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Objective Across Africa, the impact of COVID-19 continues to be acutely felt. This includes Malawi, where a key component of health service delivery to mitigate against COVID-19 are the primary healthcare facilities, strategically placed throughout districts to offer primary and maternal healthcare. These facilities have limited infrastructure and capacity but are the most accessible and play a crucial role in responding to the COVID-19 pandemic. This study assessed health facility preparedness for COVID-19 and the impact of the pandemic on health service delivery and frontline workers. Setting Primary and maternal healthcare in Blantyre District, Malawi. Participants We conducted regular visits to 31 healthcare facilities and a series of telephone-based qualitative interviews with frontline workers (n=81 with 38 participants) between August 2020 and May 2021. Results Despite significant financial and infrastructural constraints, health centres continued to remain open. The majority of frontline health workers received training and access to preventative COVID-19 materials. Nevertheless, we found disruptions to key services and a reduction in clients attending facilities. Key barriers to implementing COVID-19 prevention measures included periodic shortages of resources (soap, hand sanitiser, water, masks and staff). Frontline workers reported challenges in managing physical distancing and in handling suspected COVID-19 cases. We found discrepancies between reported behaviour and practice, particularly with consistent use of masks, despite being provided. Frontline workers felt COVID-19 had negatively impacted their lives. They experienced fatigue and stress due to heavy workloads, stigma in the community and worries about becoming infected with and transmitting COVID-19. Conclusion Resource (human and material) inadequacy shaped the health facility capacity for support and response to COVID-19, and frontline workers may require psychosocial support to manage the impacts of the COVID-19 pandemic.
The Malawian health system is structured around three levels: tertiary (large referral hospitals situated in major urban centres), secondary (district hospital) and primary (health facilities, community and home-based services). Funding for the health sector is heavily dependent on international donors.22 Health services are provided by government, private and faith-based organisations; government services are the only ones provided without fees, and recent estimates suggest they provide approximately 60% of services accessed.23 24 Despite policies being well designed, key challenges faced in the health sector include chronic underfunding, shortage of staff and fragmentation of services.24 The District Health Office (DHO) is mandated to provide management and oversight of primary healthcare facilities.25 This study was situated in Blantyre District in the Southern region, which is serviced by 31 government and faith based primary healthcare facilities (n=14 urban; n=17 rural) (see online supplemental file 1 for further characteristics of the facilities). The district has a total population of 1.25 million including Blantyre city (64%), the second largest city in Malawi. The study ran from April 2020 to August 2021. This encompassed the first and second waves of the COVID-19 pandemic in Malawi and the national rollout of the preventative vaccine. bmjopen-2021-051125supp001.pdf To understand the impact of COVID-19 on primary healthcare provision, we used a mixed method approach. Combining qualitative and quantitative research methods allowed us to capture data from across the district and gain a deeper understanding of the findings through qualitative interviews. All data collection tools were developed in consultation with the Blantyre DHO and were reviewed regularly through feedback loops to help inform service delivery improvements. Field work was conducted in two phases: For this phase, we aligned qualitative and quantitative approaches to understand the impact of the first wave of the pandemic. Quantitative structured data collection tools were selected to enable real-time data to be captured through direct observations at each healthcare facility. Tools focused on the key components of the National COVID-19 Preparedness and Response Plan,26 reporting on preparedness proxies (eg, hand washing facilities (HWFs), soap and thermometers) and observed behaviour of frontline workers (inclusive of healthcare workers and auxiliary staff) and clients (eg, mask wearing and physical distancing) (see online supplemental file 2). Qualitative interviews were selected because they allowed frontline workers to express their lived realities and explore a range of themes flexibly.27 Conducting interviews at different time points allowed us to capture health workers changing perceptions and experiences across the dynamic period of the pandemic. To reduce the risk of COVID-19 transmission with prolonged contact with participants, we conducted qualitative interviews over the telephone. bmjopen-2021-051125supp002.pdf Following the second wave of the pandemic and the national roll out of the COVID-19 vaccine, we conducted a second phase of qualitative interviews. These interviews sought to understand the perception of, and response to, the vaccine within primary healthcare clinics. Quantitative assessments were only conducted during the first phase of the study (July–November 2020). Working in all 31 rural and urban health facilities in Blantyre District, we collected structured data at three-time points (August, September and October 2020). Experienced researchers administered a questionnaire with the clinician responsible for managing the health facility or their representative. All quantitative data were collected using a preprogrammed questionnaire on KoboCollect (https://www.kobotoolbox.org) (see online supplemental file 3). The questions included data on patient management, physical