The Art of Reflective Learning in Cape Town – Protecting the Vulnerable During the COVID-19 Pandemic

Nurses in Cape Town, South Africa, helping COVID-19 patients during the pandemic.

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Cape Town, South Africa, responded quickly to the challenges presented by the COVID-19 pandemic using some of the lessons it had learned during the drought shock it experienced in 2017 and 2018, a period that acutely tested the resilience of the city. In response to the pandemic, the Chief Resilience Officer, Craig Kesson, led a transversal effort across City government that included a portfolio approach to projects and programs, paying particular attention to responding to the needs of the most vulnerable Capetonians. One of the programs in this portfolio that supported this emphasis resulted in the biggest investment in the City’s healthcare system in 20 years, and was executed in the span of two months.

Gareth Morgan, Cape Town’s Director of Resilience

“Many of the actions that we developed in our Water Strategy and honed in the Resilience Strategy are now being re-used in the COVID response. The drought learning project allowed us to reflect after the worst of that event. Because we are now attuned to the value of reflective learning, we were able to say, “This is a system-wide shock, much like a drought. It’s going to be sticky. It’s going to be with us for a long period of time.”

Gareth Morgan, Cape Town’s Director of Resilience

It was the investment into reflective learning that put the City of Cape Town’s leadership in a position to act swiftly once they identified their biggest COVID-19 needs. At the top of the list was protecting the city’s vulnerable populations, especially those living with chronic diseases, HIV, and tuberculosis. Between early June and the end of July, the city stood up 39 decanting facilities, overflow capacity medical clinics that allowed the City to un-crowd existing healthcare facilities.

This created space to distance clients receiving general primary health care services from those receiving COVID-19 services such as assessment, screening, and testing. It was crucial to build these overflow facilities quickly, as during the initial period of lockdown, they observed a definite downturn in the number of clients accessing primary health care services.

From Crisis Management to Lasting Impact

At of the end of September, South Africa has the tenth highest incidence of COVID-19 worldwide. Regional and local health departments have managed to control the pandemic in the city, which also has a significant population of people who living with HIV and tuberculosis. An estimated 20% of adults in South Africa live with HIV. When the COVID-19 hit, it was immediately clear that this would strain the city’s medical services, and they worried this would undermine decades of progress made in treating HIV and TB, and providing immunization to children.

The problem was twofold. First, the focus on treating and managing COVID-19 meant these patients were using health services that were previously dedicated to treating and helping people with HIV and other diseases. There simply wasn’t capacity to respond to the health needs of all patients, especially factoring in the requirements of social distancing. Combined with the lockdown that South Africa implemented just three weeks after its first case, on March 5, this led to a significant drop in TB testing across the country, hampering contact tracing and raising concerns of higher numbers of TB cases among Cape Town’s poorer communities. Second, congested health facilities represented a higher risk of contracting COVID-19. They were also genuinely concerned that they didn’t have enough capacity to accommodate a big COVID-19 outbreak, if it occurred.

The City was ready to confront these complex challenges. Its experience dealing with the drought had impacted Cape Town’s leadership, and now they were equipped with the means to communicate and plan efficiently, and the confidence to respond quickly and decisively to a public health crisis.

The City was ready to confront these complex challenges. Its experience dealing with the drought had impacted Cape Town’s leadership, and now they were equipped with the means to communicate and plan efficiently, and the confidence to respond quickly and decisively to a public health crisis. In the period since the drought, the Chief Resilience Officer had led the charge to invest heavily in expanding data science and project management resources. These officials, as well as many other officials who had worked on the drought response, joined the transversal effort to coordinate the portfolio of COVID-19 responses.

They recognized the need to secure medical space where clinics could continue to provide their routine services, such as family planning and immunization, continue to support their HIV and TB patients, and respond to need of patients showing symptoms of COVID-19.

