Recommendations from Guatemala to urban municipalities responding to COVID-19 in low- and middle-income countries

By Guillermo Hegel with support from Yaimie Lopez and Kim Ozano

Local governments need to review their strategies so that they pay more attention to the wider impacts that COVID-19 will have. Municipalities will need to dig deeper and identify their weaknesses in order to address them and identify better ways to deal with the crisis and its outcomes at community level.

This blog aims to stimulate thought about what actions can be taken by urban municipalities to address the current COVID-19 pandemic. Addressing COVID-19 is a collective matter in which local governments are key. I am a former Municipal Director of Health (2014-2020) for Villa Nueva in Guatemala, and current researcher, who has experience of putting evidence and policy into practice. I have received several calls asking for advice on what actions need to be considered by Municipalities to implement decisions made by the Guatemalan government and the President.

Taking into consideration the measures suggested by PAHO/WHO, and the lessons learned from countries that have already gone through the early response to COVID-19 in order to ‘flatten the curve’, it is important to consider what the impact of implementing measures now will have for urban centres in the longer term.

What are the municipalities currently doing and what are their capacities to respond to the crisis?

A quick check of the social media coming from Guatemalan urban municipalities shows their main concern in responding to COVID-19 is complying with the guidelines of the Central Government and institutions like the Ministry of Health and Social Assistance. They seem less prepared for addressing a possible crisis or for monitoring the collateral effects of COVID-19 on the family economy, violence and mental health, for example. This is likely due to the lack of: well-defined internal structures for inter-institutional coordination; adherence and application of municipal planning instruments (policies, plans and regulations); and available up to date information on health equity key indicators, disaggregated at intra-municipal level.

One of the major challenges in less economically developed countries and for municipalities in Guatemala, is that governance and accountability structures are needed to drive the COVID-19 response, yet these are fragile and lack support in times of crisis. Accountability mechanisms that have worked well within the Guatemalan government, are face-to-face meetings within citizen participation structures, such as the Municipal Development Committees (MDC) and its working commissions. But these will remain inoperative during lockdown, potentially losing the voices of the most vulnerable. Furthermore, informal settlements with little or no input from governments, such as  “Barrio 18” in Guatemala have taken the rule of law into their own hands to ensure that quarantine is followed, highlighting the role of emerging informal governance structures which should also be considered.

The following recommendations are for municipal health leaders who are, and will continue, to have challenges in developing a comprehensive COVID-19 response. They are based upon my experience and the process to develop a municipal health policy using the Urban HEART tool from WHO.

Accessing and using data to identify vulnerable populations

It is important to identify key, relevant and up-to-date information about the different sectors of the municipality, from reliable sources, to provide a better understanding about the living and working conditions in which the population lives.  Shared learning on data collection has shown that valuable data only becomes available when comprehensive coordination work is carried out to collect information within and across operating units and other public institutions. However, a consistent obstacle for many municipalities is a lack of capacity to keep databases up-to-date in the absence of automated information systems. This means collecting and accessing information is time-consuming and often neglected, especially during a crisis. Disregarding information gaps will mean that vulnerable people remain invisible, this is unacceptable as no country is protected unless all citizens are protected.

In cases where data is available, it is useful to have it visualized in digital dashboard formats to facilitate communication and decision making across stakeholders at the urban level. If this is not possible, at least presented through maps or tables. Identifying vulnerability aggregated by region, community, neighbourhood or even household would provide information of which populations are at greater risk and provide an evidenced informed response. This data will form the basis of planning or responding to crises. In addition, municipalities should seek partnerships with researchers who can support data collection and analysis.

Consider challenges faced by people living and working informally within the municipality

Understanding the needs of people living and working in urban informal spaces during this time has been identified as one of the main challenges within urban spaces. Lack of access to basic services, pre-existing levels of violence in these areas, informal economies, restricted access to markets and food and poor housing conditions, will be aspects to consider if we expect citizens to stay home. Even if remaining at home is achieved through force such as the ‘State of Siege’, recently implemented by the Government of Guatemala, the risk of infection in overcrowded homes is considerable and the absence of basic services such as drinking water or electricity makes it difficult for residents of informal settlements to have food on hand in order to remain in quarantine. In addition, without access to informal earning opportunities, the already vulnerable within these settlements are at risk of starvation. All of these factors have the potential to increase violence (intra-family and crime). Municipalities must identify what are the needs and integrate them into COVID-19 response strategies and across sectors.

Improve and understand the capacity of municipalities to respond to COVID-19

Ideally, if the municipal authorities already understand the current institutional capacity to respond to the emergency they would be expected to have plans and budgets approved address and prioritise needs. If not an evaluation of the municipal capacity to respond to the problems identified will be needed. In the case of Villa Nueva, the Health Policy provides preliminary guidelines that may be useful for the formulation of such plans and their implementation. Among the most important for the approach to COVID-19 are:

• Establish a municipal information system that enables information gathering and sharing in real time, strengthen monitoring and creating a platform for accessing information from and to citizens. These aspects will facilitate the planning of actions and coordination between actors to improve the efficiency of the response and keep decision makers and the public informed.
• Prepare a list of infrastructure, human resources, equipment and supplies within the health system in coordination with the Ministry of Health for the implementation of an Integrated Network of Health Services. This can serve as a basis to identify additional needs that must be fulfilled to address the emergency and improve coordination of actions.
• Unify diagnostic and referral protocols and organise continuous training of institutional personnel. This will facilitate municipal officials, Ministry of Health, private providers of health services and other health actors to have clarity for better institutional support for case management, thus helping to maintain the functional health system for people with serious symptoms of COVID-19.

Create healthy living environments and spaces

Local governments will need to review their strategies to consider the wider impacts that COVID-19 will have. Coordination and multi-sectorial action is needed now more than ever, including more comprehensive support from the national and sub-national level. For example, attention should be paid to creating healthy environments and spaces. This includes a properly controlled food chain with strengthened hygiene protocols in markets. Promotion of healthy principles of housing (links health with people’s habitation and living conditions) has proven to be useful to improve hygiene measures and could be considered. Access to water and sanitation, the promotion of a healthy diet, and physical activity are all important. Actions in these fields can help people living in difficult conditions to stay at home. There is a need to promote coordination and participation of the public and private sector and civil society to implement prevention campaigns and structural actions that reduce the negative effects of COVID-19 through policy development across educational, economic and social sectors.

Community participation

Community participation and coordination with different actors is extremely important to ensure success in the short, medium and long term. The existence of recognised civil society groups with communication and social networks management skills, can be of great value to send messages to the largest number of families from reliable, trusted sources that can be useful to reduce the paranoia generated often through social media. Accountability structures that facilitate the participation of citizens and promote different levels of involvement, even while staying at home, are relevant. Civil society web-based platforms that can provide reliable information, and other ways of creative communication should be investigated and supported.