Responding to COVID-19 in low- and middle-income countries: Key actions for humanitarian organisations

Written evidence submitted by ALNAP at Overseas Development Institute

Ben Ramalingam, Senior Research Associate

• To date, 218 countries have confirmed cases of COVID-19, with a majority of them taking place in humanitarian crises settings in low- and middle-countries[1]. Given its unprecedented nature, humanitarian actors cannot effectively respond to the COVID-19 pandemic by following a “business as usual” model.

• A team comprising ALNAP, the London School of Hygiene and Tropical Medicine, and the University of Geneva, led by Ben Ramalingam, worked over the course of March and April to undertake a rapid response programme of research on COVID-19 and previous relevant outbreaks (i.e. Ebola, cholera, MERS, SARS) and a implement global consultation with humanitarian decision-makers at local, national and international levels.

• ALNAP is a unique cross-sector alliance of all of the major actors in international humanitarian response, including donors, UN agencies, Red Cross Red Cross Movement, international and national NGOs, academics and think tanks.

• Our work has been endorsed in writing by Sir Mark Lowcock, United Nations Under- Secretary-General for Humanitarian Affairs: ‘[this] provides vital insights and applicable lessons based on a review of evidence from the ongoing pandemic response and integrates key findings from previous epidemic outbreaks… [it] reflects the best available current knowledge on the implications of COVID-19 for humanitarian settings.’

I. Preparing health systems

Action 1: Support national efforts to assess COVID‑19 impacts and surge capacities

1. Evidence from previous disease outbreak and epidemic responses, supported by the stakeholders we interviewed, is that effective joint epidemic preparedness plans deliver significant benefits to subsequent interventions. Given that planning and preparedness is already underway, humanitarian organisations can provide technical advice and input into the assessment process at national and subnational levels so as to strengthen the quality of the process and to help fill any gaps in preparedness and planning capacity.
2. Humanitarian organisations – especially national and local actors – have a specific role to play in ensuring that preparedness processes are as inclusive as possible, especially of the most vulnerable groups. Information on vulnerable groups may already be available through appropriate mechanisms, such as in-country focal points for gender, accountability to affected people (AAP), community engagement, and age and disability.
3. As well as considering the potential impacts of the pandemic, preparedness plans should also take into account existing surge capacities for responding to COVID-19. This includes the capacities of national and regional health systems and those of national and local civil society organisations (CSO), communities, the diaspora, faith groups and businesses or wealthy communities within each country.

Action 2: Develop and communicate clear scenarios, guidance, and protocols

4. The primary focus of immediate humanitarian response should not be on decreasing mortality of COVID-19 cases, which will be extremely difficult in most situations, but rather on preventing cases, especially among the most vulnerable groups, and protecting essential routine health services. To be effective, preparedness plans and related scenarios need to be established and combined with clear strategies and action plans that enable humanitarian responders to deal with new scenarios as they emerge[2]. Resourcing and financial plans need to be linked to COVID-19 transmission scenarios with explicit thresholds at which additional resources will be made available.
5. Preparing for these scenarios will demand considerable forward planning and stakeholder engagement. Humanitarian actors will need to engage closely with hospitals, health centres, clinics, and community networks at all levels to ensure different plans and interventions are fully understood and owned. And as well as COVID-19 specific preparations, work will also need to be done to ensure the continuity of routine essential services. Past epidemics have shown that lack of access to essential health services and closure of services unrelated to the immediate response can result in more deaths than those caused by the epidemic itself[3].

Action 3: Support integrated and coordinated decision-making and oversight

6. In line with WHO recommendations, governments of affected states will need to establish COVID-19 command and operations centres to coordinate and oversee agreed response activities. Because of the diverse settings in which humanitarian actors might be operating, there is a spectrum of ways in which they might be involved in these centres.
1. Shared: The government is willing and able to lead the response despite challenges, and there is some humanitarian capacity and willingness to work with the government to act as a trusted partner and critical friend in advocacy, delivery and learning (e.g. Afghanistan, Lebanon and Malawi).
2. Substitute: There is inadequate, unwilling or intransigent government capacity but strong civil society capacity, and the humanitarian sector in-country needs to work as the de facto response lead, with national and local actors playing a lead role (e.g. northern Syria, Yemen and Zimbabwe).
3. Supportive response: There is limited humanitarian capacity on the ground and so the humanitarian community must backstop and provide technical, financial and other resources through remote management (e.g. the Pacific Islands).

II. Preparing institutions and facilities

Action 4: Prepare across the continuum, from community to health facilities

7. Humanitarian actors should focus on preparing health services, and interventions to support them, across the continuum from community- to primary- to hospital-level care to maintain community and health system functionality during the COVID-19 Pandemic. In particular, lessons must be learned from past failures[4] and communities and community-trusted sources must be engaged and mobilised from the very outset. Health-facilities should be made COVID-19 sensitive, with designated triage and clinical assessment procedures to prevent further transmission from infected patients.

