• IOM Ebola treatment unit in Grand Cape Mount, Liberia (UNMEER/2015)

Five key steps for a health systems response to COVID-19 in Africa

Tuesday, 7 Apr 2020
As the novel Covid-19 virus spreads across the globe, countries with particularly fragile health systems can take five steps to overcome the challenge of responding to the pandemic and continuing to provide vital services.

African countries, like much of the rest of the world, are racing to protect their citizens and economies from the imminent threat of the Covid-19 virus. While not much is known about the disease yet, memories of having to rapidly learn from scratch how to cope with infectious disease outbreaks are still fresh in the West African countries that battled the Ebola crisis in 2014 and ’15.

Like Ebola, the novel Covid-19 virus threatens fragile health systems which will struggle to juggle both the pandemic response and provision of essential and routine services. When the Sierra Leonean government and UK Department for International Development (DFID) asked Options to provide support during the Ebola response, we were not known in the field of emergency response. But having supported the Sierra Leone government for many years to strengthen evidence-based health planning and resource management, it soon became clear that we had a key role to play: the country was not only suffering from the direct effects from Ebola, but the fragility of its health system also resulted in basic services not being available, causing an estimated 3,600 additional indirect deaths among mothers and babies[1].

Covid-19 potentially has an even more devastating impact on health systems as the risk of transmission is higher and patients are more difficult to test or isolate in time because they show unclear or no symptoms. However, to tackle the virus and protect their health systems, African governments can take the following five steps:

1. Death rates can be reduced significantly if essential health services continue to be provided as much as possible.

As disease outbreaks like Covid-19 cause a surge in health care demands, a government’s public health response must work in concert with its overall health-care delivery system[1]. Essential health services should be maintained and ‘routine’ services prioritised to avoid preventable deaths. But in weak health systems, we need to be realistic about what resources are available or need to be diverted to the response. This requires adaptive measures to ensure patients can still access the care, medicines and time-sensitive health services (contraception, abortion, or maternal care) they need. In addition, it is important to provide health facilities and community health workers[2] with clear national guidelines on delivering maternal and newborn health services[3] during COVID-19, including on the use of personal protective equipment (PPE) to lower the risk of disease transmission during the outbreak.

2. The effectiveness of any health crisis response depends on the strength and commitment of a country’s health workforce.

Health care workers are the backbone of any health system, making their wellbeing and emotional resilience vital to maintaining essential health services. Health emergencies like Covid-19 expose them to unusually high demand and dangers[4], including (but not limited to) a potentially unprecedented workload and emotional stress, risk of disease transmission or public stigma. Governments can protect their work force by providing health workers with guidance on how lower transmission risks for themselves and others. In addition, health workers can be supported through digital training tools on prioritising patients through triage and procedures for treating patients, information on physical and psychological coping strategies or opportunities to offer phone consultations where possible. Governments can also lower risks to patients and providers by moving selected services to Community Health Workers (provided these are provided with clear guidelines on providing safe services in the COVID-19 context), which reduces patients’ need to visit health centres.

3. As shocks to the health system of one country reverberate across the region, countries cannot tackle the virus alone.

Covid-19 ignores borders. Fortunately, Africa’s heads of states bolstered regional institutional capacity in 2017 when they established the Africa Centres for Disease Control and Prevention (Africa CDC) under the auspices of the African Union. The institute is mandated to harmonise infectious disease surveillance and control among a group of independent countries[5].

Building its capacity to provide leadership and share data, expertise and resources is vital to ensuing a coordinated response between African countries. An encouraging example that can be built on was when the Nigerian government supported Sierra Leone with testing Ebola cases through its high capacity mobile laboratory. ­Options also supported the government to coordinate between national and international laboratory partners by providing it with daily data on the Ebola testing process that enabled partners reduce the turnaround time of test results and to jointly resolve any testing capacity issues.

4. Using evidence to make efficient use of existing resources is crucial.

Evidence-based decision making is key to informing decisions to maximise and direct existing health resources to where these are needed the most, which involves regularly adapting surge capacity and contingency plans to respond to critical equipment shortages.

Options has worked with several governments to identify and track health system resources through our Facility Readiness Tool, which supports evidence based and transparent decision making on the allocation of health commodities and consumables. The tool has already been adapted to the specific needs of the COVID-19 response and are ready for governments to use.

5. Timely identification of new cases through widespread testing and active use of surveillance data can save lives.

Countries with a rigorous and extensive testing regime like South Korea have so far demonstrated success in keeping case numbers under control[6]. During the West African Ebola epidemic, however, chronic weaknesses in the laboratory system resulted in Ebola cases remaining undiagnosed for long periods, which hindered the isolation of patients and efforts to control the epidemics[7], which may poste similar challenges in tackling Covid-19.

But while diagnostic testing systems can be expensive, low resource solutions are available. Sierra Leone’s government, for example, worked with international partners to deploy mobile testing laboratories and with communities on obtaining surveillance data by using mobile phones to receive real-time information on possible new cases[8].  Identifying and planning how to maximise testing capacity and resources early, adapting testing strategies to ease pressure on laboratories, and developing low-resource surveillance approaches are key components of an effective diagnostic testing strategy.  

Each of these steps demonstrates the importance of responding to the Covid-19 outbreak with an integrated approach that carefully considers, protects and prioritises available resources alongside wider health system needs. Governments can save lives by using evidence to guide their decisions on how to maximise existing resources, coordinating their response at all levels of governance and across borders, and ensuring the provision of clear guidance to health workers and communities.  

This blog was written by Marleen Vellekoop (Programme Director, E4A-MamaYe) and Sara Nam (Technical Specialist, Options).

References

[1] Sochas L, Channon AR, Nam SL. Counting indirect crisis-related deaths in the context of a low-resilience health system: the case of maternal and neonatal health during the Ebola epidemic in Sierra Leone. Health Policy and Planning 2017 Nov; 32 (3), pages iii32– iii39. https://doi.org/10.1093/heapol/czx108.

[2] Kruk ME, Myers M, Varpilah ST, Dahn BT. What is a resilient health system? Lessons from Ebola. May 9 2015. Lancet; 385: 1910–12.

[3] Miller NP, Milsom P, Johnson G, et al. Community health workers during the Ebola outbreak in Guinea, Liberia, and Sierra Leone. J Glob Health. 2018;8(2):020601. doi:10.7189/jogh-08-020601 Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6030670/

[4] Kruk ME, Myers M, Varpilah ST, Dahn BT. What is a resilient health system? Lessons from Ebola. May 9 2015. Lancet; 385: 1910–12.

[5] Geli P. Preparing for the coronavirus and other epidemics in Africa. Brookings Institute, Africa in Focus, Feb 28 2020. Available at:  https://www.brookings.edu/blog/africa-in-focus/2020/02/28/preparing-for-... Accessed 2 April 2020.

[6] Normile, D. Coronavirus cases have dropped sharply in South Korea. What’s the secret to its success? Science Mag (internet), Mar 17 2020. Available at: https://www.sciencemag.org/news/2020/03/coronavirus-cases-have-dropped-s...

[7] Vellekoop M, Nam SL, Kwalombota K.  A health systems approach to emergency response: laboratory strengthening during the Ebola epidemic. 2016. Working in Fragile States: Lessons for Policy and Practice.

[8] Stone E, Miller L, Jasperse J, et al. Community event-based surveillance for Ebola Virus disease in Sierra leoen: implementation of a national-level system during a crisis. PLoS Curr. 2016 Dec.

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