COVID-19 disrupted health systems around the world and threatened access to essential health services, particularly for women and children. The well-being of mothers and infants depends on their continued access to these services. With COVID-19 remaining an ongoing dynamic, what are learned strategies for maintaining essential maternal, newborn, and child health services, family planning, and reproductive health services (MNCH/FP/RH) we can apply to the future?
Dr. Queen Dube, Chief of Health Services for the Malawi Ministry of Health, and Dr. Babatunde Olatunji, Executive Director for the Oyo State Primary Healthcare Board, share the adaptations and innovations born out of the pandemic that have the potential to be ongoing fixtures of MNCH/FP/RH programs into the future. Can the disruptions from the COVID-19 pandemic have a positive effect on health moving forward?
COVID-19 disrupted health systems around the world and threatened access to essential health services, particularly for women and children. The well-being of mothers and infants depends on their continued access to these services. With COVID-19 remaining an ongoing dynamic, what are learned strategies for maintaining essential maternal, newborn, and child health services, family planning, and reproductive health services (MNCH/FP/RH) we can apply to the future?
Dr. Queen Dube, Chief of Health Services for the Malawi Ministry of Health, and Dr. Babatunde Olatunji, Executive Director for the Oyo State Primary Healthcare Board, share the adaptations and innovations born out of the pandemic that have the potential to be ongoing fixtures of MNCH/FP/RH programs into the future. Can the disruptions from the COVID-19 pandemic have a positive effect on health moving forward?
MOMENTUM Presents, bringing in-depth experience in improving maternal, newborn and child health services, family planning and reproductive health care in countries around the world. Providing technical and capacity development assistance to country leaders and governments and ensuring that mothers and babies have access to essential care in order to reach their full potential. We are MOMENTUM Country and Global Leadership, funded by the US Agency for International Development and we welcome you to MOMENTUM Presents. This is the exclusive podcast series highlighting strategies for maintaining essential maternal, newborn and child health services, family planning, and reproductive health care in the face of the COVID-19 pandemic. We are discussing challenges and sharing solutions with country leaders around the world and keeping the momentum going in responding to the global pandemic.
Angela Pereira:
Welcome to MOMENTUM Presents Episode Three: Applying innovations from COVID-19 to the future.
Hello and welcome to MOMENTUM Presents. I’m Angela Pereira, the Communications Team Lead for MOMENTUM Country and Global Leadership. I’m so excited to introduce the third and final episode in our Innovating in a Pandemic trio where we look at critical innovations and strategies adopted by countries to mitigate disruptions to health services for mothers, newborns, and their families during the COVID-19 pandemic.
In the first two episodes, we’ve heard from leaders in India and Sierra Leone.
Now, in this final episode, we will go to Malawi and Nigeria and look towards the future. What have we learned from COVID-19? Are there adaptations and innovations born out of the pandemic that could be ongoing fixtures of maternal, newborn, child health, family planning, and reproductive health programs?
I am so honored to discuss these questions with two esteemed guests – Dr. Queen Dube, Chief of Health Services for the Ministry of Health Malawi and Dr. Babatunde Olatunji, Executive Secretary for the Oyo State Primary Health Care Board in Nigeria.
Let’s start with you, Dr. Dube. Thank you so much for joining us. You’re a former health care worker, a current policy maker, and a strong global advocate for maternal and newborn health. I’m really looking forward to hearing your perspective on this topic. To start, I’d like you to take us back in time to 2020, to when the COVID-19 pandemic was just taking off – what was the situation in Malawi?
Queen Dube:
Thank you very much, Angela. It's quite interesting that three years have passed since we had the first COVID-19 case in Malawi. We're actually in the third year, and it's amazing what the country has gone through and the phase where we are at the moment. I remember December 2019 when we had about COVID-19 cases in China, people thought, "Oh, well, it's going to be like bird flu. We heard about bird flu in Asia, it never got to Africa." So we were in this phase where we thought, "Okay, fine. It's also another kind of a bird flu."
And then fast forward in 2020 when we had our first case, I believe it should be around about April time. The fear that engulfed people at that time was unbelievable. And I guess it was because of a lot of uncertainty around the COVID-19 pandemic at that time. If you remember the number of people that were dying in Europe, in the US, in the UK, and people felt this side of the world, that if people are dying like that in well resourced settings, what's going to happen to us in Sub-Saharan Africa? So there was a lot of fear.
