency programme. We also assessed Ghana's Plan against the State and Local Pandemic Influenza Planning Checklist of the HHS and the CDC. The HHS/CDC scale for Community Preparedness Leadership and Networking had three options: ‘Completed’, ‘In Progress’ and ‘Not Started’. The three-option scale of the HHS/CDC ‘was meant to increase the use and development of interventions known to prevent human illness from chemical, biological, radiological agents, and naturally occurring health threats’.3 We also reviewed WHO Influenza Pandemic Preparedness Checklist-Draft (November 2004). WHO checklist required a predetermined seven-item scale to be measured as either ‘Essential’ or ‘Desirable’. The seven items were under these broad subheadings: ‘Preparing for an emergency’; ‘Surveillance’; ‘Case investigation and management’; ‘Preventing spread’; ‘Maintaining essential services’; ‘Research’; and ‘Implementation and revision’.7 Emboldened by the HHS/CDC subjective scaling method, we developed a 5-point Likert-type scale for measuring Ghana's preparedness as a case-study. This also allowed us to evaluate Ghana's preparedness and the perceived adequacy of preparedness for the Pandemic Influenza of nations in Sub-Sahara Africa by simply following the recommendations of the HHS/CDC and the WHO.
So, from published studies and other grey literature, working papers of NADMO, the Ministry of Health and other non-strategic national documents on the thematic areas of the plan, we developed key items that should be present in a response programme for considering each of the thematic areas in the National Plan. From this outcome, we developed the 5-point Likert-type scale ranging from 1 (not prepared at all), 2 (<25% preparedness), 3 (>50% preparedness), 4 (>75% preparedness) to 5 (>90% prepared). This scale reduces both acquiescence and social desirability biases. We also reviewed the pertinent laws including the 1992 Constitution of Ghana; Emergency Powers Act 472, 1994; National Disaster Management Act 517, 1996; Infectious Disease Act (Cap 78) 1908 amended 1935; and Quarantine Act (Cap 77) 1915 amended 1938. The Ghana Law Reports from 1990 through 2000 were reviewed to analyse possible quarantine and or isolation reported cases. We conducted internet search using carefully designed keywords such as ‘quarantine, Ghana, public health emergency or isolation’ and ‘Ghana, public health emergency and pandemic influenza'. The results were analysed in relation to WHO's framework for hospital emergency preparedness, and further via two-sample Wilcoxon rank sum (Mann–Whitney) tests.5
Results and discussion
The gaps identified in the National Response Plan for the Pandemic Influenza were as follows.
Gap # 1: planning and coordination
The NISPPI is not a response plan per se but the broad brush strokes or outline of a plan. A good plan would show that the response programme needed for the national level is different from what may be needed at the regional and district levels (tables 1 and 2). In addition, when we analysed ‘activity’ identified by the plan as imperative to a successful intervention against the ‘legal mandate’ to assess the system's readiness to deliver credible intervention, we noticed that there was no differences in the national preparedness programme prior to 2009 when the plan was initiated and post-2009 readiness. In tables 1 and 2, we noticed that where the activity has no legal backing, the response structure should be ready to carry the activity as part of general duty of care to the population. However, where there is the legal mandate, then the readiness should, at least, be similar to the level of the mandate. In the case of supply chain for consumables in table 1 where there is a higher level of mandate, the readiness should have been close to 4 if not the same. Where the p value is not significant, then this shows that the readiness is also the same between activity and legal mandate. Where it is significant, their readiness for the activity is significantly different from the legal mandate given to the NISPPI Working Group and first responders. In this example, the NISPPI is deviating from the legal mandate. In the case of planning and coordination, although they have not departed significantly, they are more ready for the activity than the legal mandate offers. This suggests that the NISPPI Working Group and national first responders are not ready to go the extra mile to protect the population in case of an outbreak. This further suggests that there is ‘a lack of high level political will’ for the NISPPI, due to, perhaps, cost. The pre-2009 and post-2009 readiness are essentially the same. It appears the authorities in Ghana are only reacting to demands by supranational organisations like WHO to prepare for the pandemic influenza. They have, it appears, hurriedly put something together but which does not really address the challenges the country faces in terms of emergency preparedness.
Interventions for a pandemic influenza or similar threats require concentrated effort on part of the personnel at the Emergency Operating Center (EOC). The EOC is only mentioned in passing. By not providing for an EOC/emergency operating procedures, the NISPPI diluted the coordinating role of the Avian Influenza Working Group. Coordination is not limited to activities between people, but also between resources and machinery, none of which was addressed in the NISPPI.4 ,5
Gap # 2: prevention, containment and management
The total percentage for prevention, containment and management was 21% (tables 3 and 4). This does not augur well to have a pedestrian emergency preparedness plan against the pandemic influenza. In a recent study by national researchers on the medico-legal prerequisites for quarantine and isolation, they found that the ‘National Preparedness and Response Plan for Avian and Human Pandemic Influenza: 2005–2006’ did not mention the constitutional prerequisites in case of quarantine and isolation, just as the document under review did not. That research also found that the existing legislative framework is inadequate on the issue of quarantine and isolation. The national researchers also found that forced isolation is practiced in Ghana at the ports, harbours, borders and hospitals. The authors cautioned that in the event of an actual public health emergency the full ethical and constitutional imperatives would not be observed by the Ghanaian authorities, which may lead to claims of the abuse of autonomy, due process and informed consent.2 Between activity or preparedness and the legal mandate to do so, there was no significant difference (p=0.166). Could this mean the institutions are only prepared to do what they have been legally mandated to? However, they scored higher in terms of ranks on activity preparedness (146 as against 107) and even higher when compared with the expected value (126.5). The thematic area total was also higher in this regard. There was no significant difference between pre-2009 readiness and that of post-2009 (p=1.000), meaning nothing has changed in terms of the NISPPI.
Gap # 3: surveillance, monitoring and assessment
Gap # 4: social mitigation
We evaluated the modalities for social mitigation and rehabilitation as contained in the NISPPI (tables 7 and 8). There cannot be effective social mitigation without a common needs assessment component. Needs assessment helps in the acquisition of humanitarian supplies and the equitable distribution of such items by an aid agency or national governments. The NISPPI needs to design the modalities for needs assessment.6
Gap # 5: communication and public education
We assessed the national preparedness for risk communication and public education (tables 9 and 10). Irrational fear has deleterious effects on the human body. When rumours surfaced in 2008/2009 that AH1N1 was in Ghana, the population stopped eating chicken, pork and other derivatives of these products. The Minister of Health and the Ghana Health Service staged a public durbar for eating chicken to demonstrate that chicken and pork when well prepared posed no threat to the consumer. There appears to be a technical disconnect between general disaster preparedness and the risks facing the nation in the NISPPI document.5 ,7
There are no modalities for early warning or crises risk communication in emergencies to inform the residents of an imminent threat. A score of 54% for communication and education is fairly good, but still has ample room for improvement. More needs to happen to make the national emergency preparedness for health emergency more resilient.
We are grateful to Dr Kofi Mensah Nyarko of the Ghana Health Service, Non-Communicable Diseases Unit, Korle Bu, Accra, for reading the paper and offering suggestions for improvement. We are also grateful to Dr George Amofah, former Deputy Director General of the Ghana Health Service and the Chairman of the Avian Working Group, Ghana Health Service, for his advice on the presentation of the material.
Competing interests None.
Provenance and peer review Not commissioned; internally peer reviewed.