Introduction 

As elsewhere in the world, the Islamic Republic of Mauritania (IRM) had to face important challenges during the COVID-19 pandemic. An initial assessment of the response to the pandemic in Mauritania shows several weaknesses in the response plan, and points to a series of systemic challenges. It highlights the importance of operational support during the response, and the important socioeconomic consequences, especially for the most vulnerable populations.

The operationalisation of the level of resilience of a healthcare system remains however little studied Several conceptual frameworks have been presented.29–31 The focus is often on achieving measurable results, whereas the processes for doing so are of great importance: they are not always clear, linear or achievable in the short term. This research is part of the ‘Institutional Support for the Health Sector Support Programme’ (AI-PASS or ‘Appui Institutionnel au Program d’Appui au Secteur de Santé’). It aims to support the Ministry of Health in implementing its national development plan through systemic support at several levels.

As observed in other countries, the focus of the studies done in Mauritania was merely on the epidemiological perspective of the pandemic, and on measures taken at the central level of the health system or at the level of the hospitals.

Results 

The results shows that the main focus of the response in the two Moughataas was on the set-up of a case detection and monitoring system, as in the rest of the country. Some attempts in terms of coordination and consultation were made, but these were often organized on an ad hoc basis. Many activities, such as supervision and management team meetings, were put on hold at the beginning, due to the workload. With the support of partners, some service delivery activities were reorganized, and a triage system was put in place. The analysis shows that the capacity to manage the pandemic differed between Dar Naim and Bababé: the capacity to manage and anticipate uncertainties, coordinate with key players and respond to community needs was more developed in Bababé.

Capacities to manage resilience 

Cognitive capacity

Respondents recognised the lack of analysis as a weakness at all levels of the system, despite some attempts.  In Bababé, the team tried to develop situation reports.  Discussions within the management team and with the  departmental committee made it possible to analyse  certain problems related to pandemic control. In Dar Naim, the management team decided  to organize a vaccination campaign after assessing the  vaccination coverage. At one  of the DHT meetings, the members stressed the importance of going beyond simply raising awareness of barrier  methods, but also to take action to ensure that people  were able to comply with the containment measures. For  example, it was proposed that chiefs of the communities,  civil society organizations, imams and the municipality  should be involved, and that support should be given to  families who had been put in quarantine.

Capacity to manage uncertainties

The document review and the analysis of the interviews indicate that the lack of resources is one of the greatest constraints in the management of uncertainties.  The District Medical Officers have only a modest operating budget. The fight against COVID-­19 was unforeseen, and any request for an additional budget to deal  with the pandemic would have to be made via a complex  hierarchical circuit. In practice,  therefore, most activities were organised and funded by  national governmental organizations and technical and  financial partners.

Despite this lack of resources, the document review  and analysis of the interviews indicate a certain ability to  anticipate, especially in terms of organising the COVID-­19  response. At Dar Naim, the management team adapted  the annual planning to ensure continuity of activities. At  Bababé, the management team focused on continuity of  care for chronic patients. A coordination platform was  set up to ensure dialogue between stakeholders, raise  awareness and control the flow of traders from Senegal.

However, some interviewees pointed out the difference  in adaptive capacity between the two districts. In Bababé,  numerous community activities were organised, and its  management team met regularly to adapt its strategies.  Possible reasons were that Dar Naim was more likely to  follow hierarchical instructions and decisions (given its  geographical proximity to the central level and the strong  involvement of the regional level), but also because the  community dynamic was much less tangible.

The participants noted that through the support of the diaspora, associations and municipality, several receptions of equipment and donations had  ensured that the Moughataa of Bababé could react more  quickly and effectively.

Capacity to manage interdependence

The lack of coordination  at central and regional level, and with local partners.  Guidelines changed from one moment to the next and  the national response plan lacked clear instructions and  guidelines (MMs). The regional level lacked autonomy  and capacity to support the Moughataas. In addition,  the focus was on COVID-­19 response, case detection and  follow-­up; little or no attention was given to the organisation, triage or continuity of services.

The response at district level was heavily influenced by  the ‘top-­down’ culture that dominates the Mauritanian  health system. This culture did not allow the local level to  tackle the weaknesses of the COVID-­19-­response nor to  propose alternatives.

The weak capacity of the operational and regional  levels is partly explained by the influence of the Ministry  of Interior, the power of the regional governor and that  of the district prefect in a highly hierarchical context.  This had a serious impact on the level of autonomy at  district level.

