Inadequate training.

Inadequate COVID-19 pandemic preparedness was attributed to inadequate training, particularly a lack of specialized training, as well as delayed training. One respondent, for instance, reported delays in receiving formal training at the onset of the pandemic as contained in the excerpt below.

“Facilities should have been sorted out in terms of PPEs and training them on that, training on COVID-19 and education on it and how to use PPEs and availability of PPEs. We had the training two months towards June and people were coming and really making use of the education. We teach you how to use nose masks and those things. If not when it [the pandemic] started around March, people were not coming and we were just there learning on our own, so we didn’t start with the education. We didn’t start with the training.”–Doctor HCW 5

Another participant did not anticipate that COVID-19 would affect Ghana, which subsequently contributed to the delayed training of HCWs.

"I must say that really when we were hearing about COVID, as a service, we didn’t think that COVID was going to come to Ghana. So, the preparations really were late in terms of even training the staff."–Other HCW 29

Further, the HCW remarked that the general lack of training in infectious diseases contributed to feelings of unpreparedness:

“We need highly trained staff who can deal with infectious diseases, and we don’t have that now. If we have that, then our COVID patients, we will just move them there because they already know Infection Prevention and Control (IPC) and all those things. Of course, every staff needs to practice to some level, but we need people who are properly trained so that they can highly perform in the infectious disease unit. So, we need that because we didn’t have that and that really was a challenge at the early stages of managing COVID-19.”–Other HCW 29

Other HCWs noted that lack of refresher trainings, including the absence of trainings focused on the changing trends of the pandemic, contributed to their feeling inadequately prepared:

“I said this because of lack of PPEs and refresher training on some of these issues. The refresher training will help you have a clearer understanding about the whole issue, and therefore have more interest. This is so because the trend keeps changing.”–Nurse HCW 24

Logistical challenges.

HCWs attributed their inadequate preparedness to the fragmented procurement systems. As one participant noted:

“Initial logistics were very few and limited and we did our best […] Procurement processes were slow; things that needed to be bought were not bought in time.”–Nurse HCW 17

Other participants echoed similar sentiments regarding logistical challenges, noting flaws in the distribution of essential equipment and resources:

“For the logistics, the distribution didn’t go on well. I don’t know whether it was supposed to be delivered directly into the departments, which is also not the case because they are giving them to the hospitals. It borders more on management. There are so many things I don’t know how to say them but someone saying, “I have given this” and you seeing something different at the wards, those were the issues.”–Doctor HCW 2

HCWs identified shortages in equipment and other resources needed to manage COVID-19 cases safely and effectively. For example, HCWs reported that there was a lack of PPEs during the onset of the epidemic, which compromised their safety and caused stress. As one respondent explained:

“The PPEs were not there […] let’s say face masks, for instance, that we were supposed to have, they were limited, and we sometimes have to improvise; we had to improvise with cloth masks […] In fact, it’s stressful. After every four hours, we were supposed to change [the mask] but [the masks] were not there. So, we have to wear [the same mask] throughout the day.”–Nurse HCW 26

Another HCW revealed that the absence of necessary equipment not only caused fear and worry, but was reported to compromise the quality of care they gave to COVID-19 cases:

“That is why I am saying the resources that we need were not coming. Even at the time when COVID-19 came there, we were short of nurses, and when you come in contact with a case, we have to quarantine you for some days, and you don’t have to come to work. So, the rest has to do extra duty, and so it got to a point due to shortage of staff, even if you come in contact with a case, you still come to work instead of you being quarantined, you continue coming to work and exposing yourself and others and the resources we needed, especially the PPEs, that was my main concern, they were not really there, so we have to depend on cloths and other things just to protect ourselves because of COVID-19. It was just God who protected us”–Nurse HCW 16

Information flow challenges.

