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BUILDING A RESILIENT HEALTH WORKFORCE IN FRAGILE AND CONFLICT-AFFECTED COUNTRIES TO RESPOND TO THE COVID-19 PANDEMIC AND BEYOND

K2P COVID-19 Series

AUTHORSLama Bou-Karroum, Amena El-Harakeh, Fadi El-Jardali

CITATIONBou-Karroum L, El-Harakeh A, El-Jardali, F. K2P COVID-19 Series: Building a Resilient Health Workforce in Fragile and Conflict-affected Countries to Respond to the COVID-19 Pandemic and Beyond, Knowledge to Policy (K2P) Center, Beirut, Lebanon, June 16, 2020

ACKNOWLEDGEMENT Authors would like to thank Ms. Aya Harb for supporting with literature search and Ms. Clara Abou Samra and Ms. Nour Ataya for their review.

Key Messages

Health workers are the most vulnerable in the face of a disease outbreak, particularly in fragile and conflict-affected countries. These countries are characterized by weak health systems and their health workforce is already overburdened by many challenges. Strengthening the health workforce in fragile and conflict-affected countries is critical to enable these countries to respond to pandemics and other public health crisis and health systems shocks. This document provides an overview of challenges facing health care workers in fragile and conflict-affected states during pandemics and presents strategies to support these countries in strengthening and protecting their health care workers to respond to COVID-19 pandemic and other public health crises.

Challenges facing health care workers in responding to COVID-19 pandemic:

• Shortage of health care workers triggered by wars and political instability• Resource constraints such as shortage in personal protective equipment (PPE), gloves,

testing kits), intensive care units and ventilators• Inadequate training and education on the use of such equipment and infection prevention

and control exacerbated by weak educational and training systems• Mental health concerns as a result of fear, uncertainties, fatigue, burnout, stigma, and

increased workload• Violence against health care workers including harassment, arrest and armed attacks• Refugees and internally displaced populations that presents additional burden on health

workers • Socio-political challenges in terms of lack of political will to protect and strengthen the

health workforce during COVID-19 and lack of public trust• Limited data on health care workers including data on infection and mortality rates, violence

incidents and on the status and composition of health workforce

Selection Process

2BUILDING A RESILIENT HEALTH WORKFORCE IN FRAGILE AND CONFLICT-AFFECTED COUNTRIES TO RESPOND TO THE COVID-19 PANDEMIC AND BEYOND

Strategies to protect and strengthen health workforce in fragile and conflict-affected states to respond to COVID-19 and beyond:

• Systematic and standardized data collection on mortality, infection rates and violence incidents which permits governments and stakeholders to take adequate preventive measures

• Implementing measures addressing violence against health care workers through legal systems and multi-sectoral efforts

• Raising awareness and defeating misinformation about COVID-19 through campaigns aiming to educate the public on SARS-CoV-2 spread mechanisms

• Providing international support essential to ensure an effective response to COVID-19 including the provision of PPE and essential medical supplies and training of health care workers

• Providing national guidelines on infection prevention and control measures and the use of PPE

• Strengthening community health workers as the shift of health services to these workers can reduce workload and lower infection risks to patients and providers

• Strengthening training and educational systems and build the capacities of domestic health workers through strengthening educational institutions and assessing training needs

• Training and capacity building on triage and on infection and prevention measures at the organizational level that can be given through digital training tools

• Providing financial incentives to motivate staff to work in the facilities during pandemics• Providing psychosocial and mental health support to help health workers cope with the

stigma, burnout, fatigue and workload • Providing peer, family and social support can keep health workers motivated and committed

during challenging times

We searched the following databases: PubMed, Health Systems Evidence, Google Scholar and Google using the following key words: ‘health care worker*’, ‘paramedic*’, ‘medical staff’ OR ‘health personnel’, health practitioner*’, ‘health professional*’, ‘health provider*’, ‘doctor*’, ‘nurse*’, ‘medical personnel’ and ‘conflict*’ OR ‘war’ OR ‘battle*’ OR ‘combat’ OR ‘danger’, ‘fragile state*’ and (COVID19 or Ebola or SARS OR H1N1). We also scanned the reference lists of relevant studies. Last search was run on June 7, 2020.

