Office of Maternal and Child Health and Nutrition, USAID
USAID’s development work has increasingly been taking on the adaptive management approach – an intentional approach based on continuous learning and adaptation that supports decisions and adjustments to be made in response to new information and changes in context. The uncertainty and ever-changing nature of the COVID-19 pandemic highlights the importance of such an approach, especially when trying to support the most vulnerable groups. The Urban Health Community of Practice recently hosted a webinar featuring two of the co-authors from a recently published paper on improving well-being in urban informal settlements and contributors from several East African countries to reflect on their experiences in supporting MNCH efforts for urban slum dwellers in the context of COVID-19. Their reflections highlight the importance of engaging affected communities in co-creating their solutions and using community structures to ensure a successful and sustainable response. Slides and a link to a recording of the webinar can be found here.
A One-size-fits-all Approach Will Not Work
Even the most well-intentioned interventions, when directed from “the top” or “outside” without input of those affected, will at best face unanticipated challenges and at worst result in devastating unintended consequences. This is particularly salient as we grapple with COVID-19 in urban slums or informal settlements where an estimated 1 billion people call home. To be most effective, national strategies aimed at implementing global guidelines need to be adjusted to account for the realities and disparities that exist within countries and within individual cities. While physical distancing and lockdown directives have been important to “flattening the curve” in many settings, these strategies are inconsistent with the livelihoods and living space of those who live in informal settlements – where overcrowded living situations makes staying home as, or more risky than leaving; where the majority of residents are informal workers with no savings, dependent upon face-to-face contact to survive the day; and where the lack of infrastructure or social services are exacerbated by COVID-19.
In addition, we need to focus on assets that these communities bring, and not just risks. Previous epidemics have taught us that listening to communities is critical to ensuring interventions are effective. As large cities in Africa encounter an increasing number of cases of COVID-19, the importance of local context and community engagement in developing and managing the strategies to effectively respond can not be understated.
Care-seeking challenges in Urban East Africa
Webinar contributors from Nairobi and Kampala provided insights on how COVID-19 is impacting urban centers in their countries and what more needs to be done to support addressing the health needs of those most vulnerable, the urban poor. To date, Uganda has registered 732 cases of COVID-19 (and no deaths), but the impact of the lockdown that has been in place for more than 11 weeks is impacting MNCH outcomes. In Kampala, the MaNe Project has been collecting data from health facilities that provide services for the urban poor, and at the time of the webinar they were seeing a reduction in antenatal care (ANC) initiation and attendance: 30% reduction in ANC-1 attendance and even higher reductions for continued ANC visits. Delayed care-seeking is contributing to the increase in emergency cesareans and macerated stillbirths being seen in Kampala. One of the main factors contributing to the delay is fear of being infected with COVID-19. Similarly, in Nairobi, 60% of pregnant and new moms reported significant anxiety with care-seeking – reflecting that COVID-19 would affect their decision about when AND where to seek care.
The other major cause for the delay in care-seeking emphasized in both cities is the challenge of finding (and paying for) transportation. Curfews and lockdowns have resulted in difficulty in finding available transportation, increased cost of transportation, as well as staffing shortages in hospitals as health workers struggle to reach their workplaces. Efforts from the City Authority in Kampala to put in place a free emergency transport system with a dedicated set of ambulances and a toll-free hotline have been helpful, but more effort is needed to further communicate it’s availability and “convince” skeptical beneficiaries that the service is real and is truly free.
Where does Implementation Research Fit Into All This?
Implementation research is an important tool that can inform adaptive management because it embodies the key practices of real-time inclusive planning and data-driven solutions, and it engages the key actors in the process. Implementation research fosters ownership and collaboration among those who are engaged in and make decisions that can affect the process. Community-based groups must be empowered to engage with multidisciplinary decision-making teams of technical experts to co-create their solutions and be equipped to collect and utilize real-time data; such groups are best positioned to address the evolving COVID-19 situation on their home turf.
Webinar participants talked about their efforts to support real-time data and knowledge management to inform decision-making and adjustments within the health system. Efforts such as those undertaken by the MaNe project to collect data around the clock and share it with key decision-makers through WhatsApp contribute to real-time decision-making that support quick responses especially around personal protective equipment and healthcare worker shortages. In Kenya, Jacaranda Health is supporting the COVID-19 Challenge Tracker – a map of facilities that utilizes red, yellow, and green indicators to indicate the level of service disruption (ANC, postnatal care, high-risk appointments) being experienced among the 200 mid- and high-volume facilities supported across their programs.
Taking an adaptive management and implementation research approach and capitalizing on community-led programs and groups will facilitate creation of effective strategies to counteract local myths and misconceptions, to overcome the fears and stigma around COVID-19, to advance uptake of risk reduction strategies, to modify provision of essential services, and to ensure uptake of services in unplanned settlements for those who live there.
- Dr. Jason Corburn, University of California Berkeley
- Dr. Blessing Mberu, African Population and Health Research Center, Nairobi
- Dr. Yvonne Mugerwa, Kampala MaNe, Uganda
- Dr. Sathy Rajasekharan, Kuboresha Afya Mitaani, Kenya
- Dr. Raz Stevenson, USAID