The participants noted that through the support of the diaspora, associations and municipality, several receptions of equipment and donations had  ensured that the Moughataa of Bababé could react more  quickly and effectively

However, from mid-­2020 onwards and during the  second wave, the local authorities, especially in Bababé,  began to play a more important role in quarantine  management, distribution of food and hygiene kits, and  border surveillance (MMs; interview 22, regional level).  In the absence of an effective formal body, spontaneous  efforts to coordinate with local partners to organise trainings, distribute equipment and maintain health services  emerged.

Capacity to ensure legitimacy

The analysis shows that the local population had  little or no involvement in the decision-­making process.  The measures put in place were generally very strict at  the outset, replicating those put in place in the rest of  the world. In the two Moughataas, awareness-­raising  campaigns were organised by a wide range of actors to  convey key messages. At Bababé, along the border with  Senegal, security posts were set up to minimise river  crossings by people living on the south bank. Significantly, respondents commented that little attention was  paid to the sociocultural, socioeconomic and psychosocial dimensions of the pandemic.

The importance of  supporting the most vulnerable was mentioned, but this  was not assumed as a responsibility of the management  team. The document review  showed that no coordination process had been initiated  to ensure that other actors fulfilled this role. At Dar Naim,  for example, the minutes of a meeting showed that there  had been discussions about supporting cases in quarantine, but no concrete action had been taken.

Factors facilitating resilience

Three other forms of capacity emerge from our analysis: first, the leadership capacity; second, the individual  capacities of DHT members; and third, the capacity and  resilience of the communities themselves.

In terms of leadership, four characteristics were identified by the participants: the ability to manage a team,   the ability to maintain a systemic vision, proactivity  and initiative-­taking and  the ability to coordinate.

There are notable differences between the two districts  of Dar Naim and Bababé, with Bababé appearing to  perform better.

The work culture, such as the lack of monitoring and training for managers, was identified by some participants as a determining factor in this leadership role.

It also was noted weaknesses in terms of individual capacity of the members of the young management teams in the two districts: relevant analyses were not always followed up by action ( Dar Naim). The management team was also little known by health workers and the general population, which didn’t facilitate the take-up of their role ( Dar Naim). In terms of community resilience, our results indicate that in Bababé the communities were quicker to respond than the central level itself. This was not the case in Dar Naim.

Assessing resilience: absorptive, adaptive and transformative capacity 

Overall, our results indicate that the level of resilience of the health systems in our two study districts to manage the COVID-19 pandemic was largely limited to wellintentioned attempts to absorb the shock. The pre-existing fragility of the health system and the high level of dependence on partners limited the ability of management teams to go beyond absorption. For example, catch-up vaccination campaigns and supervisions were put on hold due to a lack of resources.

Documentary analysis (reports of management team meetings) also demonstrated a certain adaptability. During the workshop in October 2020, the added value of AR was recognised, as it had equipped the management team to act. For example, working with local actors in Bababé through the departmental committee had made it possible to manage the pandemic and adapt strategies. In Dar Naim, the team decided to reorganise services to ensure continuity of care and plan activities to fill gaps in vaccination coverage. In Bababé, the team adapted the triage system on several occasions and tried to find solutions for the poor acceptability of the COVID-19 test. The transformative capacity proved to be in its infancy but was nonetheless present. For example, COVID-19 had better demonstrated the weaknesses of the health system, such as the importance of coordination with partners and dialogue with communities.

Discussion  

The aim of this study was to describe the capacity of the two Moughataas to manage the pandemic using the conceptual framework of Blanchet et al. The analysis showed that the two Moughataas had a certain capacity to absorb the crisis, but that they faced major shortcomings. The limited capacity to manage uncertainty was strongly influenced by the poor alignment of the Moughataas with the central level, and the lack of access to resources. The legitimacy of decision-making was affected by the fragility of the system. Our analysis also identified three important conditions for the development of a resilient system at district level that do not feature in the Blanchet et al framework: the existence of a learning culture, a strong community dynamic, and leadership capacity.

Conclusion 

The COVID-19 pandemic has put a great deal of pressure on healthcare systems throughout the world, but particularly in fragile contexts. Our study has shown the relevance of an in-depth contextual analysis to better identify the enabling environment and the capacities required to develop a certain level of resilience. In the case of Mauritania, the poor alignment between district and central levels, the lack of access to the necessary resources, and the highly centralised nature of the system proved to be major constraints. We also noted the crucial importance of leadership and the great potential of community dynamics in the management of systemic crises. While our case study has helped to clarify—and somewhat ‘demystify’—the key skills and conditions underpinning a resilient system, more research is needed to allow for practical operationalisation.