COVID-19: Africa needs unprecedented attention to strengthen community health systems

As the first cases of COVID-19 were confirmed in Liberia, in March, 2020, former President Ellen Johnson Sirleaf,¹ among others,² highlighted the need to adopt lessons learned from the response to the 2014–16 outbreak of Ebola virus disease in west Africa. Ebola claimed about 11 300 lives in 21 months across Liberia, Sierra Leone, and Guinea.³ Comparisons to Ebola benefit from remembering the key differences between the two viruses. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a respiratory virus and is infectious among asymptomatic carriers.⁴ SARS-CoV-2 differs from Ebola virus in terms of the reproduction number (SARS-CoV-2 5·7 vs Ebola 1·5–1·9),5, 6 incubation period (2–14 days vs 8–10 days on average),7, 8 and case fatality rate (this varies for SARS-CoV-2 but average is estimated at 4·7% as of July 7, 2020, vs up to 90% for Ebola).9, 10 COVID-19 is easier to transmit, harder to diagnose, and can quickly spread in communities.

The Ebola response showed the importance of investments that build health system resilience, notably investments in the health workforce.¹¹ Unfortunately, community engagement largely occurred too late in the Ebola response.12, 13 To date, there are no studies of how well countries adopted the lessons learnt from Ebola for COVID-19 and this will be a critical future exercise.

At the onset of the COVID-19 pandemic in sub-Saharan Africa, governments took swift action to institute lockdown measures, activate incident management response systems, and mobilise front-line health workers to be trained. However, some months into the pandemic preliminary evidence suggests that human resources for health in sub-Saharan Africa have been inadequately prepared. Community health workers (CHWs) have insufficient personal protective equipment (PPE) to ensure they can continue providing essential care¹⁴ and most countries face severe shortages of health workers.¹⁵ This situation is concerning because of the importance of CHWs in the COVID-19 response. CHWs are a key component of pandemic response strategies,¹⁶ they were used in the COVID-19 response in China,¹⁷ and there are recommendations on how CHWs can be supported to interrupt virus transmission while maintaining essential services and shielding vulnerable populations.¹⁸

Feedback from the field in Liberia is, however, alarming. In Rivercess County, Liberia, where there has only been one suspected COVID-19 case that was confirmed negative as of June 30, 2020, some caregivers refuse to attend mobile clinics or facilities for vaccinations and there has been a reduction in care seeking among some adults (Saykpah R, unpublished). People fear health workers are spreading COVID-19 and CHWs, while trusted neighbours, have insufficient PPE to convince people otherwise. The stakes are high for people's health if there is any reduction in care-seeking behaviour for preventable diseases.¹⁹ To its credit, Liberia, scarred from the Ebola outbreak, has been training its National Community Health Assistants to prevent, detect, and respond to COVID-19 while maintaining essential services and is in the process of procuring PPE for CHWs.²⁰

COVID-19 is the new public health backdrop and we cannot wait to strengthen community health systems. CHWs matter because they are trusted members of the community who are often the most accessible point of care, particularly for vulnerable populations—eg, in Sierra Leone, CHWs outnumber doctors 95 to one.²¹ Indeed, the Africa Centres for Disease Control and Prevention is planning to recruit 1 million community health volunteers to support contact tracing across sub-Saharan Africa,²² relying on existing CHW cadres. Ongoing efforts to leverage CHWs for the COVID-19 response must not be one-offs in the face of an emergency. CHWs must be equipped, trained, and supported in the long term as a crucial human resource for health.

Trillions of dollars have been committed²³ in just over 6 months for the COVID-19 response globally. A COVID-19 vaccine or therapy will take months to become commercially available and likely longer to access in low-income countries.²⁴ If a vaccine, treatment, or reliable diagnostic is available, adoption in places with shortages of human resources for health will be a struggle. A comparative US$2 billion²⁵ annual investment to bolster CHWs as a health system strengthening platform for primary care is a drop in the ocean. Now is the time to invest in community health systems in sub-Saharan Africa and avert a greater crisis.

© 2020 Last Mile Health