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Silver linings of the COVID-19 crisis in Ghana

Published on: 18/05/2020

Perspectives of a WASH systems advocate and watcher.

Using a simple handwashing device in Bongo, Ghana

Using a simple handwashing device in Bongo, Ghana. Photo: IRC Ghana

 

On March 12, 2020 Ghanaians woke up to the news that the coronavirus had “entered the country”. This brought shivers down the spines because most had prayed that the country would be spared as was the case during the Ebola pandemic. The disease dominated discussions on the airwaves and people were particularly interested in where it came from and who brought it in. Everybody was surprised and scared. The foundation of our system was shaken, and the parts began to move!!

In an address to the nation on 15th March, the President of the Republic of Ghana, H.E Nana Addo Dankwa Akufo Addo, officially confirmed six COVID-19 cases and provided an update on Ghana’s enhanced response.

His Government established an inter-ministerial committee and prepared a coronavirus response programme to achieve five key objectives: limit and stop the importation of the virus; contain its spread; provide adequate care for the sick; limit the impact of the virus on social and economic life; and, inspire the expansion of our domestic capabilities and deepen our self-reliance.

All external borders were closed. Public gatherings, including conferences, workshops, funerals, festivals, political rallies, sporting events and religious activities, such as services in churches and mosques, were suspended. Private burials were permitted with no more than 25 mourners. All universities, senior high schools, and basic schools were closed until further notice.  The Attorney General was directed to submit emergency legislation to Parliament. Further directive was given to the Minister for Health to exercise his powers, under section 169 of the Public Health Act, 2012 (Act 851).

Government machinery for combating the disease was fully activated: all sub national structures (Metropolitan, Municipal and District Assemblies (MMDAs)) were directed to form cross-sectoral committees and to prepare emergency response plans. The President held meetings with Christian and Muslim leaders to pray for the nation; traditional authorities to rally the people; leadership of political parties to rally their supporters; the medical association and scientists to strategise on combating the disease; pharmaceutical companies to diversify and produce  essential medicines; Trade Unions to discuss labour issues; the textile and fashion industry to diversify production to personal protective equipment (PPEs).

As the disease continued to spread, the Ghana Medical Association and other organisations called for further restrictions. In his third address to the nation on 28th March, 2020, the President imposed a partial lockdown in the so-called “hotspots” of infection in Greater Accra (including the sprawling township of Kasoa); Greater Kumasi; and Tema.

This seemed to catch most Ghanaians unprepared, resulting in a degree of panic and chaos. Some tried to flee to other parts of the country, others were rushing home from trips outside restricted areas. Many rushed to stockpile food and essential items, which caused hyper-inflation.

I am a professional systems advocate but I am also a concerned Ghanaian citizen. I have been following and observing how the various parts of the system are responding to the pandemic. What have we learned so far?

It is one system after all

Usually, sectoral problems are dealt with by the relevant governmental ministry, department and agency (MDAs). Under business as usual, COVID-19 would have been the sole responsibility of the Ministry of Health, Ghana Health Service and allied institutions.  

COVID-19 is different. It is not just a disease but an invisible enemy that is waging an unconventional war on the whole world; a war with no guns, missiles or artillery fire, with no one giving the order to shoot; but with a very simple war strategy that demands human acts of discipline: washing hands with soap under running water; keeping social distances; avoiding crowded areas; and, seeking medical attention when one develops the known symptoms. This requires changes in behaviours, attitudes and perceptions that sound simple but are more difficult to plan and implement than warfare, which is conducted under strict command and control. 

Recognising the need for strong focused leadership and collective action, the President set out his strategy (his five key objectives) and called on all to play their part. He has used periodic national addresses not only to update Ghanaians or introduce new measures but to rally continued support.

I quote three of my favourites of his morale boosting statements:

  1. I have first of all to tell you how proud and privileged I am to be your President, not just to fight for you but also to fight with you and help shepherd our country out of this crisis”;
  2. “The frontline of the fight against coronavirus is your front door. If you cross it, you and your family will likely be infected. So, please, stay at home”;
  3. “I assure you that we know what to do to bring back our economy back to life. What we do not know how to do is to bring people back to life”. 

It was this last one that was most inspiring and rightly received international acclaim.

There is perhaps nothing special in the executive arm of government being active in this fight. Nonetheless, it is instructive to note the admirable way they synchronised their activities to meet the dynamics of the fight and the interplay of the various arms of the government system; the executive, legislature and judiciary. The legislature ensures that submissions by the executive are passed expeditiously.  The judiciary established special courts for COVID-19 offences, and the security forces stepped up their game in enforcing the laws. The media have also acquitted themselves credibly at the forefront in channelling information to the public. 

Businesses have been severely affected by the lockdown and yet the private sector has also risen to the occasion by donating generously to support the cause. Other non-state actors such as faith-based organisations, non-governmental organisations, civil society groups, traditional authorities and individuals have extended solidarity and support; by donating directly to the Government or to institutions at the forefront of the fight as well as those in need.

