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COVID-19 in Malawi: Innovating New Approaches in Resource-Limited Settings

In Malawi, we have only now just begun to see the dramatic increases in COVID-19 cases that many other countries have – yet COVID has already made an impact on health services.  As of this writing, Malawi only recently climbed above 100 cases, with very few deaths – in part we hope this is because of the swift action and well-meaning, coordinated efforts between the public and private sectors, and preventive and curative teams working towards one common goal. 
Most of the early information about the coronavirus came from experiences in resource-rich countries. This meant that strategies to fight the outbreak were focused on resource-intensive interventions that didn’t really make sense in our context. Telecommuting, working from home, and the focus on procurement of highly technical equipment like ventilators are just a few examples.  In our context, these solutions are somewhat impractical – both at the level of public health interventions to prevent the spread of COVID as well as the level of individual patient care in primary health care. As an example, the option to work remotely is severely limited by the fact that many transactions are carried out face-to-face rather than over email, with very few people having access to personal computers. Limited access to reliable internet services is also an issue and is compounded by irregular power supply. In the case of medical care, many patients do not have phones, let alone computers, which severely limits options for development of telehealth as a means of decongesting hospitals and primary care facilities. Furthermore, much of the focus in Western countries was centered on ICU-level critical care. Malawi has very few (ventilators currently we have 17 in the country for a population of 17 million), but even fewer anesthetists and critical care nurses trained to use these devices.
We now know that coronavirus has taken many different shapes based on the local environment in which the virus is spreading.  It is important to share stories from countries with similar resources, health systems, and cultural contexts in order to build best practices and share lessons learned in a way that is more applicable to local practice rather than only relying on strategies used in countries where these are drastically different from the African context.
In Malawi, many District Hospitals developed local response teams and plans for COVID before the Central response was formalized under the Ministry of Health.  In Mangochi District, where we work, the response was headed by the District Rapid Response Team (DRRT), which had broad representation from Environmental Health, Immigration, Police, and local religious authorities in addition to the health sector. This team began mobilizing resources and working within communities to increase awareness of novel coronavirus before the Ministry of Health released its formal guidance documents and trainings for healthcare workers.                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
As we have been working to harmonize local initiatives with central guidance, the majority of our efforts to contain coronavirus cases to date have been focused on contact tracing. This has been possible mainly through front-line workers such as Health Surveillance Attendants (HSAs), Malawi’s community health workers. Due to widespread public awareness campaigns, and work with community sensitization campaigns, many suspect cases are being reported by communities for further investigation. This is largely being done at local health facilities – making the primary health care system vitally important to prevent the spread of coronavirus. 
In addition to contact tracing efforts, there has been a broad emphasis on capacity building through trainings for local healthcare workers. This has been done at all levels of the health system; from health centers to district hospitals all the way up to central level.  Trainings have involved massive multisectoral collaborations among various stakeholders, including law enforcement, health, and water just to mention a few. These trainings have been instrumental to achieving the COVID-19 containment efforts to date.
Many routine services, however, have been interrupted due to Coronavirus. In an attempt to decongest health facilities, non-emergency procedures have been postponed, and many specialty clinics have drastically reduced the number of cases seen per day. As one example, routine weights of infants and children taken in the Under 5 clinic at one District Hospital have stopped completely because the NGO who provided the scale pulled all of its workers. Similarly, vaccination programs have been disrupted in several areas of the country. Some of the better functioning vertical programs, such as provision of HIV services, have adapted strategies such as providing medication refills for 6 months, instead of the previously used 3-month interval, in order to limit the number of patients needing to travel to health facilities. However, referrals to central hospitals for higher levels of care have drastically been reduced, making complex or critical cases even more difficult to manage at the district level. This can significantly delay diagnosis or corrective procedures, leading to more advanced disease process with palliative care often the only option.
Coronavirus has been an eye-opener for ways to deal with limited resources with locally available solutions – rather than relying on donor funding. As an example, students from Malawi’s Polytechnic College have worked to design devices that range from ventilators to face shields using local materials and resources. Prior to this pandemic, there was little communication between the College of Medicine and Polytechnic – this has opened our eyes to the ways in which local engineers and healthcare workers can work together to develop locally relevant solutions.
Coronavirus has also brought back a focus to basic preventive measures for health.  Many of the things we advise should be standard practice (hand-washing, etc), but prior to coronavirus there were sinks in the hospital that had no water for months on end.  Now there is a renewed focus on basics – everyone is interested in donating buckets to health facilities to encourage good hygiene practices.  Previously healthcare issues were just left to medical people, but under coronavirus, everyone is vulnerable.
Overall, we must all continue to pull together to fight the spread of this pandemic.  General systems strengthening is key and platforms for such have been made possible in the pandemic response efforts.  Adapting processes to the local context, collaborating and innovating with unfamiliar partners, and boosting the capacity and effects of the primary health care system have all been key to helping us stave off this deadly virus.  With the engagement of PHC, we hope this national spirit and cooperation will continue to help us to successfully limit the spread.