Pandemic Plan Implementation: Operational Response

The Ministry of Health (MoH) led the coordination and execution of the pandemic plan at the national level, which was activated in April 2009. The response activities were supported by implementing agencies with different roles, shown in table 5. The implementation of the plan used the existing operational structures at national level, such as the health service infrastructure, health committees, surveillance networks and coordination and command structures.⁸⁴ District hospitals were designated to manage influenza cases. During the 2009 pre-pandemic period the national taskforce comprising technical experts met frequently to

84 See appendix 9 for command structures.

discuss management strategies and operational emergency response to pandemic influenza should it affect local areas.

Table 5: Implementing Agencies in PRPI

Task Responsible (Partners)

Technical assistance World Bank/ FAO/OCHA/MoH/WHO

Advocacy USAID/UNICEF/WHO

Funding World Bank/ FAO/OCHA/WHO

Policy development MoH/WHO/MoA

Implementation MoH/WHO/Red Cross Society

Coordination, monitoring and evaluation MoH/MoA/DoDMA/ CHAM

Logistics MoH/UNDP/World Bank/FAO/OCHA

Source: Author’s study of operationalization of PRPI.

The role of a response strategy is to maintain and quickly restore the routines and functions of civil society. Even a carefully crafted plan will fall short if it does not span jurisdictions across its partners and local agencies. The majority of policymakers were concerned that the national implementation strategy lacked clear roles and responsibilities which should have been outlined to implementing partners, stakeholders and government departments.

Policymakers also acknowledged that PRPI activities at the regional and local level fell short of the operational resources needed to effectively prevent and mitigate the impacts of influenza.

In other instances, respondents referred to the PRPI efforts, particularly guidance on pre-pandemic planning, as being fully committed to addressing the consequences and effects of the pandemic, rather than preventing it from occurring in the first place by keeping it out (border management) and stamping it out (cluster control). The implementation process lacked detailed assumptions and planning principles such as case scenarios to trigger responses and guide effective implementation of the plan. The plan was unclear on the broader concept of pandemic phases and their corresponding actions. This knowledge could have saved valuable time and money which was lost on unnecessary responses (e.g. delivery of risk communication messages and only targeting H5N1). Most policymakers (N=17) also said that no risk assessments were conducted to check for and militate social and economic disruptions if any existed.

Policymakers drew on diverse vocabularies to explain the implementation process of PRPI because of their varying roles: some focused on measures that were undertaken to reduce the effects of PI, such as immunization and antiviral drug treatment, others recounted that implementation failed to account for the delivery of effective risk communication to prepare the public to respond. The following is an extract of the interview data that summarizes how implementation of PRPI proceeded in Malawi, suggesting that it was clumsy and incomplete.

The implementation plan to enhance preparedness fell short on several important aspects needed to effectively respond to pandemic influenza.

No risk scenarios of severity were forecast. It was not clear what type of people, cities and towns would be at risk of flu or how best these could be prevented. Under the most-likely scenarios the pandemic plan is expected to indicate what courses of action are expected to prevent and mitigate pandemic flu. The basic scenarios like how to increase service output in our health facilities was absent. Attempts to outline actions on how best to facilitate food security in an event of a pandemic so that there was no food shortages were not dealt with. It was not certain how the education system would be sustained so it continuously functions while water companies continue to provide clean water. It did very little to attract the support of the public. (COM-MW-31)

As clearly noted, there was no satisfaction from the planning and implementation. All of the respondents talked about how PRPI was affected in terms of critical infrastructure preparedness. Reviewing the data as a whole, I found that preparedness not only lacked operational resources but also that the national strategic plan on pandemic influenza was inflexible and unresponsive to many aspects of preparation such as ethical planning, the consideration of the public’s perspective on the protective measures, and response recommendations that matched the level of threat.

Policymakers across the interviews were aware that the pandemic would likely make additional demands on health facilities, but response actions in the implementation plans did not take into consideration the best ways to minimize costs and maximize health service benefits. Policymakers suggested that the only way to achieve this would have been to improve the health service generally. Whilst some issues such as managing staff were an

important part of planning, policymakers remarked that little was stipulated in the plan on how best to deal with such a situation, or whether additional staff would be recruited.

Similarly, it was often said that generic public health actions, such as distributing leaflets to inform and educate the public on infection control, were initiated but quickly dismissed, e.g.

because there were no funds to print the materials.

Linked to this was the widely-expressed view that operational response structures, such as communication, surveillance, laboratory diagnostics and animal and human disease control, were weak, with limited details on how such resources could be applied to prevent and mitigate PI. These observations are consistent with discoveries in Europe during the 2009 pandemic influenza (Hashim et al., 2012). Prior to the pH1N1, the Malawi plan suggested the use of non-pharmaceutical interventions (NPIs), such as isolation, quarantine and hygiene measures, to delay the spread of influenza. Although these were the main interventions likely to be adopted, these plans were not communicated to the general population in order to maintain the day to day activities (social order). Communication helps overcome the problem of social order because people have the freedom to function as individuals as they choose, but they do not have the freedom to do things independent of society. It is this notion of organic freedom (unity between individuals and society) that allows people in society to be free to cooperate with the others. Individuals are a product of society; it is thus important that individuals and society coordinate their actions and cooperate with authorities in order to achieve public health goals peacefully.

The vaccine strategy was partially incorporated in the plan and several policymakers admitted that they were insufficiently informed about the epidemiological explanation as to why certain people should be prioritised while others should not. The issue of priority arose because NPIs, vaccines and antiviral drugs were scarce. Although scarcity was frequently cited, the plan did not directly address the logistics, storage and distribution of scarce vaccines, antiviral drugs and NPIs.

The rationale for the implementation of the plan was cited as being unfocused. Half of the policymakers interviewed pointed to the nature of preparedness. The implementation strategy leaned more towards preventing Avian Influenza (AI) through containment and mitigation of AI in domestic birds than the timely detection and prevention of influenza outbreaks in humans. An important theme was raised by a policymaker from the World Bank who

commented on the implementation strategy but made it clear that the problem of implementation was embedded in the decision-making process:

The problem is not that we did not implement responses effectively but that we were incapacitated by poor decisions regarding planning and what would trigger better responses. (WB-MW-43)