The impact of COVID-19 globally on global health systems is huge and potentially far catastrophic for Africa’s health care systems with their inherent weaknesses. Whilst efforts are made to contain any further colossal damages on our overstretched health systems, economies and livelihoods, it is imperative that we are evidence-informed to forecast, plan and put in place effective mechanisms to deal with the fallout from the unfolding pandemic and prepare adequately for its aftermath.

There is a race against time to protect human lives, livelihoods and prevent economic collapse across Africa. This requires those in positions of authority and decision-making to draw on existing strengths and resilience mechanisms built into their country health systems over the years as well as the goodwill, resourcefulness and innovativeness of frontline health workers and other stakeholders. Tapping into resilience mechanisms is particularly important as African countries cannot fully rely on the goodwill and generosity of others who may be themselves struggling to cope with the COVID-19 crisis in their own countries.

The WHO European Region has outlined 16 strategic actions all countries health systems must do in responding to COVID-19¹. One key action advanced by the WHO is the need for country level actions to address the physical and mental needs of frontline health workers. This argument is very important given that most policies for frontline workers tend to address economic and social needs, to the neglect of their psychosocial needs. In addition to the 16 actions articulated by WHO, this article intends to highlight four (4) critical health system needs as part of their implementation of existing emergency plans and future preparedness planning.

First, Strengths Weakness Opportunities and Threats (SWOT) analytics of COVID-19 must be developed and fully operationalized in relation to the building blocks for strengthening capacity as advocated by WHO. For example, isolating, testing and treating affected individuals; skilled health workforce needs and strategies to re-distribute, hire, train and deploy if needs be; health information systems that enhance contact tracing and mapping of hotspots; access to essential medicines; financial resources and safety net to mitigate economic impact on vulnerable groups; strong leadership and governance at all levels and across sectors.

In the African context, national health systems must identify cadres of workforce and extra skills training needs required to undertake critical roles for COVID-19 whilst minimizing impact on other critical clinical and non-clinical aspects of care. A critical needs assessment would ensure a fair balance in workforce redistribution particularly to high burden hotspots where the disease is likely to spread quickly. Such a balance will minimize health worker exposure and burn-out which will otherwise affect attrition rates during and post-pandemic. WHO estimates that Africa has a shortfall of 63% of the health workforce strength required to deliver the goals of Universal Health Coverage². On 16^th April, 2020, WHO reported that 32 health workers in Niger had tested positive for COVID-19, making up 7.2% of case counts in that country. Given existing shortages of the health workforce, a country like Niger cannot afford such losses of its limited skilled and trained health care staff. A huge toll on Africa’s workforce will jeopardize efforts at containment of the virus. Thus, leaders and decision makers must prioritize the protection of the health workforce, particularly the provision of adequate personal protective equipment (PPEs) and reasonable staff rotation on the job. PPEs are particularly critical for the next phase of tackling the problem i.e contact tracing for community-acquired infections and isolation/quarantine of persons with symptoms. Health worker exposure would hamper progress. For such exposed individuals, anxieties may affect morale and psychological counselling services and re-assignment to non-COVID-19 duties will be necessary even where they test negative.

Another important health system need is how country health information systems (HIS) are applied in this critical point to provide timely information and education to the public to stay safe in the midst of the pandemic. Achieving public health desirable targets such as social distancing, hand hygiene and wearing of face mask require a public that is well informed and aware of the implications of how compliance to these daily activities can support reduce the spread of the virus and protect public safety. National health teams must also address misguided information in public space. There is also leadership commitment and been open and transparent with the public in addressing the pandemic, where the public feel safe and secured that their leaders are communicating and their actions are in synergy to address the pandemic.   

 Logistics and supplies need to be ramped up quickly with careful planning for short-to-medium and long term in the unlikely event the pandemic lingers on beyond 6 months. Ideally, novel and state-of-the art technology should assist in rapid contact tracing, isolation, testing and management for confirmed cases. This process is capital intensive requiring more financial resources both within and outside Africa. Despite the best efforts of WHO, Corporate partners and the African Union, medical supplies are limited by country lockdowns and curtailment of movement of goods and trade by air, land and sea. A key component of emergency/crisis management is post-event resource management guided by national health systems preparedness planning. Wastage, pilfering and poor accountability for medical supplies and resources must be avoided to save national health systems from further weakness.