3 BUILDING A RESILIENT HEALTH WORKFORCE IN FRAGILE AND CONFLICT-AFFECTED COUNTRIES TO RESPOND TO THE COVID-19 PANDEMIC AND BEYOND

الرسائل األساسية

يعتبر العاملون في مجال الصحة األكثر ضعفا في مواجهة تفشي األمراض، السيما في البلدان الهشة والمتأثرة بمختلف الصراعات. وتعاني هذه البلدان من نظم صحية ضعيفة، كما أن القوى العاملة الصحية

تواجه العديد من التحديات المثقلة. إن تعزيز القوى العاملة الصحية في البلدان الضعيفة والمتأثرة بالصراعات أمر أساسي لتمكين هذه البلدان من االستجابة لألوبئة وغيرها من أزمات الصحة العامة

وصدمات النظم الصحية. يقدم هذا المستند لمحة عامة عن التحديات التي تواجه العاملين في مجال الرعاية الصحية في الدول الهشة والمتأثرة بالصراعات أثناء األوبئة، وتقدم استراتيجيات لدعم هذه البلدان

في تعزيز وحماية العاملين في مجال الرعاية الصحية لالستجابة لوباء كوفيد-19 ومختلف أزمات الصحة العامة.

التحديات التي تواجه العاملين في مجال الرعاية الصحية في االستجابة لوباء كوفيد-19:نقص العاملين في مجال الرعاية الصحية بسبب الحروب وانعدام االستقرار السياسي الشح في الموارد مثل النقص في معدات الحماية الشخصية )PPE( والقفازات ومعدات الفحوصات(

ووحدات العناية المركزة وأجهزة التنفس اإلصطناعيعدم كفاية التدريب والتعليم بشأن استخدام هذه المعدات والوقاية من العدوى ومكافحتها ، التي

تفاقمت بسبب ضعف نظم التعليم والتدريبمخاوف تتعلق بالصحة النفسية للعاملين الصحيين، نتيجة الخوف وعدم المعرفة والتعب واإلرهاق

والوصمة وزيادة الضغوطات العمليةالعنف ضد العاملين في مجال الرعاية الصحية بما في ذلك التحرش واالعتقال والهجمات المسلحة الالجئون والسكان المشردون داخليا مما يشكل عبئا إضافيا على العاملين الصحيين التحديات االجتماعية والسياسية من حيث انعدام اإلرادة السياسية لحماية وتعزيز القوى العاملة الصحية

خالل كوفيد-19 وانعدام الثقة العامةبيانات محدودة عن العاملين في مجال الرعاية الصحية بما في ذلك بيانات عن معدالت العدوى

والوفيات وحوادث العنف وعن وضع وحالة القوى العاملة الصحية


استراتيجيات لحماية وتعزيز القوى العاملة الصحية في الدول الهشة والمتأثرة بالصراعات لالستجابة لـ كوفيد-19 وما بعده:

جمع بيانات منهجية وموحدة بشأن الوفيات ومعدالت اإلصابة وحوادث العنف التي تسمح للحكومات وأصحاب المصلحة باتخاذ التدابير الوقائية المناسبة

تنفيذ تدابير لمواجهة والحد من العنف ضد العاملين في مجال الرعاية الصحية من خالل النظم القانونية والجهود المتعددة القطاعات

رفع مستوى الوعي ورفض المعلومات المغلوطة حول كوفيد-19 من خالل حمالت تهدف إلى التثقيف حول آليات انتشار هذا الفيروس

توفير الدعم الدولي الضروري لضمان استجابة فعالة لـ كوفيد-19 بما في ذلك توفير معدات الوقاية الشخصية واللوازم الطبية األساسية وتدريب العاملين في مجال الرعاية الصحية

توفير مبادئ توجيهية وطنية بشأن تدابير الوقاية من العدوى ومكافحتها واستخدام معدات الوقاية الشخصية

تعزيز العاملين في مجال الصحة المجتمعية حيث أن تقديم الخدمات الصحية لهؤالء العمال يمكن أن يقلل من الضغوطات العملية ويقلل من مخاطر اإلصابة بالمرضى والمقدمين.