And if you remember the early days of COVID, a lot of misinformation, disinformation was really rife. And unbelievably so, every corner of our country, if you go in the rural settings, we had a lot of misinformation. And at that time, people felt if you go to the hospital, you go and catch COVID and you die, and so we saw a drop in the number of people actually seeking care. Even for routine things things like vaccinations, things like antenatal clinic attendances, we even saw a drop in the number of facility deliveries. So yeah, it did have an impact. So we went through a period in time, the first wave, second wave and third wave, where there was a lot of fear surrounding our health facilities. People thinking this is a place where you go and get COVID, or if you have symptoms suggestive of COVID, this is a place where you just go and die, better stay at home.
So it was a scary moment for all of us. By the time we're getting to the fourth wave, people had understood what was going on with COVID so we saw a lot more people accessing services. But this is two years down the line. It’s always scary the gains that you lose within a very short period of time. It takes a long period of time for you to have a positive change and it just takes a day, a week, for you to lose the momentum. So that's what we've seen with COVID, we are going through the recovery phase where people have regained their confidence in the health services and we are seeing now almost back to normal, the 2019 times, that's where we are roughly at.
Angela Pereira:
Yeah, hearing you go back to that place, it certainly jogs my memory back to that place, too. The fear, the disinformation, and how things have gone up and down over these past years. Just in terms of the response to COVID-19 at that time, were there measures or responses that you saw for COVID-19 that could potentially have a broader, positive impact?
Queen Dube:
Angela, if I was given one minute to answer this question, this is what I would say about COVID-19. It is the impact it had on systems, our health system. Out of the blue, we were able to have a robust leadership and governance. Policies and guidelines were crafted very, very, very quickly, a governance system was put in place from the national level, moving down to the level of a community. We're talking about a matter of days, if not weeks! Training manuals and so on and so forth. Everybody was brought together round one table. COVID taught us that it is possible for us to craft one plan, have one budget, and have one report, regardless of the name of the stakeholder. So we all came round one table and developed this one plan, what we're calling the COVID national response plan. COVID also taught us how to do multi-sectoral collaboration. So we had people from our security agencies, we had people from other government agencies.
Number two, COVID taught us how to strengthen the health information system. We were able to demonstrate that within days you could set up systems using the very same human resource that we've always had for decades. COVID also taught us that our people can actually effectively use data. And so we saw use of data on a daily basis. We saw that it is possible to count every death, count every positive case of COVID, and follow up how many of them had recovered. We saw that with COVID. If we're able to do it with COVID, we can do it for everything else within the health sector.
COVID also taught us on how to deal with deficiencies in as far as the health workforce is concerned. So all these hurdles that we've always had in terms of recruitment, financial challenges, but with COVID, resources were made available for us to recruit more nurses, more doctors, more laboratory people, more physiotherapists, and so on and so forth, within a very, very short period of time. COVID also taught us that you can do a lot in as far as health financing is concerned. Government was able to allocate special resources. Donors were able to pull resources together in one basket to push for better outcomes in as far as COVID was concerned.
COVID also taught us that we needed to look at the service delivery arm. Things happened so so quickly: equipment and supplies, these were things that were documenting and reporting on mostly on a daily basis. How much oxygen was available across the whole country? District by district, facility by facility, counting on a daily basis. And I've always said it, if we're able to report like that for COVID-19, tracking our equipment and supplies, why can't we do it for everything else? In terms of infrastructure, COVID taught us to look at the gaps that were there and resources were made available through government, but also other stakeholders. And we quickly put up structures, what we're calling the isolation wards, to manage COVID-19 cases.
Why can't we do the same for maternal health? Where sometimes you have a very small delivery room with two, three delivery beds, yet you're delivering 20 mothers on a daily basis. What will it take? What type of advocacy do we need to put in place? So for me, COVID, yes, it cost a lot of people's lives, but it also taught us that within our countries, we have the capacity within. And if you remember, Angela, you know, we had issues with air travel. And so you couldn't get people to come in your countries as technical assistants to really help people with that agenda. You really needed to look within and push and tell yourselves, how do we sort out the data side of things? And out of the blue, you realize that the people that you've had for many, many, many years have the capacity that you've always looked for, it's just that maybe they were never given a chance. And so I like to look at the COVID disruption on the positive sense, and really use the health system building blocks as a measure of what COVID has been able to teach us in our countries.