Leadership and governance in the COVID-19 fight across Africa has been swift and decisive. Some national governments have enacted draconian laws and/or issued executive instruments on restrictions on movement, work, trade, human contact, hand hygiene, face/nose covering etc. with prescribed punitive measures in some cases. Perhaps the WHO guidelines and actions by other countries like China, and subsequently in Europe and the Americas provided the pathway for such decisive actions in Africa. However, the broader issues on the impact of COVID-19 such as decisive leadership in health budgets and priority investments remain unresolved. Perhaps the aftermath of this pandemic must awaken African decision makers to do more in budget allocations for health care and health care delivery.

Secondly, we need a health system learning approach in Africa to ensure better preparation for future pandemics as there are bound to be others after COVID-19.  A learning health system is “one in which science, informatics, incentives, and culture are aligned for continuous improvements and innovation, with best practices seamlessly embedded in the care process, patients and families are active participants in all elements, and new knowledge captured as an integral by-product of the care experience” ³.

Health system learning builds sustainability and emergency preparedness and provides a unique opportunity to understand contextualised system needs and builds resilience within and across systems even in the face of multiple epidemics. African health systems must emerge out of COVID-19 better prepared to innovate and advance new knowledge in dealing with future pandemics. For example, how much did African health systems learn from previous epidemics such as Ebola in West Africa between 2013-2014 and the Democratic Republic of Congo (2017-2019? Lessons learned and evidence gathered are crucial in the COVID-19 fight not only in West Africa which was at the epi-center of the 2013 Ebola outbreak, but among other Africa countries, through knowledge transfer. After Ebola, the World Bank launched a project in Africa known as the Regional Disease Surveillance Systems Enhancement to support strengthen health systems in 16 countries in West and Central Africa. Such initiatives leveraged on local resources and support, taking on a health system learning approach to ensure health systems adapt to their own needs and strategies in the case of emergencies. 

The Democratic Republic of the Congo (DRC) has seen an increase in cases of Ebola since August 2018. They have announced enhanced health system preparedness against the COVID-19 following lessons learnt in their current fight against Ebola such as isolation, testing and treatment which puts them ahead of other countries. The DRC also has better resources including equipment and infrastructure. Although the trained workforce remains limited, they have been resourceful particularly during the early detection of cases of COVID-19.  South Africa which currently has the second highest number of COVID-19 cases after Egypt has applied a health system learning approach to SARS-COV 2 testing using a network of over 200 public and private laboratories developed and deployed in the past to manage HIV and tuberculosis infections in the country. This aggressive approach will offer a rapid turn-around time from testing to real-time isolation and treatment for new infections. With the increasing numbers of new cases across the continent, African health authorities must partner with well-resourced private testing centers to meet growing demands. This is also important to ensure public health facilities do not become overburdened and incapacitated after COVID-19 particularly in countries already experiencing challenges with diagnostics.

Thirdly, a rising case burden means government investments in national health systems for research and to tackle immediate health needs must begin to increase within the next 5 years after COVID-19. Evidence-based research is vital to advancing Africa’s health needs, particularly, in accelerating progress towards the attainment of the UN Sustainable Development Goals by 2030 and the AU’s Agenda 2063 for the continent’s self-sufficiency across all sectors. Currently Africa’s burden of disease is disproportionately high, an indication that more resources will have to be committed to finding contextualised solutions. However, the continent contributes only 2% to current global research output⁴. Such research outputs are tied to national level commitment and funding. For example, in 2016, Egypt, Nigeria and South Africa alone contributed more than half (65.7%) of Africa’s total spending on research and development (R&D). National funding for research is required to build trust and create opportunities for African scientists willing to invest their skills and time to critical research areas in that benefit Africa. The lack of prioritized actions by African Governments to commit, support and expand the frontiers of research could hold back progress to Africa’s growth and development and the attainment of the AU’s 2063 agenda. Initiatives such as the Alliance for Accelerating Excellence in Africa (AESA) (African Academy of Sciences) and Grand Challenges Africa contribute to bridging the funding gap, but African Governments should do more to sustain the future of R&D across the continent. It is also gratifying to learn of the successful gene sequencing for COVID-19 by scientists in Ghana and Nigeria as part of African led efforts to help contain the pandemic. This is very commendable yet must be matched with robust public health measures at national levels. Furthermore, national priorities for health research must be heightened in Africa now more than ever with public and private sector support to enable country-level and regional evidence-gathering of what works and what does not work during a pandemic. Such evidence must inform our national health systems in learning and adapting to COVID-19 and its aftermath. 