Women weaving in Bongo, Ghana

Women weaving in Bongo, Ghana. Photo: IRC Ghana

Churches and mosques are quiet and empty, and the usual heavily attended funerals and weddings are no more, yet no one is complaining. Presidential and parliamentary elections are slated for November 2020 and by this time of year, the usual hustle and bustle of campaigning by political parties would have peaked. Yet it is quiet for now; all parties have thrown their weight behind the President in this fight. The main opposition party has formed its own COVID-19 team and provides suggestions to the government. A few jabs have been thrown, which of course is expected.

Citizen vigilantism has been on display at various parts of the country. In the absence of security forces, citizens have acted to ensure the upholding of the President’s directives and an early admonishment that Ghanaians should be citizens and not spectators.

Never have I witnessed such a high level of intra-system coordination towards a common purpose albeit some fall outs which is expected under any emergency circumstances.  I am amazed at the turn-around time from policy statements and directives by the executive to the passing of legislations by Parliament. Our public services and arms of government have been put to the test and demonstrated they are a formidable force and an asset to drive the national development agenda. The rare comradeship by political parties is a beauty to behold.

However, the system is not without patches. Intra-ministerial and inter-governmental lapses cannot be ignored, although they might be expected under an emergency and as the dust settles and we become more experienced in handling the response, we will look at smoothing out the shortfalls. Structural issues may never be resolved during this fight, but the lessons can inform how we deal with similar situations in future. 

COVID-19 has brought untold hardships but has also revealed that we as a people can work together to achieve a common purpose. I hope this will shape how we approach our development agenda post COVID-19.

Measures to mitigate the social and economic impact of COVID-19

The statement, ‘we are in this together’ has become a global mantra. But the reality is that for many it is a catastrophe. Weaknesses in our social structure are becoming more visible and hampering efforts to fight the disease.

The President established a COVID-19 Fund, to be managed by an independent board of trustees to receive contributions and donations from the public to assist in the welfare of the needy and the vulnerable. He donated three months of his own salary.

He announced a GH¢1.2 billion Coronavirus Alleviation Programme to support households and businesses. Out of this approximately 23%, GH¢280 million was allocated to provide food to the vulnerable and to cater for water bills for all Ghanaians for three months, April, May and June. Half the assistance (GH¢600 million) is being extended to micro-, small- and medium-scale businesses.

Further, Government has fully absorbed electricity bills for the poorest of the poor. For all other consumers, residential and commercial, Government will absorb 50% from April to June.

The final 27% (GH¢323 million) is being allocated for health practitioners as frontline combatants for their unrelenting efforts in the face of very limited resources.

More relief measures are planned. To restore Ghana’s economy and create a path towards growth and transformation in the face of the pandemic, the government has secured a US$ 1 billion Rapid Credit Facility from the IMF. This will help close the financing gap created as a result of shortfalls in revenues and unplanned expenditures. A GH¢3 billion credit and stimulus package has been sourced from commercial banks, with the support of the Bank of Ghana, to revitalise industries, especially those in the pharmaceutical, hospitality, services, and manufacturing sectors.

COVID-19 WASH systems legacies

Water, sanitation and hygiene are central in the war against the disease.  Many actions taken can serve as shining lights for strengthening the WASH system after the pandemic.

Clean cities and public places

Pre-COVID-19, the President had committed to making Accra the cleanest city in Africa. However, city authorities were not making much progress due to lack of funds and unwillingness of most Ghanaians to adhere to simple waste management practices.  During the lockdown, something dramatic happened. The central business districts of Tema, Accra and Kumasi were cleared of all waste and fumigated. More than 136 markets across the country and some public places were also fumigated and waste collected. Following the relaxation of the lockdown directive, Ghanaians emerged from their homes to witness and admire their clean cities. Sustainability will be a test.

Innovative handwashing apparatus

Washing hands with soap under running water is one of the simplest ways of fighting this invisible enemy. The search for solutions rekindled potential in Ghanaians.

While academia and the scientific community are designing, testing and showcasing prototypes of medical equipment, ordinary Ghanaians are creating alternatives to the “Veronica bucket’’, the popular handwashing apparatus. Significant progress has been made in solar powered and manually paddled devices that aim at eliminating contamination during handwashing. The Ghana Standards Authority has moved with lightning speed to test and approve some of these innovations.

To achieve the President’s objective of inspiring the expansion of our domestic capability and deepen our self-reliance, it is my fervent hope that such innovations will not end up on the shelves as the case has been pre-COVID-19. This ingenious creativity should be supported.

WASH service delivery

‘Water is life’, resonates more than ever in the face of the pandemic. I can say with certainty that water is an enemy of COVID-19; and its availability at the right time in the right quantities is one of the major weapons to fight this invisible enemy. The COVID-19 pandemic has redirected attention to the strong link between public health and safe water, sanitation and hygiene.

However, many people are deprived of this basic human right of access to reliable and safe water as a result of their inability to pay for the service, or of service being unreliable, or (worst of all) there simply being no service. It is estimated that about 30% of the water systems in the rural water subsector are non-functional or perform sub-optimally and many urban slum and peri-urban areas are without regular supply.

According to JMP (2019), 8% of the Ghana population have limited access to water while 10% depend on unimproved or surface water. These people face a daunting challenge in protecting themselves from this dreadful disease.