Angela Pereira:
That's a really helpful and insightful framework for breaking it down and for thinking about it. What stands in the way from taking those lessons and those measures and that will from COVID and applying it to other sectors like maternal newborn health?
Queen Dube:
What is it that actually drove us to do things the way we did them? Number one, COVID affected everybody else. It wasn't a disease for the poor. It actually affected ministers, members of parliament, chief executive officers, the rich, and people saw people that have names dying. I'll tell you, we have diseases that we've struggled with for a very, very, very long time. and we don't have the same level of dedication, why? It's the poor people that have no voice and really somebody has to stand up and speak on their behalf. Sadly, this is the truth of the matter. That's a reality that none of us wants to discuss. And that's why we still struggle with issues like cholera, still struggle with WASH issues in the 21st century, just because it's not affecting that honorable member of parliament, it's not affecting an honorable minister, it's not affecting some rich guy somewhere. Bring in a concept of equity, that regardless of somebody's social economic status, they also have a value and we must provide the right services for them.
Secondly, I mean, if you look at the maternal newborn space where a lot of these mothers are dying, you will see that it's in places where we have wars, natural disasters, and then generally the poor countries. And who is going to stand up for these women? Who is going to stand up for these women? And because it's gone on for too long. We've gotten to a stage where we feel, okay, this is what it is. Yes, women die in Africa, women die in Asia, babies die. So you get to a point where you are used to the data that you see. You look at it every day, you say, "Oh, okay, fine. Same figures." COVID, it was something new. Many people died at the same time and it shook everybody else across the whole globe. COVID, the issue was not just for Sub-Saharan Africa, the issue was a global issue.
Now, because you've gotten used to some of these figures, it doesn't make us uncomfortable. The fact that one million babies die every year in Sub-Saharan Africa, we've gotten used to that figure. You know, we are losing an entire city in a year; it doesn't make us uncomfortable. So unless we get to a place where at the global level, at the regional level, we're so uncomfortable with these figures, the way we were uncomfortable with figures surrounding HIV/AIDS, bring that same level of uncomfortability into the maternal newborn space, and surely we will push this agenda. We need to go back to the drawing board and really tackle these issues head on.
Angela Pereira:
If you had a message for other policy makers around the world on this, what would it be?
Queen Dube:
That's a million dollar question, Angela, but you know what? First and foremost, start from where you are. There's a lot of capacity from within. Sometimes countries like ours, we've tended to look outside the country for assistance, but there's a lot of capacity within our countries. And just as COVID taught us, have a very clear plan. We talk about these SDG targets that we want to hit. MMRs of under 70 per 100,000 live beds, neonatal mortality rates of under 12 per 1000 live beds. That's just a figure. And we have about seven, eight years to 2030, and really, seriously look at your own country. What are the major contributing factors to your maternal MMR and NMR? What are these individuals dying from? Is it lack of oxygen? Is it delay in presentation? Try and understand your own data. One size does not fit all.Try and develop your own country level plan. What is it that we want to do in 2023? If your MMR is at 400 or 300 or 200, say, for example, by the end of 2023, where do we want our figures to be? Do we want to drop it by 5%? What will it take to drop it? And then you have a system that religiously follows your data. What you do not measure, you cannot improve. It's good to have national plans, but those plans are nothing if they are not implemented from the level of the community.
So, so, distilling a national level plan to the level of the community, let the community own the plan and have this robust monitoring system where, on a quarterly basis, all important players are brought to the table the same way we did with COVID. And we're able to talk about these issues and tackle the issues head on. Bring in your members of parliament. Bring in your Ministry of Finance people. Bring in your community leaders. Bring in your religious leaders. And together, we can. So we need to move beyond the strategy documents to implementation. I believe we've done a lot of development of strategy documents, it's now time for us to implement and start from within. What resources are available? And what data are you measuring? Simply put, Angela, that's — that’s what I would say.
Angela Pereira:
Thank you, Queen. For you personally, what is your vision for the health of mothers and newborns and their children and families? What is your personal vision for health and healthy communities and what that looks like?
