Introduction (Context and Challenge)
With the onset of COVID-19 in March 2020 and the rising cases in the County, the Department of Health and Sanitation in Kisumu County needed to prevent and control the spread of COVID-19 by constantly communicating the right information to the community while receiving and responding to community alerts and distress calls. There was panic over the new coronavirus, and as such, members of the public depended on many sources for information on how to keep safe and avoid infection, some of which were misleading. Initially, some community members came up with myths, rumours, misconceptions and misinformation about the virus — that it was a disease of those living in major towns, for the rich, or a project for the government to make money. Later, in the second wave of infections, after the initial fear had subsided and the public was lax about the COVID-19 protocols, they would say politicians are not getting coronavirus; or all COVID-19-infected patients have died.
Implementation of the practice (Solution Path)
The County Department for Health and Sanitation internally brainstormed on a technologically coordinated response and communication on COVID-19 and settled on immediately establishing a call centre, with the help of key stakeholders.
The Department which is the custodian of the centre developed the content for the Guidelines and Protocols on case definition, infection prevention, burial protocols, testing and contact tracing. The Department reached out to key partners to support plans to start the call centre immediately, including Maseno University, which gave space and furniture to host the centre, a strong Internet network, electricity, security and stable water supply. Its students from the School of Medicine were recruited on stipend terms by the Department and trained for two days as call centre operators and on COVID-19 and related guidelines. Other partners included PharmAccess.
On May 4, 2020, the Kisumu County COVID-19 Response Call Centre was established at the Maseno University, Kisumu City Campus and officially launched on May 6, 2020, by the County Governor, Professor Anyang Nyong’o, as one of his flagship projects. The call centre staff complement, at the beginning (May–July 2020) included the Call Centre Manager, the Director of Public Health, and 18 Call Centre operators working 12-hour shifts running for 24 hours and later (August–December 2020) reduced to 6 operators working 12-hour shifts running for 24 hours. The Centre had 5 phones lines with 6 operators,1 being on standby operating 24 hours and with 12-hour shifts. The County provided the operators with meals (lunch and dinner) and transport home, services it outsourced.
On November 15, 2020, the Call Centre moved from Maseno University to the Old Maternity office awaiting renovation and furnishing of its current premises at the CME Hall at the Kisumu County Referral Hospital (KCRH) by the County Government of Kisumu in collaboration with GIS; it occupied the new home on December 23, 2020.
Sustainability
- Given the success of the Call Centre in handling COVID-19-related and unrelated calls, the Centre Manager sought to expand the Call Centre to a fully-fledged Emergency Operations Centre (EOC) and shared a concept that outlines the EOC resource needs for maximum operation with the County top management. The concept was approved and funded, and the EOC is now fully operational.
- The Kisumu success in the fight against COVID-19 enjoys donor support from CDC/GIS (donated EOC equipment/items on 23 September 2020), PharmAccess Foundation- supporting bulk SMS messaging, World Bank (airtime for rapid response team through MoH Headquarters), and USAID (behaviour change through CHWs).
- The Centre changed staff and reduced Call Centre operators from 18 to 12 as the economy was reopening, lessening the phone-call frequency. The operators were reduced to 12, then 9 and finally 6, with 3 operators at a time working the 12-hour shift during the day, and another 3 operators working at night. Each is paid KES 1,000 per day.
- Besides radio shows, the Kisumu County Department of Health and Sanitation opened a Facebook page to market the EOC. It has 40,000 likes.
- As part of the Lake Region Economic Bloc (LREB), Kisumu County is implementing the Adopt-a-School-Initiative which targets to stop the spread of COVID-19 and to mitigate its negative effects in schools through behavioural change advocacy. The programme intends to help schools develop partnerships with health stakeholders to enhance health promotion and strengthen school initiatives.
Results of the Practice (outputs and outcomes)
At the peak of COVID-19 infection and following government protocols such as curfew and lockdown, the Centre would receive 200 signals averagely. Around July/August 2020, when COVID-19 infections were at a peak, signals from the community on new arrivals in their villages from then hotspots of Mombasa, Nairobi and Machakos helped stop the spread because the Department of Health and Sanitation through the call centre relayed the information to the respective surveillance teams which followed up and tested the subjects some of who tested positive and were quarantined. The new arrivals would either have special permits to attend a burial or would use porous routes to visit their families in the village.