The announcement by the President in his coronavirus response address on 9th April, that Government will absorb water bills for all Ghanaians for April, May and June and provide water tanker services to vulnerable communities solves the affordability challenge for those with access to safe water. Sadly, it does nothing for those without. For many vulnerable rural and peri-urban communities where water tanker services are not available, the only option is to step up efforts at extending water services.

According to the same JMP report (2019), 42% of Ghanaians have limited access to handwashing facilities and 17% have no access at all. Even among the 42%, it is unclear how many practise handwashing on a regular basis. The speed with which temporary handwashing facilities are being delivered to healthcare centres, public institutions and public places is itself clear evidence of historic weaknesses in our WASH system. 

It will be a systemic failure if we are content with these temporary measures and fail to advance post COVID-19. An enduring solution to ensure that all health institutions, schools and public places have permanent safe water, sanitation and hygiene infrastructure and people practise sustained hygiene behaviour can become an enduring legacy of COVID-19. This will also curb other WASH related infections, which have seen a sharp decline following the intensive handwashing campaigns by Ghanaians.

In addition to caring for the sick, the pandemic has highlighted other health priorities, including preventive and promotive aspects of health, the need to address mental health issues, and the crucial role of emergency services. The virus has also revealed the unequal distribution of healthcare facilities. Responding to this, on 26th April the President announced a major investment in healthcare infrastructure with a decision to construct 88 healthcare facilities beginning this year.

Water provision of Bongo healthcare centre, Ghana

Water provision of Bongo healthcare centre, Ghana. Photo: IRC Ghana

Since the experience of COVID-19 has reaffirmed the strong link between WASH and health, it is imperative that WASH becomes an integral part of such interventions. Equal attention should be paid to fixing WASH infrastructure in existing health and education facilities; and public places.

The COVID-19 crisis must be a game changer on how we have viewed, valued, prioritised and managed the delivery of WASH services.

The complexities of governance in the WASH sector

The Ministry of Sanitation and Water Resources was charged to operationalise the free water directives in collaboration with agencies and local governments. How can this directive be made to work in rural and peri-urban areas?

The Ghana Water Company (GWC) is solely responsible for the management of urban water services but this is not the case for the Community Water and Sanitation Agency (CWSA) in rural areas and small towns. Both entities issued guidelines and it was clear that the directive will be easier to apply in urban areas and more complicated in rural areas and small towns. The GWC virtually owns and manages all the 90 urban water systems, supported by 15 administrative regions across the country. It has a customer base of 708,803 households with tap connections. As a utility service provider, the company has a well-regulated tariff regime, a comprehensive billing system and procedure for payment.  Therefore, it is quite easy for the company to effect the presidential water subsidy.

In the rural water subsector, there are 28,473 boreholes, 3,993 hand dug wells, 126 small community pipe schemes, 381 small towns pipe schemes and 526 limited mechanised systems. Under the ongoing rural water utility management reforms initiative, 182 of the rural and small-town water systems are now under CWSA direct management. 460 of the water systems are under NGO and private sector finance and management arrangements. The rest are under local governments, who have delegated management responsibilities to water and sanitation management teams and private contractors.

The tariff regime is fragmented because each of the 260 assemblies sets and gazettes its own tariffs within the confines of the law. Some NGOs and private water service providers fall outside the local government managed systems and their operations are unregulated.

In addition, local governments are administratively under the supervision of the Head of Local Government Service and politically answerable to the Ministry of Local Government and Rural Development. The CWSA on the other hand falls under the Ministry of Sanitation and Water Resources. With this situation, it becomes abundantly clear how complex it is to implement the President’s directive in the rural water sub sector.

Many sector practitioners have attributed the rural water sub sector challenges to the community owned and managed (COM) operational model, which is underpinned by the principles of subsidiarity and voluntarism. It was indeed a fit for purpose model at a time when community participation was the mantra under the decentralisation process in Ghana. It is believed the model is ‘at the beginning of the end’ not because community participation is no longer relevant but that because an approach based on informality and voluntarism is reaching the limits of what can realistically be achieved. 

Numerous research findings point to the inherent weaknesses in community management of water systems and its threat to sustainability. In 2017, CWSA initiated reforms which seek among other things to expand its mandate to include the management of piped water systems whilst maintaining the community’s role in providing and managing point source water systems.  As expected in any reform initiative, there is push back but government is committed to bring some sanity and harmony at that level.

Despite these challenges and complexities, the impact of government’s COVID-19 restrictive measures on the poor was immense and the subsequent directive of the President for free water services to ameliorate the situation must be implemented without complaint. In executing the directives, the leading actors are devising all means to ensure fairness and equity while ensuring that the financial sustainability of the existing facilities is not jeopardised. 

I can only hope that by resolving these issues, the systemic bottlenecks that hold the sector back will become more obvious and the necessary institutional alliances and relationships will be created to push the necessary reforms in the sector. If this is done, one day we will look back, reflect and count the robust WASH system driving the delivery of safe water, sanitation and hygiene services for everyone in Ghana as one of the COVID-19 legacies, and the war would have been won for good.

 

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