Action 5: Prioritise people, money, essential services, and goods

8. Together, governments and humanitarian organisations need to conduct a prioritisation exercise that looks across several criteria, including life- saving health interventions, protection of patients and staff, equity and ethical issues. The result of this prioritisation will determine which interventions should continue, be adapted or postponed. This will also dictate how existing resources can be allocated to the COVID-19 response. In particular:
1. Staffing options and needs based on different scenarios should from the outset be written into protocols and shared widely with all actors involved in the response, from the local to international levels.
2. Flexible financial resourcing needs to prioritise from the start. It is unlikely that all requested funds will be available, and there is potential for funding cuts from donors as they deal with their own COVID-19 responses.
3. Coordinated action on procurement and logistical issues.

Action 6: Ensure availability of personal protective equipment (PPE) for health workers and support staff

9. PPE is the most important tool to prevent the transmission of COVID-19 from patients to health workers and support staff, and vice versa. Hundreds of healthcare workers died during the Ebola Outbreak in West Africa because of lacking and suboptimal use of PPE, and the same is already happening across the developed world amid the ongoing pandemic response. Pre-positioning PPE stock and establishing and communicating protocols for why, when and how to use it are essential in the context of the COVID-19 Pandemic. Also crucial is training healthcare workers and support staff prior to, or at the very early onset of the outbreak to use PPE correctly.

III. Strengthening detection

Action 7: Prioritise syndromic facility-based surveillance

10. Lessons learned from SARS and Ebola show that when surveillance is instituted promptly, rapidly, and effectively, it enables the timely recognition of disease emergence and is an important factor in breaking chains of transmission. Evidence also shows that ineffective surveillance led to initial delays in detecting and reporting SARS and Ebola, and significantly increased their spread and impacts.

11. For COVID-19, it is primarily important to know where each setting is in the epidemic curve, so in resource-constrained settings syndromic surveillance within health facilities will likely be sufficient. Syndromic surveillance is the continual and systematic collection and analysis of data related to population and individual health indicators. In settings where there are sufficient resources and capacities to collect, and more importantly, analyse data and to act on its findings, humanitarian actors should rely primarily on information from communities, either by putting in place or building on existing surveillance systems. They will also have to be integrated with routine facility-based systems to inform decision-making[5].

Action 8: Adapt the testing approach to transmission scenarios and testing capacity

12. Testing can help determine how widespread infection is, identify risk groups and transmission patterns, anticipate next steps and guide the planning and development of appropriate strategies. Testing approaches should be context dependent:
1. In contexts with few or no cases, testing should inform containment strategies and, where feasible, facilitate contact tracing. People who have symptoms can be safely and rapidly isolated to prevent further spread.
2. In contexts with widespread transmission and in the later phases of the outbreak, polymerase chain reaction (PCR) testing could help identify and stop emerging clusters and take necessary action.
13. However, past experience shows that testing is unlikely to be a sustainable and feasible strategy in many humanitarian settings due to limited public health, laboratory and primary health care services and due to the lack internationally of available testing supplies. Testing approaches should therefore also be adapted to testing capacity.

IV. Investing in prevention

Action 9: Targeting should account for and support the most vulnerable groups

14. A key first step to targeting the response is to identify populations at risk of severe illness from COVID-19 due to underlying conditions (see figure 2). Humanitarian actors in particular have a two-pronged role to play in targeting vulnerable individuals:
1. Identifying and mapping populations vulnerable to COVID-19 (e.g. older people, those with comorbidities, refugees or displaced peoples
2. Identifying the most appropriate channels by which to reach these populations e.g. via institutional memory, existing relationships with specific groups to which target populations belong, new assessment processes

Figure 2. Definitions of populations vulnerable to COVID‑19 (10)

Action 10: Employ containment approaches to reduce transmission

15. In the absence of any vaccine or proven effective treatment for COVID-19, a key strategy for reducing transmission, mortality and pressure on the health system is to reduce mixing COVID-19 suspected and confirmed cases with non-infected individuals. Many high-income countries have implemented a combination of self- isolation, quarantine, social distancing (also known as physical distancing) and community containment (e.g. mass ‘stay-at-home’ strategies) with varying degrees of success in reducing the spread of the virus.

16. Recent evidence shows strategies combining self-isolation, moderate physical distancing and shielding will likely achieve substantial reductions in mortality due to COVID-19 in African countries[6]. However, in many humanitarian settings these measures are unlikely to be feasible and also unlikely to reach sufficiently high levels of compliance to reduce community transmission, especially in places where it will threaten people’s livelihoods. Based on the context, humanitarian actors will need to work closely with communities to implement with a range of approaches, e.g. demarcating physical distances in queues[7], creating ‘shielding green zones’ in urban settings and camps[8], and evacuating crowded facilities.