HCWs also attributed their lack of preparedness to delays in testing. As a nurse explained:

“Because, for example, if you have requested for a test and the result come and you are not aware, so you don’t even know what, yeah because if you request, if you attend to a case and the case turns out positive, it means that you have been exposed like that.”–Nurse HCW 26

Additionally, information flow challenges compromised the safety of providers and impacted their ability to effectively manage suspected and confirmed cases. A nurse explained as follows:

“The person was referred from a facility to my facility and the person has underlying conditions. When the person came to my facility, they told us that the person, they were only managing for asthma and is diabetic, and the person was on inducement. Now with all the things they told us because they said they’ve done the [COVID-19] testing over there, it wasn’t even indicated on the referral that a test was done in that regard. So, we were managing the case as a normal case. As I said, the PPEs were not there; the masks were not even there as in N95 or surgical for you to use, and the person also needs monitoring. Finally, this person, actually, one of our doctors who came and reviewed was saying actually this is the condition, and how the oxygen level was going down and he was like ok, they should do the test, only for them to take the swab and it came out positive [for COVID-19] this time round. Now, how come they missed the diagnosis from that side, and number two, they didn’t even inform us that the person was actually tested […] At this time that I am talking, a lot of us have already had contact with the patient. And they are trying to help that person get back her life, so in the long run, about two or three of us were infected, no, about four were infected.”–Nurse HCW 19

Weak clinical infrastructure.

HCWs cited insufficient number of isolation centers, ventilators, limited testing capacity, and lack of support staff, as factors that contributed to inadequate preparedness. A respondent noted that existing infrastructures from the Ebola outbreak, were inadequate in responding to COVID-19.

"Even though we had the Ebola structures that were renovated some time ago, but they couldn’t really fit into this because some of those things were quite small. So, these were some of the gaps in the response."–Other HCW 29

A participant discussed the limited number of isolation centers:

“We need more for the isolation center, we had to use one ward for the isolation. We had to leave that ward for the isolation meanwhile our wards are just two. So, the place, if we had so many cases, we would have been in hot waters because our place is very congested. We don’t have enough buildings; we need to have facilities, as in buildings so that if there is any case, we can put it there as an isolation center.–Nurse HCW 11

Sufficient supply of PPEs and adequate knowledge and training.

Adequate knowledge and training on the pandemic were reported to reduce anxiety and increase provider confidence to manage suspected COVID-19 cases. A participant discussed the quality of the training, including information to dispel some misconceptions:

“It [the training] was good. It also gave us courage and reduced anxiety. It also gave [providers] much information on misconceptions about the virus, which helped us answer questions asked by our patients.”–Nurse HCW 14

Similarly, other respondents credited adequate training and sufficient resources:

“Personally, for me, I’ll say I was ready because I had all the resources at my disposal, and through the training I had, I was very confident.”–Nurse HCW 22

HCWs’ readiness managing high consequence infectious diseases.

Some providers ascribed their preparedness to their perceived readiness to care for suspected or confirmed COVID-19 cases, as well as their experience caring for high consequence infectious disease cases. Providers discussed preparedness in the context of past management of COVID-19 cases or other high consequence infectious disease cases:

“I am prepared because I have been seeing a lot of COVID-19 patients already.”–Doctor HCW 9

"Prior to COVID-19, when we were working, we did not know that there’s something like COVID-19, but we were always prepared in handling disease conditions whether infectious or non-infectious. And so, you will not prepare for a particular disease like COVID-19, but we always have the universal preparedness that in this field. You have disease conditions that are so dangerous, like HIV; when you get it, you will be on its drugs for the rest of your life. So, any patient that you are approaching, you would always adapt to the universal precautions. COVID-19 only came to add to the numbers but we are always prepared as health workers to handle conditions as they come."–Doctor HCW 8

Pre-existing safety protocols.

HCWs also credited pre-existing protocols, such as handwashing, for their preparedness, as one participant noted:

“What is going on well is the observation of the protocols; I’m really happy, even up to now, and for me, my staff, if you are not in mask, I won’t even allow you [to work]; you must be in mask before you work. So that one, I take it upon myself as the head. I don’t know of other doctors, but for me, because of where we find ourselves, the emergency area, because I always tell them that we do all sorts of consultations so the best is to make sure you are in a mask and we have hand sanitizer and the hand washing bucket so I think on that note we are doing well.”–Doctor HCW 3

Similarly, HCWs attributed the health system’s preparedness to HCWs’ adherence to protocols:

“To me, the checking of temperature at the entrance of the outpatient department (OPD) to me is good; every client coming to the facility wearing the masks is good […] making sure that all relatives and staff wear their masks, because if the health worker doesn’t wear [masks], you are endangering yourself, as well as your family members when you go back home.”–Nurse HCW 20

Improved availability of resources and logistical support.