تعزيز أنظمة التدريب والتعليم وبناء قدرات العاملين الصحيين المنزليين من خالل تعزيز المؤسسات التعليمية وتقييم االحتياجات التدريبية

التدريب وبناء القدرات بشأن كيفية تحديد الحاالت والوقاية على المستوى التنظيمي التي يمكن تقديمها من خالل أساليب التدريب الرقمية

تقديم حوافز مالية لتحفيز الموظفين للعمل في المرافق الصحية أثناء األوبئة تقديم الدعم النفسي واالجتماعي لمساعدة العاملين الصحيين على التعامل مع الوصم واإلرهاق

والتعب والضغوطات العمليةتقديم الدعم للعاملين الصحيين من قبل األقران واألسرة والمجتمع للمحافظة على حماس والتزام

العاملين الصحيين خالل األوقات الصعبة


On March 11, 2020, the World Health Organization declared COVID-19 as a global pandemic [1]. COVID-19 has strained health systems and disrupted their ability to deliver health services [2]. The COVID-19 pandemic has put unprecedented pressure on the health care workers who are at the frontline in responding to the pandemic. COVID-19 has strained the health workers’ capacity due to the increased workload generated as a result of the large number of COVID-19 cases in need of hospitalization [3]. The health care workers are also at high risk of contracting the infection given their day-to-day contact with infected patients [4, 5]. The International Council of Nurses estimated that at least 90,000 healthcare workers have been infected as of May 2020 [6]. Health care workers were also found to be at higher risk of developing mental health and psychosocial problems [7]. On top of that, health workers are subjected to violence, assaults and harassment in different parts of the world [8].

Health workers are the most vulnerable in the face of a disease outbreak, particularly in fragile and conflict-affected countries with fragile health systems [9]. As documented from the Ebola outbreak that mostly affected countries with fragile health systems (Liberia, Sierra Lion and Guinea), health workers were 21–32 times more likely to be infected with the Ebola virus than the general public [10]. Fragile and conflict-affected countries are characterized by weak health systems. In these countries, the health workforce is faced with many challenges including shortage of

Backgroundhuman resources and inadequate planning and management such as poor supply, education and recruitment strategies, mal-distribution of the health workforce, limited availability of human resources data [11, 12]. The shortage of qualified health workers and their uneven distribution in fragile and conflict-affected countries impede the delivery and access to healthcare services. This is further exacerbated by violence, political instability and insecurity [13]. Given these conditions, fragile health systems can become rapidly overwhelmed and fail to respond to public health crises such as pandemics which can result in catastrophic consequences on people’s lives [13].

As health care workers are the backbone of health systems, strengthening the health workforce in fragile and conflict-affected countries is critical to enable these countries to respond to public health crises such as the COVID-19 pandemic. This includes ensuring an adequate number of trained, skilled and motivated health workers to meet the needs of the population in a timely, relevant, efficient, and effective manner [14]. This document provides an overview of challenges facing health care workers in fragile and conflict-affected states during pandemics and presents strategies to support these countries in strengthening and protecting their health care workers to respond to COVID-19 pandemic and other public health crises.


Definition of fragile and conflict-affected states as per the World Bank [15]

• Countries with high levels of institutional and social fragility, identified based on publicly available indicators that measure the quality of policy and institutions and manifestations of fragility.

• Countries affected by violent conflict, identified based on a threshold number of conflict-related deaths relative to the population categorized based on the intensity of violence as countries in high-intensity conflict and countries in medium-intensity conflict.


Challenges facing health care workers in responding to COVID-19 pandemic

SHORTAGE OF HEALTH CARE WORKERS

Having adequate numbers of health care workers is critical to effectively respond to COVID-19 and maintain access to essential health services [16]. However, fragile and conflict-affected states suffer from a shortage of health care workers triggered by wars and political instability in these settings [16]. This shortage can impede effective response to pandemics [17]. The shortage of trained HWCs was a major challenge in controlling the Ebola outbreak in West Africa, with this issue becoming even more severe as a result of the outbreak [18-20].

