Changing paradigms in country policy development and the need for coordination

In non-pandemic circumstances, policy making often followed a pattern in which WHO synthesised evidence and issued recommendations, which country programmes could then adapt or make specific to their own context. At the start of pandemic, the need for policy guidance during the pandemic was so urgent that countries like Uganda, Kenya, Rwanda and Zimbabwe issued policies to protect essential health services either before or concurrently with WHO. The COVID-19 pandemic put into action the call for increasing country capacity and self-dependency for policy development, and an increased need for policies that fit local contexts and available resources.5 6

Furthermore, international travel restrictions interrupted the in-person provision of technical assistance to SSA countries by experts from WHO and the West. This may have had a net effect of decreasing country-level capacity for policy making. Further investigation of policy makers’ experience in issuing rapid policies for RMNCAH should be explored. However, this may potentially be a ‘good problem’—a step towards self-reliance and building sustainable, locally owned policy making resources. For instance, in Uganda, we saw an unprecedented ‘whole’ of government mobilisation, with significant collaboration with local academia. For instance, academia from Makerere University were appointed by government to chair Technical Advisory Groups, advise the Minister of Health (MoH), and were funded to conduct rapid data analysis or to collect and present data to the MoH to guide decisions on interventions to ensure continuity of emergency health services.7 This country level policy leadership is in keeping with the spirit of the sustainable development goals, as countries take lead in developing and financing their health systems, based on their political, and hopefully local people’s aspirations.

Similarly, we posit that perhaps policy response in the wake of the COVID-19 pandemic has fomented SSA’s ability to rapidly produce policy guidelines, under emergency situation, to support continuation of RMNCAH services. Countries need to embrace this challenge, pandemic or no pandemic. However, in doing so, they still need to coordinate policy development with WHO to ensure alignment, but also to reduce the risk of creation of too different policies between countries in regions with great cross-border mobility. This could be achieved by working very closely with WHO country offices.

Country policies to sustain RMNCAH services in Uganda, Kenya, Mozambique and Zimbabwe note potentially positive changes to policy which may extend beyond the pandemic, such as multimonth dispensing of family planning methods. Other innovations for RMNCAH services continuity have included self-care in which individuals, families and communities manage parts of their healthcare.8

The international community should be partners, enablers and facilitators in supporting country-level policy makers to issue sound and rapid policy guidelines. In order for these efforts to succeed, there is need for continued and expanded collaboration between WHO, government policy makers and local academics. For instance, WHO could help to build the capacity of local technical experts in policy analysis, who then work with the MoH in policy development. Such local led efforts in policy making will require prioritised funding from national government and partners for local experts, including technical experts, civil society and academia, to have standing capacity and involvement in policy making.

Whether country policies are issued before WHO recommendations or afterwards, we note a substantial need for increased efficiency and quality in coordination of the policy making processes in countries. In many low-income and middle-income countries, there is so much fragmentation that actors are not well coordinated, resulting in uncoordinated policy making or implementation. For example, in Uganda, in the early stages of the pandemic, it was not uncommon to find different partners in the same district or hospital trying to create capacity on Standard Operating Procedures for continuity of essential health services.9

Data, innovation and policy for RMNCAH during COVID-19

As governments develop or adopt policies, they need to ensure that the policies (and the subsequent investment) balance the pandemic control with the need to mitigate the collateral damage of the pandemic. Some early reports indicated increases in maternal, neonatal and child deaths.10 11 The policies also need to be informed by local data so that they are realistic in the geographical and social context.

Many countries suspended programmes whose activities could potentially increase the risk of additional spread of the virus. Notable programmes disruptions included immunisation outreaches, Community Health Worker home visits, provision of antenatal care and nutrition assessment, and family planning or even adolescent sexual educational programmes. Some countries like Uganda chose to suspend the presence of birth companions during birth because birth companions potentially increase the risk of infection to mothers and health workers. However, this is also against the WHO quality-of-care standards that call for birth companionship.12 We find that such decisions have far reaching impact and should only be made after thorough consideration of their consequences. In this case, the absence of birth companions means that mothers do not receive emotional, psychological, physical support from trusted community members. The SSA context of having limited healthcare staff make companions an absolute essential at birth. Moreover, there is evidence to show that social support for labouring mothers leads to less operative births, shorter labour, reduced occurrence of maternal blues, and better baby outcomes.13

As countries develop new policy responses to COVID-19, there is a need for innovations in RMNCAH service delivery. Such innovations need to focus on the most vulnerable, on promoting health equity, and building resilient health systems. Promising innovations include self-care services, increased use of telemedicine, multimonth dispensing Family Planning methods and Antenatal Care medications and supplements, and Differentiated Service Delivery (DSD) model commonly used in HIV/AIDS. The DSD model aims to deliver care that is tailored to the needs of the clients, but at the same time reducing the burden to the health system.14 For instance, unlike the traditional model of HIV care, where clients pick their antiretroviral drugs from facility, in DSD model, stable clients may have their drugs delivered at their homes. This reduces facility visits for stable clients at same time allows the health facilities to focus on only those with complications.