Bloemfontein – Officials in the Department of Health in Free State Province in South Africa beam with pride when talking about their response to COVID-19. Leadership, innovation, and partnerships, they say, have been key to effectively tackling the pandemic and placed the province among those with the highest vaccination coverage in the country.

Initially, response to COVID-19 was centralized at the provincial level. Districts would gather data on paper, send the numbers to provincial level where officials would analyse it and feedback to the districts, which would then respond to an outbreak accordingly. But the delays in this lengthy process meant that by the time action was taken on the ground, infections were already high and deaths rising. “We realized quickly that this was not going to be sustainable,” says Priscilla Monyobo, World Health Organization (WHO) provincial focal person.  

Key pandemic response measures including coordination, epidemiological surveillance, contact tracing, outbreak investigation, data management and analysis, infection prevention and control, community engagement as well as vaccination were localized to the district level in July 2020.

The decentralized approach led to faster outbreak detection and better targeted response. Standardized case investigation procedures were developed for district teams, for example, the time to start investigation was cut to 24 hours down from 72 hours when it was managed at the provincial level. Cluster outbreaks were identified quickly, and districts had a better understanding of the contexts of some of the outbreak trends.

At the provincial level, an outbreak management information systems application developed through partnership between the department of health and South Africa’s biggest network provider boosted data gathering and management. Community health workers, for instance, were supplied with tablets and phones to record and report data, including on health worker infections, deaths, recoveries, expertise and location of healthcare facilities. 

We called it innovation out of necessity,” says Bandile Ntombela, the department’s information and technology director. “Innovate, otherwise people will die.” This innovative approach enabled a rapid response on a local level. The profile of each district is nuanced, continues Ntombela. “The clinicians who are based in districts have a better understanding of the context than the province. Even so, their use of the data and what they need to see would be different (from each other). So, we had to enable that.”  

The provincial department of health also leveraged an existing partnership with Right to Care—a health care organization—which has a footprint in the province’s districts, and Geographical Information Systems specialists to build a real-time data system. “We have people who are willing to expand to our communities. We acknowledged that as a department we can’t do this alone and we all need to have ownership of the issue,” says Lucy Ramongalo, Deputy Director of Standards Compliance at the department.  

With support from WHO, the provincial department of health received technical officers to support the response. Data analysts and epidemiologists were deployed to the districts. “WHO district epidemiologists could do a further deep dive of the data and then the districts could put targeted interventions into place,” says Monyobo of WHO.  

“Having strong support from our leaders played a massive role and was one of the contributing factors to our success,” says Ramongalo. At a provincial level, with this leadership in place, officials could then start to provide technical oversight and guidance. Top leadership, including the provincial premier, the provincial COVID-19 executive committee members and heads of departments, were involved from the outset of the response and continued throughout.  

“This is data-driven decision making,” says Ntombela. “We had been talking about it for a long time as a department and for the first time we got to see the impact of it. It has allowed us to expand our horizons on what can be done with data analytics to put systems in place to enable a rapid response.”

During various COVID-19 waves, the localized response, especially strong data management, proved crucial in cluster outbreak investigations in schools, nursing homes, mines, and prisons. The health authorities also developed contingency plans to ensure that risk assessment, isolation and infection prevention and control measures were implemented within 24 hours of notification of a case.

The health department and Right to Care are now working with a data dashboard developer to use vaccination data from the national electronic vaccination data system to identify and target areas where COVID-19 vaccination is low. At 56% of people above the age of 12 having received at least one dose of the vaccine, 72% of adults above 60 and 82% of health workers having completed their primary vaccination series, Free State is leading the way. “We have now covered most of the urban areas,” says Ntombela, “The data plays an important role in where to go next.”