Queen Dube:
For me, as Queen Dube, I've always said one maternal death is too many. No woman should die giving birth. We also need to move beyond survival and start to seriously think about thrival and the transform agenda, particularly in this part of the world. So, you will see that we are making progress in as far as neonatal mortality is concerned, maternal mortality is concerned, but at this time of the era, surely we shouldn't be having women with obstetric fistula. We shouldn't have babies ending up with cerebral palsy, just because of a birth trauma. So, my personal vision is we need to move beyond survival and start to talk about and tackle thrival and the transform agenda.
I also believe that our countries should make more resources available for maternal and newborn. As we've always said, a child is a father to the man. And so unless you invest in the newborn period, then forget about your future. And let me also say this. If you look at rates of adolescent pregnancy, child marriages within this part of the world, the figures are alarming. We tend to talk about mothers dying, we do not talk about the root cause of these things that we're dealing with. Now, if you have regions where 40, 50% of your adolescents, of people that are married, are actually children, then you have a long way to go.
So, let's address the root cause of these maternal death and neonatal death issues. No child should be giving birth to another child. This is something that gives me sleepless nights, when I walk into the neonatal unit and then I see — you wonder, are these siblings? And you're told that, "No, these are actually mothers." So no child should be giving birth to another child. Let them use their childhood to thrive and to transform.
Angela Pereira:
Thank you so much for your insights, Queen. I love your call to action for us to move beyond survival to thrival. Is there anything else that you would like to mention today?
Queen Dube:
Thank you, Angela. Just to say that behind those figures — and I say this all the time — behind those figures that we caught are faces of people. Some of these mothers end up losing their lives, they leave behind children, orphans, and their future is disturbed. And so we need to move beyond the figures and start to see faces of people. If you think about a million newborns dying every year, think about little graves. That's a million graves. And once we start to look at those figures that way, I believe all of us will stand up and take a step.
Sometimes I get emotional with these issues and I know we can do better. We did it with COVID. We can do better.
Angela Pereira:
I think too often, the emotion is taken out of it and people just go into their little bubbles and do their own specific thing and you don't look and think about the big picture and what we really should be working for. Your perspectives there are just so very needed in this world.
Queen Dube:
Thank you very much and you have a lovely day!
Angela Pereira:
Thank you, Queen.
Let’s now go over to Dr. Olatunji to hear if there are similar or unique takeaways in Nigeria gleaned from the pandemic that could impact maternal, newborn, and child health moving forward.
Dr. Babatunde Olatunji, you are Executive Secretary for the Primary Health Care Board in Oyo State. All primary health care facilities are under your leadership. You have also been a champion for quality care.
Thank you so much for joining us. I’d like to start with the same first question that we posed to Dr. Dube: Could you take us back in time to 2020 to the beginning of the COVID-19 pandemic? What was the situation in Oyo State?
Babatunde Olatunji:
Thank you. In 2020, with the outbreak of COVID-19, it was a global pandemic. Nations of the world responded in different ways, but almost into the same set of objectives: to curtail the infection and mitigate against the impacts.
In Oyo State, the response was in line with the federal government response, maybe some local contents as a formal response. There was a general lockdown in the country. The state did not do a complete, total lockdown; it was a strategic lockdown. People were allowed to move about. Gathering of many people in open spaces were discouraged.
The state government tried to mitigate the effect of the lockdown of people by providing relief materials for them. And part of our response in the state was to activate the process of disease surveillance and notification in the state, which is available across the local government area and the political wards.
As part of the response, the state set up the Isolation Center, which is COVID treatment centers, not in the usual open field like other states were doing. We used existing government facilities, which were upgraded, remodeled, and re-conformed to answer the niche for the COVID-19 response. Any person coming to the state to support the states were made to come to the central points to know what they want to give.
As part of the response of the state, the aid system was running continuously, but not as wide as how it could be. All the aid personnel were given protective garments and they were encouraged to protect themselves.
The principle of social distancing was integrated and prevention measured by the use of face masks. The state government produced these face masks in large quantities, using locally available materials.
With the lockdown, it would adversely affect the economy. So, what the state did was to engage local people to sew the face masks, so that some funds passed back to the system, as a form of recycle. The relief materials, food materials that were procured, we ensured that we did not get anything from the refinished products or that might be imported. They were locally available products from farms. These were a few things the state did.