Over a remarkably short eight weeks beginning in early June, the City developed overflow clinic facilities to create the capacity needed to meet all these demands on existing facilities. They created 39 new facilities, starting with the areas with the greatest need for support. Of these, they repurposed 28 halls retrofitted with the essentials to create a clinic environment, and they constructed 11 clinics with prefabricated structures. To staff the new clinics, Cape Town recruited 266 new people, including certified medical officers, professional nurses, and pharmacists. This multimillion-dollar Rand project represents the single biggest investment in the city’s healthcare system in 20 years.

Infographic illustrating Capte Town's COVID-19 rapid response to the pandemic by creating thirty nine centers, including twenty eight facilities by repurposing halls retrofitted with the bare essentials and eleven new clinics constructed with pre-fabricated structures. The project time was eight weeks, hired two hundreds and sixty six people, including certified medical officers, professional nurses, and pharmacists.

Councilor Zahid Badroodien, Mayoral Committee Member for Community Services and Health, Cape Town

“The expansion of our facilities will ensure that we are able to continue providing our full basket of services to clients during this time…to attend to all health needs, without crowding our waiting areas and therefore decreasing the risk of transmission.”

Councilor Zahid Badroodien, Mayoral Committee Member for Community Services and Health, Cape Town

This new clinic capacity has had a number of benefits. It alleviated the strain on existing clinics and staff, ensuring that families could continue to receive routine medical care, and vulnerable populations did not have to go without treatment or be at risk of contracting COVID-19 while seeking primary health care services. Reducing the disruption to primary healthcare services was a huge win. It also minimized the chance of cross-infection in a healthcare facility, and meant that those with symptoms of COVID-19 could be isolated from the general population to contain the spread, and receive the treatment they need. As of September 29, there were only 4,400 active cases in Cape Town and the average number of new cases per week had been on a downward trend for almost two months. Over the course of the pandemic, Cape Town has recorded 76,500 confirmed cases of COVID-19.

The repurposed halls also offered a crucial opportunity to make critical repairs and upgrades, addressing issues that may have been left alone if not for this COVID response. Once the pandemic has passed and there is no need for these clinics in repurposed halls, they can be returned to their pre-pandemic functions, but with the benefit of this essential maintenance having occurred. The prefabricated structures will be staying, serving as long-term resources for the communities where they were built. They will continue as additional health clinics, giving residents easy access to the services they need.

New clinic facility created in Cape Town, South Africa, as part of a COVID-19 rapid response to the pandemic.

A Future Built on Reflective Learning

The flexible infrastructure Cape Town created so quickly is a perfect example of a resilient investment, because the buildings are flexible. Building up additional, flexible health capacity in these communities puts their people and Cape Town as a whole in a stronger position to respond to the next unexpected disruption. From a quick, effective response to a public health threat, Cape Town is creating enduring benefits that increase equitable access to healthcare, an essential resource.

Beyond leaving behind new and refurbished infrastructure, and building the city’s medical care institutions, the story of Cape Town’s rapid response to COVID-19 is about recovery. As national shut-down restrictions continue to ease, for example with the opening of the country to international travel starting on October 1 and easing public gathering requirements, Cape Town is in a good position to be able live with COVID-19, which may be around for well over another year, and can cope with new outbreaks if they occur.

Cape Town is now very focused on its COVID-19 recovery, as are many cities, and on continuing to supporting its vulnerable communities. Like they did with the drought, they are capturing the lessons of the pandemic response through deliberate reflective learning, in order to be prepared for future shock events.

“There is such value in trying to capture what we are doing in various stages in the pandemic. So we built the apparatus for reflective learning within the organization.

Gareth Morgan, Cape Town’s Director of Resilience

39

new overflow clinic facilities created over eight weeks beginning at the end of June.

11

clinics constructed with prefabricated structures and left to continue supporting their communities.

266

new people recruited, including certified medical officers, professional nurses, and pharmacists.

The Art of Reflective Learning in Cape Town – Protecting the Vulnerable During the COVID-19 Pandemic