Building resilient health systems in Africa beyond the COVID-19 pandemic response

Introduction
Since the outbreak of the COVID-19 pandemic in December 2019 in China, health systems across the globe have struggled to contend with unprecedented shocks arising from this novel disease. Health systems in Africa are attracting more attention than before as these fragile systems have previously struggled to respond to the effects of health emergencies and pandemics. After the 2014 Ebola outbreak in parts of Africa, governments were encouraged by the WHO to improve the resilience of their health systems. This led to advocacy for a clear and concise definition of health system resilience. Fragility is the insufficient capacity of the state, system and/or communities to manage, absorb or mitigate risks. Resilience is what happens when a health system adapts to shocks or stress in a context of robustness.
Health system resilience has been defined as the ability of health actors, institutions and populations to demonstrate absorptive, adaptive, accessible and transformative capacities to prepare for and effectively respond to health system shocks and disturbances. Health system resilience is directly linked to health system governance—that is, resilience depends on the choices of groups and individuals as they make, change, monitor and enforce the rules (formal and informal) that govern the health system.8 The COVID-19 pandemic has laid bare the longstanding structural drivers of health inequities. There are concerns that public health policy could exacerbate the deleterious effects of these inequities if deliberate efforts are not made to factor these social vulnerabilities into public health practices and health system governance.
Egypt was the first African country to report COVID-19 on 14 February 2020. As of 31 May 2021, there have been 170 002 963 confirmed COVID-19 cases, 3 539 381 confirmed deaths and 1 546 316 352 vaccine doses administered. On 17 April 2020, the WHO stated that Africa could be the next COVID-19 epicentre. But available data so far do not reflect the projected impact of this novel disease on the region. Health systems across Africa are not new to dealing with deadly infectious disease outbreaks. West African countries such as Guinea, Liberia, Nigeria and Sierra Leone were faced with an Ebola epidemic from 2014 to 2016. Insights obtained from dealing with the epidemic might have strengthened those health systems somewhat as these disease outbreaks also put a considerable strain on their health systems in the process. However, resilience requires robustness. While some health systems have demonstrated features of adaptiveness in responding to a new challenge, such adaptiveness can only go so far in the context of weak, fragile and non-robust health systems.
The additional burden of dealing with COVID-19 is taking its toll on already fragile health systems. Ensuring adequate supply of protective equipment, laboratory testing, therapeutics, mechanical ventilators, isolation of confirmed or suspected cases, contact tracing and treatment for severe illness, and just dealing with the sheer number of COVID-19 cases have been daunting in Africa, and even in places with much better infrastructure. The situation is exacerbated by limited health services in rural compared with urban areas. This is occurring in a region that is struggling to implement vital infection control measures such as frequent handwashing, lockdowns and social distancing strategies aimed at slowing the spread of SARS-CoV-2.
Many countries in Africa have lean health financing and infrastructure development. With 25% of the global disease burden, sub-Saharan Africa has 3% of the world’s health manpower. One in three Africans—422 million people—are estimated to earn below $1 a day in rural areas. Weak health systems response to the COVID-19 pandemic could easily precipitate a monumental socioeconomic crisis. There is a clear and present need to improve the resilience of health systems across Africa. It is an inevitably daunting task (given variations across the continent) which WHO has been at the forefront of championing.
Understanding the resilience of health systems to COVID-19 calls for cross-country (within Africa and beyond) comparative analyses of the technical and political response to the pandemic. In this article, we highlight four health system challenges to controlling COVID-19, and offer potential strategies to address them, considering the nuances of the systems across Africa and their widely varying current level of resilience.

Source: British Medical Journal