The shortage of health care workers is exacerbated by the severe shortage of quality personal protective equipment (PPE), gloves, very limited testing capacity (including portable testing kits), significant lack of intensive care units and ventilators [21-23] and other medical supplies needed by frontline health workers in fragile and conflict-affected states [24-27]. Shortages in PPE and supplies were also observed during the response to the Ebola outbreak coupled with a lack of standardized infection prevention and control (IPC) protocols and a lack of safe patient transportation [26, 28]. For instance, South Sudan has four ventilators per 11 million people, Chad has three ventilators per 5 million people, and in northern Syria there is one ventilator for every 36000 people [29]. Fragile and conflict-affected states countries have limited capacity to purchase or produce essential equipment and supplies to effectively respond to COVID-19 mainly due to the lack of technical expertise, training and regulatory frameworks [30]. This shortage can increase the risk of infection among health workers and hamper the delivery of care to patients as providers might fear the risk of infection [26].

RESOURCE CONSTRAINTS


In addition to the provision of care without appropriate PPE, health care workers are lacking training on the use of such equipment and infection prevention and control and health care workers lack preparedness, information and skills to respond to this specific type of virus [5, 31, 32]. Pandemics such as COVID-19 places additional burden on fragile and conflict-affected states, a setting already suffering from weak education and training systems. For instance, fragile states were found to lack adequate infrastructure to train sufficient numbers of medical professionals to meet population health needs [33]. During conflict, training institutions often lose mentors and educators and those are sometimes replaced with less qualified staff [34]. Also, the reliance during war and conflict on emergency on-the-job training by NGOs and local providers hindered the development of skills of health care workers [35]. The dependence of health authorities on non-public providers can divert governmental efforts from building long-term education and training strategies [36]. These countries also lack national standards and quality assurance in education and training institutions which also affected the quality of education in these settings and hamper the health system response to public health shocks [35, 37].

INADEQUATE TRAINING AND EDUCATION

A systematic review has shown that health care workers are facing mental health problems including stress, anxiety, depression, insomnia due to the COVID-19 pandemic [38]. Reasons behind developing mental health problems included fear of exposure to infection themselves or their families, speculations and uncertainties about the virus mode of transmission and treatment protocols, long working hours, fatigue, occupational burnout, stigma, rapidity of spread and lack of vaccine, and increased workload [3, 5, 38, 39]. The toll of COVID-19 on mental health of health workers can be more severe in fragile and conflict-affected contexts [40]. For instance, the Ebola outbreak created fear and a stressful environment for the HCWs who were not sufficiently trained to respond to the outbreak. Alexander et al. (2010) highlighted that HCWs were stigmatized and rejected by communities due to the high infection rate among them [41].

MENTAL HEALTH CONCERNS


Health care workers are subjected to violent attacks and harassment in different areas around the world. The reason behind this violence is the perception of health care workers as a public health hazard resulting from misinformation by the public on how COVID-19 spread. In conflict-affected states, health facilities continued to be attacked amid the COVID-19 pandemic. For instance, a hospital maternity ward in Afghanistan was subjected to armed attack on May 20, 2020 killing 13 civilians including medical staff [8, 42]. In Syria, health care facilities were also still under violent attacks. During the pandemic, these attacks against health care workers and facilities can deny people from accessing health services when it is much needed [8]. Doctors were also threatened and detained in some states for speaking to the media and giving “false” or “unsanctioned” information during the COVID-19 state of emergency [32].

VIOLENCE AGAINST HEALTH CARE WORKERS

In many fragile and conflict-affected countries, physical distancing and self-isolation are very hard to achieve because residents including refugees and internally displaced populations live in high-density residential areas and camps. This is combined with limited access to water and washing facilities, unpredictable and persistently deteriorating socio-economic, cultural, and environmental conditions, common electric power cuts, and constrained health services and health infrastructure to respond to COVID-19 [21, 43]. As a result, these regions become particularly vulnerable to a severe outbreak which can jeopardize the health workforce’s response in these states due to increased workload and resource constraints.

