COVID-19: Africa needs unprecedented attention to strengthen community health systems
Authors: Lyudmila Nepomnyashchiy, Bernice Dahn, Rachel Saykpah, Mallika Raghavan
Journal: The Lancet (2020)

As the first cases of COVID-19 were confirmed in Liberia, in March, 2020, former President Ellen Johnson Sirleaf,1Sirleaf EJ Coronavirus: what the world can learn from Ebola fight. BBC, March 30, 2020https://www.bbc.com/news/world-africa-52061547Date accessed: June 25, 2020Google Scholar among others,2Sawyer I Congo's Ebola fight has lessons for COVID-19. Human Rights Watch, March 26, 2020https://www.hrw.org/news/2020/03/26/congos-ebola-fight-has-lessons-covid-19Date accessed: June 25, 2020Google Scholar 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.3BBCEbola: mapping the outbreak. BBC, Jan 15, 2016https://www.bbc.co.uk/news/world-africa-28755033Date accessed: June 25, 2020Google Scholar 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.4Hub staff reportAsymptomatic spread makes COVID-19 tough to contain.Johns Hopkins Magazine. May 12, 2020; https://hub.jhu.edu/2020/05/12/gigi-gronvall-asymptomatic-spread-covid-19-immunity-passports/Date accessed: June 25, 2020Google Scholar SARS-CoV-2 differs from Ebola virus in terms of the reproduction number (SARS-CoV-2 5·7 vs Ebola 1·5–1·9),5Sanche S Lin Y Xu C Romero-Severson E Hengartner N Ke R High contagiousness and rapid spread of severe acute respiratory syndrome coronavirus 2.Emerg Infect Dis. 2020; 26: 1470-1477Crossref PubMed Scopus (981) Google Scholar, 6Khan A Naveed M Dur-E-Ahmad M Imran M Estimating the basic reproductive ratio for the Ebola outbreak in Liberia and Sierra Leone.Infect Dis Poverty. 2015; 4: 13Crossref PubMed Scopus (71) Google Scholar incubation period (2–14 days vs 8–10 days on average),7US Centers for Disease Control and PreventionClinical questions about COVID-19: questions and answers.https://www.cdc.gov/coronavirus/2019-ncov/hcp/faq.html#:~:text=Based%20on%20existing%20literature%2C,2%E2%80%9314%20daysDate: June 28, 2020Date accessed: June 30, 2020Google Scholar, 8US Centers for Disease Control and PreventionEbola.https://www.cdc.gov/dotw/ebola/index.html#:~:text=The%20incubation%20period%20for%20Ebola,is%208%20to%2010%20daysDate accessed: June 30, 2020Google Scholar 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).9Roser M Ritchie H Ortiz-Ospina E Hasell J Coronavirus pandemic (COVID-19). Our World In Data.https://ourworldindata.org/coronavirusDate: July 7, 2020Date accessed: July 3, 2020Google Scholar, 10WHOEbola virus disease.https://www.who.int/news-room/fact-sheets/detail/ebola-virus-diseaseDate: Feb 10, 2020Date accessed: June 30, 2020Google Scholar 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.11Kruk ME Myers M Tornorlah Varpilah S Dahn BT What is a resilient health system? Lessons from Ebola.Lancet. 2015; 385: 1910-1912Summary Full Text Full Text PDF PubMed Scopus (403) Google Scholar Unfortunately, community engagement largely occurred too late in the Ebola response.12Miller NP Milsom P Johnson G et al.Community health workers during the Ebola outbreak in Guinea, Liberia, and Sierra Leone.J Glob Health. 2018; 8020601PubMed Google Scholar, 13Perry HB Dhillon RS Liu A et al.Community health worker programmes after the 2013-2016 Ebola outbreak.Bull World Health Organ. 2016; 94: 551-553Crossref PubMed Scopus (50) Google Scholar 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 care14Ballard M Westgate C COVID19: it ain't over until there's PPE all over.Think Global Health. May 4, 2020; (Date)https://www.thinkglobalhealth.org/article/covid-19-it-aint-over-until-theres-ppe-all-over?mc_cid=cb86b8c16d&mc_eid=c8fb41925eDate accessed: June 25, 2020Google Scholar and most countries face severe shortages of health workers.15Human Rights WatchAfrica: COVID19 exposes healthcare shortfalls.https://www.hrw.org/news/2020/06/08/africa-covid-19-exposes-healthcare-shortfallsDate: June 8, 2020Date accessed: June 13, 2020Google Scholar This situation is concerning because of the importance of CHWs in the COVID-19 response. CHWs are a key component of pandemic response strategies,16Boyce M Katz R Community health workers and pandemic preparedness: current and prospective roles.Front Public Health. 2020; 7: 62Crossref Scopus (54) Google Scholar they were used in the COVID-19 response in China,17Xinhua NetXi focus: Xi replies to letter from community workers fighting COVID-19 in Wuhan.Xinhua Net. April 9, 2020; http://www.xinhuanet.com/english/2020-04/09/c_138960910.htmDate accessed: June 25, 2020Google Scholar and there are recommendations on how CHWs can be supported to interrupt virus transmission while maintaining essential services and shielding vulnerable populations.18Ballard M Bancroft E Nesbit J et al.Prioritising the role of community health workers in the COVID-19 response.BMJ Global Health. 2020; 5e002550Crossref PubMed Scopus (127) Google Scholar 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.19Walker D Chi Y-L Glassman A Chalkidou K More harm than good? The net impact of COVID-19 policies is what matters for health. Center for Global Development, May 15, 2020https://www.cgdev.org/blog/more-harm-good-net-impact-covid-19-policies-what-matters-healthDate accessed: June 25, 2020Google Scholar 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.20Wiah OS Subah M Varpilah B et al.Prevent, detect, respond: how community health workers can help in the fight against COVID-19.BMJ Opinion. March 27, 2020; https://blogs.bmj.com/bmj/2020/03/27/prevent-detect-respond-how-community-health-workers-can-help-fight-covid-19/Date accessed: June 25, 2020Google Scholar 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.21World BankPhysicians per 1,000 and community health workers per 1,000.https://data.worldbank.org/indicator/SH.MED.PHYS.ZSDate: 2020Date accessed: June 25, 2020Google Scholar 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,22Africa CDC African Union rolls out partnership to accelerate COVID-19 testing.https://africacdc.org/news-item/african-union-rolls-out-partnership-to-accelerate-covid-19-testing/Date: June 4, 2020Date accessed: June 25, 2020Google Scholar 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 committed23Cornish L Interactive: who's funding the COVID-19 response and what are the priorities.Devex. May 28, 2020; https://www.devex.com/news/interactive-who-s-funding-the-covid-19-response-and-what-are-the-priorities-96833Date accessed: June 25, 2020Google Scholar 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.24Atherly D Opinion: to deliver a COVID-19 vaccine equitably, we must start planning now.Devex. May 7, 2020; https://www.devex.com/news/opinion-to-deliver-a-covid-19-vaccine-equitably-we-must-start-planning-now-97168Date accessed: June 25, 2020Google Scholar 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 billion25USAID Center for Innovation and ImpactFinancing Alliance for HealthDalberg AdvisorsStrengthening primary health care through community health workers: closing the $2 billion gap.https://www.usaid.gov/cii/strengthening-primary-health-care-through-community-health-workers-closing-2-billion-gapDate: Nov 28, 2017Date accessed: June 25, 2020Google Scholar 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. We declare no competing interests.