The call centre would also respond to distress calls from pregnant women in labour who required an ambulance to evacuate them or from people asking for a dead body to be collected. Other alerts were about people exercising without masks, overcrowded vehicles, etc. Women who called for ambulance services as of 30 August were 781, with 584 of them successfully helped. Dispatching ambulances to all locations within the County has thus enabled access to healthcare, especially by women in labour, during curfew hours.
To successfully follow up on the reported cases, the Centre developed a tool for bio-demographic and socio-economic data capture and actions taken. The tool classifies calls into COVID-19-related phone calls and unrelated phone calls.
COVID-19-related calls include those of persons exhibiting COVID-19 signs and symptoms; persons with a history of travel who are now in the community; and COVID-19 contacts.
Unrelated phone calls include:
- calls from mothers experiencing labour pains. Such calls usually start from midnight, and due to curfew, there are usually no bodaboda (motorcycle taxi) riders at that hour;
- threats of lynching for those who arrived in the village from corona hotspot towns around Aug/Sept 2020;
- distress calls from displaced villagers who need evacuation and support on basic needs during floods, especially in Nyando;
- A citizen inquiring why they never received COVID-19 cushioning funds (KES 1,000) like their neighbour. The National Security Intelligence had identified beneficiaries;
- Requesting help with rent arrears;
- Sexual Gender-based violence (SGBV):
- due to the imposed curfew, men go home early and become quarrelsome. Health workers are also facing SGBV associated with stigma even from their families. For example, a health worker was told by the spouse not to go home lest she infects them.
- defilement and teenage pregnancy — the County Director of Education has reported 688 cases since COVID-19 started in March 2020.
- Stigma and discrimination — families with patients exhibiting similar symptoms to corona were branded corona-infected.
- Requests for the:
- list of surveillance officers.
- list of Sub-county reproductive health coordinators.
- list of extra-condiment coordination officers of health.
- list of Sub-county Public Health Officers.
- list of Sub-county police commandant.
- County Commissioner.
Around September 2020, the County implemented Adopt-a-School Initiative by the Lake Region Economic Bloc (LREB) which links pregnant girls with Community Health workers to take them for ante-natal clinics and link them with the local chiefs to take them back to school and also rescue those already married.
Reports on the call centre’s life-saving work prompted the County Government to increase the number of ambulances from 7 to 21. By November 2020, the call centre had registered 18,517 calls cumulatively. The calls responded to and completed successfully were 256 (34%). As of 23 March 2021, cumulative calls were 21,188. At peak season, the centre would record 200 calls, this went down to 125, then 60 calls and currently 45 calls per day. The call operators, using their medical background, evaluate and refer them to health facilities.
For proper follow-up and linkage, the centre launched the Luscii Mobile App by PharmAccess which is a telemedicine self-assessment tool for patients to evaluate themselves using a checklist of signs and symptoms in the comfort of their homes for signs and symptoms of various illnesses and these are communicated to a call centre operator who evaluates the results and refers the patient to a health specialist who responds and advises on medication. Of the 740 registered users, 580 are active.
The Centre introduced M-Tiba bulk messaging by PharmAccess. The County must get consent from citizens to send them the text blast (an SMS text message sent from a single source to a large group of people simultaneously). The County received consent back in 2019 when registering households for UHC. Some 294,000 households out of 320,000 were registered.
The Centre is appropriately anchored in the Risk Communication and Community Engagement Unit. It is headed by the Centre Manager who underwent training on Call Centre Curriculum Development by Amref, equipping him with the right knowledge to run the Call Centre. It is manned by trained and knowledgeable operators who give proper referral and linkages, thus building a communication network between different health departments. The Call Centre successfully handled many non-COVID related calls to warrant expansion into a fully-fledged Kisumu County Emergency Operation Centre (EOC).
On COVID-19, the EOC handles case management, logistics, WASH, sample management lab, training, surveillance, epidemiology and Risk Communication & Community Engagement. The County has an Incident Command Structure — the County Director of Public Health & Sanitation is the Incident Commander and has a Deputy. Then there is a Surveillance Team Manager, an EOC Manager, and a Logistics Officer, and this is cascaded up to Sub-county Health Management Team.