REFUGEES AND INTERNALLY DISPLACED POPULATIONS


In some fragile and conflict-affected states, there is a lack of political will to initiate a coordinated response to the COVID-19 outbreak. In some conflict-affected countries, governments are unable or unwilling to fully protect and assist the health workforce and citizens in building a safe environment[21]. Conflict settings suffer from an overall lack of public awareness, particularly in terms of knowledge about the health system’s capacity to respond to the outbreak, and lack of public trust in the response due to several factors including lack of transparency about the number of cases [21]. In Syria, health professionals have indicated a sharp rise in deaths caused by pulmonary infections and pneumonia. However, with the limited testing capacity (only one functioning COVID-19 detection device is available in a hospital in Damascus), it was hard to indicate COVID-19 in all cases [21].

SOCIO-POLITICAL CHALLENGES

Data on infection and mortality rates and routine data collection on violence against health workers is lacking worldwide and conflict-affected states are no exception [8, 44]. In addition, plans and scale-up strategies for the development of the health workforce are often informed by limited data about the status and composition of the current workforce [12]. For instance, in Afghanistan, the first Human Resources for health development plans drafted in 2003 were vague; policymakers had no concrete Human Resources data on how many health workers required testing and certification, what their professional categories were, or where they were based.

LIMITED DATA ON HEALTH CARE WORKERS


Strategies to protect and strengthen the health workforce in fragile and conflict-affected states to respond to COVID-19 and beyond The following strategies intend to inform efforts at the government and development partners, organizational and individual level to protect and strengthen health care workers in fragile and conflict-affected states.

Government and development partners level 01.


• Systematic data collection on mortality, infection rates and violence: To protect health care workers against infection, data on health care workers infections and mortality needs to be systematically collected by governments and held centrally at a global level [6]. This kind of data permits governments and concerned parties to take adequate preventive measures. To this data, there is no systematic and standardized record of infection and mortality rates among health care workers globally [45]. In addition, the development of concrete human resources data and information systems is crucial to develop data-driven policies on human resources strengthening and development in these settings.

• Implementing measures addressing violence against health care workers: In addition to data on infections and mortality rates, data needs to be systematically collected on the incidence and types of attacks against health care workers in the context of the COVID-19 pandemic [8]. This is mostly relevant to the fragile and conflict-affected states where political instability and violence is predominant [44]. Understanding the scope of the problem allows designing effective interventions to prevent the incidence of violence. Governments should also collaborate with civil society, community groups, and media to shed light on the problem of violence against healthcare workers and improve the reporting and prevention of such incidence [8]. National governments should also address violence through legal systems by developing or enforcement policies and laws condemning attacks on health workers [8].

• Raising awareness and defeating misinformation about COVID-19: Misinformation about COVID-19 can lead to the demonization of health workers and might lead to violence and stigma consequently. In this regard, raising public awareness and educating the public on SARS-CoV-2 spread mechanisms through campaigns is important to correct such misinformation and protect health workers. The right for people to have access to information is protected under international human rights law. Health care workers should also be given the freedom to speak up and provide accurate and timely information about Sars-CoV-2 and how to limit transmission [32]. Governments, international bodies, community stakeholders and organizations must play an essential role in leading such initiatives.


• Providing international support: In fragile and conflict-affected states, international support is essential to ensure an effective response to pandemics. A global response is needed to protect health workers including the provision of PPE and essential medical supplies and training of health care workers to overcome the challenge faced in these settings of limited resources. The World Health Organization (WHO) has also played a major role in supporting governments in countries suffering from widespread transmission (Guinea, Liberia, and Sierra Leone) [46]. Through close collaboration with local health authorities, the WHO supported establishing systems for continuous monitoring, supportive supervision, and improvement of IPC standards in Ebola facilities to ensure the safety of HCWs [46]. Other forms of support included increasing access of HCWs to psychosocial support, organizing safety trainings, developing policies and procedures to ensure safe working conditions, conducting workplace needs assessments to prevent health and safety risks [46]. Coordination among national governments and international donors is pivotal to ensure alignment between international support and national health needs [47].

