COVID-19: Addressing Health Systems Deficits and Peculiarities in the African Region

Despite weeks of uncertainty and speculation, it is now evident that the COVID-19 pandemic has taken firm root in much of sub-Saharan Africa. As of July 27, 2020, the World Health Organization (WHO) reported 712,920 COVID-19 cases in Africa, with 11,900 deaths, and a case fatality rate of 1.7%1. These cases in the African continent account for 4.4 % of the total number of 16,114,449 cases of COVID-19 reported in the six WHO world regions during the same period. The 11,900 deaths in Africa accounts for approximately 1.8 % of the 646,641 associated with global deaths. Of note, is the observation that a preponderance of the cases and mortality in Africa (up to 70%) are concentrated in five countries – Algeria, Egypt, Nigeria, South Africa, and Ghana 1 . This special edition of the  African Journal of Reproductive Health  (AJRH) features primary research, commentaries, and reviews on the COVID-19 pandemic experiences within Africa's context. Being a continent with unusual developmental challenges and health systems characteristics, it was evident right from the beginning that the virus would manifest in ways different from the rest of the world. The AJRH is uniquely positioned to report the specific indicators of the pandemic in the African continent as revealed in this special edition. From the papers presented, four major concerns and characteristics that seem to epitomize the relative understanding or misunderstanding of the virus within the context of African countries are highlighted. First, there is the perception in many of the published research findings and commentaries that the rates and mortality from COVID-19 in Africa may be low as compared to other parts of the world 2,3 . While the emerging data on incidence and mortality statistics of the pandemic in corresponding regions of the world may have substantiated this view, it has not considered the deficiencies that have been inherent in the chronicling of the pandemic in the African continent. The other regions of the world have done relatively well in the rate of testing of populations for the virus. Still, many African countries have continued to lag in this indicator. Currently, a total of COVID-19 tests per 1,000 population of 158.98, 129.9, and 108.51 have been reported from the USA, the UK, and Italy respectively4. By contrast, South Africa, with the highest rate of testing in Africa, has a total test per 1,000 of 46.044. Nigeria, a country with the highest population in Africa of over 205 million persons, has currently tested 1.27 per 1000 4 , with only 267,842 persons tested since the pandemic began in the country 5 . Indeed, if the rate of positives of 41,180 in the 267,842 persons tested for the virus in Nigeria is considered (15.4% rate of positivity), it is evident that many more persons are positive in the country 5 . The perceived low incidence of COVID-19 in Africa is a mismatch against the available data. It must not be taken as gospel until more data and better rates of testing for the virus are achieved widely on the continent. The second dimension in consideration of COVID-19 in Africa is the observation that while many countries have struggled to provide health and social services to restrain the virus, there has been the fear that other essential health services are being neglected in the African continent. Several articles and commentaries in this edition of AJRH allude to this perspective, with major concerns being raised for the resulting deficits in the management of sexual and reproductive health services 6-8 . With African countries currently experiencing the worst indicators of reproductive, maternal, and child health 9 , it has been posited that with the emergence of COVID-19 and the resultant reduced access of women and children to evidence-based services, these indicators would worsen 10 thus, limiting the prospects for achieving the Sustainable Development Goals related to health and social equity in the continent. Indeed, with the lockdowns and economic restrictions that have featured as part of the approaches for limiting the virus in the continent, it has been proposed that many more unwanted pregnancies, unsafe abortion, and unwanted births will occur. While these concerns are justified, this journal's position is that empirical evidence are needed to document the effects and impact of the COVID-19 pandemic on Africa's health systems, especially its effects on the provision of alternative health services. In particular, we call for the development of innovative interventions and approaches within national health systems to limit the pandemic and ensure the continuity and high-impact delivery of essential services. Such interventions would be tested with true experimental (randomized controlled trial) or quasi-experimental designs to provide evidence-based outcomes for effective service delivery that can be scaled for use globally and to curtail future pandemics. A third debate that has featured repeatedly during the COVID-19 pandemic in the African continent is the role of traditional versus orthodox methods of treatment. To date, there are no vaccines or effective medications for the treatment of the virus. The recommendation by WHO for the use of hydroxychloroquine and azithromycin has emboldened many African scientists to envision the development of local remedies for the disease particularly because hydroxychloroquine (the synthetic version of quinine derived from a medicinal plant) 11 has been used for the treatment of malaria in Africa for many years. In particular, many argue that since herbal medicines, have been used for the treatment of malaria, it is possible that such drugs could be useful for the treatment of COVID-19 as well. In this context, many African countries are working on providing indigenous treatment for the virus. The AJRH affirms that while efforts to find indigenous treatment for COVID-19 are commendable, such efforts must follow time-honored research protocols and procedures using proven scientific methods. A fourth and final challenge identified for COVID-19 in the articles published in this edition of the AJRHis the current lack of fidelity and trust among Africans about the virus and the preventative strategies known to curtail the spread of the virus. The WHO recommends testing, quarantine of infected persons, self-isolation, handwashing, and the use of sanitizers and facemasks to prevent the community spread of the disease 12 . However, despite the widespread knowledge of these prevention measures, the compliance with the recommendations has been low, especially in countries that are currently witnessing an upsurge in transmission rates. In Nigeria, for example, new cases of the virus are emerging despite several weeks of lockdowns and sustained dissemination of information on prevention. This observation has been attributed to a lack of trust among community constituents about the real essence of the virus and the effectiveness of health measures designed to curtail its spread. Many observers doubt the existence of the virus, with some proposing explanatory models that range from the mundane to the ridiculous. The paper by Lee et al 13 in this edition of the journal provides empirical data to substantiate the lack of trust of health systems among African populations as compared to other parts of the world. It presented a cross-sectional study comparing trust levels in health recommendations for COVID-19 between respondents in Ethiopia, the Democratic Republic of Congo (DRC), and South Korea. The study revealed that trust levels were three times higher in DRC than in Ethiopia, and 29 times higher in South Korea than in Ethiopia. The paper recommended a need for rapid scaling of health education, information, and practices in the two African populations studied. Indeed, we believe that strategies to curtail the spread of the virus in Africa must include sustained efforts to disseminate accurate information, eliminate skepticism, and build community understanding. We conclude that African countries have specific peculiarities in the experience of COVID-19 that may hinder or propel the virus's elimination sooner or later. This special edition of the AJRH has highlighted some of the challenges and peculiarities to foster Africa's contribution to the early curtailment of the pandemic. While many parts of the developed world are witnessing a declining incidence of the virus, African populations seem to be on the accelerating phase of its development. We fear that unless specific measures are taken to counter some of the misunderstandings about the virus and the challenges facing its prevention in Africa, the disease might fester for a more extended period in the continent than is currently envisaged.