COVID-19 and health care inaccessibility in sub-Saharan Africa
Authors: Erin Hulland
Journal: The Lancet Healthy Longevity (2020)

The first case of COVID-19, the disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), in sub-Saharan Africa was confirmed in Nigeria on Feb 27, 2020, followed by the first regional death in Burkina Faso on March 18, 2020.1Mennechet FJD Dzomo GRT Coping with COVID-19 in sub-Saharan Africa: what might the future hold?.Virol Sin. 2020; (published online Sept 1.)https://doi.org/10.1007/s12250-020-00279-2Crossref Scopus (19) Google Scholar Since these initial events, more than 1 million cases and 20 000 deaths have been confirmed in the region.2Africa CDC Outbreak brief 34: COVID-19 pandemic.https://africacdc.org/download/outbreak-brief-34-covid-19-pandemic-8-september-2020/Date: Sept 8, 2020Date accessed: September 24, 2020Google Scholar Despite initial fears of catastrophic spread and high mortality of COVID-19 in Africa, mainly because of high frequencies of HIV and tuberculosis co-infections in combination with weak health systems,1Mennechet FJD Dzomo GRT Coping with COVID-19 in sub-Saharan Africa: what might the future hold?.Virol Sin. 2020; (published online Sept 1.)https://doi.org/10.1007/s12250-020-00279-2Crossref Scopus (19) Google Scholar the toll of the pandemic has remained lower than expected. However, based on previous research showing gaps in health facility accessibility in sub-Saharan Africa,3Ouma PO Maina J Thuranira PN et al.Access to emergency hospital care provided by the public sector in sub-Saharan Africa in 2015: a geocoded inventory and spatial analysis.Lancet Glob Health. 2018; 6: e342-e350Summary Full Text Full Text PDF PubMed Scopus (202) Google Scholar, 4Alegana VA Maina J Ouma PO et al.National and sub-national variation in patterns of febrile case management in sub-Saharan Africa.Nat Commun. 2018; 94994Crossref PubMed Scopus (28) Google Scholar, 5Hulland EN Wiens KE Shirude S et al.Travel time to health facilities in areas of outbreak potential: maps for guiding local preparedness and response.BMC Med. 2019; 17: 232Crossref PubMed Scopus (28) Google Scholar, 6Juran S Broer PN Klug SJ et al.Geospatial mapping of access to timely essential surgery in sub-Saharan Africa.BMJ Glob Health. 2018; 3e000875Crossref PubMed Scopus (64) Google Scholar populations without access to health care are probably not receiving COVID-19 testing, resulting in under-reporting of the true toll of the pandemic in this region. In an Article in The Lancet Healthy Longevity, Pascal Geldsetzer and colleagues mapped health facility (in)accessibility among people aged 60 years or older across sub-Saharan Africa.7Geldsetzer P Reinmuth M Ouma PO et al.Mapping physical access to healthcare for older adults in sub-Saharan Africa and implications for the COVID-19 response: a cross sectional analysis.Lancet Healthy Longev. 2020; 1: e32-e42Scopus (15) Google Scholar Older people and those with comorbidities are most at risk for negative sequelae and death from COVID-19. Therefore, Geldsetzer and colleagues focused their analyses on this vulnerable population, filling an existing gap in health facility accessibility research in sub-Saharan Africa.1Mennechet FJD Dzomo GRT Coping with COVID-19 in sub-Saharan Africa: what might the future hold?.Virol Sin. 2020; (published online Sept 1.)https://doi.org/10.1007/s12250-020-00279-2Crossref Scopus (19) Google Scholar 15·9% (95% CI 10·1–24·4) of people aged 60 years or older had travel times longer than 2 h to access any health facility,7Geldsetzer P Reinmuth M Ouma PO et al.Mapping physical access to healthcare for older adults in sub-Saharan Africa and implications for the COVID-19 response: a cross sectional analysis.Lancet Healthy Longev. 2020; 1: e32-e42Scopus (15) Google Scholar suggesting minimal linkage to the health system, including COVID-19 testing and diagnosis. Moreover, access to hospitals (locations at which patients with COVID-19 with moderate-to-severe presentations would need treatment) ranged from a median travel time of 41 min (IQR 34–54) in Burundi to 1655 min (1065–2440; more than 24 h) in Gabon. For all adults aged 60 years or older, 9·6% (95% CI 5·2–16·9) had travel times to the nearest hospital of 6 h or longer. These analyses and resulting maps are invaluable for identifying locations where populations might be currently underserved by health-care facilities and where linkage to care could be scant. Moreover, the maps provide a foundation for addressing vaccine delivery challenges for future COVID-19 vaccination efforts. These analyses, paired with investigations of other high-risk groups and insights into facility capacity and readiness, will be instrumental in mitigating the effect of COVID-19 across sub-Saharan Africa. In addition to identifying and mapping older populations at-risk for COVID-19 underserved by current health facility infrastructure, Geldsetzer and colleagues developed a new database of geocoded public and private health facilities in sub-Saharan Africa,7Geldsetzer P Reinmuth M Ouma PO et al.Mapping physical access to healthcare for older adults in sub-Saharan Africa and implications for the COVID-19 response: a cross sectional analysis.Lancet Healthy Longev. 