distancing, WASH provision and practices, the presence and use of PPE and patient attendance at routine health services. The team photographed clinic registers (without any identifying patient data) for OPD, EPI, TB, FP, HIV and cancer screening services; these data were collected from January 2019 to September 2020 to allow for comparison of patient numbers pre-COVID-19. bmjopen-2021-051125supp003.pdf Following analysis of each round of data collection, ‘score cards’ were generated for each health facility. The score cards summarised how the healthcare facilities were implementing COVID-19 preventative measures, including training of frontline staff and WASH materials. This included the location and presence of HWFs (including soap and water), stock and use of PPE including face masks and thermometers, waste management and case management of suspected COVID-19 cases. These scorecards were then provided to the DHO team through monthly feedback loops to provide guidance on which healthcare facilities had managed to adapt their practices and which facilities required further support. Qualitative assessments were undertaken across both phases of the study. Following the generation of the scorecards from initial quantitative data collection, eight healthcare facilities were purposively sampled to be included in the qualitative component. In the sample, we included both rural (n=4) and urban facilities (n=4). In these healthcare facilities, we conducted a total of 81 interviews with 38 participants, all frontline workers. In table 1, we provide a breakdown of the participants included in each round of the interviews and the number conducted at each time point. Semistructured qualitative interviews were conducted over the telephone and guided by a discussion guide (see online supplemental file 4). These interviews happened at five-time points (July–August, September, October–November 2020 and April–May and August 2021) to allow us to capture the dynamic nature of the pandemic and the rollout of the vaccine programme. Summary of qualitative sampling bmjopen-2021-051125supp004.pdf For each round of the interviews, we used a purposive sampling approach that aimed to sample a wide range of frontline workers including those employed in support and operations at the health facilities. In July/August, we included auxiliary staff (guards, ground staff, patient attendants and cleaners) recruiting up to four participants in each healthcare facility. In September 2020, due to time and resource constraints, we repeated interviews with two participants per healthcare facility; this sample included both a health worker and an auxiliary worker. Between October and November 2020, we conducted a third set of interviews with the healthcare facility in-charges, those who manage the clinic (or their representative), these interviews focused more on broader changes to care provision. Between April and August 2021, we undertook a second phase of interviews with in-charges (or their representative). Key themes included experiences delivering care during the COVID-19 pandemic. Participants were asked during the interviews to reflect on the pandemic including preparedness of clinics and training on COVID-19, changes in the provision of care as well as perceived changes in patient behaviour. Finally, the impact of working during the pandemic on frontline workers’ well-being and lives. The second phase of interviews explored the rollout of the COVID-19 vaccination programme and its impacts on patient attendance. We took a pragmatic approach to sampling, constrained by conducting fieldwork during the pandemic and financial limitations and did not seek to achieve data saturation. However, we did generate a significant of data through the 81 interviews from a range of participants that was triangulated with quantitative data and structured observations. Quantitative discrete data related to COVID-19 preparedness within the facility was downloaded from KoboCollect (https://www.kobotoolbox.org) as a.csv file, cleaned and analysed using Microsoft Excel V.16 (Microsoft Corporation, Redmond, Washington, USA). Continuous data related to the department and attendance from health records were abstracted from photographs to Microsoft Excel V.16 for comparative analysis between 2019 and 2020 attendance across specific services. All data were analysed for Blantyre as a whole and as a comparison between urban and rural facilities. For the qualitative data, we used thematic content analysis28 (see online supplemental file 5 for coding strategy). All transcripts were transcribed and imported into NVivo V.12 (QSR, International) to facilitate data management and analysis. Initial themes were identified, and key gaps were included in subsequent rounds of data collection. The study team (drawing together the quantitative and qualitative researchers) held weekly debriefing sessions to allow for discussion of findings from each week’s data collection. Any new avenues of inquiry were incorporated into the data collection. Halfway through the study, we presented initial findings to the DHO to gain feedback and participant checking. bmjopen-2021-051125supp005.pdf For the qualitative interviews, the participant information sheet and consent form were shared on WhatsApp before the interview to allow participants to review the information. Before the research began, the information was reviewed again, and oral consent was taken from the participants. No data WERE collected from the clinic, including clinic registers contained patient’s personal information. This study was developed in partnership with the Blantyre DHO, specifically the team leading the COVID-19 preparedness and response for primary healthcare within Blantyre District. Halfway through the project, we presented our initial findings to the District Health COVID-19 Task Force during their weekly meetings for direct feedback, incorporating their suggestions into the qualitative data collection.