HCWs advised health facilities to have an ample supply of resources:

“That is what I am saying that the facility also depends on the resources available. If they are not there, what will the staff do? So, it’s all about having resources”–Nurse HCW 16

HCWs also indicated that for the health system to be prepared to respond to the pandemic, logistics need to be considerably improved:

“I will say that you see when you talk about the PPEs like this, it’s when this virus came that we saw most of the PPEs. Sometimes when you see this overall and things, scarcely will you see people wear them, aha. And it was when the virus came that they had to send for some from China and those kinds of things. I think we should have them readily available so that we can also, the health system, will also be [prepared] adequately.”–Nurse HCW 12

Adequate training.

HCWs recommended trainings on infectious diseases and psychological preparedness, both of which were perceived to be critical for HCW preparedness. As a participant discussed:

“So, one of the things we’ve not been doing even though we’re talking about it is the regular training of staff; going through drills and things to go through these things so that when it comes, the staff will be fully prepared psychologically and everything. And again, like we talked about earlier, we need psychological preparedness for all our staff, in every situation that they might encounter and all those things. I think it’s very important and it’s something we talk about but something we don’t do regularly. We only do it when we have epidemic outbreaks like Ebola and then also now COVID. But I think at least it should be something that should be part and parcel of the training of staff and regularly done at our health facilities, regions, and districts.”–Other HCW 29

HCWs also suggested pandemic preparedness be incorporated into the curricula taught at health institutions to participants:

“In the training institutions, the health training institutions, that is where we have to start from, so that any person that has an appointment with the Ghana Health Service has already been trained on epidemic outbreaks. So, that when they come, what we only need to do is to add on. But most of these people would come and they have no knowledge about epidemics because we normally will leave that to the medics. We leave that to the technical people. But the nurses and the rest only have knowledge about epidemics. So, right from the training institutions, it should be part of the health curriculum, so that we train them from school before they enter the service. And, when they enter the service, we also give them training.”–Doctor HCW 1

Improved clinical infrastructure.

HCWs recommended improving the clinical infrastructure, particularly by increasing the number of isolation centers, testing facilities, and equipment such as ventilators, to ensure health system and HCW readiness:

“We still have problems with equipment like I mentioned the ventilators, incubators, this no bed syndrome. Somebody was interviewed on TV. I don’t know whether you saw her, and she was even a midwife, and they were referring her from a facility in Accra to one facility, but when they called all facilities, there was no bed, so she landed in one of the hospitals. So, enough equipment like beds and all that, so what when people are in an emergency, you can get a bed at least to put the patient.”–Other HCW 27

Capacity building.

HCWs noted that capacity building is necessary for the health system to better prepare and respond to pandemics in the future. One participant noted the need for a disaster preparedness program that includes a thorough strategy for resource mobilization, training on COVID-19 management, mental health support, and funding:

“There should be disaster preparedness programs in place so that we won’t wait for something to happen before we will now be looking for ways and means to deal with them, and our staffing level should be enough so that things like these will not run [into a] shortage. We need a lot so that an issue like this we can deal with it and the training was not adequate. Then you come in contact with a case, they quarantine you, nobody cares about how you are feeling, you know. No emotional therapy: you will be scared if the results comes and you are positive. Nobody cares about you there. So, we need to prepare before anything like this so that it will not be surprising, and they should have funds aside for emergencies like.”–Nurse HCW 16

Decentralized health system.

HCWs recommended decentralizing the government response to the pandemic and making information broadly accessible at all levels:

“The challenges like I said before, especially the national response if we can decentralize it, even to the facility level so that the facility information is available to everyone; okay this is the national situation, this is the regional, this is our facility situation too, so that everybody is aware and has the information.”–Nurse HCW 26