2020; 1: e32-e42Scopus (15) Google Scholar adding to existing records of public facilities for widespread use.3Ouma PO Maina J Thuranira PN et al.Access to emergency hospital care provided by the public sector in sub-Saharan Africa in 2015: a geocoded inventory and spatial analysis.Lancet Glob Health. 2018; 6: e342-e350Summary Full Text Full Text PDF PubMed Scopus (202) Google Scholar, 8Maina J Ouma PO Macharia PM et al.A spatial database of health facilities managed by the public health sector in sub Saharan Africa.Sci Data. 2019; 6: 134Crossref PubMed Scopus (78) Google Scholar Although this data source is comprehensive, two datasets were used to produce the list, and the degree of overlap between datasets remains unaddressed. Furthermore, no deduplication processes were reported, suggesting potential duplicative entries within this novel list. If these duplicate entries have differing geocoordinates, travel times will be calculated separately for each entry, resulting in an inaccurate profile of health facility accessibility. Future analyses should consider formally assessing the degree of duplication between the two datasets and removing duplicates to provide the most comprehensive and accurate openly available public and private health facility list for sub-Saharan Africa. As shown by previous research,5Hulland EN Wiens KE Shirude S et al.Travel time to health facilities in areas of outbreak potential: maps for guiding local preparedness and response.BMC Med. 2019; 17: 232Crossref PubMed Scopus (28) Google Scholar, 9Kruk ME Gage AD Arsenault C et al.High-quality health systems in the Sustainable Development Goals era: time for a revolution.Lancet Glob Health. 2018; 6: e1196-e1252Summary Full Text Full Text PDF PubMed Scopus (1277) Google Scholar, 10Fullman N Yearwood J Abay SM et al.Measuring performance on the Healthcare Access and Quality Index for 195 countries and territories and selected subnational locations: a systematic analysis from the Global Burden of Disease Study 2016.Lancet. 2018; 391: 2236-2271Summary Full Text Full Text PDF PubMed Scopus (565) Google Scholar the ability to prevent, detect, and respond to infectious disease threats (including COVID-19) requires timely access to high-quality health systems. The research by Geldsetzer and colleagues provides vital evidence on physical accessibility to health facilities among at-risk older populations, but scant information exists on the quality of such facilities, capacity to provide essential health-care services, ventilation capacity, and facility readiness for infectious disease treatment and prevention of nosocomial COVID-19 transmission. Future research is needed to identify facilities with ventilation capacity and calculate travel times to such facilities, to identify additional barriers beyond physical access to widespread vaccine delivery, and to better understand facility quality and treatment readiness. I declare no competing interests. Mapping physical access to health care for older adults in sub-Saharan Africa and implications for the COVID-19 response: a cross-sectional analysisOur high-resolution maps of estimated travel times to both hospitals and health-care facilities of any type can be used by policy makers and non-governmental organisations to help target additional health-care resources, such as makeshift hospitals or transport programmes to existing health-care facilities, to older adults with the least physical access to care. In addition, this analysis shows the locations of population groups most likely to under-report COVID-19 symptoms because of low physical access to health-care facilities. Full-Text PDF Open AccessAge: the least important number?Nov 14, 2020, marked World Diabetes Day. First launched in 1991, this day was a little different in 2020. Although global incidence of type 2 diabetes continues to increase, the world's focus is elsewhere, watching the unfolding tragedy of the COVID-19 pandemic. At first glance, the two diseases seem utterly dissimilar: one is a viral infection with unknown pathogenesis, the other a well-studied non-communicable disease. However, notably, the two share at least one aspect: both appear to increase with age. Full-Text PDF Open Access