The economic impact of COVID-19 in Africa is huge with a projected 15% drop in foreign direct investments (FDI) due to COVID-19⁵. A reduction in FDI means that will impact health budget allocations. Ironically, FDIs in Africa are currently increasing in direct response to COVID-19 as evidenced by a recent World Bank approval of USD 370 million to assist 10 African countries fight the pandemic and a USD10 billion African Development Bank (ADB) COVID-19 response relief facility to African governments ^6,7. These efforts are aimed to help mitigate and contain the potential medium to long term economic impacts of the pandemic.

The interventions of the ADB, World Bank and others offer great opportunities for national health systems to leverage on and change the narrative of how currently weak African health systems and economies recover after COVID-19. There is enough evidence to support country level request for robust infrastructural upgrades, re-tooling and resourcing of health systems to cope with future emergencies whilst ensuring a continuum of population health and improving livelihoods.

Lastly, equity and solidarity in the context of COVID-19 are core tenets to advancing global health security as espoused by WHO in its 2018 publication titled: Managing epidemics: “key facts about major deadly diseases”. Equity within and across countries in meeting the health needs of all population groups is vital in the midst of this pandemic. In the midst of a global pandemic such as this, there is a real risk of neglecting local epidemics and the under-resourcing of existing health programs essential for vulnerable populations. WHO’s call for ensuring and maintaining continuity of care, support and effective mobilization of the health workforce must be adhered to. National governments must share best practices and advance each other with scientific knowledge. African countries must remain open and transparent and apply ethical standards in dealing with all issues regarding the pandemic to minimise a spike in cases across the continent.

In conclusion, building resilient health systems in Africa during crises like COVID-19 requires identifying cost-effec­tive interventions and employing a health system learning approach. We emphasize the need for solidarity, continuity of care and prioritizing health systems resilience beyond the crisis through well-coordinated multi-sectoral national response teams that deliver empirical SWOT analysis of the health building block, invest in, and rely on research evidence to inform decision-making in the short, medium to long term.

Conflict of interest: None

References

1.  WHO, Regional Office in Europe. Strengthening the health system response to COVID-19 Recommendations for the WHO European Region Policy brief (1 April 2020)

• World Health Organization. Health workforce requirements for universal health coverage and the Sustainable Development Goals: Human Resources for Health Observer Series No.17. 2016
• McGinnis JM, Olsen L, Yong PL, editors. Value in Health Care: Accounting for Cost, Quality, Safety, Outcomes, and Innovation: Workshop Summary. National Academies Press; 2010 May 3.
• Schemm Y. Africa doubles research output over past decade, moves towards a knowledge-based economy. Research trends. 2013;35:11-12.
• Tralac. Impact of the coronavirus (COVID-19) on the African Economy. https://www.tralac.org/news/article/14483-impact-of-the-coronavirus-covid-19-on-the-african-economy.html Accessed 21st April, 2020.
• World Bank. In the face of coronavirus, African countries apply lessons from Ebola response. 2020. https://www.worldbank.org/en/news/feature/2020/04/03/in-the-face-of-coronavirus-african-countries-apply-lessons-from-ebola-response 
• African Development Bank Group. African Development Bank Group unveils S10 billion response facility to curb COVID-19. 2020. https://www.afdb.org/en/news-and-events/press-releases/african-development-bank-group-unveils-10-billion-response-facility-curb-covid-19-35174

About the author

Martin Ayanore, PhD is a Health Economist and Head, Department of Health Policy Planning and Management, School of Public Health, University of Health and Allied Sciences, Ho, Ghana.