COVID-19 lockdown implementation in Ghana: lessons learned and hurdles to overcome

Recent global health crises include Hantavirus Pulmonary Syndrome, Severe Acute Respiratory Syndrome (SARS), H5N1 Influenza, H1N1 Influenza, Middle East Respiratory Syndrome (MERS), and the Ebola virus outbreak [9, 10]. Preparedness, targeting disease prevention, is critical as hospitals may struggle to care for an increased magnitude of patients, especially given resource constraints. This reasoning contributed to decisions in most countries to impose restrictions due to COVID-19, including lockdowns. Even so, adequate preparation and response to outbreaks requires resources for the public health infrastructure. Hospitals and clinics have detected and treated most of those infected during COVID-19 outbreaks [11]. Based on the current WHO data, Ghana’s government expenditure on health as a percentage of total government expenditure is low, around 6.82% in 2014 [12]. COVID-19 has highlighted the often-ignored need for a massive boost in governments’ health spending, especially investment in the public health infrastructure to meet growing health needs and expectation of citizens.

An early study in Lebanon showed nationwide lockdown in 2020 had a significant impact on minimizing the spread of the pandemic and containing the virus [13]. What is an appropriate policy response or a disproportionate one? What works well in one country may not be as effective elsewhere. Lockdown implementation in some lower-middle-income countries (LMICs) proved to be effective [13], but not so in Ghana where government halted implementation due to intra-urban socioeconomic inequalities and the economic impact of lockdown on informal sector workers. Thus, we encourage policy makers to consider all contextual factors in their countries when planning a lockdown.

What might be unintended consequences on people, particularly on vulnerable groups? In many LMICs, including Ghana, lockdown led to several unplanned consequences. In two Ghanaian cities lockdown distressed those with few resources, particularly residents of the urban slums; halted activities of the informal sector, the largest sector and source of employment, and the major contributor to the national income; and slowed socioeconomic activities in major cities. Restrictions of all forms, including lockdown, bans on public gathering, religious services, schools, workplaces, and public places of entertainment, and bans on travel and sporting activities all produced socioeconomic and health adversity for people and the economy. In Ghana, these provoked swift action by the Government of Ghana to lift the lockdown.

To navigate such complexities more effectively, decision makers should move to a problem-solving strategy that addresses specific problems as part of a wider, dynamic system [14] and focuses on appropriate and sustainable solutions––an approach known as systems thinking. Systems thinking for COVID-19 will necessitate health system leaders to manage district health systems more effectively. The role of district managers is crucial: they are strategically positioned to work directly with local actors, particularly community members, to engage them in systems thinking, and strengthen health system performance and response to COVID-19.

Use of local data to generate knowledge helps policy-makers identify and effectively respond to specific challenges [15]. Information should be clearly and timely communicated to all stakeholders to foster effective, coordinated efforts against outbreaks. Communication about the core components and capabilities of public health can provide guidance needed to promote commitment for sustainable public health services, especially among the general public, academics, private sector policy-makers, regulators, public health professionals, and professional organizations [11]. Disease outbreaks, whether from an influenza epidemic or an act of bioterrorism [16], may pose unique challenges for disease detection, treatment, and prevention [17]. Often feeble decision-making capacities at the district level have contributed to poor management and coordination of health service delivery, and hindered scale-up of proven health interventions [18]. Thus, there is an urgent need to build district manager capacities for systems thinking and practice for sustainable solutions during public health emergencies.

Pandemics start with and end in the community. Community engagement is crucial for health systems preparedness and response to diseases and outbreaks. Governance in Ghana relies on both traditional and civil leaders with distinct, yet sometimes overlapping, powers and interests in managing societal problems. Although the president communicated the lockdown strategy and security agencies chiefly enforced it, traditional and civil leaders played key roles in managing transmission mitigation strategies for the COVID-19 lockdown. Communities trained and engaged in outbreak preparedness and response become vital contributors to effective detection and resilient response to disease outbreaks [16]. This includes improved adherence to prevention measures such as wearing masks, regular washing of hands, and practice of social or physical distancing–even without government-regulated restrictions.

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