• Providing national guidelines on infection prevention and control: Providing health facilities and community health workers with clear national guidelines on the use of PPE and infection and prevention control measures is crucial to lowering the risk of disease transmission during the outbreak while maintaining the delivery of essential health services such as maternal and newborn health services during COVID-19 [48].

• Strengthening community health workers: Community health workers played a crucial role in responding to COVID-19 pandemic countries with fragile health systems [48-50]. Shifting selected health services to community health workers can be considered as a strategy to lower infection risks to patients and providers by reducing the volume of patients in need to visit health centers [48]. The shift to community health workers can also reduce the workload of existing medical staff in health centers [49]. This calls to include community health workers in PPE projections and to collect data on community health workers numbers, services and distribution to inform plans and projections [50]. Governments and development partners are called to reconsider payment arrangements for this category of workers such as paying for supplemental hours and paying for sick leaves. It is also important to train community health workers and share information and updates with them regularly as protocols and policies on COVID-19 are subject to frequent changes. Cost-effective ways of sharing information and updates can include the use of mobile technology such as text messages and mobile applications [50].

• Strengthening training and education systems: Health Systems should support and strengthen the capacities of domestic health workers at all levels, along the lines of the long-term health system strengthening and reform strategies, to increase resilience and health-care response capacity [47]. Government and development partners should work on strengthening educational institutions and assessing training needs [51]. Health authorities are to define the required products of training and education and to ensure that students have sufficient opportunity to gain the appropriate clinical practice within the health system that responds to community needs [47].

Organizational level

02.


• Training and capacity building: Training of health care workers on prioritizing patients through triage and on infection and prevention measures improved their skills and knowledge and reduced the fear among staff in addition to increasing confidence in providing care [3]. When coupled with the supply of essential resources such as PPEs, bleach and gloves training was found to be more effective when it was coupled with [5]. Training can be provided to health workers through digital training tools on triage and treatment protocols, information on physical and psychological coping strategies or opportunities to offer phone consultations where possible [48].

• Providing financial incentives: Providing health workers with financial incentives in addition to their salaries can motivate staff to work in the facilities during pandemics and can provide an additional income source to help health workers cope during the challenging times [5, 26].

• Providing psychosocial and mental health support: Psychosocial support provided by social workers and mental health workers can help health workers cope with the stigma of being a health worker during an epidemic [5]. To mitigate mental health problems in health care workers, screening of health workers involved in treating and diagnosing patients with COVID-19 should be regularly undertaken by multidisciplinary Psychiatry teams to evaluate stress, depression and anxiety [38].


Individual level

03.• Peer, family and social support: Peer support was reported as one of the factors playing an

important role in keeping health workers motivated and committed during challenging times. Health workers can encourage each other, and share skills and knowledge about treatment protocols and infection and prevention control measures. Additionally, receiving support from managers and senior health workers was reported to increase the confidence of health workers in treating patients on their own after these patients [5, 7, 39]. Support from family can also motivate health workers and help them cope with the stressing situation imposed by the pandemic [5, 38].


COVID-19 pandemic presents an opportunity for fragile and conflict-affected states to reconsider and emphasize the role of their health care workers. This document helps draw the attention of national and international stakeholders to challenges faced by health care workers in fragile and conflict-affected states. It presents some key evidence-informed strategies on government, development partners, organizational and individual levels for strengthening the health workforce in these settings. Governments and other international concerned parties should consider strengthening health care workers in fragile and conflict-affected states beyond COVID-19 to build a resilient health workforce that can respond to pandemics and other public health crises and health systems shocks.

BEYOND COVID-19


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Knowledge to Policy (K2P) CenterFaculty of Health SciencesAmerican University of BeirutRiad El Solh, Beirut 1107 2020Beirut, Lebanon+961 1 350 000 ext. 2942-2943 www.aub.edu.lb/[email protected]

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