And, the response was quite commendable and effective. In fact, most of our strategies were being copied by the federal government.
Angela Pereira:
What about community engagement and making sure that communities felt like they could still continue to access safe, quality health care at facilities, during a pandemic?
Babatunde Olatunji:
So, we have the health education units at the local government areas. So, we activate them to do more of community engagement and awareness creation, information dissemination – to talk in the local language that people would be able to understand.
We activated this surveillance mechanism. It is a health education component. We were working hand-in-hand. We started a community test center of COVID-19 to be able to know what's the prevalence in our community. The quality of information and engagement strategy we used in the community made it possible and easier to come out and join hands in combating the pandemic.
Angela Pereira:
That was a really interesting picture of what the situation looked like in Oyo State at the beginning of the pandemic. And I think, in so many countries, there was this urgent, rapid response like what you're describing. But now – two and half years, almost three years on – are there any of those kind of initial systems or initial tactics put in place for COVID-19 that can maybe continue to have a positive influence on how care is provided in the state going forward?
Babatunde Olatunji:
Thank you. When every person really were responding to the COVID-19 pandemic, to set up treatment camps, isolation camps, many people were using tents in the open streets, but our state used existing facilities. All we did was to upgrade those facilities, equip them, and provide all that we do in those facilities. Now, COVID-19 seems to have abated and we're getting back to normal life. Those facilities are still running now, so it becomes an advantage that during COVID-19, attention was paid to those facilities. They’re so much upgraded now. We’ll now be able to work in a better environment with the right equipment that we might not have been able to source for initially.
Part of the change we were able to gain for the COVID-19 which we seem to be sustaining now is a culture of hand washing and hand hygiene and hand sanitizers. We have a standard procedure to do infection prevention control, which the culture would not be so high before COVID-19. With the advent of COVID-19, the culture became well-established, and now, after COVID-19, we are still imbibing with the culture and the practice. So, that to me is a positive take away.
Angela Pereira:
Great, thank you. That's really good point about handwashing. Often, improving infection prevention and control in health facilities can springboard into improving quality care more broadly. Tell us more about your vision for quality health care.
Babatunde Olatunji:
The gold standard should be the quality health care service. And at the primary health care level, one of the areas we identified challenge was infrastructure. So, in the principle of the ward health system, which is the bedrock or the foundation, it was designed that we should renovate and upgrade at least one primary health care facility in each of the political wards.
And in Oyo state, we have 351 political wards. That means as of today, we are operating 351 primary health care facilities to be able to render minimum service package. Aside that, we understand the issue of funding, that there must be adequate funding to run the system.
So, by way of our engineering, it was designed now that we ask source funding of at least seven point five percent of monthly allocation devoted to running PHC, which is what we started in January now in the last one year, which has been supporting our vision. And part of the quality of health care services delivery, we make procurement and distribution of drugs to facilities now a routine. It has to be done every month.
And again, no matter what you do, we need to generate qualitative data – data capturing, too – to ensure that we have the human resources components, then capacity building for the human resource. It's something we do at a continuous basis.
Now, we have engagement with partners to support the state in building capacity of the personnel that we have on the ground, so that they can effectively discharge what they are supposed to do.
Vis a vis … it has been continuous improvement. So for me, the cup is half filled, not half empty.
Angela Pereira:
Thank you. Dr Olatunji. Half-filled indeed.
And thank you to both you and Dr. Dube for giving us an optimistic view of the future. That we can turn the investments and lessons of COVID-19 into positive forces for the future of maternal, newborn, and child health.
Queen said if we can do it for COVID-19, we can do it for maternal and newborn health. And Dr. Olatunji said that because of improvements to quality of care during the pandemic, the cup is half full. It’s a hopeful note to end on as we apply these lessons of COVID-19 to maternal, newborn, child health, and reproductive health going forward.
This wraps up the third episode of Innovating in a Pandemic, a series from MOMENTUM Presents podcast. You can listen to the previous episodes of MOMENTUM Presents wherever you get your podcasts.
I’m Angela Pereira, thank you so much for listening.
This concluded this edition of MOMENTUM Presents.For more information about our work, please visit www.usaidmomentum.org and follow us on Twitter at @USAID_Momentum for additional resources.