Action 11: Support socially and economically sensitive approaches to quarantine and isolation

17. When shielding, quarantine, or self-isolation measures are put in place for affected populations, humanitarian actors should work to mitigate other adverse effects. Such containment interventions are likely to have adverse socioeconomic impacts on individuals and their households.

18. Containment strategies undertaken or supported by humanitarian organisations and their partners needs to be clearly grounded in social and cultural contexts and be sensitive to existing economic inequities and vulnerabilities. Additionally, it will also be important for humanitarian actors to consider the needs of people with disabilities, young children, pregnant and lactating mothers, and those with special dietary needs.

Action 12: Implement WASH interventions for effective infection prevention and control

19. Better WASH practices can be achieved through behaviour-change interventions, with the main areas of focus for humanitarian actors being communities and healthcare facilities. In addition to COVID-19-specific WASH programming, efforts need to ensure continuity of existing WASH services and infrastructure.

20. Interventions for the COVID-19 response should focus on community and health facilities. In settings where access to water and soap are limited, WASH interventions could include: (i) expanding water tank provision; (ii) providing more handwashing stations; and (iii) distribution of alcohol-based hand rubs, which can be produced locally. To improve the community’s acceptance of WASH practices, humanitarian organisations should dedicate sufficient resources for behaviour-change interventions and communication campaigns.

V. Enhancing case management

Action 13: Adapt health facilities and protocols

21. There are two distinct scenarios that humanitarian actors may face, to enable them to organise the delivery of timely and quality care for suspected and confirmed COVID-19 patients in humanitarian settings: Individual patients coming to the facility, and Simultaneous influx of many patients to the facility.

22. Delivery of care for suspected or confirmed COVID-19 cases should be adapted to these different possible scenarios, and include the following components: (i) Triage before entering the facility; (ii) Designated space for symptomatic patients; (iii) Referral for testing and treatment centre; (iv) Disinfection of contaminated surfaces, and (v) Contact-tracing where appropriate and feasible.

Action 14: Deliver appropriate and relevant critical care measures

23. Data from high-income countries suggest 5% of symptomatic cases will require ventilation or become critical, 15% of patients with ‘severe’ diagnoses will need oxygen and remaining cases will be ‘mild’, requiring basic care. Some experts have called for essential emergency and critical care for those patients who do become critically unwell[9]. Basic interventions for humanitarian actors to implement would include: (1) delivering oxygen to patients lying on their front (‘proning’); (2) suction; (3) chest physiotherapy; and (5) appropriate use of antibiotics for bacterial infections to help improve outcomes.

24. However, it should be noted that an intensive care unit or critical- care-focused model for many humanitarian settings will be extremely challenging to comprehensively implement at the scale that will be needed, given the limited capacities in humanitarian settings in terms of intensive care unit beds, specialist equipment and trained staff.

Guiding principles

25. In addition to humanitarian principles[10], which need to remain the core guiding principles of the COVID 19 response, the following seven additional cross-cutting principles should shape how each of the above-mentioned actions are implemented: (i) Mobilise locally appropriate, joined-up community-led initiatives; (ii) Support local actors to lead the response; (iii) Work in politically and socially sensitive ways; (iv) Duty of care for response workers at all levels is essential; (v) Establish and share ethical guidelines for the response; (vi) Anticipate and work collectively to offset adverse secondary impacts; and (vii) Invest in operational learning, research and innovation efforts.

26. While health is the entry point for these actions and principles, they also have implications for other humanitarian sectors – notably WASH, shelter, and food security and nutrition. As such, effective multistakeholder coordination is critical.

27. The following factors and limitations should also be noted when applying the actions to various humanitarian contexts:

1. Operational responses will by necessity rely on national and local actors at the centre, so success is contingent on, and resources provided for, community-led and locally driven efforts.
2. While there are a number of similarities with previous humanitarian epidemic responses (e.g. SARS and Ebola), a simple ‘cut-and-paste’ application of lessons from the past is not advisable as each epidemic is distinct and is shaped by different contexts.
3. The majority of COVID-19 response strategies and operational guidance have been designed for high-income countries and require significant adaptations for use in humanitarian responses.
4. Humanitarian responses are challenged by the fact that there are major COVID-19-related crises ongoing in every country in the world, and that typical operations – built on deployment of international staff and resources – will not be possible in many settings due to international travel restrictions and border closures.
5. Evidence-based learning needs to be at the centre of the effort, but considerable uncertainty and knowledge gaps remain about the appropriate mix and some modalities for interventions.

28. As the pandemic evolves, and alongside it the humanitarian response, it is crucial that humanitarian actors and policymakers make the best decisions possible as they adapt to the challenging and resource-constrained contexts in which they are operating.