Lessons learnt
- The EOC service has kept the County Government alert because help may be needed urgently without notice, and issues raised in calls need to be completely resolved, else the community will lose trust and call numbers will go down. The number of callers is determined by the messaging that goes out, how you respond and act on the calls and how you support the community when they have issues.
- Sometimes callers call and hang up, perhaps trying if the line works or if the call is charged. While it is free for callers, the County pays 1 shilling per minute and the bill per month depends on the number of callers.
- Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCAH) is crucial in call centres for rescue, response, and action-taken report, e.g. those not responded to could be due to no security at night, no ambulance or impassable terrain, all allowable reasons as per the call centre operations policy.
In partnership with PharmAccess, the Centre Mobilised the community through bulk COVID-19 SMS messages on:
- Containment measures
- Wearing of masks
- Washing hands with soap and clean running water frequently
- Social distancing
- Signs and symptoms of COVID-19
- Avoid unnecessary travel
- RMNCAH messages, e.g. if in labour at night, call the toll-free number 0800 720 575. Citizens call for free, but the County pays for the line through a Safaricom post-pay bill.
Bulk messaging was one way of marketing the Kisumu County EOC and its services and also communicating with the community. For example,
- In case of labour pain, call 0800 720 575
- Protect your loved ones from COVID-19; wash your hands...
- Sometimes members of the community and police officers would call about the collection of dead bodies found in town or streets during the COVID-19 pandemic. Members of the public and police officers feared removing such dead bodies to the mortuary saying, unlike the Public Health Officers, they are not trained on infection, prevention and control (IPC) and have no PPEs. This, therefore, necessitated the County Department of Health and Sanitation in collaboration with WHO to sensitize police officers on IPC during a 60-day COVID-19 community engagement and behaviour change campaign. The strategy involved social, political and administrative leadership engagement activities in the 3 high-risk Sub-counties (Kisumu Central, Kisumu East and Kisumu West).
- Systemic, structural challenges can affect the operations of a call centre. For example, the curfew hours start at 8 pm while most emergencies happen after midnight. The Centre had to get curfew passes for pregnant mothers in labour. The Centre also mapped out the mothers and attached them to the County's 3,000 Community Health Workers, who would monitor them and assist with evacuation when need arises.
- Sustaining the EOC operators is expensive. The operators would sometimes write nasty letters if payment delayed due to requisition of payment processes. There are only 5 phones, which may not be enough at the peak of an emergency.
- Sometimes, callers would be unavailable on phone after requesting for evacuation, for example. Currently, a caller has to give alternative contact numbers.
- Establishing the socio-economic statuses has enhanced better profiling to best recommend County residents for COVID-19 support and aid to those affected by floods.
- Through screening, disease surveillance and quarantine services, the County has managed to record better prevention and management practices.
- Users of the Luscii App (self-assessment tool for COVID-19) experience stigma, whereas others lack smartphones through which they can access the services offered by the App.
- Many residents fear seeking health services in our health facilities due to fear of contacting COVID-19. Continuous sensitization is necessary.
- Some calls come from other Counties where Kisumu County healthcare providers cannot coordinate health services. All Counties should have functional EOCs.
Recommendations (Conclusion)
- The Kisumu County Emergency Operation Centre (EOC) offers a continuum of care on COVID-19 public health surveillance, RMNCAH activities and other socio-economic issues, e.g. floods, gender-based violence and psychosocial issues. A Public Health Emergency Operation Centre must be fully funded to support its activities to function optimally.
- A technological and multi-sectoral approach is more effective in initiating and running the EOC.
- The buy-in of the top management of the County is crucial to the survival of the centre.
- Always prepare a concept note with factual information to initiate a dialogue on the support you need.
- It is important to respond to the calls; else the public will lose confidence in the toll-free number and will not use it. This calls for the deployment or hiring of more staff (Nurses, Emergency Medical Technicians) to work at the EOC.
- Data collected through the calls should be used to improve public health service delivery through innovative initiatives.
- Continuous sensitization on the purpose of the EOC is important to maintain community trust. It is also important to communicate factual information to counter myths.
- When communicating with the community, use the most commonly used languages.
- All Counties should have functional EOCs.
Further reading
Kisumu County website, Kisumu County Department of Health and Sanitation Facebook page